Citation Nr: 21004118 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 16-15 337A DATE: January 26, 2021 ORDER Entitlement to an initial compensable rating for the service-connected bilateral hearing loss is DENIED. Entitlement to service connection for a left shoulder disability, to include as secondary to the service-connected right achilles tendon disability, is DENIED. Entitlement to service connection for a right shoulder disability, to include as secondary to the service-connected right achilles tendon disability, is DENIED. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected right achilles tendon disability, is DENIED. Entitlement to service connection for a right knee disability, to include as secondary to the service-connected right achilles tendon disability, is DENIED. Entitlement to service connection for a cervical spine disability, to include as secondary to the service-connected right achilles tendon disability, is DENIED. REMANDED Entitlement to service connection for a left ankle disability is REMANDED. Entitlement to service connection for a right ankle disability is REMANDED. Entitlement to a rating in excess of 10 percent for the service-connected right achilles tendon disability is REMANDED. Entitlement to service connection for a left arm disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a right arm disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a left elbow disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a right elbow disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a left wrist disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a right wrist disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a left hip disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to service connection for a right hip disability, to include as secondary to the service-connected right achilles tendon disability, is REMANDED. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is REMANDED. FINDINGS OF FACT 1. At worst, the Veteran has demonstrated Level I hearing loss, bilaterally. 2. The preponderance of the evidence is against a finding that the Veteran’s left shoulder condition was incurred in or aggravated by service; additionally, his left shoulder condition is not proximately due to, or aggravated by, the service-connected right achilles tendon disability. 3. The preponderance of the evidence is against a finding that the Veteran’s right shoulder condition was incurred in or aggravated by service; additionally, his right shoulder condition is not proximately due to, or aggravated by, the service-connected right achilles tendon disability. 4. The preponderance of the evidence is against a finding that the Veteran’s left knee arthritis was incurred in or aggravated by service; additionally, his left knee arthritis condition is not proximately due to, or aggravated by, the service-connected right achilles tendon disability. 5. The preponderance of the evidence is against a finding that the Veteran’s right knee arthritis was incurred in or aggravated by service; additionally, his right knee condition is not proximately due to, or aggravated by, the service-connected right achilles tendon disability. 6. The preponderance of the evidence is against a finding that the Veteran’s cervical spine / neck conditions were incurred in or aggravated by service; additionally, his cervical spine / neck conditions are not proximately due to, or aggravated by, the service-connected right achilles tendon disability. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100 (2020). 2. The criteria for entitlement to service connection for a left shoulder disability have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 3. The criteria for entitlement to service connection for a right shoulder disability have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 4. The criteria for entitlement to service connection for a left knee disability have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 5. The criteria for entitlement to service connection for a right knee disability have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 6. The criteria for entitlement to service connection for a cervical spine disability have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020).   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from May 1974 to May 1976. The matters addressed in this decision were previously remanded by the Board in July 2018 for further evidentiary development. Following the issuance of an August 2020 supplemental statement of the case (SSOC) by the agency of original jurisdiction (AOJ), these matters have been returned to the Board for further appellate consideration. In January 2020, the Board issued another remand addressing the issues of entitlement to service connection for sleep apnea, hypertension, a left foot disability, posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). It appears that the AOJ is still undertaken the requested development and has not yet returned these matters to the Board. Accordingly, the Board will not address these matters at this time. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany his service-connected bilateral hearing loss. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). As noted above, the Veteran’s entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Entitlement to a compensable rating for the service-connected bilateral hearing loss disability is denied. On September 2, 2014, the Veteran submitted a VA Form 21-4138. Thereby, the Veteran renewed a claim for service connection for bilateral hearing loss. At that time, the Veteran also submitted a report from his medical provider. Therein, the provider relayed that, “(s)ince his military service (the Veteran) complains of . . . hearing loss secondary to high noise during military operations. He uses earphones.” In February 2015, the agency of original jurisdiction (AOJ) issued a rating decision. Therein, the AOJ granted the Veteran’s claim for service connection for bilateral hearing loss. The AOJ assigned a non-compensable rating, effective September 2, 2014. In September 2015, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran contested the non-compensable rating assigned for the service-connected bilateral hearing loss. The Veteran requested the “maximum” rating for the hearing loss disability. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of puretone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test. The horizontal columns in Table VI represent 9 categories of decibel loss based on the puretone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. The percentage evaluation is found from Table VII (in 38 C.F.R. § 4.85 and the statement of the case) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level “V” and the poorer ear had a numeric designation of Level “VII” the percentage evaluation is 30 percent. See 38 C. F. R. § 4.85. Regulations also provide that in cases of exceptional hearing loss, i.e., when the puretone threshold at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (a). The provisions of 38 C.F.R. § 4.86 (b) further provide that when the puretone threshold is 30 decibels or less at 1,000 hertz and 70 decibels or more at 2,000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIA, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. The Board must assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran’s bilateral hearing loss is rated under 38 C.F.R. § 4.85, Diagnostic Code 6100. Throughout the course of the appeal, this disability has been rated as non-compensable. The Veteran contends that his bilateral hearing loss is more severe than currently evaluated. In December 2014, the Veteran underwent a VA examination that considered the severity of his service-connected hearing loss disability. At that time, the Veteran demonstrated the following puretone values: HERTZ DEC ‘14 1000 2000 3000 4000 Average RIGHT 20 40 35 40 34 LEFT 25 35 40 40 35 Additionally, the Veteran demonstrated 92 percent right ear speech discrimination. The Veteran demonstrated 96 percent left ear speech discrimination. These audiometric findings equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. See 38 C.F.R. § 4.85, Table VI. When those values are applied to Table VII, a non-compensable (0 percent) evaluation reflects the Veteran’s bilateral hearing loss under the provisions of 38 C.F.R. § 4.85. In March 2017, the Veteran underwent a VA examination that considered the severity of his service-connected hearing loss disability. At that time, the Veteran demonstrated the following puretone values: HERTZ March ‘17 1000 2000 3000 4000 Average RIGHT 20 40 40 40 35 LEFT 25 40 35 45 36 Additionally, the Veteran demonstrated 96 percent speech discrimination, bilaterally. These audiometric findings equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. See 38 C.F.R. § 4.85, Table VI. When those values are applied to Table VII, a non-compensable (0 percent) evaluation reflects the Veteran’s bilateral hearing loss under the provisions of 38 C.F.R. § 4.85. In July 2018, the Board considered the Veteran’s claim for an increased rating for the service-connected hearing loss disability. At that time, the Board remanded the claim to the AOJ to secure a VA examination report that addressed the severity of the Veteran’s service-connected hearing loss disability. In April 2019, an Audiological General Note was generated at the San Juan VA Medical Clinic (VAMC). At that time, the Veteran demonstrated the following puretone values: HERTZ April ‘19 1000 2000 3000 4000 Average RIGHT 20 30 40 30 30 LEFT 15 40 40 45 35 Additionally, the Veteran demonstrated 92 percent speech discrimination, bilaterally. These audiometric findings equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. See 38 C.F.R. § 4.85, Table VI. When those values are applied to Table VII, a non-compensable (0 percent) evaluation reflects the Veteran’s bilateral hearing loss under the provisions of 38 C.F.R. § 4.85. In February 2020, the Veteran underwent a VA examination that considered the severity of his service-connected hearing loss disability. At that time, the Veteran demonstrated the following puretone values: HERTZ FEB ‘20 1000 2000 3000 4000 Average RIGHT 20 30 40 40 33 LEFT 20 40 40 45 36 Additionally, the Veteran demonstrated 96 percent speech discrimination, bilaterally. These audiometric findings equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. See 38 C.F.R. § 4.85, Table VI. When those values are applied to Table VII, a non-compensable (0 percent) evaluation reflects the Veteran’s bilateral hearing loss under the provisions of 38 C.F.R. § 4.85. Throughout the appellate period, the Veteran has credibly reported difficulties arising from the service-connected bilateral hearing loss disability. The Board notes that the Veteran is competent to report the symptoms that accompany the service-connected hearing loss disability; however, identification of the severity of his bilateral hearing loss requires education, training, and experience that simply falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1733 n. 4 (Fed. Cir. 2007). Based on the foregoing, the Board concludes that the criteria for an initial compensable rating for the Veteran’s service-connected hearing loss have not been met at any time during the applicable claim period, September 2, 2014 to present. Accordingly, the Veteran’s claim for an increased initial rating for his bilateral hearing loss disability must be denied. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran’s service as shown by the Veteran’s service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for bilateral shoulder disabilities, to include as secondary to the service-connected right achilles tendon disability, is denied. In September 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran also submitted correspondence from his private medical provider. Thereby, the Veteran initiated claims for service connection for bilateral shoulder disabilities. Again, to warrant an award of direct service connection the evidence must support a current disability, the in-service incurrence of a disease or injury, a nexus between the first and second requisite elements. See Hickson, 12 Vet. App. at 253. To warrant an award of secondary service connection the evidence must support a current disability, a service-connected disability, and a competently identified nexus between the first and second requisite elements. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In August 2008, the Veteran’s service treatment records (STRs) were associated with the claims file. After review, the Board notes that the Veteran was not seen or treated for a shoulder condition during service in the United States Army. During the Veteran’s clinical evaluation for separation from service, the military examiner noted normal upper extremities, spine and other musculoskeletal. The Board notes that the Veteran’s treatment records from the San Juan VA Medical Clinic (VAMC) have been associated with the claims file on multiple occasions during the claim period. The Board notes that the Veteran has competently reported shoulder pain. However, after deliberate review, the Board finds that the records do not identify an etiological relationship between the Veteran’s shoulder condition(s) and military service and/or the service-connected right achilles tendon disability. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include the bilateral shoulders. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral shoulder disabilities to obtain a VA examination that addressed the nature and etiology of the Veteran’s upper extremity disabilities. In February 2020, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured shoulder conditions. The VA examiner noted a diagnosis for bilateral shoulder degenerative arthritis. The Veteran reported that he started enduring bilateral shoulder pain in 2012. The VA examiner opined that, “bilateral shoulder conditions are less likely than not related to service. (These) condition were diagnosed several years after service. Degenerative arthritis of the shoulder was diagnosed by x-ray in year 2019 which is several years after service and is due to normal progression of aging process.” The VA examiner also opined that, “current bilateral shoulder conditions were less likely than not aggravated or caused by service-connected right achilles condition. . . . Medical evidence supports the fact that (these) conditions are completely unrelated to each other anatomically and by pathophysiology. There is no evidence that this shoulder conditions were aggravated by right achilles condition.” The Board notes that the Veteran currently maintains diagnoses for bilateral shoulder degenerative arthritis. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, the evidence within the claims file reflects that the Veteran did not incur a shoulder injury or disease during service in the United States Army. Moreover, the Veteran did not demonstrate a shoulder disorder until decades after separation from military service. Consequently, the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board notes that the Veteran has been service connected for a right achilles tendon disability since April 2008. Consequently, the second requisite element for secondary service connection is substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, after deliberate review, the Board concludes that the claims file is devoid of a competently and adequately identified medical nexus between the Veteran’s current shoulder disabilities and the service-connected right achilles tendon disability. Consequently, the final requisite element for secondary service connection has not been substantiated. Id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claims for service connection for bilateral shoulder disabilities. Since the preponderance of the evidence is against these shoulder claims, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claims of entitlement to service connection for left and right shoulder disabilities must be denied, because the preponderance of the evidence weighs against his claims. 3. Entitlement to service connection for bilateral knee disabilities, to include as secondary to the service-connected right achilles tendon disability, is denied. In September 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran also submitted correspondence from his private medical provider. Thereby, the Veteran initiated claims for service connection for bilateral knee disabilities. Again, to warrant an award of direct service connection the evidence must support a current disability, the in-service incurrence of a disease or injury, a nexus between the first and second requisite elements. See Hickson, 12 Vet. App. at 253. To warrant an award of secondary service connection the evidence must support a current disability, a service-connected disability, and a competently identified nexus between the first and second requisite elements. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In August 2008, the Veteran’s service treatment records (STRs) were associated with the claims file. After review, the Board notes that the Veteran was not seen or treated for a knee condition during service in the United States Army. During the Veteran’s clinical evaluation for separation from service, the military examiner noted normal lower extremities, spine and other musculoskeletal. The Board notes that the Veteran’s treatment records from the San Juan VA Medical Clinic (VAMC) have been associated with the claims file on multiple occasions during the claim period. The Board notes that the Veteran has been diagnosed with bilateral knee osteoarthritis. However, after review, the Board finds that the records do not identify an etiological relationship between the Veteran’s knee osteoarthritis and military service and/or the service-connected right achilles tendon disability. In March 2017, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured