Citation Nr: 21003943 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 16-13 444 DATE: January 25, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected obstructive sleep apnea is denied. Service connection for diabetes mellitus, (type 2 diabetes), to include as secondary to service-connected obstructive sleep apnea is denied. REMANDED Service connection for bilateral hearing loss is remanded. Service connection for a right knee disability is remanded. Service connection for a left knee disability is remanded. Service connection for a right foot disability is remanded. Service connection for a left foot disability is remanded. FINDINGS OF FACT 1. The Veteran’s hypertension is proximately caused by and/or is aggravated by his service-connected obstructive sleep apnea. 2. The probative evidence has not shown that the Veteran’s diabetes mellitus is proximately caused by and/or is aggravated by his service-connected obstructive sleep apnea. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, to include as secondary to service-connected obstructive sleep apnea have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. 2. The criteria for service connection for diabetes mellitus, to include as secondary to service-connected obstructive sleep apnea have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1992 to April 1996. He was discharged under Honorable Conditions, for purposes of VA. Thereafter, he served from April 1996 to October 1998, and at that time, he was discharged under “Other than Honorable Conditions.” This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In January 2019 the Veteran and his spouse, M.B., testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In May 2019, the Board remanded the case to the RO for further evidentiary development. Service Connection A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Thus, secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). 1. Hypertension The Veteran asserts that he is entitled to service connection for hypertension, as secondary to his service-connected sleep apnea. See January 2019 Videoconference Hearing Transcript. The Veteran was diagnosed with sleep apnea in October 2007. See e.g. April 2008 Pulmonary Note (noting that the Veteran was diagnosed with mild obstructive sleep apnea at the San Diego, VA in October 2007). He has been service-connected for this disability, since an effective date of August 21, 2012. Additionally, medical treatment records reflect that the Veteran currently has hypertension, which was initially diagnosed in January 2004, prior to his diagnosis of obstructive sleep apnea. See January 2004 Private Treatment Progress Notes. For an assessment of the Veteran’s claim, VA obtained medical opinions on the etiology of the Veteran’s hypertension. In May 2019, however, the Board determined that a February 2016 medical opinion was inadequate for deciding this claim. Thus, as it found that this opinion was inadequate for determining this claim, and a remand directive instructed that VA obtain a new medical opinion, this opinion shall not be attributed any probative value. Nonetheless, the Veteran has submitted private opinions from Dr. J.H., in support of his claim. In a January 2019 opinion, Dr. J.H. explained that obstructive sleep apnea is known to exacerbate a number of medical problems, including obesity, hypertension, type 2 diabetes, and post-traumatic stress disorder. He explained that the Veteran has been diagnosed with diastolic dysfunction and concentric left hypertrophy, which can also be worsened by the Veteran’s obstructive sleep apnea and hypertension. Thereafter, he opined that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Although, this opinion mentions a list of disabilities that are known to be exacerbated by obstructive sleep apnea, which is inclusive and not limited to, hypertension, this opinion is inadequate as Dr. J.H. rendered a vague and broad opinion, stating that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Thus, as Dr. J.H. does not specifically identify hypertension in his opinion that the Veteran’s “obstructive sleep apnea has complicated a number of his medical issues”, nor is a clear, adequate rationale provided to support the opinion, it is inadequate for supporting the Veteran’s claim. In a subsequent, August 2019 opinion, Dr. J.H. disclaimed that he could not definitively state that the etiology of the Veteran’s hypertension is from his obstructive sleep apnea, although this was “certainly possible.” However, he opined that it is more likely than not the obstructive sleep apnea has aggravated his hypertension. As the rationale for this opinion, Dr. J.H. vaguely reasoned that there is an abundant medical literature showing a link between obstructive sleep apnea and high blood pressure; and that it is his medical opinion that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Five years prior, Dr. J.H. had rendered a similar opinion, stating that it was his opinion that the Veteran’s “obstructive sleep apnea has complicated his hypertension . . .”, and in which he had noted that obstructive sleep apnea “is known to exacerbate a number of medical