Citation Nr: 21061325 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 18-26 297 DATE: October 1, 2021 ORDER Service connection for a right elbow disability is dismissed. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is granted. REMANDED Service connection for a left ankle disability is remanded. Service connection for a right ankle disability is remanded. Service connection for left foot bunions, corns and calluses is remanded. Service connection for right foot bunions, corns and calluses is remanded. Service connection for bilateral foot fungus and peeling is remanded. Service connection for left foot numbness is remanded. Service connection for right foot numbness is remanded. Service connection for headaches is remanded. Service connection for Bell's palsy is remanded. Service connection for a left shoulder disability is remanded. Service connection for a left knee disability is remanded. Service connection for a right knee disability is remanded. Service connection for atrial fibrillation is remanded. Service connection for hypertension is remanded. Service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. On May 10, 2021, prior to the promulgation of a decision in the appeal, the Veteran indicated during his hearing before the Board that a withdrawal of this appeal is requested as to the issue of entitlement to service connection for a right elbow disability. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, disabling hearing loss for VA purposes. 3. The probative evidence of record is at least in equipoise as to whether the Veteran's tinnitus is a result of service or etiologically related to noise exposure during a period of ACDUTRA. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met for the issue of entitlement to a service connection for a right elbow disability. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 19.55 (2020). 2. The criteria for establishing service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2020). 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from July 1981 to July 1984, with additional service in the Army Reserve, Army National Guard, and Air National Guard. The Veteran testified before the undersigned Veterans Law Judge during a May 2021 hearing and a transcript is of record. These matters are on appeal from a September 2017 rating decision. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The presumption of service connection applies to anyone who served on active duty for 90 days of active, continuous service. 38 C.F.R. § 3.307(a)(1) (2017); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Post-service development of an "organic disease of the nervous system" to a degree of 10 percent within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Hearing loss and tinnitus are "organic diseases of the nervous system" and are subject to presumptive service connection under 38 C.F.R. § 3.309(a). Fountain v. McDonald, 27 Vet. App. 258 (2015). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, service connection on a presumptive basis under 38 C.F.R. § 3.309(a) is not warranted for periods of ACDUTRA. See Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). To the extent the Veteran is alleging his disabilities are a result of injury or disease incurred or aggravated during his time in the Reserves or the National Guard, he must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1 (a), (d) (2020); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110. Thus, the threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran had the disability for which service connection is sought at any time during the period on appeal. In the absence of proof of a disability during that period, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Right Elbow Disability The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by his authorized representative. Id. Withdrawal is only effective if it is explicit, unambiguous, and done with the Veteran's full understanding of the consequences. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). Withdrawal of an appeal will be deemed a withdrawal of the notice of disagreement and, if filed, the substantive appeal, as to all issues to which the withdrawal applies. 38 C.F.R. § 19.55. On May 10, 2021, during his hearing before the Board, the Veteran indicated that he wished to withdraw this appeal for the issue of service connection for a right elbow disability. Once transcribed as a part of the record of his hearing, this satisfies the requirements for the withdrawal of a substantive appeal. See Tomlin v. Brown, 5 Vet. App. 355 (1993). At the hearing, the undersigned explained that the merits of these claims would not be addressed, and that should the Veteran wish to seek service connection for the withdrawn issues, a new claim would need to be filed, and that this could impact the effective date assigned for any benefits that were eventually granted. The Veteran has clearly expressed unambiguous intent to withdraw the appeal for this issue. The Board therefore finds that the Veteran's statement meets the criteria for withdrawal of the appeal for this issue. Because the Veteran has withdrawn this appeal for this issue, there remain no allegations of errors of fact or law for appellate consideration with regard to this issue. Accordingly, the Board does not have jurisdiction to review this issue, and the claim is dismissed. 