Citation Nr: 21065893 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 16-42 912 DATE: October 27, 2021 ORDER Entitlement to an initial compensable rating for deviated nasal septum is denied. Entitlement to an initial rating in excess of 20 percent for right shoulder strain is denied. REMANDED Entitlement to service connection for left shoulder condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for low back condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for left knee condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for right knee condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for bilateral plantar fasciitis, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for sinusitis, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for cervical spine degenerative joint disease, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for right ankle condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for sleep apnea and associated sleeping disorder, to include as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. The Veteran's deviated nasal septum due to trauma is not manifested by a 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side. 2. The Veteran's right (dominant) shoulder strain results in painful limitation of motion at the shoulder level but is not shown to be manifested by nonunion or dislocation of the clavicle or scapula, a humerus impairment, or ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for deviated nasal septum are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.951(b), 4.3, 4.7, 4.97, Diagnostic Code 6502 (2021). 2. The criteria for an initial rating in excess of 20 percent for right shoulder strain are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5201 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from November 1982 to November 1985. These matters are before the Board of Veterans' Appeals (Board) on appeal from August 2015 and August 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a January 2017 rating decision, the Agency of Original Jurisdiction (AOJ) increased the Veteran's rating for his right shoulder disability from 10 percent to 20 percent effective December 29, 2013. The Veteran's claims for entitlement to service connection for left shoulder condition, low back condition, bilateral knee conditions, bilateral plantar fasciitis, and sinusitis; and claims for an increased rating for a deviated nasal septum and right shoulder disability were previously before the Board in December 2018 when the Board remanded them for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). With respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Degenerative and/or traumatic arthritis as shown by X-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the United States Court of Appeals for Veterans Claims (Court) rejected VA's argument that § 4.59 requires painful motion, such that the mere presence of joint pain is not sufficient. Id. at 428-29. The Court held that under § 4.59, "the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint," explaining that § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that § 4.59 does not require "objective" evidence but can be satisfied with lay and other non-medical evidence. Id. at 429. 1. Deviated Nasal Septum The Veteran and his attorney generally contend the Veteran is entitled to an increased rating for his deviated septum. See VA Form 21-0958, Notice of Disagreement (NOD), dated June 2016. The AOJ has assigned a noncompensable rating for the Veteran's deviated septum under Diagnostic Code 6502. Under Diagnostic Code 6502, deviation of the nasal septum is assigned a 10 percent rating when there is a 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97. A November 2017 computed tomography (CT) of the sinuses showed a deviated nasal septum to the left. A December 2019 X-ray of the sinuses showed a deviated nasal septum to the left, and a December 2019 X-ray of the nasal bones showed mild leftward deviation of the nasal septum. May 2015, November 2019, and November 2020 VA examination reports for the Veteran's deviated nasal septum reflect that the Veteran's nasal passages were not 50 percent obstructed and that neither passage was completely obstructed. Aside from the medical evidence above, the Board notes the Veteran's reports at his VA examinations of residual facial discomfort, obstructed airflow, and congestion. The Board also notes the Veteran's reports that he uses Flonase. Regarding the Veteran's report of obstructed airflow, the determination of the percentage of nasal airway obstruction is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As the Veteran is not shown to be other than a layperson without the appropriate training and expertise to make the medical determination required, he is not competent to provide a medical opinion upon which this claim turns. Therefore, based on the three VA examinations, the preponderance of the evidence is against a finding that the Veteran's deviated nasal septum due to trauma has resulted in a 50-percent obstruction of the nasal passage on both sides or a complete obstruction on one side. The Board has considered whether another diagnostic code would afford a higher or separate rating. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Although there is an indication the Veteran has sinusitis, the Veteran has a claim pending for service connection for sinusitis. As the claim for that disability is currently pending, it would be improper to evaluate the deviated nasal septum under the sinusitis rating criteria. If the claim of service connection for sinusitis is later granted, the disability will be properly evaluated at that time. Therefore, a preponderance of the evidence is against a finding that a higher rating is warranted under other diagnostic codes for the nose or respiratory system. As such, a preponderance of the evidence is against a finding that the Veteran is entitled to a compensable rating under Diagnostic Code 6502. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App., 49, 53-56 (1990). 2. Right Shoulder The Veteran and his attorney generally contend the Veteran is entitled to an increased rating for his right shoulder disability. See VA Form 21-0958, Notice of Disagreement (NOD), dated June 2016. The Veteran has been assigned a 20 percent rating for his service-connected right shoulder strain pursuant to the criteria of Diagnostic Code 5201. 38 C.F.R. § 4.71a. The November 2020 VA examination report reflects that the Veteran is right handed. Therefore, the Veteran's right upper extremity is his major upper extremity. Under Diagnostic Code 5201, for the major extremity, a 20 percent rating is assigned for limitation of motion at shoulder level, a 30 percent rating is assigned for limitation of motion midway between the side and shoulder level, and a 40 percent rating is assigned for limitation of motion to 25 degrees from side. 38 C.F.R. § 4.71a. Normal range of motion of the shoulder is flexion and abduction from 0 to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with 0 degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to 'limitation of motion of' the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Diagnostic Code 5200 evaluates ankylosis of the shoulder. The record contains no evidence of shoulder ankylosis, and the Veteran has not described symptoms that are suggestive of ankylosis. Therefore, this Diagnostic Code is not applicable and will be discussed no further. 38 C.F.R. § 4.71a. Diagnostic Code 5202 evaluates impairment of the humerus. The record contains no evidence of impairment of the humerus, and the Veteran has not described symptoms that are suggestive of impairment of the humerus. Therefore, this Diagnostic Code is not applicable and will be discussed no further. 38 C.F.R. § 4.71a. Diagnostic Code 5203 evaluates impairment of the clavicle or scapula. Under Diagnostic Code 5203, 20 percent is the highest schedular rating available; there also is no evidence of impairment of the clavicle or scapula. Therefore, this Diagnostic Code will not be discussed further. 38 C.F.R. § 4.71a. The rating criteria for Diagnostic Code 5201 were revised during the course of the Veteran's appeal, effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453, 76,463 (Nov. 30, 2020) (codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201). The amendment to Diagnostic Code 5201 continues to provide for the major extremity a 20 percent rating where range of motion is at shoulder level and explains that this is where flexion and/or abduction is limited to 90 degrees. A 30 percent rating continues to be warranted where range of motion is midway between the side and shoulder level, which is defined to be flexion and/or abduction limited to 45 degrees. A 40 percent rating is warranted where flexion and/or abduction is limited to 25 degrees from the side. The proposed rulemaking indicates that these revisions are not meant to alter the previously applicable rating criteria, but are meant to clarify the specific ranges of motion that qualify as limitations to ensure rating personnel consistently apply the criteria. 82 Fed. Reg. 35, 719, 35,722 (Aug. 1, 2017). Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted the Secretary of VA to do otherwise and the Secretary did so. See VAOGCPREC 7-2003. Additionally, VA's Office of General Counsel has determined that the amended rating criteria can be applied only for the period from and after the effective date of the regulatory change. The Board can apply only the former regulation to rate the disability for periods preceding the effective date of the regulatory change. However, the former rating criteria may be applied prospectively, beyond the effective date of the new regulation. See VAOPGCPREC 3-2000. Turning to the relevant medical evidence of record, the Veteran attended a VA examination in May 2015 for an evaluation of his right shoulder condition. The VA examiner diagnosed the Veteran with right shoulder strain. Range of motion testing revealed the Veteran had flexion to 140 degrees, abduction to 170 degrees, external rotation to 75 degrees, and internal rotation to 90 degrees. The Veteran had pain in all planes of motion, and the VA examiner noted that the Veteran's range of motion itself contributed to functional loss in the form of limited overhead reach. There was objective evidence of localized tenderness or pain on palpation in the glenohumeral joint line. The Veteran had pain with weight bearing, and there was objective evidence of crepitus. The Veteran had no additional loss of range of motion upon repetitive use testing. The VA examiner noted that pain significantly limited the Veteran's functional ability with repeated use over time. The VA examiner noted that pain significantly limited the Veteran's functional ability during flare-ups. The examiner noted that an additional contributing factor of