Citation Nr: 21003580 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 15-08 803 DATE: January 22, 2021 ORDER Entitlement to an increased 20 percent evaluation, but no higher, for a service-connected lumbar strain is granted, effective February 21, 2017. REMANDED Entitlement to service connection for a disability manifested by joint and muscle pain is remanded. Entitlement to service connection for a disability manifested by chronic fatigue is remanded. Entitlement to service connection for a respiratory disorder is remanded. Entitlement to service connection for diverticulitis is remanded. Entitlement to service connection for a stomach disorder is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for cysts is remanded. Entitlement to service connection for a disability manifested by headaches is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a urinary tract condition is remanded. Entitlement to service connection for psoriasis is remanded. Entitlement to service connection for radiculopathy of the right lower extremity is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for arthritis of the bilateral shoulders is remanded. Entitlement to service connection for arthritis of the bilateral knees is remanded. FINDING OF FACT The evidence is at least evenly balanced that, since February 21, 2017, after repeated use over time, the Veteran’s thoracolumbar spine was capable of greater than 30 degrees but not greater than 60 degrees forward flexion; but the preponderance of the evidence is against a finding that his spine disability has ever caused ankylosis or reduced forward flexion to 30 degrees or less. CONCLUSION OF LAW Since February 21, 2017, the criteria for an increased 20 percent evaluation for a service-connected lumbar strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1968 to January 1970 and from January 1991 to June 1991, with additional periods of service in the Tennessee Army National Guard. Most of issues listed above came to the Board from an April 2013 decision of the Agency of Original Jurisdiction (AOJ). The increased rating claim and the service connection claims for disabilities of the knees, shoulders and neck were denied in a separate rating decision, issued in May 2015. As the Board explained at the hearing, no VA Form 9 was received with respect to the second set of issues. Nevertheless, the undersigned accepted a statement from the Veteran's representative, submitted on VA Form 646, in lieu of a substantive appeal and, accordingly, all the issues noted above will be addressed in the same document. Increased Rating for Lumbar Strain Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board may consider whether separate ratings may be assigned for separate periods of time a practice known as staged ratings, whether or not the claim concerns an initial rating. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The ratings for thoracolumbar degenerative disc disease were assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237 (lumbosacral strain). The General Formula for Diseases and Injuries of the Spine (General Formula) applies to this diagnostic code, unless it is appropriate to evaluate the disability under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board will apply whichever method results in the higher rating. Under the General Rating Formula, a thoracolumbar spine injury is rated as follows: a 10 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Under 38 C.F.R. § 4.71a, an intervertebral disc syndrome may be rated under either the General Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Under the Formula for Rating Intervertebral Disc Syndrome, incapacitating episodes having a total duration of least 2 weeks but less than 4 weeks during the past 12 months warrant a rating of 20 percent. Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrant a 40 percent rating. Incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrant a 60 percent rating. The rating criteria further explain, under Note (1), that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Under 38 C.F.R. § 4.40, DeLuca v. Brown, 8 Vet. App. 202, 206 (1995) and Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011), VA is generally required to consider whether the disability resulted in a level of functional loss greater than that already contemplated by the assigned rating based on limited motion. Relevant factors include weakness, fatigability, lack of coordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Whenever possible, VA examiners assessing the nature of additional functional loss should describe any additional functional limitations, if possible, in terms of additional degrees of range of motion loss. See Mitchell, 25 Vet. App. at 33. Factual Background In September 2012, the AOJ granted service-connected compensation for lumbar strain with an initial disability rating of 10 percent. The AOJ assigned the rating based on an examination report, dated July 2012. This report identified a diagnosis of lumbar strain, initially diagnosed in 1991. According to the examiner, forward flexion of the thoracolumbar spine ended at 70 degrees and objective evidence of painful motion began at 60 degrees. Extension ended at 20 degrees, which is also the point when painful motion began. Right and left