Citation Nr: 21062435 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 19-04 513 DATE: October 7, 2021 ORDER Entitlement to service connection for a low back disorder is granted. Entitlement to service connection for residuals of traumatic brain injury (TBI) is denied. Entitlement to service connection for a headache disorder is granted. REMANDED Entitlement to an initial rating greater than 10 percent for left femoral head avascular necrosis with proximal stress fracture left femoral shaft based on limitation of thigh extension is remanded. Entitlement to an initial compensable rating for left femoral head avascular necrosis with proximal stress fracture left femoral shaft based on limitation of thigh flexion is remanded. Entitlement to an initial compensable rating for left femoral head avascular necrosis with proximal stress fracture left femoral shaft based on impairment of the thigh is remanded. Entitlement to an initial rating greater than 10 percent for right hip avascular necrosis based on limitation of extension is remanded. Entitlement to an initial compensable rating for right hip avascular necrosis based on limitation of flexion is remanded. Entitlement to an initial compensable rating for right hip avascular necrosis based on impairment of the thigh is remanded. Entitlement to an initial rating greater than 10 percent for left elbow lateral epicondylitis is remanded. Entitlement to an initial rating greater than 10 percent for right elbow lateral epicondylitis is remanded. Entitlement to an initial rating greater than 10 percent for left foot hallux valgus is remanded. Entitlement to an initial rating greater than 10 percent for right foot hallux valgus is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for a disability manifested by left groin pain is remanded. Entitlement to service connection for anemia is remanded. Entitlement to service connection for a left upper extremity disorder claimed as hand numbness is remanded. Entitlement to service connection for a right upper extremity disorder claimed as hand numbness is remanded. Entitlement to service connection for hypertension is remanded. REFERRED The issue of entitlement to service connection for a disorder manifested by mood swings secondary to service-connected disabilities was raised in a July 2021 Board hearing and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran has a current low back disability that began during or is otherwise related to active service. 2. The preponderance of the evidence is against finding that the Veteran has residuals of TBI related to an in-service injury or service-connected disability. 3. The evidence is at least in equipoise as to whether the Veteran has a headache disorder that began during or is otherwise related to active service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a low back disorder have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for residuals of TBI have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a headache disorder have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2014 to February 2015. In July 2021, a virtual hearing was held before the undersigned Veterans Law Judge. At that time, the record was held open for 30 days. Additional evidence was received, and automatic waiver applies. See 38 U.S.C. § 7105(e). At the hearing, the Veteran reported mood swings as a symptom of the medication that he takes to treat service-connected disabilities. This reasonably raises a claim of entitlement to service connection for a disorder manifested by mood swings secondary to service-connected disabilities. This issue is referred to the agency of original jurisdiction (AOJ) for appropriate action. See Bailey v. Wilkie, 33 Vet. App. 188 (2021) (for legacy appeals, the Board is required to refer to the AOJ for adjudication in the first instance claims of entitlement to secondary service connection that are reasonably raised during the adjudication of a formally initiated increased rating claim, regardless of whether the Veteran files a separate, formal claim). The Veteran also testified that he has hearing loss and tinnitus related to service. Under 38 C.F.R. § 3.1(p), a "claim" must be submitted on an application form prescribed by the Secretary. See 79 Fed. Reg. 57,696 (Sept. 25, 2014) (eliminating informal claims by requiring that, effective March 24, 2015, claims be filed on standard forms). Accordingly, the appellant is advised that if he wishes to file a claim for service connection for hearing loss and tinnitus, he must do so on the prescribed form. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310(b). Entitlement to service connection for a low back disorder In August 2015, VA denied service connection for a lower back condition. The Veteran disagreed with the decision and perfected this appeal. He contends that he has a low back disorder related to service or service-connected disability. Review of service treatment records shows that the Veteran underwent Medical Evaluation Board (MEB) proceedings in November 2014. At that time, he reported back pain from the level of his shoulder blades down into the lower lumbar spine. On average the intermittent back pain is rated a 5/10 on a pain scale of 0 to 10 and occurs 2-3 times per week. Back pain is self-limiting, and he had not seen a provider or had treatment for this complaint. Physical examination was normal. The Veteran was diagnosed as having lumbago. The Veteran underwent a VA back examination in July 2015. He reported that his back went out on him in June 2014 and he has had pain since which he states is constant and his back feels weak. Range of motion testing was abnormal, and the examiner stated that this was affected by his bilateral hip condition/pain, but the back examination was otherwise unremarkable. X-rays revealed an incidental finding of posterior element sclerosis at L5. No diagnosis was provided. The Veteran submitted a July 2021 report from a private physician, Dr. S.B. He indicated that the report was based on objective review of the