Citation Nr: 21065136 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-17 479 DATE: October 25, 2021 ORDER Service connection for residuals of a traumatic brain injury (TBI) is denied. Service connection for a right hip disability is denied. Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. REMANDED The claim for service connection for a neck disability is remanded. The claim for service connection for a scar near the left eye is remanded. The claim for service connection for a left hip and/or thigh disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has residuals of an in-service TBI. 2. The preponderance of the evidence is against a finding that a current right hip disability was incurred in or caused by service. 3. The preponderance of the evidence is against a finding that a current left knee disability was incurred in or caused by service. 4. The preponderance of the evidence is against a finding that a current right knee disability was incurred in or caused by service. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for residuals of a TBI have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). 2. The criteria for establishing entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). 3. The criteria for establishing entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). 4. The criteria for establishing entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1994 to December 1995, with additional service in the Army Reserve and the Wisconsin Army National Guard from December 1995 to April 2014. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This matter was previously before the Board in January 2019, at which time it was remanded for further development. The requested development was completed, and the case has been returned to the Board for further appellate action. The Board notes that during the August 2016 Board hearing, the Veteran testified that he was seeking service connection for astigmatism of the left eye. However, service connection for astigmatism of the left eye was denied in November 2001 and August 2015 rating decisions because astigmatism is a refractive error of the eye not subject to VA disability compensation. The Veteran has not appealed the denial of service connection for astigmatism; therefore, that issue is not presently before the Board. 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. § 1110, 1131; 38 C.F.R. § 3.303. 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. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Active military, naval, or air service includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in the line of duty, or any period of INACDUTRA which the individual concerned was disabled or died from injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101(21), (24); 38 C.F.R. §§ 3.6(a), (c), (d). In other words, service connection may be granted for injury or disease incurred while on ACDUTRA and for injury incurred while on INACDUTRA, but not disease. 38 U.S.C. § 101(24). For National Guard service, ACDUTRA is defined as full-time duty performed by members of the National Guard of any State under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(22)(C); 38 C.F.R. § 3.6(c)(3). INACDUTRA is defined as duty (other than full-time duty) performed by a member of the National Guard of any State under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d)(4). Thus, in order for National Guard service to be qualifying service for VA compensation purposes, the period of service must have been "federalized," that is to say, his or her unit was ordered into Federal service under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 C.F.R. § 3.6 (c), (d). 1. Entitlement to service connection for residuals of a TBI As an initial matter, the Board notes that service connection has been granted for persistent depressive disorder. Therefore, the issue of entitlement to service connection for a psychiatric disorder, other than residuals of a TBI, is not presently before the Board. The Veteran seeks service connection for residuals of a TBI, which he asserts were caused by in-service head injuries. During a July 2015 VA TBI examination, the Veteran reported sustaining three in-service head injuries; one when he slipped on ice, one when he passed out in a sauna or hot tub, and one when he was hit with a beer bottle. During an August 2015 VA neck examination, the Veteran reported sustaining two concussions during service, one when he allegedly slipped on soap in the shower, and one when he was allegedly pushed in the shower. During the August 2016 Board hearing, the Veteran testified that he was hit his head during service when he fell coming out of either a shower or sauna. He also testified that he got into a physical altercation and received a laceration from a beer bottle, for which he believes he received stitches. He further testified that he has memory problems; gets headaches at times; and goes to bed late and has a hard time waking up early. Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that the Veteran has residuals of an in-service TBI. Service treatment records show that in October 1994, the Veteran sought treatment for left knee pain after slipping on ice and landing on his left knee. There was no mention of a head injury, and the Veteran was discharged to full duty. In November 1994, the Veteran reported injuring his right little toe after slipping and falling on ice. The diagnosis was a contusion of the little toe. There was no mention of a head injury. In June 1995, the Veteran received treatment after passing out when leaving a sauna to get a drink of water. He reportedly lost consciousness for a few seconds, hit his head, and subsequently complained of a mild headache. The assessment was vasovagal syncope and scalp laceration. He received sutures in the left temporal scalp area, which were removed 11 days later, and he was discharged to full duty. In October 1995, the Veteran received treatment after being assaulted at a night club and losing consciousness. A CT scan of head revealed apparent mild thickening of the tympanic membrane on the right with a small amount of fluid or soft tissue abutting its medial posterior border, which may represent blood consistent with the Veteran's history. The treatment provider indicated that such could be secondary to a tympanic membrane injury and recommended a consultation with an ear, notes, and throat (ENT) specialist. The diagnoses included cerebral concussion, right hemotympanum, and contusion of the right occiput and right mandible. The Veteran was advised to take motrin and avoid contact sports for one month. Later in October 1995, the Veteran sought treatment for pain in the right shoulder blade and right side of the neck ever since he was "sucker punched" at a bar eight days earlier. A physical examination revealed tenderness over the right trapezius muscle, and the assessment was a cervical strain. The Veteran was advised to continue motrin, add Flexeril, apply heat, rest, and do gentle range motion stretching. About two weeks later, the Veteran again sought treatment for back and shoulder pain, which he believed could be related to being hit at the night club. The assessment was a paraspinal muscle strain, and the Veteran was advised to avoid heavy lifting and ruck marching for two weeks and continue Flexeril. On a November 1995 report of medical history, the Veteran reported having or having a history of a head injury and frequent dizziness or fainting spells, and frequent or severe headache. He denied any periods of unconsciousness, loss of memory, or amnesia. A November 1995 report of medical examination shows that the Veteran's head was normal, and he was neurologically and psychiatrically normal upon his discharge from active duty. Post-service treatment records show a history of psychiatric and substance abuse treatment since approximately 1998. During a November 2015 private psychiatric evaluation, the Veteran reported sustaining head injuries while slipping in the shower in 1994, passing out in a sauna in 1995, and being hit with a bottle in 1995, all of which he claimed resulted in concussions. The impression was bipolar affective disorder II, intermittent explosive disorder, and ADHD by history. Post-service treatment records show that the Veteran again reported a history of in-service TBIs on a few other occasions, and a January 2021 VA optometry treatment record shows that the Veteran reported a history of TBI with asthenopia and photophobia. The Veteran underwent a VA TBI examination with a neurologist in July 2015, during which he reported in-service head injuries resulting from slipping on ice and falling, passing out in a sauna, and being hit with a beer bottle. It was noted that the Veteran was always oriented to person, time, place, and situation, and there was no evidence of impaired memory, attention, concentration, or executive functions. Social interaction was routinely appropriate, and judgment, motor activity, and visual spatial orientation were all normal. There was no evidence of subjective symptoms or neurobehavioral effects, and the Veteran was able to communicate by spoken and written language and comprehend spoken and written language. The examiner indicated that a neurological examination was normal, and there was no evidence of any residuals attributable to a TBI. The VA examiner reviewed the evidence of record and opined that it was less likely than not that the Veteran had any residuals of an in-service TBI. In support of this, the examiner explained that with respect to the in-service falls on ice, service treatment records showed injuries to the toe and knee, and there was no evidence of a TBI related to those falls. With respect to the fall at the sauna, the Veteran was diagnosed with syncope, or fainting, which is a common complication due to excessive water loss, and there was no evidence of a TBI related to that fall. With respect to the assault in the night club, the examiner indicated that the discharge diagnosis of mild cerebral concussion appeared to be based on the CT finding of "apparent mild thickening of the right tympanic membrane with apparent small amount of fluid or soft tissue abutting its medial posterior aspect." However, there was no mention of any cognitive abnormalities, and the CT scan specifically indicated that there was "no evidence of intracranial hemorrhage, mass, or mass effect of the brain parenchyma or other apparent intracranial abnormalities." The examiner indicated that blood behind the tympanic membrane can be evidence of basilar skull fracture, which is a very serious injury, however, such would be accompanied by additional intracranial abnormalities, including intracranial blood on CT. The examiner indicated that in the Veteran's case, there were no such findings, and the radiologist who interpreted the CT scan indicated that the findings were suggestive of possible tympanic membrane injury, not intracranial brain injury. Moreover, the Veteran was advised to follow up with an ENT specialist, not a neurologist. The examiner further noted that the Veteran was seen eight days later with musculoskeletal complaints; however, again there was no mention of cognitive difficulties or any other symptoms suggestive of a possible TBI. The Board finds the opinion of the July 2015 VA examiner to be highly probative and persuasive, as it was provided by a physician who specializes in neurology and is supported by a detailed explanation based on a review of the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). To the extent that the Veteran believes that he has residuals of a TBI that are related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, the diagnosis and etiology of TBIs are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis and/or etiology of claimed residuals of a TBI is not competent medical evidence. As the preponderance of the evidence is against a finding that the Veteran has residuals of an in-service TBI, service connection for residuals of a TBI is denied. 