disability is less movement than normal. The Veteran had normal right shoulder strength. The examiner noted the Veteran did not have ankylosis or an impairment of the humerus. The examiner noted that the functional impact of the Veteran's right shoulder condition was that the Veteran would have difficulty lifting with the right arm, overhead lifting, and overhead reaching. The Veteran reported pain, decreased range of motion, in that he could not "really reach over [his] head", and reduced strength in the right shoulder. He reported taking nonsteroidal anti-inflammatory drugs for treatment. In addition, he reported flare-ups once or twice a month that were moderate and lasted up to one week. He also indicated that changes in the weather could make the shoulder hurt more than usual. A January 2018 right shoulder X-ray showed moderate right glenohumeral osteoarthritis and decreased subacromial interval, which is suggestive of chronic rotator cuff degeneration. The Veteran attended an additional VA examination in November 2019 for an evaluation of his right shoulder condition. The VA examiner diagnosed the Veteran with right shoulder strain and degenerative arthritis. Range of motion testing revealed the Veteran had flexion to 110 degrees, abduction to 90 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The Veteran had pain in all planes of motion, and the examiner noted that the pain did not result in functional loss. Furthermore, the VA examiner noted that the Veteran's range of motion itself did not contribute to functional loss. There was objective evidence of localized tenderness or pain on palpation in the rotator cuff. The Veteran had pain with weight bearing, and there was objective evidence of crepitus. The Veteran had no additional loss of range of motion upon repetitive use testing. The VA examiner noted that pain, fatigue, and lack of endurance significantly limited the Veteran's functional ability with repeated use over time, and the examiner was able to describe in terms of range of motion. With repeated use, the examiner estimated flexion was to 100 degrees, abduction to 80 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The VA examiner noted that pain, fatigue, and lack of endurance significantly limited the Veteran's functional ability during flare-ups, and the examiner was able to describe in terms of range of motion. During flare-ups, the estimated flexion was to 100 degrees, abduction to 80 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The examiner noted that an additional contributing factor to disability is that he would be unable to lift more than 20 pounds. The Veteran had normal right shoulder strength. The examiner noted the Veteran did not have ankylosis or an impairment of the humerus. The examiner noted that the functional impact of the Veteran's right shoulder condition was that the Veteran would be unable to lift more than 20 pounds. The Veteran reported deep pain, down inside the bone. He reported flare-ups where he cannot move his shoulder. The Veteran attended a final VA examination in October 2020 for an evaluation of his right shoulder condition. The VA examiner diagnosed the Veteran with right shoulder strain. Range of motion testing revealed the Veteran had flexion to 130 degrees, abduction to 130 degrees, external rotation to 80 degrees, and internal rotation to 80 degrees. The Veteran had pain with flexion and abduction, and the examiner noted that the pain caused functional loss. The VA examiner noted that the Veteran's range of motion itself did not contribute to functional loss. There was no objective evidence of localized tenderness or pain on palpation. The Veteran had no pain with weight bearing, and there was no objective evidence of crepitus. The Veteran had no additional loss of range of motion upon repetitive use testing. The VA examiner noted that pain significantly limited the Veteran's functional ability with repeated use over time, and the examiner was able to describe in terms of range of motion. With repeated use, the examiner estimated flexion to 120 degrees, abduction to 120 degrees, external rotation to 80 degrees, and internal rotation to 80 degrees. The VA examiner noted that pain significantly limited the Veteran's functional ability during flare-ups, and the examiner was able to describe in terms of range of motion. During flare-ups, the estimated flexion to 120 degrees, abduction to 120 degrees, external rotation to 80 degrees, and internal rotation to 80 degrees. The examiner noted that there were no additional contributing factors to disability. The Veteran had normal right shoulder strength. The examiner noted the Veteran did not have ankylosis or an impairment of the humerus. The examiner noted that the functional impact of the Veteran's right shoulder condition was that Veteran would have difficulty lifting greater than 25 pounds overhead in an occupational setting due to pain. The Veteran reported severe flare-ups that occur weekly and last several hours. He stated the flare-ups are precipitated by overhead lifting and are alleviated by rest. He reported having difficulty with overhead lifting. The Veteran's right shoulder disability has manifested primarily in limited motion and pain. A preponderance of the evidence is against a finding the Veteran is entitled to a rating in excess of 20 percent. Under Diagnostic Code 5201, a 30 percent rating is assigned for limitation of motion midway between side and shoulder level. There has been no point during the appeal period where the Veteran's right shoulder range of motion has been limited to midway between the side and shoulder level; indeed, at worst, the Veteran's flexion has been 100 degrees and abduction has been measured to 80 degrees. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. §§ 4.40, 4.45. The Board recognizes the Veteran's complaints of pain and functional loss as a result of his right shoulder condition, notably his difficulty with lifting, carrying, and movement, as reflected in the VA examination reports. However, when considering the Veteran's functional loss and the Veteran's reports of pain and functional limitations during flare ups, the November 2019 and October 2020 examiners estimated that during periods of flare ups and after repeated use over time, the Veteran would be able to move the right arm to no less than 100 degrees for flexion and no less than 80 degrees for abduction. The functional impact from the Veteran's flare-ups and after repeated use over time do not in themselves show further functional impairment, but rather indicate the very symptoms and functional impairment upon which the 20 percent rating is already assigned. Therefore, the evidence does not more nearly approximate that his motion was limited to midway between the side and shoulder, even when considering functional impairment from flare-ups and after repeated use over time. Thus, a rating in excess of 20 percent is not warranted. The Board acknowledges the Veteran's attorney's February 2021 Third Party Correspondence where the attorney contended there has been no discussion of the Veteran's flare-ups for his right shoulder condition. However, as noted above, the November 2019 and October 2020 VA examiners provided estimates for the Veteran's right shoulder range of motion during flare-ups and that information has been considered in evaluating the Veteran's claim for an increased rating. Thus, the Board concludes there has been compliance with Sharp v. Shulkin, 29 Vet. App. 26 (2017). Regarding the amended rating criteria effective February 7, 2021, the amendment specifies that midway between side and shoulder level is defined as 45 degrees and at shoulder level is defined as 90 degrees. The proposed rulemaking clarifies that this means 45 degrees or less, and 90 degrees or less. 82 Fed. Reg. at 35,722. The Board acknowledges that there is no medical evidence pertinent to the Veteran's right shoulder claim since the amended regulations went into effect; however, as is noted above, there has been no point throughout the appeal period where the Veteran's right shoulder range of motion has been limited to less than 45 degrees from the side. Notably, at the October 2020 VA examination, the most recent medical evidence of record, the Veteran had flexion to 120 degrees and abduction to 120 degrees. Thus, a rating in excess of 20 percent is not warranted under the amended Diagnostic Code 5201, from February 7, 2021. A 20 percent rating is the maximum evaluation under Diagnostic Code 5203; therefore, Diagnostic Code 5203 would not entitle the Veteran to a rating in excess of 20 percent. As is noted above, the evidence of record does not reflect the Veteran has ankylosis or impairment of the humerus; therefore, a rating in excess of 20 percent is not available under Diagnostic Codes 5200 or 5202. In sum, the Board finds the criteria for a rating in excess of 20 percent for the Veteran's service-connected right shoulder condition are not met. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the appellant's claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App., at 53-56. REASONS FOR REMAND 1. Left Shoulder 2. Low Back 3. Left and Right Knees 4. Bilateral Plantar Fasciitis Following the Board remand in December 2018 to in part obtain VA opinions as to the etiology of these conditions, the VA examiner opined in November 2020 that it is less likely than not that the Veteran's left shoulder condition, low back condition, left knee condition, right knee condition, and bilateral plantar fasciitis are directly related to service or caused or aggravated by a service-connected disability. However, the opinions in the record are inadequate for evaluation purposes as the opinions do not contain a discussion of the Veteran's lay statements, including whether the disabilities are related to an injury during the Veteran's service. Thus, as the November 2020 opinions and rationale do not reflect consideration of the Veteran's statements, additional VA opinions are necessary. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). 5. Sinusitis Following a November 2020 VA examination, the VA examiner opined that it is less likely as not that the Veteran has sinusitis that is directly related to his service or caused or aggravated by a service-connected disability. In support of the opinions, the examiner reasoned that there is no pathology to render a diagnosis of sinusitis. A review of the record illustrates that there are multiple diagnoses of sinusitis in the record, including a diagnosis at a November 2019 VA sinusitis examination. Thus, as the evidence of record illustrates that the Veteran has had sinusitis diagnosed during the appeal period, an additional VA opinion is necessary to adequately evaluate the Veteran's claim. 