medical records provided, his medical training/experience, and review of current literature. He stated that the VA examiner's claims that the abnormal range of motion was due to hip disease was incorrect. Further, that the statement concerning the imaging was also incorrect. The physician stated that the medical records show the lumbar spinal disease is sclerosed at the L5 level with scoliosis present convexed to the left. In his opinion, the Veteran had a valid claim that it was at least as likely as not secondary to his enlistment activities. In support of this opinion, the physician referenced medical literature suggesting that the claim of back pain is very commonplace in Veterans who have endured basic military training and that unspecified low back pain during service predicts low back pain in later life. Regarding whether there is current disability, the record contains evidence both for and against the claim. That is, the VA examiner indicated that there was no diagnosis whereas the private physician indicated there was evidence of lumbar spinal disease. The evidence is at least in equipoise and resolving reasonable doubt in the Veteran's favor, the Board finds a current disability. As indicated, the Veteran complained of low back pain prior to separation and lumbago was noted. He reported continued back pain and the record also contains a private medical opinion indicating that the Veteran's current back issues are at least as likely as not related to service. The record does not contain probative evidence to the contrary concerning nexus. Thus, service connection is warranted. 38 C.F.R. § 3.303. Entitlement to service connection for residuals of TBI and for headaches In August 2015, VA denied service connection for residuals of TBI and for headaches. The Veteran disagreed with the decision and perfected this appeal. He contends that he has a TBI related to service or service-connected disability, and that his headaches started in service and/or are a residual of TBI. At the hearing, the Veteran testified that he had fallen twice during service while performing obstacle course runs and hit his head. The first time, he slipped on the handlebars and fell back. On his final physical training run, he had a femur fracture and slipped and fell on the side of his head. He reported that he lost consciousness for a split second. He had a little knot on his head and balance and equilibrium were off. His reported that his headaches started after his fall and he indicated that he went for treatment a couple of times during service. He reported continued headaches. Service treatment records are negative for any treatment or findings related to TBI or head injuries. A September 2014 record indicates that the Veteran was administered a self-report three question TBI screen per MEB. Review of records and the questionnaire indicate that he did not sustain a significant head injury nor has current symptoms due to head injury. There was no indication for conducting neuropsychological testing. The November 2014 MEB report documents the Veteran's reports of mild, intermittent headaches that have occurred 2-3 times over the past 3 weeks. He had not been seen for this complaint. Diagnosis was listed as headaches. A January 2015 record notes a complaint of headache associated with acute sinusitis. On VA TBI examination in July 2015, the Veteran reported a fall down the stairs at his sister's apartment a few months ago. He stated that he hit his head on the concrete and has headaches 1-2 times a week since that time. The examiner reviewed the Veteran's records and conducted a physical examination to include assessment of facets of TBI-related cognitive impairment and subjective symptoms. She stated that the Veteran's symptoms were less likely than not related to a TBI incurred in service and he did not have a history of TBI. The occasional headaches could not be substantiated in his records. On VA headache examination in July 2015, the Veteran reported he was seen during service with complaints of headaches associated with cold and sinus symptoms. Prior to discharge he had headaches 2-3 times over the past 3 weeks, but he had not been seen for this complaint and no diagnosis of a chronic headache condition. The Veteran reported continued headache pain, but the examiner indicated that the examination was normal. The Veteran submitted a disability benefits questionnaire (headaches) completed by a private physician, Dr. S.B., in July 2021. He indicated that the Veteran had been diagnosed with a headache condition (migraine including migraine variants). A July 2021 report from Dr. S.B. notes the Veteran's report that he was walking down the stairs at his sister's house a few months after discharge and fell down the step hitting his head and losing consciousness. He stated that the pain and weakness in his hips caused his hips to give out and then he fell and hit his head. He claimed that his headaches which began in the service have gotten even worse. The physician opined that the Veteran's headaches are at least as likely as not secondary to his TBI due to service-connected bilateral hip disease. The physician discussed various mechanisms for head injuries and noted that patients with mild TBI are most likely to report tension-type followed by migraine-type headaches. A coup-contrecoup brain injury which occurred in the Veteran's situation is at least as likely as not the cause of his headache and he is still suffering symptoms from the TBI to the present. The physician further stated that even though the Veteran claimed to have headaches while enlisted, a sentinel injury like the TBI confirms these headaches are ongoing and persistent and need to be service connected. On review, the Board does not find credible evidence of an in-service TBI or residuals thereof. The Board acknowledges the Veteran's testimony that he hit his head on two occasions during service. He is competent to report this information, but it is contradicted by evidence of record. Specifically, these events were not