problems[,] including hypertension . . .” See March 2014 Private Medical Opinion. However, no particular medical literature was cited to support either March 2014 or August 2019 opinion, nor was clear reasoning, explaining how and/or why the Veteran’s obstructive sleep apnea aggravates his hypertension, provided. Thus, the Board finds that these opinions are vague and speculative; and accordingly, they are not persuasive or entitled to significant probative weight. Pursuant to the May 2019 remand directives, the RO obtained a new VA opinion on the Veteran’s hypertension. In this December 2019 opinion, a VA examiner opined that it is less likely than not (less than 50 percent probability), the Veteran’s hypertension is due to his service-connected obstructive sleep apnea. As the rationale for this opinion, the VA examiner explained that the Veteran has essential hypertension. She clarified that “essential” means, “not due to another condition.” She also explained that the causes of essential hypertension are genetics, family history, age, obesity, and inactivity, among other risk factors; and that the Veteran has several of these causative risk factors. Further, the VA examiner opined that it is less likely than not the Veteran’s hypertension is aggravated, beyond its natural progression, by his service-connected obstructive sleep apnea. As the rationale for this opinion, the VA examiner explained that the Veteran has hypertension, without evidence of clinically significant complications of hypertension; a September 2019 lab demonstrated that the Veteran had good renal function; he has no history of cardiovascular disease; and that his blood pressure is mostly satisfactory, in control, with occasional elevations, which is usual control for most people with hypertension. She also explained that the Veteran is on a 3-drug regimen for hypertension, which is not unusual for his age and characteristics, and that thus, this is not suggestive of aggravation. With respect to the Veteran’s obstructive sleep apnea, she explained that the Veteran’s treated AHI is 7.7, which is relatively low. From concluding that the Veteran’s treated AHI is low, she also reasoned that this is not suggestive of aggravation of hypertension. The Board finds that this December 2019 medical opinion is adequate, as it is based on the Veteran’s medical history, it clearly describes the nature of the Veteran’s hypertension, and provides sufficient details to allow the Board to make a fully informed decision. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Specifically, by defining and explaining the nature and severity of the Veteran’s hypertension and obstructive sleep apnea disabilities, this VA opinion provides a clear rationale as to why there is no correlation between the Veteran’s hypertension and service-connected obstructive sleep apnea. Further, the medical evidence clearly demonstrates that the Veteran’s service-connected obstructive sleep apnea could not have caused the Veteran’s hypertension, because the Veteran was diagnosed with hypertension, in 2004, prior to the date he was diagnosed with obstructive sleep apnea, in 2007. Additionally, as there is no probative, controverting medical evidence to suggest that the Veteran’s hypertension was aggravated by his obstructive sleep apnea, the Board also finds that the preponderance of the evidence is against this claim, and thus, service connection for hypertension, due to, and/or aggravated by service-connected obstructive sleep apnea, must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Type 2 Diabetes The Veteran asserts that he is entitled to service connection for type 2 diabetes, as secondary to his service-connected obstructive sleep apnea. Particularly, at his videoconference hearing, he asserted that the Veteran’s type 2 diabetes has been aggravated by his service-connected obstructive sleep apnea. The Veteran, through his representative, explained that he had been on insulin since 2007 or 2008, and that his type 2 diabetes is characteristic of a regulation of activities. See January 2019 Videoconference Hearing Transcript. The Veteran was diagnosed with obstructive sleep apnea in October 2007. See e.g. April 2008 Pulmonary Note (noting that the Veteran was diagnosed with mild obstructive sleep apnea at the San Diego, VA in October 2007). He has been service-connected for this disability, since an effective date of August 21, 2012. Additionally, medical treatment records reflect that the Veteran currently has type 2 diabetes, which was initially diagnosed in January 2004, prior to his diagnosis of his service-connected obstructive sleep apnea. See January 2004 Private Treatment Progress Notes (noting that the Veteran was possibly diabetic, and that fasting blood work would be obtained); see also January 2004 Hematology Laboratory Report (confirming diagnosis of diabetes). For an assessment of the Veteran’s claim, VA obtained medical opinions on the etiology of the Veteran’s type 2 diabetes. In May 2019, however, the Board determined that a January 2016 medical opinion was inadequate for deciding this claim. Thus, this opinion shall not be attributed any probative