Citation Nr: 21002501 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 12-28 124 DATE: January 13, 2021 ORDER Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a right knee disability is granted. Entitlement to service connection for upper gastrointestinal disability, to include dysphagia, to include as secondary to service-connected lumbar spine disability and associated medications thereto, is granted. REMANDED Entitlement to service connection for cervical spine disability, to include as secondary to service-connected lumbar spine disability, is remanded. Entitlement to service connection for neurologic condition(s) of the left upper extremities, to include as secondary to service-connected lumbar disability, is remanded. Entitlement to service connection for neurologic condition(s) of the right upper extremities, to include as secondary to service-connected lumbar spine disability, is remanded. Entitlement to service connection for headaches is remanded and deferred. Entitlement to service connection for lower gastrointestinal disability, to include irritable bowel syndrome (IBS), irritable bowel disease (IBD), and chronic diarrhea, to include as secondary to service-connected lumbar spine disability and associated medications thereto, is remanded. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected lumbar spine disability and associated medications thereto, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his left knee disability had its onset in service, and is otherwise at least as likely as not etiologically related to an in-service event, injury, or illness. 2. Resolving reasonable doubt in the Veteran’s favor, his right knee disability had its onset in service, and is otherwise at least as likely as not etiologically related to an in-service event, injury, or illness. 3. Resolving reasonable doubt in the Veteran’s favor, his upper gastrointestinal disability, to include dysphagia, is proximately due to the medications associated with his service-connected lumbar spine disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for upper gastrointestinal disability, to include dysphagia, as secondary to medications associated with service-connected lumber spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1973 until his honorable discharge in June 1977. This appeal is being treated expeditiously on the Board of Veterans’ Appeals’ (Board) docket pursuant to 38 U.S.C. §§ 5109B, 7112 and 38 C.F.R. § 20.902(d). This case comes before the Board on appeal from an August 2012 rating decision by the Lincoln, Nebraska, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied service connection for sixteen claims, including those claims addressed within this decision. See August 2012 Rating Decision – Codesheet. In December 2017, the Veteran and his spouse testified at a videoconference Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the record on appeal. During the hearing, the undersigned held the record open for 30 days to allow for the submission of additional evidence. In a May 2018 decision, the Board, pertinent to this case, denied the Veteran’s claims for dysphagia and hemorrhoids, and remanded other claims for further evidentiary development. The Veteran subsequently appealed the Board’s decision denying his claims for dysphagia and hemorrhoids to the United States Court of Appeals for Veterans Claims (CAVC). Based on a joint motion to remand submitted by the parties, CAVC entered an order in January 2019 vacating the Board’s decision and remanding the matter to the Board for readjudication. In April 2020, the Board remanded the Veteran’s case to the RO for further development. Specifically, the Board directed the RO to obtain VA medical examinations and opinions as to the Veteran’s claims, to include opinions as to the theory of secondary service connection for certain claims. Evidentiary Standards In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). 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). The Board, as factfinder, is responsible for assessing the credibility and weight to be given to evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336–37 (Fed. Cir. 2006). When assessing the credibility of lay documentary evidence, the Board may consider factors such as facial plausibility, bias, self-interest, internal consistency, and consistency with other evidence of record. Caluza v Brown, 7 Vet. App. 498, 511 (1995); Southall-Norman v. McDonald, 28 Vet. App. 346, 355 (2016). When assessing oral testimony before the Board, the Board may consider the demeanor of the witness(es), the facial plausibility of the testimony, and the consistency of the testimony with other testimony and affidavits submitted on behalf of the veteran. Caluza, 7 Vet. App. at 511. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a “service connection.” 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by a service-connected disability. 38 C.F.R. §§ 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where aggravation is the relied upon theory, compensation may only be provided to that degree over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. 1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected lumbar spine disability 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected lumbar spine disability As the disposition and analysis for each of these issues is the same, the Board will address them together. First element: A current disability As to the first element of service connection, a current disability, the Veteran underwent diagnostic testing on both knees in May 2012 during a VA examination. X-rays of each knee showed “minimal joint space narrowing of the medial compartments bilaterally. Mild chondrocalcinosis of the right knee.” In addition, the examiner found “mild degenerative joint disease” in both knees. May 2012 VA Medical Examination. The October 2019 VA-contracted medical professional diagnosed the Veteran with joint osteoarthritis in both knees. October 2019 VA- Contracted Knee and Lower Leg Conditions Disability Benefits Questionnaire (Knee/Leg DBQ). The most recent VA-contracted examination in October 2020 indicated that the Veteran suffered from knee strain in both of his knees, but not osteoarthritis in either knee. October 2020 Knee/Leg DBQ. The Board finds each medical professional is competent to examine and diagnose the Veteran’s bilateral knee conditions. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (the competence of VA examiners is presumed absent evidence to the contrary). The Board also finds each medical professional’s examination and diagnosis credible and probative. Therefore, the Board finds the first element is satisfied; the Veteran has (or had) a left knee and right knee disability during the pendency of the appeal. Davidson, 581 F.3d 1313; Pond, 12 Vet. App. 341; see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that an appellant satisfies the current disability requirement “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary’s adjudication of the claim”). Second element: An in-service event, injury, or illness, or aggravation thereof As to the second element of service connection, an in-service event, injury, or illness that occurred while on active duty, the Board finds the evidence supports such a finding. In his March 2014 correspondence, the Veteran asserted that due to his military occupational specialty (MOS) as a weapons mechanic, his duties required him to carry heavy loads of munitions and load them onto aircrafts “with no help from other load crew members” and he had to do so in a “hurried” manner. His duties caused his left knee to lock and buckle underneath him because of the strain placed on it. This subsequently led him to place more strain on his right knee as to he tried to favor his left knee and his back. The Veteran submitted photographs along with a statement in support of claim in November 2017. He stated that as part of his MOS while stationed at Ellsworth Air Force Base, it was his duty to load nuclear weapons and conventional weapons inside the bomb bay or wings of B-52 bombers. It was his job “to physically push the weapons trailers into place.” He loaded or unloaded a B-52 bomber two to four time per week over the course of two-and-a-half years. He provided photographs that he asserted depicted his typical duties, which included crew members pushing a rocket launcher trailer and large missiles into position. He stated that the body positions and strain on the crew members’ faces were what he experienced on a constant basis. He specifically stated that he had to place his body in the same precarious positions as the crew members depicted in the photographs. In addition, VA received a November 2017 statement in support of claim (dated April 2014) in which the Veteran stated that during his military service at a U.S. Royal Thai Air Force base from January 1974 to January 1975, he served as a weapons mechanic. He loaded and unloaded ordnance and weapons systems for combat operations in 12-hour shifts, six days a week. During his December 2017 Board hearing, the Veteran testified that prior to his military service, he did not experience bilateral knee pain. He testified that he began experiencing bilateral knee pain in service. He noticed that when there was a lot of pressure applied, such as when he loaded bombs and rockets, his bilateral knee pain increased. He specifically recalled such pain while in service at Ellsworth Airforce Base when he pushed munitions trailers as part of his duties. During his service, the Veteran’s knees “clicked,” “popped,” and “would lock from time to time.” The Veteran’s wife submitted a March 2012 statement in which she stated that she met the Veteran in August 1973 and believed he was in “excellent physical health.” Over the proceeding several months, she never recalled him complaining of any knee problems. While the Veteran served in the military, he sent his wife letters. She recalled that in his letters he described the physical demands of his MOS, including how his back and knees hurt but that he was afraid to tell his crew members and chief because he did not want to be labeled badly. After they were married, and while the Veteran was still on active duty, she stated that she recalled him coming home from duty and complaining of his knee pain. She went with him several times to sick call where he complained of knee pain. According to the Veteran’s service treatment records (STRs), during his December 1976 separation examination, he complained of bilateral discomfort in his knees and bilateral retropatellar pain. He stated he had continuous pain over the past two years, “especially exacerbated by pushing heavy loads.” The Veteran’s X-rays were normal at that time, and the physician diagnosed the Veteran with mild to moderate bilateral chondromalacia. An earlier December 1976 STR indicated the Veteran experienced a “trick or locked” left knee since 1972. The Veteran did not report such a history in a January 1973 STR report of medical history. The Board finds the Veteran is competent to report his experiences related to his active military service, including the duties he performed. The Board also finds the Veteran is competent to report the symptoms and sensations of pain he experienced in each of his knees while in service and thereafter, including the severity, frequency, duration, and onset of his pain. The Board also finds the Veteran’s recollection of his MOS duties and sensations of knee pain is credible, particularly considering the Veteran’s clear and detailed statements and testimony. Absent evidence to the contrary, the Board finds the Veteran’s statements, testimony, and the medical evidence of record probative. As such, the Board finds the Veteran’s MOS as a weapons mechanic routinely put strain on his knees, which constitutes an in-service event for purposes of this case. Furthermore, his documented in-service complaints of bilateral knee pain and diagnosis of bilateral chondromalacia constitutes an in-service illnesses/injury. Therefore, the second element is satisfied. Davidson, 581 F.3d 1313; Pond, 12 Vet. App. 341. Third element: a causal link between the Veteran’s current disability and in-service incurrence or aggravation As to the third element of service connection, a causal link between the Veteran’s current disability and in-service incurrence or aggravation, the Board finds the medical evidence of record is in equipoise. First, the Board addresses the evidence in the Veteran’s favor. He submitted a February 2012 medical opinion from Dr. L.I., a private physician, who stated that he reviewed the Veteran’s “well-organized and very comprehensive medical records.” Dr. L.I. also stated he provided medical care to the Veteran for several years. He opined that the Veteran’s MOS duties, which “required a significant amount of lifting in complicated and precarious positions,” more likely than not created a lumbosacral condition that in turn placed undue stress on his knees, which resulted in cartilaginous joint degeneration. Absent evidence to the contrary, the Board finds Dr. L.I. is competent to provide an opinion on the etiology of the Veteran’s bilateral knee conditions. The Board also finds Dr. L.I. is credible. The Board finds Dr. L.I.’s opinion probative. The Board finds that Dr. L.I.’s opinion can reasonably be read as opining that the Veteran’s bilateral knee conditions are directly related to his MOS duties, which caused a lumbosacral disability and his bilateral knee disabilities. McCray v. Wilkie, 31 Vet. App. 243, 257 (2019) (Board is capable of interpreting medical opinion evidence) (citing Harvey v. Shulkin, 30 Vet. App. 10, 20 (2018)). The Veteran submitted a June 2012 opinion from Dr. C.V., a private physician, who stated he “recently reevaluated” the Veteran in May 2012. He reviewed the Veteran’s military records and his own clinical notes. He opined that the Veteran’s bilateral knee conditions were “more likely than not the result of lifting and twisting while bomb loading onto F-4’s.” He reasoned that the repetitive stress placed on the knee joints led to knee pain as noted in his STR’s. Dr. C.V. provided a second opinion in December 2014. He clarified that his second opinion was based on review of the Veteran’s military records, his own clinical notes, and the Veteran’s post-service medical records. Thus, he cured the