knee and lower leg conditions. The VA examiner reported a diagnosis for bilateral knee osteoarthritis. At that time, the Veteran reported chronic knee pain for a few years, which was accompanied by difficulty walking. The VA examiner opined that the bilateral knee osteoarthritis was less likely than not (less than 50% probability) proximately due to, or the result of, the Veteran’s service-connected right achilles tendon disability. The VA examiner supplied the following rationale: “claimed (bilateral) knee condition have different anatomical sites, with different biomechanical properties and different pathophyological process unrelated to each other. It is worth mention, that Veteran was also found with degenerative disease, this condition is less likely as not related to active service, is more likely related to the natural aging process.” In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include bilateral knee osteoarthritis. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral knee disabilities because the March 2017 VA examiner did not address the aggravation prong of the secondary service-connection analysis. In February 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured knee and lower leg conditions. The VA examiner noted a diagnosis for bilateral knee degenerative joint disease (DJD). The Veteran reported bilateral knee pain, and he claimed that it was the result of the service-connected right achilles tendon disability. The VA examiner opined that the Veteran’s bilateral knee DJD was less likely than not (less than 50 percent probability) incurred in or caused by the Veterans’ service in the United States Army. The VA examiner noted that there was no evidence for any knee conditions during the Veteran’s service. The VA examiner also opined that the Veteran’s bilateral knee DJD was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected right achilles tendon disability. The VA examiner supplied the following rationale: “actual gait biomechanics on which there is not weightbearing toward any specific area has not caused any knee derangements. Actual knee conditions are due to aging process.” The VA examiner also opined that the Veteran’s bilateral knee DJD was less likely than not (less than 50 percent probability) aggravated beyond its natural progression by the service-connected right achilles tendon disability. The Board notes that the Veteran currently maintains diagnoses for bilateral knee DJD. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, the evidence within the claims file reflects that the Veteran did not incur a knee injury or disease during service in the United States Army. Moreover, the Veteran did not demonstrate a knee disorder until decades after separation from military service. Consequently, the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board notes that the Veteran has been service connected for a right achilles tendon disability since April 2008. Consequently, the second requisite element for secondary service connection is substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, after deliberate review, the Board concludes that the claims file is devoid of a competently and adequately identified medical nexus between the Veteran’s current knee disabilities and the service-connected right achilles tendon disability. Consequently, the final requisite element for secondary service connection has not been substantiated. Id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claims for service connection for bilateral knee disabilities. Since the preponderance of the evidence is against these knee claims, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claims of entitlement to service connection for left and right knee disabilities must be denied, because the preponderance of the evidence weighs against his claims. 4. Entitlement to service connection for a cervical spine disability, to include as secondary to the service-connected right achilles tendon disability, is denied. In September 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran also submitted correspondence from his private medical provider. Thereby, the Veteran initiated a claim for service connection for a cervical spine disability. Again, to warrant an award of direct service connection the evidence must support a current disability, the in-service incurrence of a disease or injury, a nexus between the first and second requisite elements. See Hickson, 12 Vet. App. at 253. To warrant an award of secondary service connection the evidence must support a current disability, a service-connected disability, and a competently identified nexus between the first and second requisite elements. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In August 2008, the Veteran’s service treatment records (STRs) were associated with the claims file. After review, the Board notes that the Veteran was not seen or treated for a cervical spine condition during service in the United States Army. During the Veteran’s clinical evaluation for separation from service, the military examiner noted normal neck, spine and other musculoskeletal. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include the chronic cervical spine pain and myositis para-cervical spine muscles. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claim for service connection for a cervical spine disability, because the March 2017 VA examiners did not address the aggravation prong of the secondary service-connection analysis. The Board notes that the Veteran’s treatment records from the San Juan VA Medical Clinic (VAMC) have been associated with the claims file on multiple occasions during the claim period. After review, the Board finds that the VAMC treatment records do not identify or address a condition related to the Veteran’s cervical spine / neck. In a January 2019 Anesthesiology Operative Note, the VA provider reported that the Veteran demonstrated full range of motion of the neck. In February 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured neck (cervical spine) conditions. The VA examiner noted diagnoses for cervical spine degenerative arthritis and degenerative disc disease (DDD). The Veteran reported that cervical spine pain began 10 years ago. During the examination, the Veteran reported a cervical spine spasm, which resulted in 10/10 pain. The VA examiner opined that the Veteran’s cervical spine conditions were less likely than not (less than 50 percent probability) incurred in or caused by the Veterans’ service in the United States Army. The VA examiner supplied the following rationale: “there is no evidence at the STR’s that during active duty service Veteran had any cervical trauma, injury at the cervical spine or any treatment regarding cervical condition. Current cervical condition was diagnosed several years after service, 2020. Current condition is due to normal progression of aging process.” The VA examiner also opined that the Veteran’s cervical spine conditions were less likely than not (less than 50 percent probability) caused or aggravated by the Veteran’s service-connected right achilles tendon disability. The VA examiner supplied the following rationale: “medical evidence supports the fact that (these) conditions are completely unrelated by anatomy and by pathophysiology. There is no evidence that cervical condition has been aggravated by service connected right achilles condition.” The Board notes that the Veteran currently maintains diagnoses for cervical spine degenerative arthritis and DDD. Consequently, the first requisite element for direct and secondary service connection have been substantiated. See Hickson, 12 Vet. App. at 253; Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, the evidence withing the claims file reflects that the Veteran did not incur a cervical spine / neck injury or disease during service in the United States Army. Moreover, the Veteran did not demonstrate a cervical spine / neck disorder until decades after separation from military service. Consequently, the second requisite element for direct service connection has not been substantiated. See Hickson, 12 Vet. App. at 253. The Board notes that the Veteran has been service connected for a right achilles tendon disability since April 2008. Consequently, the second requisite element for secondary service connection is substantiated. See Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. However, after deliberate review, the Board concludes that the claims file is devoid of a competently and adequately identified medical nexus between the Veteran’s current cervical spine degenerative arthritis and DDD and the service-connected right achilles tendon disability. Consequently, the final requisite element for secondary service connection has not been substantiated. Id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claims for service connection for a cervical spine / neck disability. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claims of entitlement to service connection for a cervical spine / neck disability must be denied, because the preponderance of the evidence weighs against his claim. REASONS FOR REMANDED Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication. 1. Entitlement to service connection for bilateral ankle disabilities, and a rating in excess of 10 percent for the service-connected right achilles tendon disability, are remanded. In August 2020, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case (SSOC). Therein, the AOJ continued to deny the Veteran’s claims for service connection for bilateral ankle disabilities. The AOJ also continued to deny the Veteran a rating in excess of 10 percent for the service-connected right achilles tendon disability. In December 2020, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured ankle conditions. The VA examination report and opinions also addressed the current severity of the Veteran’s service-connected right achilles tendon disability. The Board observes that the pertinent VA examination report (and opinions) were associated with the Veteran’s electronic claims folder after the AOJ issued the SSOC on August 12, 2020. Since the pertinent medical records were added to the Veteran’s claims file 4 months after issuance of the SSOC, it is clear the AOJ did not review these records; consequently, a Supplemental Statement of the Case (SSOC) must be furnished to the Veteran and his representative. See 38 C.F.R. § 19.31. If the Board were to consider this evidence in the first instance, this potentially could be prejudicial because the Veteran, in effect, would “lose one bite of the apple,” meaning the benefit of one level of judicial review. Cf., Bernard v. Brown, 4 Vet. App. 384 (1993). Thus, the Board concludes that the AOJ should have the opportunity to review the December 2020 VA examination report and issue a SSOC. See 38 C.F.R. § 19.37 (b). The Board may not consider additional evidence not previously reviewed by the AOJ, unless a waiver of initial AOJ review is obtained from the Veteran. Disabled American Veterans, et. al. v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003); 38 C.F.R. § 20.1304 (c). The Veteran has not submitted a waiver of AOJ consideration of the new evidence received since issuance of the August 2020 SSOC, and the AOJ has not issued an SSOC with consideration of the newly received evidence. On remand, the agency of original jurisdiction should issue a SSOC that considers all the evidence received since the August 2020 SSOC. In reaching this conclusion, the Board observes that the Veteran filed his substantive appeal on April 29, 2016. For all substantive appeals received on or after February 2, 2013, if, either at the time or after the AOJ receives a substantive appeal, the claimant or the claimant’s representative submits evidence to either the AOJ or the Board for consideration in connection with the issues on appeal, such evidence shall be subject to initial review by the Board unless the claimant or the claimant’s representative requests in writing that the AOJ initially review such evidence. See Section 501 of the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law (PL) 112-154 (amending 38 U.S.C. § 7105 by adding new paragraph (e)). However, as this evidence does not appear to have been submitted by either the Veteran or his accredited representative, the claims must be remanded for the AOJ for readjudication with consideration of the newly received evidence. 