lateral flexion and also right and left lateral flexion were all normal (30 degrees). During repetitive use testing, there was no additional loss of range of motion in any of these planes. According to the examiner, functional loss associated with the Veteran’s spine disability consisted of less movement than normal and pain on movement. There was guarding or muscle spasm, but these symptoms were not severe enough to cause abnormal gait or abnormal spinal contour. The examiner identified symptoms of radiculopathy in the left lower extremity. Based on this finding, the AOJ granted service connection for left lower extremity radiculopathy and assigned a separate 20 percent rating, effective December 23, 2011. The Veteran did not appeal the rating assigned to his left lower extremity radicular symptoms and his separate claim for service connection for similar symptoms in his right lower extremity will be remanded for the reasons below. Under these circumstances, there is no need for the Board to review the descriptions of neurological symptoms of the lower extremities during its summary of the July 2012 examination report or of the subsequent evidence. The July 2012 examiner also reviewed imaging studies and confirmed the presence of arthritis. The examiner wrote that the Veteran’s back disorder caused pain when standing for long periods of time. The Veteran’s next thoracolumbar spine examination took place in May 2015. The diagnosis section of the examiner’s report identified lumbosacral strain. According to the medical history section of the report, the Veteran had experienced low back pain since his military service. But he did not report flare-ups affecting his lower back. During initial testing, range of motion was normal during forward flexion, extension, right and left lateral flexion, and during right and left lateral rotation. There was no evidence of pain with weight-bearing. The Veteran’s thoracolumbar spine was capable of repetitive use, and he experienced no additional loss of function or range of motion after three repetitions. According to the examiner, the Veteran was also examined after repetitive use over time. The report indicates that pain, weakness, fatigability or incoordination did not significantly limit functional ability after repeated use over time. There were no muscle spasms and no guarding. The Veteran did experience localized tenderness, but this did not result in abnormal gait or abnormal spinal contour. The examiner wrote that the service-connected lumbosacral strain did not affect the Veteran’s ability to work. According to the transcript of his February 2017 hearing testimony, the Veteran said that his back had become “a lot worse” than it was at the time of the previous examination. Based on this testimony and the failure of earlier examination reports to comply with 38 C.F.R. § 4.59 and Correia v. McDonald, 28 Vet. App. 158 (2016), the Board ordered a new back examination. The post-remand examination report, dated August 2019, indicated diagnosis of lumbosacral strain and degenerative arthritis. Once again, the Veteran did not report experiencing flare-ups of the thoracolumbar spine. But range of motion was more limited than at the time of the May 2015 examination. Forward flexion was zero to 70 degrees. Extension was from zero to 20 degrees. Right and left lateral flexion and right and left lateral rotation were all zero to 20 degrees. No pain was noted during the testing. The examiner further indicated that there was no evidence of pain with weight-bearing. The thoracolumbar spine remained capable of repetitive use and, after three repetitions, there was no additional loss of range of motion. According to the examiner, the Veteran did not report experiencing functional loss or loss of functional impairment of the spine, both before and after repetitive use testing. In other words, there was no pain, fatigue, weakness, lack of endurance, or incoordination after three repetitions. The examiner did, however, indicate that pain limited functional ability after repeated use over a period of time. After repeated use over time, the examiner estimated that forward flexion would limited to 60 degrees; extension would be reduced to 15 degrees; right and left lateral flexion would be reduced to 15 degrees; and right and left lateral rotation would likewise be reduced to 15 degrees. Once again, there were paraspinal muscle spasms, but they were not severe enough to result in abnormal gait or abnormal spinal contour. According to the examiner, there were no other factors contributing to disability. There was no ankylosis and the Veteran did not have intervertebral disc syndrome. In describing the functional impact of the disability, the examiner wrote that the Veteran was unable to sit or stand for long periods. He was also unable to job, jump, climb, bend, squat, swim, or kneel. Section 17 of the report (“remarks”) addressed the remand instructions concerning 38 C.F.R. § 4.59 and Correia. According to the examiner, there was no objective evidence of pain on non-weight bearing. The results of range of motion testing in passive motion were the same as the results of active testing noted above. Analysis Based on the post-remand examination report, the AOJ increased the rating assigned to the Veteran’s service-connected lumbosacral strain from 10 percent to 10 percent, effective August 9, 2019 (the date of the post-remand examination). This rating was assigned based on the provision of the general rating formula which authorizes a 20 percent rating when forward flexion is greater than 30 degrees but not greater than 60 degrees. 