2. Bilateral Hearing Loss The Veteran contends that he has bilateral hearing loss that was caused by noise exposure while deployed to Kuwait, which was during a period of ACDUTRA. Impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of those frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Hearing loss does not constitute a disability if it does not meet the threshold requirements of 38 C.F.R. § 3.385; Palczewski v. Nicholson, 21 Vet. App. 174, 179-80 (2007). The Veteran was afforded a VA examination in March 2017. The hearing examination results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 15 LEFT 10 10 15 10 15 Speech recognition was 100 percent in each ear. The clinician diagnosed normal hearing bilaterally. The record contains no other hearing examination results during the period on appeal. Although it has been more than four years since the March 2017 VA examination, there has been no contention that the Veteran's hearing has worsened since that examination. The Board has also considered the Veteran's assertions regarding his hearing loss. However, the determination of whether hearing loss is sufficiently severe to be disabling as defined by VA regulations requires specific audiometric and speech recognition testing. Thus, to the extent that the Veteran's statements express a medical opinion that his hearing loss is disabling under VA regulations, their probative value is outweighed by that of the VA examination results. The VA examination results show that the Veteran's hearing loss is not severe enough in either ear to be considered a disability for VA purposes as set forth in 38 C.F.R. § 3.385. As the evidence does not establish that the Veteran had disabling hearing loss as set forth by VA regulations during the period on appeal, the Board finds that service connection is not warranted. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that current disability requirement is satisfied when a claimant "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim."). During the May 2021 hearing, the Veteran's attorney contended that all of the March 2017 VA examinations were inadequate because their rationales focused on a nexus to the Veteran's period of active duty service but not to any period of ACDUTRA. However, because the evidence does not demonstrate the existence of a current disability, the VA examiner did not provide an opinion with regard to the etiology of hearing loss and, even if the examiner had, the adequacy of that opinion would have been moot. 3. Tinnitus The Veteran contends that his tinnitus was caused by noise exposure during his deployment to Kuwait during a period of ACDUTRA. The Veteran's service personnel records note deployment to Kuwait in October 2001. The Veteran was afforded a VA examination in March 2017. The Veteran reported constant tinnitus that started while he was in Kuwait. The clinician found that it was less likely than not that the Veteran's tinnitus was caused by military noise exposure because there were "no changes in hearing attributable to noise from a specific episode or period of exposure." During the May 2021 hearing, the Veteran testified that his service in Kuwait placed him near the flight line and that ringing in his ears had its onset during that service and has continued to the present. A current disability is shown by the evidence of record. Tinnitus is a type of disorder associated with symptoms capable of lay observation. Charles v. Principi, 16 Vet. App. 370 (2002). The Board has no reason to doubt the veracity of the Veteran's reports of experiencing tinnitus since his deployment to Kuwait. In light of the totality of the circumstances, and after resolving all reasonable doubt in the Veteran's favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran's noise exposure in Kuwait was an injury in the line of duty during a period of ACDUTRA and that his tinnitus was due to that injury. Accordingly, the Board finds that granting service connection for tinnitus is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. § 3.303(a). REASONS FOR REMAND The majority of the Veteran's claims stem from his service in the National Guard. The Agency of Original Jurisdiction (AOJ) has obtained a report that appears to list the Veteran's dates of active duty for training (ACDUTRA), but only from 2001 to 2015. The Veteran served in the Army Reserve from July 1984 to March 1985, in the Army National Guard from March 1985 to June 1987, and in the Air National Guard from January 1993 to September 2016. On remand, the AOJ should clarify the Veteran's dates of ACDUTRA. The Veteran's service treatment and personnel records appear to be incomplete. In a March 2018 letter, VA informed the Veteran of its efforts to locate outstanding service personnel records, but did not do so with regard to the service treatment records. In an April 2019 statement, the Veteran's attorney requested that VA make another attempt to obtain any outstanding service treatment records. On remand, the AOJ should attempt to obtain these records. In addition, VA treatment records prior to May 25, 2017 have been associated with the claims file. During the May 2021 hearing, the Veteran testified as to continued treatment for the issues on appeal, including a left bunionectomy. A remand is warranted to attempt to obtain records of any additional surgery or treatment pertinent to the issues on appeal. See 38 U.S.C. § 5103A(c)(1)(B) (2012); 38 C.F.R. § 3.159(c)(3) (2020). The Board emphasizes that, with regard to all of the issues below, it is not determining whether or not the Veteran's statements regarding the onset and continuity of his symptoms are credible at this time, as the additional development set forth in the directives below could impact that determination. 1. Service connection for a left ankle disability is remanded. 