value. Nonetheless, the Veteran has submitted opinions and/or letters, from private medical service providers, about the nature, severity, and etiology of his type 2 diabetes. In a January 2019 correspondence, I.G., a nurse practitioner, noted that she was treating the Veteran for his type 2 diabetes, and that in order for her to manage his insulin dependent condition, she placed the Veteran on a restricted diet, and instructed him to avoid strenuous occupational and recreational activities, with the intention of avoiding hypoglycemic episodes. Although this correspondence is purported to serve as evidence of the severity of his type 2 diabetes, no opinion was rendered on causation or aggravation, based on his service-connected sleep apnea. Additionally, in a January 2019 private opinion, Dr. J.H. explained that obstructive sleep apnea is known to exacerbate a number of medical problems, including obesity, hypertension, type 2 diabetes, and post-traumatic stress disorder. He explained that the Veteran has been diagnosed with diastolic dysfunction and concentric left hypertrophy, which can also be worsened by the Veteran’s obstructive sleep apnea and hypertension. Thereafter, he opined that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Although this opinion mentions a list of disabilities that are known to be exacerbated by obstructive sleep apnea, which is inclusive and not limited to, type 2 diabetes, this opinion is inadequate as Dr. J.H. rendered a vague and broad opinion, stating that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Thus, as Dr. J.H. does not specifically address type 2 diabetes in his opinion that the Veteran’s “obstructive sleep apnea has complicated a number of his medical issues”, nor is a clear, adequate rationale provided to support the opinion, it is inadequate for supporting the Veteran’s claim. In a subsequent, August 2019 opinion, Dr. J.H. disclaimed that he could not definitively state that the etiology of the Veteran’s type 2 diabetes is from his obstructive sleep apnea, although this was “certainly possible.” However, he opined that it is more likely than not the obstructive sleep apnea has aggravated his type 2 diabetes. As the rationale for this opinion, Dr. J.H. vaguely reasoned that there “is an abundant medical literature showing a link between obstructive sleep apnea and type 2 diabetes; and that it is his medical opinion that the Veteran’s obstructive sleep apnea has complicated a number of his medical issues. Five years prior, Dr. J.H. had rendered a similar opinion, stating that it was his opinion that the Veteran’s “obstructive sleep apnea has complicated his. . . diabetes,” and in which he had noted that obstructive sleep apnea “is known to exacerbate a number of medical problems[,] including . . . diabetes mellitus.” See March 2014 Private Medical Opinion. No particular medical literature was cited to support either March 2014 or August 2019 opinion, nor was clear reasoning, explaining how and/or why the Veteran’s obstructive sleep apnea aggravates his type 2 diabetes, provided. Thus, the Board finds that these opinions are vague and speculative; and therefore, inadequate to support the Veteran’s claim. Pursuant to the May 2019 remand directives, the RO obtained a new VA opinion on the etiology of the Veteran’s type 2 diabetes. In this December 2019 opinion, a VA examiner opined that it is less likely than not (less than 50 percent probability) the Veteran’s type 2 diabetes is proximately due to, or the result of the Veteran’s service-connected obstructive sleep apnea. As the rationale for this opinion, the VA examiner explained that the Veteran has several well-established risk factors for diabetes, such as, family history, obesity, ethnicity, and inactivity. She explained that he has a genetic and family tendency, as he had a family history of diabetes, citing a July 2007 treatment note. She further explained that as obesity is also a cause, the Veteran’s BMI is 45. Additionally, with respect to the severity of his obstructive sleep apnea, she explained that the Veteran’s treated AHI is 7.7, which is relatively low, and that it would not be expected to be a primary cause of diabetes. The VA examiner also opined that it is less likely than not, the Veteran’s diabetes is aggravated by the Veteran’s service-connected obstructive sleep apnea. As the rationale for this opinion, she explained that the Veteran’s diabetes had improved within the prior 3 years, leading up to this examination; his A1c level improved from 10.6, in 2016, to most a recent A1c level of 7.0, in September 2019. Then, she explained that this is an improvement, rather than an aggravation of his diabetes. The VA examiner further stated that the Veteran’s obstructive sleep apnea is now treated, and that treated sleep apnea would not be expected to aggravate diabetes. The Board finds that this December 2019 medical opinion is adequate, and that it is the most probative medical opinion, of record, as it is based on the Veteran’s medical history, and it clearly describes the nature and severity of the Veteran’s type 2 diabetes and obstructive sleep apnea disabilities, to explain why the