deficiency of his June 2012 opinion in which he failed to indicate that he reviewed the Veteran’s medical records. He reaffirmed his June 2012 opinion. He relied on the same reasoning and added that the Veteran submitted photographs depicting the typical ordnances he moved, weighing 250 to 1000 pounds apiece. These photographs are contained within the Veteran’s claims file. Dr. C.V. also completed a Knee/Leg DBQ in February 2019 for the Veteran. Within it, he conducted appropriate testing and documented his findings. He appropriately described the Veteran’s medical history, considered his lay statements, and otherwise completed the DBQ. He opined that the Veteran’s bilateral knee conditions were more likely than not due to the Veteran’s “carrying heavy ordnances” associated with his MOS while in military service. Absent evidence to the contrary, the Board finds Dr. C.V. is competent to provide an opinion on the etiology of the Veteran’s bilateral knee conditions. The Board also finds Dr. C.V. is credible. The Board further finds the opinion is probative as it was based on review of the Veteran’s medical records, consideration of his lay statements, and is relatively well-reasoned. As to the medical evidence against the Veteran, the RO obtained two VA examiners’ opinions. In July 2012, the VA examiner conducted a thorough review of the Veteran’s medical records, considered his relevant lay statements, and conducted a thorough in-person examination. The July 2012 VA examiner opined that the Veteran’s bilateral knee disabilities were less likely as not related to, incurred in, or caused or aggravated by his military service. The examiner reasoned that the Veteran’s current symptoms were not typical of chondromalacia. His post-military knee injuries and respective knee surgeries were more likely to have led to his current bilateral knee disabilities, and there was no continuity within the Veteran’s medical records as to his bilateral knee disabilities. Absent evidence to the contrary, the Board finds the July 2012 VA examiner is competent. The Board also finds the examiner is credible. The Board finds the examiner’s opinion if afforded little probative weight, however, because the examiner did not define or otherwise explain the point at which the Veteran’s in-service events and injuries were superseded by his post-service injuries and surgeries such that his in-service events and injuries were no longer a potential basis for causation of his current bilateral knee disabilities. A March 2019 VA-contracted examiner conducted a thorough review of the Veteran’s medical records, considered his relevant lay statements, and conducted a thorough in-person examination. The March 2019 VA examiner opined that the Veteran’s bilateral knee disabilities were less likely than not incurred in or caused by his military service. The examiner reasoned that his chondromalacia in service was different from his present arthritis. He stated chondromalacia is commonly known as “runner’s knee,” a condition where the cartilage under the kneecap deteriorates some due to heavy use (typically running). The condition resolves in a few months, typically with rest. The examiner then relied on the evidence that the Veteran had knee surgeries on both knees over the years, although it was not clear if he had meniscectomies on both knees or just one knee. “Regardless, the chondromalacia in 1976 would not typically lead to a meniscal tear. A meniscal tear is typically due to an acute twisting impact type event.” March 2019 VA -Contracted Medical Opinion (received by VA in May 2019). His mild bilateral degenerative joint disease was likely due to his many years of chronic wear and tear and would be common in males his age. Absent evidence to the contrary, the Board finds the March 2019 VA examiner is competent. The Board also finds the examiner is credible. The Board finds the examiner’s opinion probative as it is well-reasoned, addresses the Veteran’s medical history, and considered his relevant lay statements. Considering the medical evidence as a whole, the Board finds Dr. L.I.’s February 2012 positive nexus opinion, Dr. C.V.’s December 2014 positive nexus opinion, and the March 2019 VA examiner’s negative nexus opinion are all of relatively equal probative value. While the Board is unable to determine the absolute cause of his bilateral knee disability, the law does not require such certainty. Because the evidence is in relative equipoise, the Veteran is afforded the benefit of the doubt. 38 U.S.C. § 5107(b). Therefore, the Board finds the third element is satisfied. Davidson, 581 F.3d 1313; Pond, 12 Vet. App. 341. Accordingly, the Board finds the Veteran is entitled to service connection on a direct basis for his left knee disability and his right knee disability, respectively. As the Board has granted service connection on a direct basis, awarding the Veteran a full grant of benefits sought, an analysis of secondary service connection is unwarranted. 3. Entitlement to service connection for upper gastrointestinal disability, to include dysphagia, to include as secondary to service-connected lumbar spine disability Although the Veteran’s argument focuses on secondary service connection, the Board finds an analysis of direct service connection is warranted by the record and the Veteran’s representative’s general request made during the Veteran’s Board hearing. See Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record). Direct Service Connection First element: A current disability As to the first element of secondary service connection, a current disability, the competent, credible, and probative evidence of record is in relative equipoise as to whether the Veteran presently has or had an upper gastrointestinal (upper GI) disability, to include dysphagia. As such, providing the Veteran the benefit of the doubt, this element is satisfied. Davidson, 581 F.3d 1313; Pond, 12 Vet. App. 341; 38 U.S.C. § 5107(b). The Board notes that his upper gastrointestinal disability was not continuously present throughout the pendency of this appeal. Regardless, even if a condition resolves during the claims period, the Veteran is still entitled to service connection as long as he had the disability at any time during the pendency of the claim. See McClain, 21 Vet. App. at 321. A May 2012 VA examiner noted that the Veteran claimed he had dysphagia, but the examiner did not address whether the Veteran had then-existing dysphagia during the examination. The Board finds the Veteran competent to report his sensations and experiences related to his upper GI, but he is not competent to diagnose himself without the necessary medical training, knowledge, and experience. Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). The Veteran’s private physician, Dr. C.V., completed a February 2019 esophageal conditions DBQ in which he noted the Veteran was diagnosed with dysphagia in 2016 and that he had dysphagia and other associated symptoms during the examination in February 2019. A March 2019 VA-contracted examiner recorded the Veteran’s January 2018 upper endoscopy revealed “extrinsic stenosis at the upper esophageal sphincter,” but otherwise his exam was “normal” as to his esophagus, stomach, and duodenum. The March 2019 VA-contracted examiner found “no diagnosable stomach condition.” The October 2020 VA-contracted examiner recorded that the Veteran reported he suffered from dysphagia and reflux. The Veteran also reported a “globus sensation,” which “is the feeling of having a lump in the throat when in fact there is nothing there.” October 2020 VA-Contracted Medical Opinion. The examiner’s conclusion, however, was that there was no diagnosis of dysphagia. The examiner relied on the Veteran’s barium swallow test and general examination, and he concluded the Veteran’s globus sensation was subjective. Finally, the Board notes the Veteran’s VA medical records generally report he has “oropharyngeal dysphagia” when noting his current “problems.” The Board does not find any one opinion more credible or probative than another opinion, and each medical professional is competent to render a diagnosis. Thus, the Board affords the Veteran the benefit of the doubt and finds that a current upper GI disability existed, to include dysphagia and globus sensation, during the pendency of this appeal. Second element: An in-service event, injury, or illness, or aggravation thereof As to the second element of service connection, an in-service event, injury, or illness, or aggravation thereof that occurred while on active duty, the Veteran generally asserts that he incurred food poisoning, or something similar, while on active duty service in Thailand in 1974. The Veteran’s STRs do indicate that in July 1974 he reported persistent diarrhea without a fever, which started in June 1974. He experienced diarrhea five times a day unless he took Lomotil. An August 1974 STR indicated his diarrhea persisted. He experienced symptoms four to five times a day. He was prescribed Kaopectate. His June 1976 separation examination noted that he experienced “occasional indigestion due to diet, self-treated with Tums.” Nevertheless, the Veteran does not assert, nor does the record reasonably assert, that the Veteran’s upper GI disability is related to his 1974 in-service illness while in Thailand. The Veteran nor his representative have provided any guidance to the Board on a theory that would connect his upper GI disability with that of the illness he incurred in 1974 while in Thailand. Particularly, his 1974 STRs did not document any upper GI issues, only lower GI issues. Rather than a claim for direct service connection, the Board understands the Veteran’s claim to be one for secondary service connection for his upper GI disability as due to his lower GI disability. He testified at the hearing that based on his lower GI disability, “now, I’ve got dysphagia.” December 2017 Board Hearing Transcript, at 23. This is a claim for secondary service connection. He makes no argument that his illness in Thailand is directly related to his dysphagia. The Board finds no evidence of an in-service onset, event, injury, or illness, or aggravation thereof reasonably related to his dysphagia or associated symptomatology. As such, the second element is not satisfied and direct service connection for the Veteran’s upper GI disability is not warranted. Davidson, 581 F.3d 1313; Pond, 12 Vet. App. 341. Secondary Service Connection First element: A current disability As to the first element of secondary service connection, a current disability, for reasons previously discussed, the Board finds the Veteran has or had during the pendency of his appeal an upper GI disability, to include dysphagia. This element is satisfied. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. Second element: A current service-connected disability As to the second element, a current service-connected disability, the Veteran is currently service connected for lumbar spinal stenosis (lumbar spine disability). He has been service connected for that disability since January 27, 2012. This is the primary service-connected disability that he cites as the basis for his present secondary-service-connection claim. The Veteran is also service connected for seven additional disabilities, not including his left and right knee disabilities that the Board has granted service connection for within this decision. The Board finds it unnecessary to address any of those previously service-connected disabilities because the Veteran’s lumbar spine disability has the longest period of service connection and provides a sufficient basis to grant secondary service connection. This element is satisfied. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. Third element: A causal link The crux of this claim is the third element, whether the Veteran’s upper GI disability was caused by or aggravated by his service-connected lumbar spine disability. Here, the Board finds the evidence is in relative equipoise. As such, providing the Veteran the benefit of the doubt, the third element is satisfied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448 As the theory of causation will result in a full grant of service-connection benefits, the Board finds it unnecessary to address the theory of secondary aggravation in this instance. “Proximate cause” is defined as “[t]hat which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred.” Black’s Law Dictionary 1225 (6th ed. 1990); see Forshey v. West, 12 Vet. App. 71, 74 (1998), aff’d sub nom. Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002), rev’d on other grounds by, Morgan v. Principi, 327 F.3d 1357 (Fed. Cir. 2003) (adopting “proximate cause” definition); VAOPGCPREC 6-03. When there are potentially multiple causes of a harm, an action is considered to be a proximate cause of the harm if it is a substantial factor in bringing about the harm and the harm would not have occurred but for the action. VAOPGCPREC 6-03 (citing Shyface v. Secretary of Health & Human Svs., 165 F.3d 1344, 1352 (Fed. Cir. 1999)). VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. The Veteran’s private physician, Dr. L.I., provided a February 2012 opinion in which he opined that, after review of the Veteran’s medical history and knowledge obtained from being his personal treatment physician, the Veteran’s stomach conditions, to include hyperacidity, reflux disease, and subsequent dysphagia, were caused by the multiple medications he took to control his lumbar spine disability, which included anti-inflammatory medication, pain medication, and muscle relaxants. The Board finds Dr. L.I. competent and credible, but his opinion is afforded relatively minimal probative weight because he did not indicate that he considered the extent of Veteran’s medications, to include dosages, frequency, or duration, in relation to his medical history. For example, he did not identify whether specific amounts of medications were constant or fluctuated, nor did he identify specific medications that the Veteran was prescribed or when. This leads the Board to question whether the Veteran’s upper GI symptomatology would fluctuate. His overall opinion and rationale are quite vague and broad. Dr. C.V. provided an opinion in December 2014. Dr. C.V. opined that, after review of the Veteran’s medical records, military records, and own clinical notes, that it was at least as