2. Entitlement to service connection for bilateral arm disabilities, to include as secondary to the service-connected right achilles tendon disability, is remanded. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include the bilateral arms. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral arm disabilities to obtain a VA examination that addressed the nature and etiology of the Veteran’s upper extremity disabilities. In February 2020, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured arm conditions. The VA examiner noted a diagnosis for a left bicep tendon tear (by MRI). The Veteran reported that he suffered a left bicep tear during a fall in 2017. The VA examiner opined that, “left bicep tendon tear it is less likely than not related to service. . . . It was diagnosed in year 2018 by MRI after a fall he had in year 2017 not service related. This condition is due to the fall the Veteran had in year 2017.” The Board notes that the Veteran’s treatment records from the San Juan VAMC have been associated with the claims file on multiple occasions during the claim period. The Board notes that the Veteran has competently reported bilateral arm pain during the claim period. However, after deliberate review, the Board finds that the records do not identify an etiological relationship between the Veteran’s reported left and right arm pain and his military service and/or the service-connected right achilles tendon disability. The Board notes that the February 2020 VA examiner did not opine on an etiological relationship, if any, between the Veteran’s diagnosed left bicep tear and the service-connected right achilles tendon disability. Moreover, the Board notes that the VA examiner did not opine on the etiology of the competently identified bilateral arm pain, which is noted in the Veteran’s San Juan VAMC treatment records. The Board notes that, in a 2018 Federal Circuit case (Saunders v. Wilkie), the Court held that pain alone, without an accompanying diagnosis or identifiable condition, can constitute a disability if it causes functional impairment of earning capacity. 886 F.3d at 1368. The February 2020 VA examiner did not address the Veteran’s competent reports of bilateral arm pain. Consequently, the Board finds the VA examiner’s opinion(s) for this direct and secondary analysis are inadequate. On remand, the AOJ must secure a VA examination report that addresses the etiology of the Veteran’s competently identified bilateral arm pain. 3. Entitlement to service connection for bilateral elbow disabilities, to include as secondary to the service-connected right achilles tendon disability, is remanded. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician identified current diagnoses for elbow disorders. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral elbow disabilities to obtain a VA examination that addressed the nature and etiology of any currently endured elbow disorder. In February 2020, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured elbow and forearm conditions. The VA examiner reported that the Veteran did not have a current bilateral elbow condition. During the VA examination, the Veteran complained of occasional bilateral elbow pain, which was worse during cold and rainy days. The VA examiner relayed that there was no pathology identified on the right or left elbow during the examination. The VA examiner did not provide a medical opinion for direct or secondary service connection because, “medical opinion will not be render since it will be for educational purposes only. (sic)” During the appellate period, the Veteran has stated that his elbows are painful. The Veteran is competent to report this pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Again, the Board notes that, in a 2018 Federal Circuit case (Saunders v. Wilkie), the Court held that pain alone, without an accompanying diagnosis or identifiable condition, can constitute a disability if it causes functional impairment of earning capacity. 886 F.3d at 1368. The February 2020 VA examiner did not address the Veteran’s competent reports of bilateral elbow pain. Consequently, the Board finds the VA examiner’s opinion(s) for this direct and secondary analysis are inadequate. On remand, the AOJ must secure a VA examination report that addresses the etiology of the Veteran’s competently identified bilateral elbow pain. 4. Entitlement to service connection for a bilateral wrist disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. In September 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran also submitted correspondence from his private medical provider. Thereby, the Veteran initiated claims for service connection for bilateral wrist disabilities. The Board notes that the Veteran’s treatment records from the San Juan VAMC have been associated with the claims file on multiple occasions during the claim period. The Board notes that, in August 2018, the Veteran underwent stretching exercises for the triceps, biceps and wrist flexors. The Veteran also underwent strengthening exercises for the elbow, forearm and wrist. However, after review, the Board notes that a diagnosis for a wrist disorder was not among the Veteran’s San Juan VAMC treatment records. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include bilateral wrist osteoarthritis. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral wrist disabilities to obtain a VA examination that addressed the nature and etiology of any currently endured bilateral wrist disorder. In February 2020, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured wrist conditions. The VA examiner relayed that the Veteran did not have a current wrist condition. Bilaterally, the Veteran did not demonstrate wrist pain during the examination, to include with weight bearing and during palpation. The Veteran denied any left or right wrist injury and/or an acute or chronic condition. The Veteran denied any wrist injury during military service. The Board notes that the VA examiner reported that imaging studies of the Veteran’s wrists had not been performed. The VA examiner opined that, “(n)o medical opinion for direct service connection of the left or right wrists or aggravation of the left or right wrists is rendered since the veteran denies pain or any chronic or acute wrist condition, injury or complaints during or after his military service and the physical examination done today of the left and right wrist is unremarkable, furthermore all medical records available were reviewed and there is no left or right wrist condition, injury or complaint found.” The Board observes that the Veteran’s medical provider identified a diagnosis for bilateral wrist osteoarthritis in July 2014. However, the February 2020 VA examiner relayed that the Veteran’s medical records were reviewed, and a wrist condition was not found. Moreover, the February 2020 VA examiner reported that imaging studies were not performed to confirm or deny the presence of bilateral wrist osteoarthritis. As the February 2020 VA examiner’s negative opinions were based on the fact that there was no bilateral wrist condition reported in the Veteran’s medical records, the Board finds that it was based on an inaccurate factual premise, which renders the opinion inadequate. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Accordingly, on remand, an addendum opinion regarding the nature and etiology of the Veteran’s current wrist conditions, if any, should be obtained. Barr v. Nicholson, 21 Vet. App. 303, 31 (2007). 5. Entitlement to service connection for a bilateral hip disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. In September 2014, the Veteran submitted a VA Form 21-4138. At that time, the Veteran also submitted correspondence from his private medical provider. Thereby, the Veteran initiated claims for service connection for bilateral hip disabilities. In July 2018, the Board addressed the Veteran’s claims for service connection for multiple musculoskeletal disabilities. At that time, the Board noted that, in July 2014, the Veteran’s private physician had identified current diagnoses for multiple musculoskeletal disorders, to include bilateral hip osteoarthritis. The Board noted that the physician opined that the Veteran’s musculoskeletal disorders were more probable than not secondary to his military service. The Board found that the opinion was not adequate for adjudicatory purposes, because the etiological opinion was not specific. Moreover, the Board found that the physician did not support his conclusion with a complete rationale with supporting data and reasoned medical explanations. The Board remanded the Veteran’s claims for service connection for bilateral hip disabilities because the March 2017 VA examiner delivered an contradictory opinion. The Board observed that the VA examiner opined that the Veteran’s bilateral hip conditions were not due to his service-connected right achilles tendon disability, but then stated that such conditions were the direct result of his altered gait caused by his service-connected right achilles tendon disability. The Board found that clarification was necessary. The Board also noted that the VA examiner did not address the aggravation prong of secondary service connection. The Board remanded the claims service connection for bilateral hip disabilities for a clarification opinion that thoroughly addressed all theories of entitlement. In February 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured hip and thigh conditions. The VA examiner noted that the Veteran did not currently have a diagnosis for hip or thigh conditions. The VA examiner relayed that, “(t)he veteran denies any left or right hip acute or chronic condition. He denies injury to either joint during his military service. He does c/o left shoulder injury due to a fall associated to dizziness and a left knee and ankle pain but denies having any hip condition, injury or complaints.” The VA examiner reported that bilateral hip imaging studies had not been performed. The VA examiner opined that, “(n)o medical opinion for direct service connection of the left and right hips or aggravation of the left or right hips is rendered since the veteran denies pain or any chronic or acute hip condition, injury or complaints and the physical examination done today of the left and right hips is unremarkable, furthermore all medical records available were reviewed and there is no hip condition, injury or complaint found.” The Board observes that the Veteran’s medical provider identified a diagnosis for bilateral hip osteoarthritis in July 2014. However, the February 2020 VA examiner relayed that the Veteran’s medical records were reviewed, and a hip condition was not found. Moreover, the February 2020 VA examiner reported that imaging studies were not performed to confirm or deny the presence of bilateral hip osteoarthritis. As the February 2020 VA examiner’s negative opinions were based on the fact that there was no bilateral hip condition reported in the Veteran’s medical records, the Board finds that it was based on an inaccurate factual premise, which renders the opinion inadequate. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Accordingly, on remand, an addendum opinion regarding the nature and etiology of the Veteran’s current hip conditions, if any, should be obtained. Barr v. Nicholson, 21 Vet. App. 303, 31 (2007). 