2. Service connection for a right ankle disability is remanded. VA must provide an examination with regard to a claim for disability compensation when there is competent evidence of a disability that may be associated with an in-service disease, injury or event, but there is insufficient information to make a decision on the claim. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). During the May 2021 hearing, the Veteran testified that his ankle symptoms had their onset during basic training for his period of active duty service and have continued to the present. The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. Id., at 83. This evidence meets that threshold, and an examination is necessary. 3. Service connection for left foot bunions, corns and calluses is remanded. 4. Service connection for right foot bunions, corns and calluses is remanded. 5. Service connection for bilateral foot fungus and peeling is remanded. 6. Service connection for left foot numbness is remanded. 7. Service connection for right foot numbness is remanded. During the May 2021 hearing, the Veteran testified that his foot symptoms had their onset during his October 2001 deployment to Kuwait. This evidence meets the low threshold for determining whether the evidence indicates that there may be a nexus between a current disability and an in-service event, injury, or disease and an examination is necessary. 8. Service connection for headaches is remanded. During the May 2021 hearing, the Veteran testified that his headaches had their onset during a drill weekend in 2009. This evidence meets the low threshold for determining whether the evidence indicates that there may be a nexus between a current disability and an in-service event, injury, or disease and an examination is necessary. 9. Service connection for Bell's palsy is remanded. During the May 2021 hearing, the Veteran testified that his Bell's palsy had its onset on his way home from drills in 2003. This evidence meets the low threshold for determining whether the evidence indicates that there may be a nexus between a current disability and an in-service event, injury, or disease and an examination is necessary. 10. Service connection for a left shoulder disability is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination in March 2017. The clinician's opinion only considered a nexus to active duty service, but the Veteran has attributed this disability to a period of ACDUTRA. For this reason, a remand is warranted to obtain an additional medical opinion. 11. Service connection for a left knee disability is remanded. 12. Service connection for a right knee disability is remanded. The Veteran was afforded a VA examination in March 2017. The clinician's opinion only considered a nexus to active duty service, but the Veteran has attributed his left knee disability to a period of ACDUTRA and his right knee disability to his left knee disability. For this reason, a remand is warranted to obtain an additional medical opinion. 13. Service connection for atrial fibrillation is remanded. The Veteran was afforded a VA examination in March 2017. The clinician's opinion only considered a nexus to active duty service, but the Veteran has attributed this disability to a period of ACDUTRA. For this reason, a remand is warranted to obtain an additional medical opinion. 14. Service connection for hypertension is remanded. The Veteran was afforded a VA examination in March 2017. The clinician's opinion only considered a nexus to active duty service, but the Veteran has attributed this disability to a period of ACDUTRA. For this reason, a remand is warranted to obtain an additional medical opinion. 15. Service connection for erectile dysfunction is remanded. The Veteran was afforded a VA examination in March 2017. The clinician's opinion only considered a nexus to active duty service, but the Veteran has attributed this disability to medication for his hypertension. For this reason, a remand is warranted to obtain an additional medical opinion. The matters are REMANDED for the following action: 1. Request the complete dates of the Veteran's ACDUTRA in the Army Reserve from July 1984 to March 1985, Army National Guard from March 1985 to June 1987, and Air National Guard from January 1993 to September 2016 by day and month from the appropriate agency or agencies. A Chronological Statement of Retirement Points is not sufficient to fulfill this request. 2. Obtain any outstanding service treatment records from the Veteran's active duty, Army Reserve, Army National Guard, and Air National Guard service. Make as many requests as are necessary to obtain relevant records and only end efforts to do so if the records sought do not exist or further efforts to obtain those records would be futile. All negative responses must be documented. If no records are available, the claims folder must indicate this fact and the Veteran should be notified; this notice should advise the Veteran to submit any copies of these records he might have in his possession. 3. Obtain any outstanding VA treatment records for the Veteran, specifically including but not limited to any records dated after May 25, 2017, including any records of a left bunionectomy in or around 2018. The Agency of Original Jurisdiction (AOJ) shall document, in writing, all efforts to obtain these records, to include any formal finding that the records are unavailable. 4. Schedule the Veteran for an examination with an appropriate clinician for his left and right ankle disabilities. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current left or right ankle disability had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. The Veteran's statements in his September 2016 claim regarding in-service injuries. b. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 5. Schedule the Veteran for an examination with an appropriate clinician for his left and right foot bunions, corns, and calluses. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current left or right foot disability including bunions, corns, and calluses had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 6. Schedule the Veteran for an examination with an appropriate clinician for his bilateral foot fungus and peeling. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current skin disability of the left or right foot, including fungus and peeling, had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 7. Schedule the Veteran for an examination with an appropriate clinician for his left and right foot numbness. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current disability of the left or right foot manifested by numbness had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 8. Schedule the Veteran for an examination with an appropriate clinician for his headaches. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current headaches had their origin in service or are related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 9. Schedule the Veteran for an examination with an appropriate clinician for his Bell's palsy. The entire claims file and a copy of this remand must be made available to the clinician for review. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current Bell's palsy had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 10. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's left shoulder disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current left shoulder disability had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. National Guard treatment records from November 2011 and February 2013 discussing the Veteran's left shoulder symptoms. b. The Veteran's statements during the March 2017 VA examination regarding the onset and continuity of his symptoms. c. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 11. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's left and right knee disabilities. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current left knee disability had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. b. Whether it is as least as likely as not that any current right knee disability was caused by the Veteran's left knee disability. c. Whether it is as least as likely as not that any current right knee disability was aggravated beyond its natural progression by the Veteran's left knee disability. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. November 1987 private treatment records discussing the Veteran's left knee symptoms and surgery. b. April 1994 private treatment records discussing the Veteran's right knee symptoms and surgery. c. A November 1998 medical opinion by a private physician regarding the functioning of the Veteran's right knee. d. The Veteran's statements during the March 2017 VA examination regarding the onset and continuity of his symptoms. e. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 12. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's atrial fibrillation. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current atrial fibrillation had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. A March 2010 National Guard treatment record noting a recent diagnosis of atrial fibrillation. b. An April 2010 private treatment record discussing the history and etiology of the Veteran's atrial fibrillation. c. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 13. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's hypertension. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide an opinion as to whether it is as likely as not (a probability of 50 percent or greater) that any current hypertension had its origin in service or is related to the Veteran's active service, including any period of active duty for training (ACDUTRA) during the Veteran's service in the Army Reserve, Army National Guard, or Air National Guard. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. A March 2016 National Guard treatment record noting a recent diagnosis of hypertension. b. The Veteran's statements during the March 2017 VA examination regarding the onset and continuity of his symptoms. c. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 14. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's erectile dysfunction. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as least as likely as not that any current erectile dysfunction was caused by the Veteran's hypertension, including as an effect of medication. b. Whether it is as least as likely as not that any current erectile dysfunction was aggravated beyond its natural progression by the Veteran's hypertension, including as an effect of medication. The clinician is advised that, for the purposes of this opinion, a disability is current if present at any point during the period on appeal, which began on June 28, 2016. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. The Veteran's statements during the March 2017 VA examination regarding the onset and continuity of his symptoms. b. The Veteran's testimony during the May 2021 hearing regarding the onset and continuity of his symptoms. The rationale for any opinion expressed should be provided. Note that the Veteran's service treatment records may be incomplete and the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 15. Ensure that the directives specified in this remand have been implemented. If they have not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998) 16. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ryan Frank, 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.