2. Entitlement to service connection for a right hip disability Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that a current right hip disability was incurred in or caused by service. Service treatment records show that the Veteran reported right hip pain in June 1994 and in July 1994. In August 1994, the Veteran reported right hip and ankle pain for the past month. The assessment was right dorsal foot centration, and he was advised to avoid running for 72 hours, then run at his own pace for three days. Subsequent service treatment records show no additional complaints of right hip pain, despite complaints of various other orthopedic issues. See AZ v. Shinseki, 731 F.3d 1303, 1311 (Fed. Cir. 2013). Upon the Veteran's discharge from active duty, he reported having or having a history of swollen or painful joints and arthritis, rheumatism, or bursitis on a November 1995 report of medical history. However, he did not specify the location of his joint pain and whether it was still present. A November 1995 report of medical examination shows that the Veteran's lower extremities and musculoskeletal system were normal upon his discharge from active duty. Despite seeking treatment for various orthopedic conditions, post-service treatment records show no complaints of or treatment for right hip pain until approximately May 2004. See AZ, 731 F.3d at 1311. At that time, the Veteran reported right hip and hernia pain. Imaging studies of the pelvis and hips were normal, and the diagnoses were right inguinal hernia and right hip pain. Thereafter, a February 2009 medical examination conducted during the Veteran's National Guard service shows that his lower extremities and musculoskeletal system were normal, and he denied any swollen or painful joints; arthritis, rheumatism, or bursitis; dislocated joints, including hips; or limitation of motion of any joints, including hips, on an accompanying report of medical history. In June 2010, the Veteran reported slipping on gravel and having right hip pain ever since. Imaging studies of the right hip were normal. In January 2011, the Veteran sought treatment for right knee pain, and it was noted that the right hip exhibited good range of motion without any discomfort. The Veteran underwent a VA examination in August 2015, during which he reported right hip pain and crepitation. A physical examination revealed no tenderness or pain on palpation or pain with weight bearing, and the right hip exhibited full range of motion without any evidence of pain. Imaging studies revealed a normal right hip with no evidence of degenerative changes, fracture, or avascular necrosis. The examiner indicated that the Veteran did not have a diagnosis of a right hip disability. The Veteran underwent another VA examination in January 2016, during which he reported slipping and falling on his right hip during service. He reported current symptoms of daily discomfort over the posterolateral aspect of the right hip. The examiner diagnosed the Veteran with bursitis of the right hip and opined that it was less likely than not incurred in or caused by service. In support of this, the examiner explained that the Veteran sustained an in-service muscle strain in June 1994, but post-service treatment records did not show complaints of right hip pain until 2004 and again in 2010. The examiner indicated that it is likely that the in-service hip strain resolved, as would be expected for a simple muscle strain, and his current right hip condition was likely related to events that occurred after service. The Veteran underwent another VA examination in December 2020, during which he reported falling, bruising, and straining his hips many times during service. It was noted that the Veteran described vague, intermittent symptoms of lower back and right sacroiliac (SI) joint pain, and he did not describe a clear progression of the symptoms that he experienced in 1994. A physical examination revealed no tenderness or pain on palpation or pain with weight bearing, and the right hip exhibited full range of motion without any evidence of pain. The examiner indicated that the Veteran did not have a diagnosis of a right hip disability at that time. The examiner reviewed the evidence of record and opined that it was less likely than not that the Veteran's current right hip complaints were incurred in or caused by service. In support of this, the examiner explained that service treatment records show that the Veteran had a simple, uncomplicated right hip strain during service, and there was no evidence of continued right hip complaints upon his discharge from active duty. Additionally, the examiner indicated that the location of the Veteran's currently identified pain was in his lower back and right SI joint, and not int the same location as his in-service right hip pain. The Board finds the opinions of the VA examiners to be highly probative and persuasive, as they are supported by reasoned medical explanations based on a review of the evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Although the Veteran believes that he has a current right hip disability that is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v, 492 F.3d at 1377. In this regard, the diagnosis and etiology of hip disabilities are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis and/or etiology of a current right hip disability is not competent medical evidence. As the preponderance of the evidence is against a finding that a current right hip disability is related to service, service connection for a right hip disability is denied. 