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. In April 2010, the Veteran submitted a statement in a foreign language. In August 2020, a translation was associated with the claims file. Therein, the Veteran relayed that, “I joined the (Puerto Rico) police. Although it was a job that required a lot of physical activity, I had to hide my pains because I could not afford to lose my job.” The Veteran relayed that, “(a)s time went by, the problems became more complicated, and it became harder for me to complete my job because I could not remain on my feet for long periods of time, and when I had to go to the range . . . my ailments became more complicated. I had to retire before my time and avoid being terminated of employment for failing to comply with my job.” In September 2014, correspondence from the Veteran’s medical provider was associated with the claims file. Therein, the provider noted service-connected disabilities and conditions that are not service connected. After providing an extensive medical report on the Veteran’s disabilities and conditions, the provider opined that, “(the Veteran) is 100% disable and his service connected disabilities significantly affect his ability to perform in a competitive work environment.” In January 2015, the Veteran submitted a VA Form 21-8940. Thereby, the Veteran sought increased compensation based on unemployability. The Veteran relayed that he last worked as a police officer in September 2005. The Veteran relayed that he retired after 25 years as a police officer. In January 2015, a VA Form 21-4192 was associated with the claims file. Therein, the Veteran’s former employer relayed the Veteran worked for 25 years as a policer officer. The Veteran was reported to have worked 40 hours a week. The reporting police official relayed that the Veteran’s police department employment ended by “Resignation of Board.” The Board observes that the Veteran is currently service connected for the following disabilities: left lumbar paravertebral myositis (20 percent), right achilles tendon injury (10 percent), tinnitus (10 percent), and bilateral hearing loss (non-compensable). The Board finds that the claim for entitlement to TDIU is inextricably intertwined with the claims remanded herein, the outcome of which could possibly have bearing on whether the Veteran meets the schedular criteria for TDIU benefits during the appeal. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Consequently, the Board will defer consideration of the Veteran’s claim for a TDIU rating until after his pending service-connection claims are appropriately addressed and/or adjudicated. Consequently, the matters are REMANDED to the AOJ for the following action: 1. Readjudicate the Veteran’s claims for service connection for bilateral ankle disabilities, and for a rating in excess of 10 percent for the service-connected right achilles tendon disability in light of all the additional evidence added to the record since the August 2020 SSOC. 2. If available, the VA 2020 VA examiner must supply an addendum opinion that addresses the nature and etiology of the Veteran’s competently reported bilateral arm pain. If unavailable, the Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured bilateral arm disorders. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any currently endured bilateral arm disorders had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any bilateral arm disorders currently endured by the Veteran was either (i) caused by or (ii) aggravated by the Veteran’s service-connected right achilles tendon disability? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his bilateral arm disorders. 3. If available, the VA 2020 VA examiner must supply an addendum opinion that addresses the nature and etiology of the Veteran’s competently reported bilateral elbow pain. If unavailable, the Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured bilateral elbow disorders. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any currently endured bilateral elbow disorders had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any bilateral elbow disorders currently endured by the Veteran was either (i) caused by or (ii) aggravated by the Veteran’s service-connected right achilles tendon disability? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his bilateral elbow disorders. 4. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured bilateral wrist disorders. All necessary testing must be performed, to include imaging studies. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any currently endured bilateral wrist disorders had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any bilateral wrist disorders currently endured by the Veteran was either (i) caused by or (ii) aggravated by the Veteran’s service-connected right achilles tendon disability? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his bilateral wrist disorders. 5. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured bilateral hip disorders. All necessary testing must be performed, to include imaging studies. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any currently endured bilateral hip disorders had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any bilateral hip disorders currently endured by the Veteran was either (i) caused by or (ii) aggravated by the Veteran’s service-connected right achilles tendon disability? The VA examiner MUST specifically address the contradictory opinion supplied by the VA examiner in March 2017, regarding an etiological relationship between the Veteran’s left hip and the modified gait caused by the service-connected right achilles tendon. The VA examiner must also specifically address whether the Veteran’s service-connected right achilles tendon has aggravated any hip condition identified by imaging studies. Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his bilateral hip disorders. 6. After completing any other development that may be warranted, the AOJ should readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative must be given a supplemental statement of the case (SSOC) and a reasonable opportunity to respond before the record is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.