documented on the in-service TBI screen, which was part of his MEB processing and thus occurred following any physical training and the alleged injuries. The Veteran also did not report these head injuries on TBI examination shortly after discharge but instead reported a post-service event. Even the private medical opinion submitted by the Veteran fails to mention the alleged in-service head injuries. As to whether the Veteran has current residuals of TBI, the record contains evidence both for and against the claim. That is, the VA examination indicates the Veteran does not have TBI residuals and the July 2021 private opinion indicates that he does. On review, the Board does not find the private opinion as probative as the VA opinion on this question. First, there is no indication that the private physician actually examined the Veteran, and it appears the diagnosis was based on review of the medical records provided (which do not show a diagnosis of TBI), the physician's medical training, and review of current literature. Further, the private physician is trained in internal medicine and pharmacology and thus, the diagnosis was not made by one of the types of specialists identified as appropriate for initially diagnosing TBI (physiatrist, psychiatrist, neurosurgeon, or neurologist). In contrast, the VA TBI examination was conducted by a physiatrist and based on both physical examination and review of the record. Accordingly, the Board finds it more probative. To the extent the private examiner relates the claimed condition to the service-connected hip disability, this does not serve to establish secondary service connection in the absence of diagnosed TBI residuals. In summary, the evidence preponderates against finding that the Veteran currently has residuals of TBI related to an in-service injury or service-connected disability. In making this determination, the Board acknowledges the Veteran's lay contentions, but notes he has not shown that he has the medical training, experience, or expertise to be competent to diagnose a TBI or to provide a medical etiology opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Regarding headaches, the Board acknowledges that the July 2015 VA headache examination was reported as normal, and that the private opinion suggests headaches are a residual of TBI. Notwithstanding, service treatment records document the Veteran's reported complaints and headaches were noted prior to separation. The Veteran also provided credible statements regarding continuing symptoms since that time. The evidence is at least in equipoise as to whether the Veteran's headaches had their onset during or are otherwise related to service. Resolving reasonable doubt in his favor, service connection is warranted. 38 C.F.R. § 3.303. REASONS FOR REMAND As to all issues remanded herein, updated VA medical records should be obtained. 38 C.F.R. § 3.159(c)(2). Entitlement to initial increased ratings for left femoral head avascular necrosis with proximal stress fracture left femoral shaft and for right hip avascular necrosis In August 2015, VA granted service connection for left femoral head avascular necrosis with proximal stress fracture left femoral shaft and for right hip avascular necrosis. Each disability was assigned three separate ratings as follows: 10 percent under Diagnostic Code 5251; noncompensable under Diagnostic Code 5252; and noncompensable under Diagnostic Code 5253. The Veteran disagreed with the decision and perfected this appeal. He contends that the assigned ratings do not adequately reflect the severity of his disabilities. In his January 2019 VA Form 9, the Veteran reported that his hips are getting worse to the point of tremendous pain constantly. At the hearing, he testified that his hips are significantly worse since his last examination. The Veteran most recently underwent a VA hip and thigh examination in July 2015. Given his contentions and the length of time since examination, a current examination is needed. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Entitlement to initial increased ratings for left and right elbow lateral epicondylitis In August 2015, VA granted service connection for left and right elbow lateral epicondylitis and assigned noncompensable ratings effective February 28, 2015. The Veteran disagreed with the decision and in October 2018, the ratings for each elbow were increased to 10 percent from February 28, 2015. The Veteran subsequently perfected this appeal. He contends that the assigned ratings do not adequately reflect the severity of his disabilities. In his January 2019 VA Form 9, the Veteran reported that he experienced limitation and reduced strength in both elbows and that his conditions were getting worse. At the hearing, he testified that his elbow pain and loss of motion were worse than when he was last examined. The Veteran most recently underwent a VA elbow examination in July 2015. Given his contentions and the length of time since examination, a current examination is needed. See Snuffer. Entitlement to initial increased ratings for left and right foot hallux valgus In August 2015, VA granted service connection for left and right foot hallux valgus and assigned a noncompensable rating for each foot from February 28, 2015. The Veteran disagreed with the decision and in November 2018, VA increased the rating for each foot to 10 percent from February 28, 2015. The RO indicated that this was the highest evaluation possible for this disability and thus, considered this to be a complete grant of the benefit sought. Regardless, a statement of the case (SOC) has not been furnished regarding these issues nor is there any indication that the appeal is currently being processed by the AOJ. As the Veteran submitted a notice of disagreement, a remand is required for the AOJ to issue a SOC addressing these issues. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Entitlement to TDIU In his January 2019 VA Form 9, the Veteran reported that he believed all his conditions should be increased because he was struggling with bills and could not work. In a March 2019 statement, the Veteran again stated that he was unable to work because of his conditions. Accordingly, a claim for TDIU is inferred herein. Rice v. Shinseki, 22 Vet. App. 447 (2009) (A claim of entitlement to a total disability rating based on individual unemployability is "part of," and not separate from, a claim of entitlement to an increased rating). On review, VA has not developed or adjudicated the claim of entitlement to TDIU. Additionally, considering the grants herein as well as the requested development, the Board finds it necessary to defer this issue. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Entitlement to service connection for left and right knee disorders In August 2015, VA denied service connection for left and right knee pain. The Veteran disagreed with the decision and perfected this appeal. At the hearing, the Veteran testified that his knee pain started during physical training and got worse. He also stated that his orthopedic surgeon told him that everything is off because of his hips and gait and he wanted secondary service connection considered. Review of service treatment records shows that the Veteran underwent MEB proceedings in November 2014. At that time, he reported bilateral knee pain (left worse than right) for "several months" without history of specific injury. He had not been seen by a provider or had any treatment for this complaint during service. Physical examination of the knees was negative. The Veteran was diagnosed as having right and left knee strains. The Veteran underwent a VA knee examination in July 2015. Knee range of motion was abnormal, but the doctor stated the limitations were due to body habitus and hip condition. The examiner stated that the Veteran did not have a current diagnosis associated with his claimed knee pain. On review, the Board finds that additional examination is needed to determine whether the Veteran has current knee disorders and whether they are related to service or service-connected disorders. In making this determination, it is noted that pain without a diagnosis can constitute a current disability if the pain results in functional impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Entitlement to service connection for bilateral pes planus In August 2015, VA denied service connection for bilateral pes planus. The Veteran disagreed with the decision and perfected this appeal. He generally contends that he has flat feet that began during or are otherwise related to service. At the hearing, the Veteran testified that during service an Army doctor told him he had fallen arches. He reported continued symptoms and that he wears arch supports that do not seem to alleviate the pain. Service treatment records show that on enlistment examination in October 2013, the Veteran's feet were reported as normal with a normal arch. On MEB proceedings in November 2014, the Veteran reported bilateral foot pain with prolonged standing or walking. Physical examination of the feet revealed mild to moderate pes planus bilaterally. The Veteran underwent a VA foot examination in July 2015. Pes planus was not noted. Given the findings in service along with the Veteran's reports of continued foot pain, additional examination is warranted to determine whether he has a current disability related to service. See Saunders. Entitlement to service connection for a disability manifested by left groin pain In August 2015, VA denied service connection for left groin pain. The Veteran disagreed with the decision and perfected this appeal. At the hearing, the Veteran testified that he experiences pain in the joint and muscular pain in the groin. He argues that the pain is secondary to his hip. Service treatment records document complaints of left groin pain related to avascular necrosis. On VA general medical examination in July 2015, the examiner stated that the claimed groin pain is addressed on the hip and thigh examination and is a symptom of the left hip condition. The Board notes, however, that the July 2015 VA hip and thigh examination does not specifically address the Veteran's groin pain or indicate whether all his complaints are attributed to or a part of the service-connected hip disability. Accordingly, additional examination is warranted. Entitlement to service connection for anemia In August 2015, VA denied service connection for anemia. The Veteran disagreed with the decision and perfected this appeal. MEB proceedings in November 2014 note the Veteran reported that recent blood work revealed low hemoglobin and hematocrit. He was asymptomatic and had not had evaluation or treatment related to this abnormal lab result. In July 2015, the Veteran underwent a VA hematologic examination. Current examination did not show anemia nor did medical records show a chronic condition of anemia. At the hearing, the Veteran testified that an Army doctor told him he had anemia and gave him iron pills which he still takes. He indicated that there should be a VA prescription for this. VA records indicate a prior history of anemia, but the Board is unable to locate a prescription for iron pills or evidence of current diagnosis. Given the Veteran's testimony, the Board finds it necessary to defer this issue pending the receipt of updated VA medical records. Entitlement to service connection for left and right upper extremity disorders claimed as hand numbness In August 2015, VA denied service connection for numbness in the hands, left and right upper extremities. The Veteran disagreed with the decision and perfected this appeal. At the hearing, the Veteran testified that his whole pinky goes completely numb on both sides and his fingertips as well. The numbness travels from the back of his elbows all the way to his fingertips. He indicated that his doctor told him the numbness could be caused by nerve involvement in his elbows. The Veteran's attorney argued that whatever the diagnosis is for the numbness, it is more than likely secondary to the service-connected