3. Entitlement to service connection for a left knee disability Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that a current left knee disability was incurred in or caused by service. Service treatment records show that in October 1994, the Veteran reported slipping on ice a week earlier and landing on his left knee and having persistent pain with running. The assessment was a left knee contusion, and the Veteran was released to full duty. In November 1994, the Veteran reported left knee pain after falling while roller blading two days earlier. The assessment was a contusion, and the Veteran was placed on physical profile. In December 1994, the Veteran reported continued left knee pain after falling three weeks earlier. The assessment was a contusion. In January 1995, the Veteran reported that his left knee pain following the roller blading fall initially got better; however, he began experience pain again about two weeks earlier. The assessment was left knee pain, possible meniscal injury, and the Veteran was placed on physical profile for another 14 days. Imaging studies performed in February 1995 revealed a normal left knee with no evidence of fracture, dislocation, joint effusion, arthritic changes, or other abnormalities. The Veteran was advised to resume running with a profile. A March 1995 follow-up treatment record shows that the Veteran reported right knee pain for the past five months ever since he fell on it in October 1994. However, the Board finds that the notation of "right" knee pain is clearly an error, as the Veteran injured his left knee in the October 1994 fall and was placed on physical profile and received treatment for left knee pain, not right, for the following five months. Moreover, that treatment record notes "no records" under the "comments" section, and the treatment provider specifically asked the Veteran to "bring records" to his follow-up appointment scheduled for April. In April 1995, the Veteran reported continued left knee pain despite injection, pain relievers, and rest. The diagnoses included chronic left knee pain and possible neuroma and/or post-trauma scar tissue. The Veteran was advised to run at his own pace and distance for the next ten days. In May 1995, the Veteran reported continued left knee pain. A physical examination revealed mild crepitus without any evidence of pain and no effusion or tenderness to palpation. The assessment included left knee pain and possible prepatellar bursitis. The Veteran was given a profile to run at his own pace. Subsequent service treatment records show no additional complaints of left knee pain after May 1995. Upon the Veteran's discharge from active duty, he reported having or having a history of swollen or painful joints and arthritis, rheumatism, or bursitis on a November 1995 report of medical history. However, he did not specify the location of his joint pain and whether it was still present. A November 1995 report of medical examination shows that the Veteran's lower extremities and musculoskeletal system were normal upon his discharge from active duty. After service, the Veteran filed a claim for service connection for left knee disability in March 1998 and a bilateral knee disability in December 2000. In February 1999, a psychiatric treatment provider noted that the Veteran had griding on patellofemoral testing, and the treatment indicated that he thought the Veteran had patellofemoral arthritis. However, despite records showing treatment for numerous orthopedic issues, post-service treatment records show no treatment for a left knee condition until approximately October 2012. See AZ, 731 F.3d at 1311. At that time, the Veteran reported scraping his left shin and striking his left kneecap at work five days earlier, and he denied any past chronic conditions. The assessment was contusions of the left knee, shin, and hip and strain of the left hip external rotator muscles. Thereafter, a February 2009 medical examination conducted during the Veteran's National Guard service shows that his lower extremities and musculoskeletal system were normal, and he denied any swollen or painful joints; arthritis, rheumatism, or bursitis; knee trouble; dislocated joints, including knees; or limitation of motion of any joints, including knees, on an accompanying report of medical history. In February 2013, the Veteran reported slipping on ice and landing on his left knee and hip and slipping again, twisting his left knee and ankle. In March 2013, the Veteran reported continued pain after falling on ice about two weeks earlier. An MRI of the left knee revealed ACL, PCL, and MCL sprains; joint effusion with pronounced synovitis, mild prepatellar bursitis, nonspecific patchy intermediate to increased signal noted of bone marrow without definite confluent contusion or fracture; and sprain of popliteus muscle. Subsequent treatment records show continued complaints of left knee pain between 2013 and 2014. The Veteran underwent a VA knee examination in August 2015, during which he reported sustaining multiple knee injuries during service from falling on ice and current symptoms of knee swelling and soreness with walking. The examiner diagnosed the Veteran with left knee bursitis and opined that it was less likely than not incurred in or caused by service. In support of this, the examiner explained that service treatment records showed no additional treatment for left knee pain after May 1995, and there were no left knee complaints noted on the Veteran's