service-connected obstructive sleep apnea does not cause or aggravate the Veteran’s type 2 diabetes. Further, the medical evidence clearly demonstrates that the Veteran’s service-connected obstructive sleep apnea could not have caused the Veteran’s type 2 diabetes, because the Veteran was diagnosed with type 2 diabetes in 2004, prior to the date he was diagnosed with obstructive sleep apnea, in 2007. Additionally, there is no probative medical evidence to suggest that the Veteran’s type 2 diabetes is aggravated by his obstructive sleep apnea. While the Board does not discount or underscore the Veteran’s assertions about the severity of his type 2 diabetes, as indicated at his January 2019 videoconference hearing, the probative evidence does not show that his type 2 diabetes has been aggravated by obstructive sleep apnea. In this regard, the preponderance of the evidence is against this claim, and thus, secondary service connection for type 2 diabetes, due to, and/or aggravated by service-connected obstructive sleep apnea, must be denied. Gilbert, 1 Vet. App. at 53; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The Board regrets further delay, but finds that additional developments are necessary before a decision may be rendered on the remaining issues on appeal. 1. Bilateral Hearing Loss The issue of bilateral hearing loss was previously remanded by the Board for additional development. In the May 2019 remand, the Board determined that the Veteran may now have a current hearing loss disability, under 38 C.F.R. § 3.385 (for purposes of VA compensation). Therefore, it remanded the issue of bilateral hearing loss, and directed that an in-person VA examination be scheduled to determine the nature and etiology of any current hearing loss. Although the Veteran was afforded a VA examination in January 2020, however, the VA examiner could not determine whether he had current hearing loss, for VA purposes. Specifically, the VA examiner determined that puretone thresholds for the right and left ears could not be tested. The VA examiner reasoned that responses to puretone thresholds varied significantly, even with re-instruction; speech reception thresholds were also in very poor agreement with puretone averages; and that accordingly, these results were considered invalid for rating purposes. Thus, as this VA examination could not determine whether the Veteran has bilateral hearing loss, a remand is required for a new VA examination to retest the Veteran, determine whether he has a current hearing loss disability, for VA purposes, and if so, determine the etiology of the Veteran’s bilateral hearing loss. The Veteran is encouraged to cooperate and participate in this process as well. 2. Right and Left Knee Disabilities (Bilateral Knee Disability) The service connection claims for the right and left knee disabilities were also before the Board, previously. In the May 2019 remand, the Board determined that the March 2014 VA examiner did not find that the Veteran had a diagnosis of osteoarthritis, and that more recent records, from June 2015, indicate that the Veteran has a current diagnosis of bilateral osteoarthritis of the knee, and given the Veteran’s competent reports of in-service symptoms of knee pains, with the possibility that they represented an early indication of this disability, which could be subject to presumptive service connection, the Board remanded this issue for an addendum opinion. Specifically, the Board instructed that by obtaining an addendum opinion, a VA examiner was to determine whether it is at least as likely as not, that the Veteran’s contentions that he first developed knee pain during his honorable period active service, represented an early indication of arthritis. Accordingly, a VA examiner rendered an addendum opinion in December 2019. In this addendum opinion, which is responsive to the May 2019 Board remand, a VA examiner opined, in pertinent part, that the knee pain during kneeling, which was reported in the Veteran’s STRs during service, was less likely than not indicative of arthritis. As part of the rationale for this opinion, the VA examiner cited to two in-service treatment records, which are evidence of in-service bilateral knee injury; an August 2007 post-service X-ray, which reflects normal knees, with no degenerative changes; and a February 2014 post-service MRI which reflected, “no significant degenerative changes suggesting arthritis.” Then, the VA examiner determined that the knee pain during kneeling, reported in STRs, during service, was less likely than not indicative of arthritis. The VA examiner further reasoned that “X-rays of both knees done in 2007 did not show arthritis, and therefore, he would not have had arthritis during service. However, this opinion is inadequate because the VA examiner provided an insufficient rationale to support this opinion. Specifically, the examiner was not asked to opine as to whether the Veteran definitively had arthritis in service; rather, the question was designed to elicit a response as to whether the knee injury and treatment in service were of sufficient severity to constitute an early indication of arthritis. The medical