38 C.F.R. § 4.71a. Neither the initial range of motion test results, nor the results after three repetitions, nor the results during passive motion or in non-weight bearing, actually satisfied these criteria. However, the examiner’s estimate of range of motion after repeated use over time did satisfy the criteria for a 20 percent rating and, pursuant to 38 C.F.R. § 4.40, DeLuca and Mitchell, the previously assigned 20 percent rating is appropriate based on that estimate. To avoid the possibility that the previously assigned rating might undercompensate the Veteran, the Board will move forward the effective date of the 20 percent rating to February 21, 2017, the date of the Veteran’s hearing testimony. The August 2019 examination findings are consistent with his testimony that, after he was examined in May 2015 but before the collection of the most recent set of test results, his back symptoms became “a lot worse” than they had been. Resolving reasonable doubt in the Veteran’s favor, see 38 C.F.R. § 4.3, the Board will assume that the Veteran’s symptoms met the criteria for a 20 percent rating since then. The preponderance of the evidence is against a rating higher than 10 percent before February 21, 2017 because, before the hearing, it was not factually ascertainable that an increase in disability had occurred. See 38 U.S.C. § 5110(b)(3). Before the hearing, the most recent and comprehensive piece of evidence concerning the Veteran’s back symptoms is the May 2015 examination report. At that time, there was normal range of motion in the Veteran’s thoracolumbar spine during all of the initial range of motion tests. After repetitive use testing, the range of motion in the Veteran’s spine remained completely normal. According to the examiner, the Veteran was being examined after repeated use over time and that, nevertheless, range of motion was normal and there was no evidence of pain during testing or in weight-bearing. This statement strongly indicates that the symptoms identified in the August 2019 report – specifically, the examiner’s estimate of reduced range of motion after repeated use over time – did not exist at the time of the May 2015 examination. This finding is also consistent with the hearing testimony indicating an increase in the severity of the Veteran’s symptoms between May 2015 and August 2019. The preponderance of the evidence is against a rating higher than 20 percent at any time during the relevant appeal period. The general rating formula authorizes a higher rating of 40 percent if forward flexion is 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. But there is no evidence from any source that the range of motion in the Veteran’s spine has ever been limited to such a degree. The most recent test results, which occurred after the increase in severity described by the Veteran in his February 2017 hearing testimony, indicated that forward flexion remained 70 percent both initially and after repetitive use. According to the examiner’s estimate, the Veteran’s symptoms just barely satisfied the criteria for the currently assigned 20 percent rating after repeated use over time. The examiner wrote that there was no ankylosis, a conclusion which is consistent with the earlier examination reports. The Board has considered the formula for rating intervertebral disc syndrome (IVDS) based on incapacitating episodes. But both the May 2015 and August 2019 examiners wrote that the Veteran did not have IVDS. The Board has considered the Veteran’s statements. In June 2015, he wrote that he believed he should receive a 30 percent rating for his service-connected lower back disorder. While the Veteran is competent to describe symptoms he personally experienced, see Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the June 2015 statement merely indicated his desire to receive greater compensation for his spine. It did not identify or describe symptoms which would authorize the assignment of a 30 percent rating under either the general rating formula or the alternative formula for rating IVDS based on incapacitating episodes. Although his hearing testimony indicated that he had experienced an increase in the severity of his back symptoms, the hearing transcript also failed to explain why a 30 percent rating should apply. Nor did the Veteran testify that he ever experienced ankylosis or that forward flexion in his thoracolumbar spine was ever limited to 30 degrees or less. In summary, resolving reasonable doubt in his favor, the Board will move forward the effective date assigned to the Veteran’s previously assigned 20 percent rating from August 9, 2019 to February 21, 2017. See 38 C.F.R. § 4.3. The Veteran has the burden of proving, at least to an equipoise standard, all of the requirements of his claim for an increased rating. See 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Because the preponderance of the evidence weighs against a finding that his service-connected lumbosacral strain satisfied