separation examination. The examiner further explained that post-service treatment records show no left knee symptoms for many years after service, and the Veteran sustained a clear left knee injury after service, which was unrelated to his in-service knee symptoms. The Board finds the opinion of the VA examiner to be highly probative and persuasive, as it is supported by a reasoned medical explanation based on a review of the evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Although the Veteran believes that he has a current left knee disability that is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v, 492 F.3d at 1377. In this regard, the diagnosis and etiology of knee disabilities are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis and/or etiology of a current left knee disability is not competent medical evidence. As the preponderance of the evidence is against a finding that a current left knee disability is related to service, service connection for a left knee disability is denied. 4. Entitlement to service connection for a right knee disability Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that a current right knee disability was incurred in or caused by service. Service treatment records show that in March 1995, the Veteran reported right knee pain for the past five months ever since he fell on it in October 1994. However, as found above, the Board finds that the notation of "right" knee pain was clearly an error, as the Veteran injured his left knee in the October 1994 fall and was placed on physical profile and received treatment for left knee pain, not right, for the following five months. Moreover, the treatment provider indicated that no records were available at that appointment. Upon the Veteran's discharge from active duty, the Veteran reported having or having a history of swollen or painful joints and arthritis, rheumatism, or bursitis on a November 1995 report of medical history. However, he did not specify the location of his joint pain and whether it was still present. A November 1995 report of medical examination shows that the Veteran's lower extremities and musculoskeletal system were normal upon his discharge from active duty. After service, a February 1999 psychiatric treatment provider noted that the Veteran had griding on patellofemoral testing, and the treatment indicated that he thought the Veteran had patellofemoral arthritis. In December 2000, the Veteran filed a claim for service connection for a bilateral knee disability. Thereafter, a February 2009 medical examination conducted during the Veteran's National Guard service shows that his lower extremities and musculoskeletal system were normal, and he denied any swollen or painful joints; arthritis, rheumatism, or bursitis; knee trouble; dislocated joints, including knees; or limitation of motion of any joints, including knees, on an accompanying report of medical history. In November 2009, the Veteran sought treatment for right ankle pain, and he specifically denied any knee pain associated with it. Despite records showing treatment for numerous orthopedic issues, post-service treatment records show no actual treatment for a right knee condition until approximately June 2010. See AZ, 731 F.3d at 1311. At that time, the Veteran reported right hip pain with occasional radiation to the posterior knee after slipping on gravel. Thereafter, in January 2011, the Veteran reported right knee pain ever since he slipped on ice and hit his knee on the doorjamb of a car the day before. An MRI of the right knee revealed prepatellar soft tissue swelling, no joint effusion or fracture, and well-maintained joint spaces. The assessment was a contusion and right knee strain. The Veteran underwent a VA knee examination in August 2015, during which he reported multiple knee injuries during service from falling on ice. He also reported sudden onset of knee pain, possible the right, while painting on a ladder after service and current symptoms of knee swelling and soreness with walking. The examiner diagnosed the Veteran with right knee bursitis and opined that it was less likely than not incurred in or caused by service. In support of this, the examiner explained that although a service treatment record noted a complaint of right knee pain, it should have said "left," as it was actually the Veteran's left knee that injured. The Veteran underwent a VA examination of his right knee again in January 2016, during which he reported slipping and falling on his right knee multiple times during service, which he claimed was diagnosed as bursitis, and he reported current symptoms of intermittent right knee discomfort. The examiner diagnosed the Veteran with right knee patellofemoral syndrome versus bursitis and opined that it was less likely than not that a current right knee disability was incurred in or caused by service. In support of this, the examiner explained that the Veteran injured his left knee during service, and there was no evidence of a right knee injury during service or persistent right knee symptoms since service. The examiner further noted that a 2009 National Guard report of physical examination made no mention of a chronic right knee problem, and the Veteran reported slipping and hitting his knee on a door jamb of a car years after service in 2011. The Board finds the opinion of the VA examiners to be highly probative and persuasive, as they are supported by reasoned medical explanations based on a review of the evidence of record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Although the Veteran believes that a current right knee disability is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v, 492 F.3d at 1377. In this regard, the diagnosis and etiology of knee disabilities