likely as not that the Veteran’s upper GI disability was caused by the Veteran’s repeated use of medication over the course of 30 years to control the pain associated with his lumbar spine disability (and now service-connected bilateral knee disabilities). In particular, he noted that medications such as Darvocet and Ibuprofen taken over the course of 35 years would play such a role. Dr. C.V. also provided a February 2019 esophageal conditions DBQ in which he again opined that the Veteran’s dysphagia was more likely than not secondary to the erosion caused by taking chronic NSAIDs (nonsteroidal anti-inflammatory drug) for his knees and back. He specifically identified Ibuprofen and Meloxicam. The March 2019 VA-contracted examiner opined that the Veteran’s upper GI disability was less likely than not due to any medications (NSAIDS, etc.) that he may have taken, even to excess, due to his back, cervical spine, knee, or hip conditions. The examiner reasoned that NSAIDS can disrupt the protective mucus lining of the stomach resulting in ulceration, pain, and bleeding, but it does not typically lead to IBS with its associated bloating, cramping, diarrhea, and constipation. He relied on the Veteran’s January 2018 esophagogastroduodenoscopy (EGD) that showed no abnormality in either the Veteran’s stomach or the proximal duodenum. He reasoned that “[i]f excessive NSAID use was causing any problems, it would most likely be first spotted in the stomach by EGD, but this was not the case.” Absent evidence to the contrary, the Board finds the March 2019 VA-contracted examiner is competent. The Board also finds the examiner is credible. The Board also finds the examiner’s opinion probative in this matter, but to a limited extent. It is well-reasoned and properly considered the Veteran’s medical history and lay statements. The examiner, however, relied on the Veteran’s December 1976 exit examination, noting he did not report nor did the evaluator note “abdominal cramping, bloating, diarrhea, etc.” As discussed, the Veteran’s December 1976 exit examination did record his “occasional indigestion.” If the examiner had not written “etc.”, then his opinion would be very probative, but it appears he overlooked this notation. Thus, the Board can only afford the opinion relatively minimal probative weight because the Board does not know whether the Veteran’s “occasional indigestion” factored into the examiner’s rationale or opinion. Finally, the RO obtained a medical opinion from a VA-contracted examiner in October 2020, but the Board finds the opinion deficient. The examiner provided a negative nexus opinion, but for his rationale he merely stated, “lumbar condition has no direct correlation to the ability to swallow. . . . more likely [globus] sensation due to cervical condition.” He generally cited the barium swallow results. The examiner provided no explanation linking his conclusions. His general conclusions are not a rationale. Thus, the while the Board does not doubt the examiner’s competency or credibility as to this issue, his opinion is afforded no probative value. Providing the Veteran the benefit of the doubt, the Board must conclude that the evidence of record places the ultimate issue of causation, under a secondary-service-connection theory, in relative equipoise. Even though the Board may have reasonable concerns with Dr. L.I. and Dr. C.V.’s opinions when compared to the March 2019 VA examiner’s opinion, it is only the Board’s duty to judge the credibility of the evidence and weigh it. In this case, the weight of the competent, credible, and probative evidence is in relative equipoise as to causation. Therefore, the Board finds the third element is satisfied. As all elements for secondary service connection for the Veteran’s upper GI disability are satisfied, the Board need not address the theory of aggravation. Accordingly, the Veteran is entitled to service connection for his upper GI disability, to include dysphagia, as secondary to his medications associated with his service-connected lumbar spine disability (and now left knee disability and right knee disability). REASONS FOR REMAND In the Board’s April 2020 decision, the following claims were remanded to the RO for further development. The Board notes this will now be the third remand to obtain adequate VA medical opinions. 1. Entitlement to service connection for cervical spine disability, to include as secondary to service-connected lumbar spine disability, is remanded. As part of its April 2020 remand, the Board instructed the RO to schedule the Veteran for a VA examination and render an opinion as to the nature and etiology of his cervical spine disability. The examiner was asked to provide an opinion as to whether the Veteran’s cervical spine disability was caused by or aggravated by his service-connected lumbar spine disability. The Board directed the examiner to consider the Veteran’s lay statements about his onset and symptomatology and to consider and discuss various medical evidence. The examiner opined, as to causation, that the Veteran’s cervical spine disability was less likely than not caused by his lumbar spine disability because the Veteran had multiple neck fusions from a slip and fall while working for a railroad post-service, which was the cause of his pain. As to aggravation, the examiner relied on the Veteran’s December 1976 exit examination, which showed no neck issues, and he stated there was a lack of neck issues in service. He then relied on the Veteran’s work injury to opine that his cervical spine was less likely than not aggravated by his lumbar spine disability. The Board finds the examiner’s opinions on causation and aggravation inadequate because neither is supported by logical rationale. The examiner merely pointed to the Veteran’s post-service work injury as the cause for his cervical spine disability. The examiner did not discuss any of the evidence to which the Board directed him. Nor did the examiner connect his rationale to his opinion. The simple fact that the Veteran had a post-service work injury of his neck does not mean that he did not suffer a cervical spine disability prior to his post-service work injury. The examiner failed to provide any medical evidence to discount the reasonable possibility or otherwise explain why the Veteran’s lumbar spine disability could not have affected the Veteran’s cervical spine condition prior to his post-service injury. Moreover, on further review of the claims file, it appears that an adequate opinion as to direct service connection was not obtained. A March 2019 VA medical opinion failed to address the Veteran’s assertions of in-service head/neck injuries as a weapons mechanic. The examiner provided a negative nexus opinion based solely on a lack of neck issues in the Veteran’s STRs. Therefore, the opinion has no probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion.”); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (opinion is adequate “where it is based upon consideration of the veteran’s prior medical history and examinations[.]”). Therefore, remand is required because the Board cannot properly address the Veteran’s claim for service connection for a cervical spine disability at this point based on medical evidence of record. 