the criteria higher than 10 percent prior to February 21, 2017 or the criteria for a rating higher than 20 percent since then, the claim for an increased rating is otherwise denied. REASONS FOR REMAND Concerns Applicable to the Veteran’s Claims in General In July 2018, the Board remanded all of the service connection claims in this appeal to verify the various periods of the Veteran’s reserve service. Previously available personnel records indicated that he was a member of the Army National Guard of Tennessee from February 1975 to June 1984 and from April 1986 to August 1997. His service medical records indicated treatment for complaints concerning the skin, prostate, and urinary tract in the late 1980s and in 1990 – but before the beginning of his second period of active duty service in January 1991 – suggesting that the records related to treatment during National Guard service. The Board instructed the AOJ to make appropriate efforts to verify his periods of reserve service, noting that these efforts, “should include appropriate information requests using the [personnel information exchange] PIES system, appropriate information requests to the Defense Finance and Accounting Service (DFAS), electronic mail follow-up to the VA Liaison Office at the National Personnel Records Center (NPRC), follow-up by a military records specialist, contact with the Veteran’s duty station at the time of his separation from service, and any other procedures required by the VA Adjudication Procedures Manual, M21-1, Part III, Subpart iii, Chapter 2, Section I.” To attempt to comply with these orders, the AOJ requested information from the NPRC using PIES request codes NG1 and RV1 in May 2019. The responses to both requests read “All available [service treatment records] were previously uploaded into VBMS.” According to the Adjudication Manual, PIES codes NG1 and RV1 are used to request service treatment records for Veterans no longer serving in the National Guard or Reserves, respectively, when service treatment records cannot be located from the appropriate records custodian. See M21-1, Part III, Subpart iii, Chapter 2, Section D, Topic 3(d) (“Other PIES request codes”) (last updated March 7, 2019). This manual provision and the NPRC’s responses to the May 2019 requests suggest that they may not have been the most appropriate request codes. The manual suggests that request codes S01 (“service verify only the unverified periods of service shown”) or S02, S02-V (“service verify all periods of service”) would likely be better calculated to verify the periods of active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). See Id. The AOJ also wrote to the Tennessee Army National Guard requesting personnel records. The records obtained as a result include a document listing three periods of INACDUTRA and four periods of ACDUTRA, all in 1986 or 1987. But this corresponds to a relatively short interval within the scope of the Veteran’s National Guard service (1975 to 1984 and 1986 to 1997) with no periods of verified service during most of those years. Under these circumstances, it would be premature to assume that this list is complete, especially given the AOJ’s failure to make PIES requests using request code S01, the apparent failure to seek financial documents from DFAS, and the failure to seek assistance from a military records specialist or NPRC liaison. When the Board remands an appeal, the claimant obtains a right to compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Because the Board instructed the AOJ to determine the appellant’s National Guard duty status and, for many potentially relevant periods of time, his duty status remains unclear, this appeal must be remanded again. Issues in which New Medical Opinions are Needed When it previously remanded this case, the Board instructed the AOJ to obtain new medical opinions to help decide several of the issues on appeal. Based on its own initiative, the AOJ arranged new examinations and obtained medical opinions concerning other issues. When VA undertakes to provide a medical opinion, “[the Secretary] must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided.” Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because any of them could be potentially depend on the results of the requested development concerning the Veteran’s National Guard service, all of the remaining service connection claims will be remanded. Because of weaknesses in some of the previously obtained medical opinions, the Board will also instruct the AOJ to obtain new reports concerning some of these claims. In July 2018, the Board instructed the AOJ to obtain an opinion concerning the claim for service connection for psoriasis. As the Board explained, the AOJ had previously denied the claim because, according to a December 2014 examination report, no psoriasis was present at the time of the examination. This finding is was inadequate to decide the claim because the presence of a disability at the time of the filing of a claim or during its pendency is sufficient to meet the current disability requirement, even if the disability resolves before the Board's adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board noted that, in his hearing testimony, the Veteran said that in February 2017 he believed he had psoriasis