are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis and/or etiology of a current right knee disability is not competent medical evidence. As the preponderance of the evidence is against a finding that a current right knee disability is related to service, service connection for a right knee disability is denied. In reaching the above conclusions, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claims, the doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a neck disability is remanded. Service treatment records show that the Veteran was diagnosed with a cervical strain in October 1995. The Veteran underwent a VA examination in August 2015, and the examiner opined that the Veteran's currently diagnosed arthritis at C6-7 was less likely than not incurred in or caused by service. In support of this, the examiner explained, in part, that the in-service muscle strain resolved without any sequela, and post-service treatment records show that the Veteran was first treated for neck, thoracic, and lumbar issues after a 2001 post-service motor vehicle accident. However, post-service treatment records shows that that the Veteran report neck and upper middle back pain prior to that, in November 1998. Accordingly, the claim is remanded to obtain a supplemental opinion. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) 2. Entitlement to service connection for a left eye scar is remanded. During the August 2016 Board hearing, the Veteran testified that he had a scar resulting from the in-service physical altercation. As previously noted, service treatment records show that the Veteran was assaulted in a night club in October 1995. Additionally, he received sutures for a left temporal scalp laceration following the syncopal episode in the sauna in June 1995. The only identifying body mark noted on the Veteran's November 1995 separation examination was a scar on the left thigh. However, in light of the in-service laceration to the left temporal scalp, the Board finds that Veteran should be provided with a VA scars examination to determine whether he has a scar near the left eye that is related to service. See McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). 3. Entitlement to service connection for a left hip and/or thigh disability is remanded. Treatment records show that the Veteran sustained a left thigh/groin strain in August 2011 during a relay race while performing physical training with the Wisconsin Army National Guard. As noted above, for National Guard service, ACDUTRA is defined as full-time duty performed by members of the National Guard of any State under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(22)(C); 38 C.F.R. § 3.6(c)(3). INACDUTRA is defined as duty (other than full-time duty) performed by a member of the National Guard of any State under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d)(4). Thus, in order for National Guard service to be qualifying service for VA compensation purposes, the period of service must have been "federalized," that is to say, his or her unit was ordered into Federal service under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 C.F.R. § 3.6 (c), (d). In the January 2019 remand, the Board directed the agency of original jurisdiction (AOJ) to obtain a medical opinion as to whether a current left hip or thigh disability is related to the left thigh strain the Veteran sustained during training in August 2011. However, the Veteran's personnel records do not show that the physical training with the Wisconsin National Guard in August 2011 was federalized service under 32 U.S.C. §§ 316, 502, 503, 504, or 505. 38 C.F.R. § 3.6 (c), (d). To the extent that the Board's prior remand directives may be interpreted as finding the Veteran sustained a left hip or thigh injury during a period of ACDUTRA or INACDUTRA, as defined by applicable VA regulations, the Veteran is on notice that the Board has not made such a determination. See, e.g. Smith v. Wilkie, 32 Vet. App. 332, 339 (2020) (an appellant must first be given notice and an opportunity to respond before the Board reverses a prior Board remand's characterization of evidence as credible). Accordingly, the claim is remanded to provide the Veteran with an opportunity to respond to this notice. The matters are REMANDED for the following action: 1. Provide the claims file to an appropriate VA clinician to obtain a medical opinion with respect to the Veteran's claim for service connection for a neck disability. Do not schedule the Veteran for another examination unless it is deemed necessary by the examiner to respond to the question presented. Following a review of the claims file, the clinician should provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran's current arthritis of the cervical spine was incurred in or caused by service, including an October 1995 cervical strain. A complete rationale must be provided. The examiner's opinion should reflect consideration of post-service treatment records showing complaints of neck and upper middle back pain as early as November 1998 (Medical treatment record Government Facility, received 12/21/00). 2. Provide the Veteran with a VA scars examination. After examination and review of the claims file, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran has any scars near the left eye that are related to the October 1995 altercation at a night club and/or the June 1995 left temporal scalp laceration. A complete rationale for all opinions should be provided. 3. Advise the Veteran to submit any evidence he has showing the physical training with the Wisconsin National Guard in August 2011 was federalized service under 32 U.S.C. §§ 316, 502, 503, 504, or 505. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Banister, 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.