evidence also entails a medical opinion from a VA Staff Physician. Specifically, in an August 2019 procedure note, Dr. L.L.L. opined that it is at least as likely as not that the Veteran’s early knee pain, from his active duty service, was an early indication for the arthritis of his knees, seen on his 2014 MRIs. However, as this opinion is not supported by a rationale, it is inadequate for determining this claim. Additionally, and in support of his claim, the Veteran has submitted a private opinion from a certified family nurse practitioner, I.G. In this September 2019 private opinion, I.G. opined that the Veteran’s knees are “military service [connected].” However, this opinion failed to provide a sufficient rationale for its opinion. Rather, as a justification to support her opinion that the Veteran’s bilateral knee disability is etiologically related to his service, I.G. merely provided a discussion of the Veteran’s history, predominantly discussing his bilateral foot disabilities, and cited to an internet article from a law firm, which does not constitute as medical evidence and/or medical literature, as the author of the literary content has not shown or demonstrated that he/she is qualified to render a medical opinion, with the specialty an/or requisite training in diseases of the musculoskeletal system. See 38 C.F.R. § 3.159(a)(1) (explaining that “[competent] medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions; Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical nad scientific articles and research reports or analyses.”). As is the case here, a private medical opinion is not entitled to any weight in a service-connection claim, if it contains only data and conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that “a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion”); see too, Dennis v. Nicholson, 21 Vet. App. 18, 22 (2007) (holding that “[the] Court has long held that merely listing evidence before stating a conclusion does not constitute an adequate statement of reasons and bases”). Thus, this opinion is inadequate for determining this claim. As none of the medical opinions, of record, are adequate for determining these claims, a remand is required for an addendum opinion, for a clarification of the etiology of the Veteran bilateral knee disability. 3. Right and Left Feet Disabilities (Bilateral Foot Disability) The service connection claims for the right and left foot disabilities were previously before the Board, as well. Specifically, in the May 2019 remand, the Board determined that the Veteran had not been afforded a VA examination for his bilateral foot disabilities. Therefore, it remanded these issues for a VA examination and opinion on the etiology of the Veteran’s bilateral foot disabilities. In doing so, it directed, in pertinent part, that a VA examiner determine whether the Veteran has had any disability of either foot, since his May 2013 claim, other than bilateral pes planus, which was noted on entry in April 1992; and to opine whether any such foot disability arose in, or is otherwise etiologically related to his honorable active service, specifically considering the Veteran’s contention that his foot symptoms began during boot camp and got worse, due to military training. Accordingly, the Veteran was afforded a VA examination in January 2020. After this examination, a VA examiner opined that the Veteran’s bilateral foot disability was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As the rationale for this opinion, the VA examiner reasoned, in pertinent part, that the Veteran had pre-existing pes planus prior to enlistment, and that there is no documentation of in-service aggravation of pes planus, foot complaints, nor treatment. The VA examiner further opined that it is less likely than not the Veteran’s bilateral foot gout “arising in or is otherwise etiologically related to his honorable active service.” The VA examiner reasoned, in pertinent part, that there is no documentation of an in-service occurrence, aggravation, nor treatment for this medical condition. He further noted that right foot X-ray “reveals Degenerative Joint Disease First Metatarsophalangeal Joint” and that this “appears to be an incidental finding, as there is no record of localized symptoms[,] symptomatic of Degenerative Joint Disease First Metatarsophalangeal Joint.” These opinions, however, are not responsive to the May 2019 Board remand. Additionally, in rendering these opinions, however, the VA examiner did not account for the Veteran’s contentions that his foot symptoms began during boot camp and got worse, due to military training. Rather, these opinions are wholly based on the lack of evidence of in-service complaints and/or treatment. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that a VA examination is inadequate where the VA examiner did not comment on the Veteran’s report of in-service injury and instead relied entirely on the absence of evidence in the service treatment records to provide a negative opinion). Additionally, and in support of his claim, the Veteran has submitted a private opinion from a certified family nurse practitioner, I.G. In this September 2019 private opinion, I.G. opined that the Veteran’s “flat feet . . . and chronic ankle swelling and pain is military service connect.” However, this opinion failed to provide a sufficient rationale for its opinion, and as a matter of fact, given that the Veteran’s bilateral pes planus pre-existed his service, she also failed to render an opinion as to whether the Veteran’s bilateral pes planus was aggravated by his active service. Rather, as a justification to support her opinion that the Veteran’s bilateral foot disability is etiologically related to his service, I.G. merely provided a discussion of the Veteran’s history, and cited to an internet article from a law firm, which does not constitute as medical evidence and/or medical literature, as the author of the literary content has not shown or demonstrated that he/she is qualified to render a medical opinion, with the specialty an/or requisite training in diseases of the musculoskeletal system. See 38 C.F.R. § 3.159(a)(1). As this opinion merely provides data, to include the Veteran’s medical history of bilateral foot disabilities, as well as an internet article from a source that is not qualified to render a medical opinion, this medical opinion is not entitled to any weight, as it contains only data and conclusions. See Nieves-Rodriguez, 22 Vet. App. at 304. Thus, this opinion is inadequate for determining these claims. Summarily, a remand by the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, a remand is required for compliance with the Board’s May 2019 remand directives, and specifically, an addendum opinion, for a clarification of the etiology of the Veteran’s bilateral foot disabilities. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new VA examination with an audiologist (VA examiner) to determine the presence, and if any, etiology of his bilateral hearing loss. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. Determine whether the Veteran has hearing loss, for VA purposes. b. If so, opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral hearing loss is the result of an in-service injury, illness, disease, or event; and/or is otherwise related the Veteran’s active service. In rendering an opinion, consider the Veteran’s lay statements about onset and symptomatology, including his contentions about exposure to significant noise during his active service. 2. Also, obtain an addendum opinion from the VA examiner who rendered the December 2019 VA opinion, for a clarification of the etiology of the Veteran’s bilateral knee disability. If the VA examiner who provided the December 2019 VA opinion is unavailable, obtain the addendum opinion from another qualified clinician. If an examination is necessary for obtaining an opinion, schedule the Veteran for a new VA examination. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. opine whether it is at least as likely as not (more than 50 percent probability), any bilateral knee disability, including and not limited to, osteoarthritis of the knee, is the result of an injury, illness, or event in service; was incurred in service; and/or is otherwise related to his active service. b. In rendering an opinion, the VA examiner must also consider medical evidence of the Veteran’s February 2015 diagnosis of osteoarthritis of the knee. c. With a clear, detailed rationale, the VA examiner must explain whether the Veteran’s initial report of knee pain, during his active service, was an early indication of osteoarthritis of the knee. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. 3. Also, obtain an addendum opinion from the VA examiner who rendered the December 2019 VA opinion, for a clarification of the etiology of his bilateral foot disabilities. If the VA examiner who provided the December 2019 VA opinion is unavailable, obtain the addendum opinion from another qualified clinician. If an examination is necessary for obtaining an opinion, schedule the Veteran for a new VA examination. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. Identify all foot disabilities that the Veteran has been diagnosed with since his May 2013 claim, other than the bilateral pes planus that was noted, on entry into service in April 1992. b. For the bilateral pes planus, opine whether it is at least as likely as not (more than 50 percent probability) the Veteran’s bilateral pes planus was permanently aggravated by his active service. “Aggravation” means an increase in severity of the disorder beyond any medically established baseline. c. For each of the other foot disabilities, other than bilateral pes planus, opine whether it is at least as likely as not (more than 50 percent probability) the pertinent foot disability is the result of an illness, injury, disease, or event in service; was incurred in service; and/or is otherwise related to his active service. d. In rendering an opinion for each foot disability, the VA examiner should consider the Veteran’s assertions that his foot symptoms began during boot camp, and/or that it worsened as a result of his military training. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V-N. Pratt 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.