on his back and chest. Accordingly, in its remand orders, the Board instructed the AOJ, “If the examiner indicates that the Veteran does not currently have psoriasis, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that shin splints have existed at any time since December 23, 2011?” Although the AOJ obtained a new VA skin examination report and a new opinion, both dated August 2019, the examiner seems to have ignored the quoted language. Instead, the examiner justified an unfavorable opinion because “[t]here is no objective evidence on exam to support a diagnosis of the claimed condition of psoriasis. No nexus can be established.” To remedy this failure to comply with Board’s remand orders, the AOJ should obtain a new opinion on psoriasis. For similar reasons, the Board must order a new opinion concerning the Veteran’s claimed radiculopathy of the right lower extremity. In an August 2019 medical opinion, the examiner concluded that, because there was “no objective evidence on exam to support a diagnosis of the claimed condition of radiculopathy of the right lower extremity . . . [n]o nexus can be established.” This opinion is inadequate because the examiner failed to reconcile it with a May 2015 examination report indicating mild intermittent pain and mild paresthesias of the right lower extremity, which the May 2015 examiner specifically identified as radiculopathy. On remand, the AOJ should obtain a new opinion. See McClain, 21 Vet. App. at 321. With respect to the Veteran’s claimed hypertension, the AOJ obtained an unfavorable opinion from the August 2019 examiner. Unfortunately, the examiner only stated a conclusion without explaining the medical reasons for deciding that a causal relationship between hypertension and service was less likely than not. “An adequate medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (quoting Nieves-Rodrigeuz v. Peake, 22 Vet. App. 295, 301 (2008)). On remand, the AOJ should obtain a new opinion concerning the etiology of the Veteran’s hypertension, including a clear rationale for the examiner’s conclusion. As for the Veteran’s claimed disabilities of the neck, shoulders, and knees, he has testified that musculoskeletal disabilities, including arthritis of his knees and shoulders and spondylosis of the cervical spine, were caused by his running and jumping when carrying heavy equipment, including a full backpack and a machine gun. The Board’s July 2018 remand requested opinions on these issues, which the AOJ provided in August 2019. For each of these disabilities, the examiner indicated that, carrying heavy equipment for only six months could not have caused the claimed disabilities. This statement relies on a premise (that the Veteran only ran with heavy equipment for six months) which could be undermined by the discovery of additional periods of National Guard service. After verifying the Veteran’s periods of National Guard or reserve service, the AOJ should obtain a new opinion from the examiner to assess whether the relevant time might have caused or aggravated the claimed disabilities. With respect to the knees, the examiner should consider the possibility that a statement in the August 2019 knee examinations report (“The veteran's diagnosed knee conditions are due to use over time and wear and tear and are not related to any exposure event in SW [A]sia”) could potentially support the Veteran’s suggestion that running with heavy equipment caused or aggravated his knee disabilities. The matters are REMANDED for the following action: 1. The AOJ should make reasonable efforts to verify the dates and durations of any periods of ACDUTRA or INACDUTRA. These efforts should include new appropriate requests using the PIES system, including request codes S01, S02, and S02-V. If those requests are not successful, then the AOJ should pursue reasonable follow-up methods, including appropriate information requests to the Defense Finance and Accounting Service (DFAS), electronic mail follow-up to the VA Liaison Office at the National Personnel Records Center (NPRC), contact with the Veteran's duty station at the time of his final separation from service. 2. Obtain a medical opinion concerning the probability of a relationship between current psoriasis and any in-service disease, injury, or event, including the psoriasis noted on his June 1991 separation examination and the Veteran's current psoriasis. The AOJ should obtain the requested opinion from a qualified person or persons. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If the examiner indicates that the requested opinion cannot be provided without a new in-person examination, a new examination should be arranged. After the records review and examination of the Veteran, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that currently existing psoriasis OR PSORIASIS THAT HAS EXISTED AT ANY POINT SINCE DECEMBER 23, 2011 had its onset during active duty service or was otherwise caused or aggravated beyond their normal progression by any in-service disease, injury, or event, including the Veteran’s exposure to oil files and environmental hazards during his 1991 deployment to Southwest Asia? If the examiner indicates that the Veteran does not currently have psoriasis, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that psoriasis has existed at any time since December 23, 2011? A complete rationale should be provided for all the requested opinions. In explaining his or her opinion, the examiner should address the psoriasis noted in the Veteran’s service treatment records. 