2. Entitlement to service connection for neurologic condition(s) of the left upper extremities, to include as secondary to service-connected lumbar disability, is remanded. 3. Entitlement to service connection for neurologic condition(s) of the right upper extremities, to include as secondary to service-connected lumbar spine disability, is remanded. As the disposition for each of these issues is the same, the Board will address them together. As to the Veteran’s claim for neurologic conditions of the left and right upper extremities, in the Board’s April 2020 remand, the Board instructed the RO to obtain a new VA examination and medical opinion for each claim. With respect to each claim, the examiner was asked to provide an opinion as to whether each condition was caused by or aggravated by the Veteran’s lumbar spine disability. In addition, the Board anticipatorily requested the examiner to opine on whether the conditions were caused by or aggravated by the Veteran’s cervical spine disability. The Veteran was not service connected for a cervical spine disability. This added unnecessary confusion to the remand directives, which resulted in inadequate opinions. The examiner opined that the Veteran’s neurologic conditions of the left and right upper extremities were likely caused by the Veteran’s cervical spine disability. The examiner incorrectly assumed the cervical spine disability was service connected when, in fact, it was not and is currently not. Consequently, the examiner did not properly discuss whether the Veteran’s neurologic conditions were caused the Veteran’s lumbar spine disability. As to aggravation, the examiner did discuss the Veteran’s lumbar spine disability. He opined the Veteran’s neurologic conditions were less likely than not aggravated by the Veteran’s lumbar spine disability. For his rationale, the examiner only provided a list of facts. He did not connect the facts with any reasoning. He only stated that the Veteran had neck fusion in 1989 with nerve issues, there was no mention of neck issues in service, and he was injured post-service. Statements like these can be acceptable in some instances, if properly connected, but this is not such an instance. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012); Monzingo v. Shinseki, 26 Vet. App. 97, 105–06 (2012) (finding no clear error when a medical examiner “did not explicitly lay out [her] journey from facts to a conclusion.”). The examiner’s rationale does not address why the Veteran’s lumbar spine disability did not aggravate the Veteran’s cervical spine disability. He basically attributed the cervical spine disability to another cause, but never addressed why the lumbar spine disability could not be a source of causation or aggravation. Therefore, remand is required because the Board cannot properly address the Veteran’s claim for service connection for neurologic conditions of the left and right upper extremities at this point based on medical evidence of record. 4. Entitlement to service connection for headaches is remanded and deferred. As part of its April 2020 remand, the Board instructed the RO obtain an addendum opinion as to the nature and etiology of his headaches. The Board requested the examiner to provide an opinion as to whether the Veteran’s headaches were caused by or aggravated by his cervical spine disability. Again, the Veteran was not and is not service connected for his cervical spine disability. This caused unnecessary confusion on remand. Nevertheless, the examiner opined the Veteran’s headaches were caused by his cervical spine disability. The Veteran does not assert, nor does the record reasonably raise the assertion that the Veteran’s headaches are due to his lumbar spine disability. He only asserts his headaches are secondary to his cervical spine disability. Accordingly, this claim is inextricably intertwined with the appeal for service connection for his cervical spine disability, which is remanded for additional development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, consideration of this claim must be deferred pending resolution of his claim for service connection for his cervical spine disability. 5. Entitlement to service connection for lower gastrointestinal disability, to include irritable bowel syndrome (IBS), irritable bowel disease (IBD), and chronic diarrhea, to include as secondary to service-connected lumbar spine disability and associated medications thereto, is remanded. As part of its April 2020 remand, the Board instructed the RO to obtain an addendum opinion as to the nature and etiology of his lower gastrointestinal (lower GI) disability. The examiner, however, failed to provide an adequate rationale for his opinions in every respect. The examiner was asked to identify if the Veteran had any stomach conditions throughout the pendency of his appeal. The examiner was also asked to opine whether it was at least as likely as not that the Veteran’s stomach conditions were caused by or aggravated by his service-connected disabilities and associated medications thereto. The examiner found the Veteran did not suffer from irritable bowel syndrome (IBS) or chronic diarrhea at that time because his then-present symptoms were not associated with such disabilities. The examiner failed to identify if and when the Veteran had any lower GI disabilities throughout the pendency of the appeal. To this extent, the Board finds it is necessary to make findings of fact as to whether the Veteran has, or had during the pendency of his appeal, a lower GI disability. A May 2012 VA examiner documented that the Veteran sought medical treatment throughout the 1990s for stomach issues, including gas, irritation, abdominal distention, belching, cramping, and was diagnosed with irritable bowler syndrome (IBS). A March 2019 VA-contracted medical examiner documented that the Veteran was diagnosed with IBS in 2002. During the March 2019 VA-contracted examination, the examiner documented that the Veteran suffered from alternating diarrhea, abdominal distension, and cramping on a frequent basis. The March 2019 VA-contracted examiner found the Veteran had inflammatory bowel disease (IBD). The Veteran’s private physician, Dr. C.V., completed an intestinal conditions DBQ in February 2019, which documented that the Veteran was diagnosed with IBS in 2012. He documented that the Veteran’s symptoms included diarrhea once per week and occasional nausea, which also included frequent episodes of abdominal distress. An October 2020 VA-contracted medical examiner recorded that the Veteran suffered from abdominal pain and diarrhea on a monthly basis. Based on the foregoing competent, credible, and probative evidence, the Board does not find any one opinion more credible or probative than another opinion, and each medical professional is competent to render a diagnosis. Thus, the Board affords the Veteran the benefit of the doubt and finds that a current lower GI disability existed during the pendency of the appeal, to include IBS, IBD, and/or chronic diarrhea. McClain, 21 Vet. App. at 321 (even though the disability resolves prior adjudication, service connection may still be granted); 38 U.S.C. § 5107(b). Furthermore, the October 2020 VA-contracted examiner’s opinion on aggravation stated, “his medical record is confusing when and if he had a stomach condition with so many different opinions[.] I am going with findings at today’s exam as no diagnoses for stomach condition and with no current condition there is no baseline severity.” October 2020 VA-Contracted Medical Opinion (as to aggravation). The examiner did not address any of the Veteran’s medications as potential sources of the Veteran’s lower GI issues. In addition, his only rationale was that there was no direct correlation of the Veteran’s current symptoms to his lumbar spine disability. In short, the examiner failed to provide an adequate opinion. Therefore, remand is required because the Board cannot properly address the Veteran’s claim for service connection for a lower GI disability at this point based on the medical evidence of record. 6. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected lumbar spine disability and associated medications thereto, is remanded. As part of its April 2020 remand, the Board instructed the RO to schedule the Veteran for a VA examination and render an opinion as to the nature and etiology of his hemorrhoids. The Veteran, however, declined a visual rectum inspection, which is the Veteran’s right, because he stated he did not presently have hemorrhoids. As such, the Veteran is not entitled to another examination. See generally Turk v. Peake, 21 Vet. App. 565, at 569 (2008) (citing 38 C.F.R. § 3.655). Nonetheless, as part of the Board’s directives, it requested the examiner to consider the May 2012 VA examination, which indicated that the Veteran possibly had hemorrhoids secondary to his gastrointestinal issues, and an October 2014 urology consult note that suggested the presence of internal, palpated hemorrhoids. The Board specifically requested the examiner to “discuss all discrepancies with any findings on diagnoses, from all medical opinions and/or treatment notes associated with the claims file.” The examiner merely provided an opinion that the Veteran did not have hemorrhoids and it was less likely than not that his hemorrhoids were due to his active service because it “is 30 plus years past military service and no causation for internal hemorrhoid while in service.” This rationale is deficient. It is illogical, does not address the questions presented, and is unsupported by a discussion of factual evidence. The VA-contracted examiner failed to accomplish any of the Board’s requested directives. Therefore, remand is required because, as the Board stated in its April 2020 decision, there is no adequate medical evidence contained within the claims file on which to base a decision on this issue. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran’s outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain an addendum opinion from the October 2020 VA-contracted examiner, or another appropriately qualified clinician if that examiner is unavailable, as to the onset and etiology of the Veteran’s cervical spine disability. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide the following opinions: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s cervical spine disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease? (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed cervical spine disability was caused by (proximately due to or as the result of) his service-connected lumbar spine disability? (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s currently diagnosed cervical spine disability was aggravated by his service-connected lumbar spine disability? The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following: (a.) The Veteran’s claims that as part of his military occupational specialty as a weapons mechanic, he constantly had to duck, walking under the belly of F-4 Phantom aircrafts, and that due to his height, 6’ 2’’, he constantly struck his head hard on the underbelly of the aircrafts while loading and unloading rockets, ammunition, and bombs, which caused him to jam his neck, develop back problems, and develop an antalgic gate, all of which he claims placed undue stress on his cervical spine. See March 2004 Correspondence. (b.) His belief that his subsequent neck surgery was caused by the weakening of his cervical spine due to his duties and injuries during active military service. (c.) The Veteran’s private medical records from November 1985, which reflect that the Veteran reported having neck pain and stiffness since August 1983, as a result of low back surgery. (d.) VA records dated August 2004, which show a history of neck surgery, and a report of a motor vehicle accident in the previous month or two, which caused irritation of the neck. (e.) VA records dated May 2009, which show that the Veteran had a claim pending before his accident in April 2006, when he fell on ice and injured his neck. (f.) VA records dated February 2012, which reflect a diagnosis of cervical spine degenerative disease, though no X-ray findings were referenced. These records also show a history of spinal fusion in 1989. (g.) A December 2017 statement in which the Veteran reported that the 1989 surgery was the result of a slip and fall injury that occurred while he was working as a civilian. (h.) A March 2017 CT scan which shows fusion at C3-4 and C4-5, with intact hardware, but otherwise, unremarkable findings. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his cervical spine disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of an in-service onset, event, injury, or illness associated with his cervical spine disability or the assertion that the Veteran’s service-connected lumbar spine disability led to his cervical spine disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). 3. After any additional records are associated with the claims file, obtain an addendum opinion from the October 2020 VA examiner, or another appropriately qualified clinician if that examiner is unavailable, as to the onset and etiology of the Veteran’s neurologic condition(s) of the left and right upper extremities. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s neurologic condition(s) of the left upper extremity was caused by (proximately due to or as the result of) his service-connected lumbar disability? (b.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s currently diagnosed neurologic condition(s) of the left upper extremity was aggravated by his service-connected lumbar disability? The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. (c.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s neurologic condition(s) of the right upper extremity was caused by (proximately due to or as the result of) his service-connected lumbar disability? (d.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s currently diagnosed neurologic condition(s) of the right upper extremity was aggravated by his service-connected lumbar disability? The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his left and right upper extremity disabilities, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of a neurologic condition(s) of the left and right upper extremities in service or the assertion that the Veteran’s service-connected lumbar spine disability led to his currently diagnosed neurologic condition(s) of the left and right upper extremities. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). 4. After any additional records are associated with the claims file, obtain an addendum opinion from the October 2020 VA examiner, or another appropriately qualified clinician if that examiner is unavailable, as to the onset and etiology of the Veteran’s lower gastrointestinal (lower GI) disabilities, to include irritable bowel syndrome (IBS), irritable bowel disease (IBD), and chronic diarrhea. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. For purposes of the opinion, the examiner is advised that the Board has determined, as a matter of fact and law, that the Veteran suffered from IBS, IBD, and/or chronic diarrhea at points throughout the pendency of his appeal. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s lower GI disabilities had their onset in or are otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s lower GI disabilities were caused by (proximately due to or as the result of): 1. his medications associated with his service-connected lumbar disability or bilateral knee disabilities, or 2. his service-connected upper GI disability, to include dysphagia. (c.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s lower GI disabilities were aggravated by: 1. his medications associated with his service-connected lumbar disability or bilateral knee disabilities, or 2. his service-connected upper GI disability, to include dysphagia. The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following: (a.) A July 1974 service treatment record (STR) in which he reported persistent diarrhea without a fever, which started in June 1974, and diarrhea five times a day unless he took Lomotil. (b.) An August 1974 STR that indicated his diarrhea persisted; that he experienced symptoms four to five times a day; and that he was prescribed Kaopectate. (c.) The June 1976 separation examination that noted that he experienced “occasional indigestion due to diet, self-treated with Tums.” (d.) The May 2012 VA examination that documented that the Veteran sought medical treatment throughout the 1990s for stomach issues, including gas, irritation, abdominal distention, belching, cramping, and was diagnosed with IBS. (e.) The March 2019 VA-contracted medical examination that documented that the Veteran was diagnosed with IBD in 2002. During the March 2019 examination, the Veteran suffered from alternating diarrhea, abdominal distension, and cramping on a frequent basis. (f.) The Veteran’s private physicians, Dr. L.I. and Dr. C.V.’s, February 2012 and December 2014 medical opinions, respectively, as to the effect of the Veteran’s medications on his upper GI disabilities. (g.) Dr. C.V.’s February 2019 esophageal conditions DBQ that stated the Veteran’s upper GI disabilities were more than likely secondary to his chronic use of NSAIDs in relation to his lumbar spine and bilateral knee disabilities. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of lower GI disabilities in service or the assertion that the Veteran’s medications for his service-connected lumbar spine and bilateral knee disabilities led to his lower GI disabilities. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). 5. After any additional records are associated with the claims file, obtain an addendum opinion from the October 2020 VA examiner, or another appropriately qualified clinician if that examiner is unavailable, as to the onset and etiology of the Veteran’s hemorrhoids. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. For purposes of the opinion, the examiner should assume the Veteran had hemorrhoids in 2014 as indicated during the October 2014 urology consult. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hemorrhoids had their onset in or are otherwise etiologically related to an in-service event, injury, or disease. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hemorrhoids were caused by (proximately due to or as the result of): 1. his medications associated with his service-connected lumbar disability or bilateral knee disabilities, or 2. his service-connected upper GI disability, to include dysphagia. (c.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hemorrhoids were aggravated by: 1. his medications associated with his service-connected lumbar disability or bilateral knee disabilities, or 2. his service-connected upper GI disability, to include dysphagia. The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following: (a.) A July 1974 service treatment record (STR) in which he reported persistent diarrhea without a fever, which started in June 1974, and diarrhea five times a day unless he took Lomotil. (b.) An August 1974 STR that indicated his diarrhea persisted; that he experienced symptoms four to five times a day; and that he was prescribed Kaopectate. (c.) The June 1976 separation examination that noted that he experienced “occasional indigestion due to diet, self-treated with Tums.” (d.) The May 2012 VA examination that documented that the Veteran sought medical treatment throughout the 1990s for stomach issues, including gas, irritation, abdominal distention, belching, cramping, and was diagnosed with IBS. (e.) The March 2019 VA-contracted medical examination that documented that the Veteran was diagnosed with IBD in 2002. During the March 2019 examination, the Veteran suffered from alternating diarrhea, abdominal distension, and cramping on a frequent basis. (f.) The Veteran’s private physicians, Dr. L.I and Dr. C.V.’s, February 2012 and December 2014 medical opinions, respectively, as to hemorrhoids and upper GI disabilities. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of hemorrhoids in service or the assertion that the Veteran’s medications for his service-connected lumbar spine and bilateral knee disabilities, or his upper GI disability led to his hemorrhoids. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). 6. The RO is requested to review the medical opinions carefully once obtained, to ensure compliance with the Board’s remand directives, making sure all opinions contain appropriate opinions and rationales, that the correct evidence has been reviewed, considered, and/or discussed. If the RO finds deficiencies in any respect as to any of the medical opinions/rationales, it shall take the necessary and proper steps to cure the deficiencies before returning the case to the Board, if necessary. This may include, and is not limited to, obtaining additional medical records, obtaining clarification of private or VA medical opinions, allowing the Veteran or his representative to supplement the case with additional evidence, seeking new examinations based on development of the evidence, and otherwise following all development to its reasonable and logical conclusion(s). Once all necessary and proper steps have been completed, and development has reached its logical conclusion(s), the RO is to readjudicate the Veteran’s claims. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. F. Sawka, 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.