bilateral elbow condition. Review of service treatment records shows that the Veteran underwent MEB proceedings in November 2014. He reported numbness and tingling intermittently in the hands and fingers. This occurs on average twice a day and will last a few seconds before resolving. He had not been seen for this complaint during service. No neurologic deficits were noted on physical examination. Diagnosis was listed as paresthesias bilateral hands. The Veteran underwent a VA peripheral nerves examination in July 2015. The examination was reported as normal, and no diagnosis was provided. As indicated, the Veteran testified as to continued symptoms in the upper extremities. He is competent to report his symptoms and additional examination is warranted to determine whether he has current upper extremity disorders and whether they are related to service or service-connected elbow disorders. Entitlement to service connection for hypertension In August 2015, VA denied service connection for hypertension. The Veteran disagreed with the decision and perfected this appeal. In his January 2019 VA Form 9, the Veteran reported that all his pain was making his blood pressure high. At the hearing, he testified that his blood pressure was elevated during his medical board process and he was diagnosed with high blood pressure. Service treatment records note various elevated blood pressure readings but do not show a confirmed diagnosis of hypertension. On VA hypertension examination in July 2015, the Veteran's blood pressure was recorded as 130/80, 138/89, and 128/82. The examiner stated that the Veteran had not been diagnosed with high blood pressure and is on no medications. VA records dated in July 2015 indicate elevated blood pressure, will monitor. Note dated in January 2018 indicates that the Veteran has had several previous reads of systolic blood pressures in the 140s-150s and that day, had systolic blood pressures in the 160s-170s on three separate checks. It could be white coat hypertension versus pain as the Veteran was young to have primary hypertension. There was no mention of hypertension in previous notes. The Veteran was given a blood pressure cuff and instructed to log daily blood pressures at home. On review, it is unclear whether the Veteran has a confirmed diagnosis of hypertension and if so, whether it is related to service or service-connected disability. Additional examination is warranted. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from October 2018 to the present. 2. Develop the claim of entitlement to TDIU, to include asking the Veteran to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left femoral head avascular necrosis with proximal stress fracture left femoral shaft and right hip avascular necrosis. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. In so doing, the examiner is specifically requested to state whether the Veteran's groin pain is a symptom of his already service-connected hip disorders or whether it represents a separate and distinct disability. If there is a separate disability, additional examination should be scheduled as needed to complete all applicable disability benefit questionnaires. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left and right elbow lateral epicondylitis. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Send the Veteran and his representative, if any, a SOC that addresses the issues of entitlement to initial ratings greater than 10 percent for left and right foot hallux valgus. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. 6. Schedule the Veteran for a VA examination for his claimed left and right knee disorders. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a) Does the Veteran have a left and/or right knee disorder that is at least as likely as not related to service, including his reports of knee pain and diagnosis of knee strain noted on MEB proceedings in November 2014. (b) If any knee disorder is not directly related to service, is it at least as likely as not proximately due to or aggravated (i.e., worsened beyond its natural progression), by service-connected bilateral hip and foot disorders? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 7. Schedule the Veteran for a VA examination for his claimed bilateral pes planus. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. Is it at least as likely as not that any pes planus is related to active service, to include the objective findings of pes planus noted therein? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 8. Schedule the Veteran for a VA examination for his left and right upper extremity disorders claimed as hand numbness. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a) Does the Veteran have a right and/or left upper extremity disorder that is at least as likely as not related to service, including his reports of hand numbness and diagnosis of bilateral hand paresthesias noted on MEB proceedings in November 2014. (b) If any upper extremity disorder is not directly related to service, is it at least as likely as not proximately due to or aggravated (i.e., worsened beyond its natural progression), by service-connected bilateral elbow disorders? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 9. Schedule the Veteran for a VA examination for his claimed hypertension. The examiner must review the claims file. The examiner should state whether the Veteran has had a confirmed diagnosis of hypertension at any time during the appeal period from February 2015 to the present. If so, the examiner is asked to provide a response to the following: (a) Is it at least as likely as not related to service, including the elevated blood pressures noted therein? (b) If hypertension is not directly related to service, is it at least as likely as not proximately due to or aggravated (i.e., worsened beyond its natural progression), by service-connected disability, to include pain related to same? A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Carsten, 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.