3. Obtain a medical opinion concerning the probability of a relationship between any currently existing right lower extremity radiculopathy and in-service disease, injury, or event or the Veteran’s service-connected lumbosacral strain. The AOJ should obtain the requested opinion from a qualified person or persons. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If the examiner indicates that the requested opinion cannot be provided without a new in-person examination, a new examination should be arranged. After the records review and examination of the Veteran, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that any currently existing right lower extremity radiculopathy OR RIGHT LOWER EXTREMITY RADICULOPATHY THAT HAS EXISTED AT ANY POINT SINCE DECEMBER 23, 2011 had its onset during active duty service or was otherwise caused or aggravated beyond their normal progression by any in-service disease, injury, or event, including the Veteran’s exposure to oil files and environmental hazards during his 1991 deployment to Southwest Asia or is proximately due to or the result of the Veteran’s service-connected lumbosacral strain? If the examiner indicates that the Veteran does not currently have right lower extremity radiculopathy, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that right lower extremity radiculopathy has existed at any time since December 23, 2011? A complete rationale should be provided for all the requested opinions. In explaining his or her opinion, the examiner should address the right lower extremity radiculopathy noted in a May 2015 VA thoracolumbar spine examination report. 4. Obtain a medical opinion concerning the probability of a relationship between current hypertension and any in-service disease, injury, or event, including the Veteran’s exposure to environmental hazards during his service in the Persian Gulf. The AOJ should obtain the requested opinion from a qualified person or persons. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If the examiner indicates that the requested opinion cannot be provided without a new in-person examination, a new examination should be arranged. After the records review and examination of the Veteran, the examiner should provide an opinion on the following question: Is it at least as likely as not (50 percent probability or more) that currently existing hypertension had its onset during active duty service or was otherwise caused or aggravated beyond its normal progression by any in-service disease, injury, or event, including the Veteran’s exposure to oil files and environmental hazards during his 1991 deployment to Southwest Asia? THE EXAMINER SHOULD THOROUGHLY EXPLAIN THE MEDICAL REASONS FOR HIS OR HER CONCLUSION. 5. After verifying the Veteran’s periods of INACDUTRA or INACDUTRA, obtain a series of new medical opinions concerning the probability of a relationship between the Veteran’s military service, including his credible testimony concerning the physical stress associated with carrying a heavy backpack and a machine gun during his deployment to Saudi Arabia, and current disabilities of the bilateral knees, bilateral shoulders, and neck. The AOJ should obtain the requested opinions from a qualified person or persons. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If the examiner or examiners indicate that the requested opinions cannot be obtained with a new in-person examination, a new examination should be arranged. After the records review and, if necessary, the examinations are complete, the relevant examiners will provide an opinion on the following question with respect to each of the above claimed disabilities: Is at least as likely as not (50 percent probability or more) that the Veteran's current disability had its onset during active duty service or was otherwise caused or aggravated beyond its normal progression by any in-service disease, injury, or event including repetitive stress injuries associated with carrying a back pack and machine gun? The examiner is advised that the absence of in-service medical records describing treatment for the claimed disabilities, standing alone, is not sufficient to justify an unfavorable opinion. A complete rationale should be provided for all the requested opinions. In describing his or her conclusion concerning the knees, the examiner should address a statement from the August 2019 knees examination report (“The veteran’s diagnosed knee conditions are due to use over time and wear and tear and are not related to any exposure event in SW [A]sia”) and explain why this statement does, or does not, support the Veteran’s suggestion that he could have developed his current knee disabilities while running while carrying heavy equipment. 6. The AOJ must ensure that the examination reports and opinions requested above comply with the directives of   this remand. If any report or opinion is deficient in any manner, the AOJ must implement corrective action. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Nye, 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.