6. Cervical Spine Following an October 2019 VA examination, the VA examiner opined that it is less likely than not that the Veteran's cervical spine condition is proximately due to or the result of his service-connected right shoulder disability. Per VA regulations, service connection may be granted for a disability that is "proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310. Additionally, any increase in severity of a nonservice-connected disease (i.e., aggravation) that is proximately due to or the result of a service-connected disease will be service-connected. The October 2019 opinion does not address whether the Veteran's service-connected right shoulder disability has aggravated the Veteran's cervical spine condition. Therefore, as the October 2019 VA opinion is inadequate to evaluate the Veteran's claim for service connection for cervical spine condition, an additional VA opinion is necessary to adequately evaluate the etiology of the Veteran's cervical spine condition. 7. Right Ankle The Board cannot make a fully-informed decision on the issue of service connection for right ankle condition because no VA examiner has opined whether the Veteran has a right ankle condition that is related to his service. The Board notes that the record does not contain a diagnosis of a right ankle condition. However, the September 2018 VA Form 21-0958, Notice of Disagreement, reflects that the Veteran reported foot pain. Therefore, as it is unclear from the record whether the Veteran has a right ankle condition, the claim is remanded to afford a VA examiner the opportunity to clarify any diagnosis of the Veteran's right ankle, and if a diagnosis is not identified, then to determine if pain alone results in functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (if pain alone results in functional impairment, even if there is no identified underlying diagnosis, such pain can constitute a disability); see also Wait v. Wilkie, 33 Vet. App. 8 (2020) (to establish the presence of a disability pursuant to Saunders, there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity). 8. Erectile Dysfunction The Board cannot make a fully-informed decision on the issue of entitlement to service connection for erectile dysfunction because no VA examiner has opined whether the Veteran's erectile dysfunction is caused or aggravated by a service-connected disability. Thus, a remand is necessary to obtain a VA examination and opinion as to the nature and etiology of the Veteran's erectile dysfunction. 9. Sleep Apnea The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a sleep disorder because no VA examiner has opined whether the Veteran has a sleep disorder that is directly related to his service or is caused or aggravated by a service-connected disability, including a deviated septum. Thus, a remand is necessary to obtain a VA examination and opinion as to the nature and etiology of any sleep disorder, to include sleep apnea. The matters are REMANDED for the following actions: 1. Obtain and associate with the Veteran's electronic record VA treatment records from December 2020 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claims, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After completing the development requested in item 1, obtain a medical opinion from an appropriate reviewing clinician for the Veteran's left shoulder, low back, bilateral knee, bilateral plantar fasciitis, and cervical spine claims. The electronic claims file must be made available to the medical professional for review in connection with the request for an opinion. If the reviewing clinician determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the reviewing clinician should address the following: (a.) Left Shoulder Condition i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder condition is related or attributable to his military service, to include an injury during basic training? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder condition is caused by his service-connected right shoulder disability or any other service-connected disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder condition is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected right shoulder disability or any other service-connected disability? In answering questions (ii) and (iii), the reviewing clinician is asked to specifically address the Veteran's statement at his October 2020 VA examination that he developed left shoulder pain in 1987 from compensating for his right shoulder disability. If the Veteran's left shoulder condition has been aggravated by his service-connected right shoulder disability or any other service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. (b.) Low Back Condition i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition is related or attributable to his military service? In answering this question, the reviewing clinician is asked to specifically address the Veteran's statement at his November 2019 VA examination that his back pain started in service after getting tackled during a football game, and his statement at his October 2020 VA examination that he developed back pain from physical training. ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition is caused by a service-connected disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition is aggravated (i.e., any increase in the severity beyond its natural progression) by a service-connected disability? If the Veteran's low back condition has been aggravated by a service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. (c.) Left and Right Knee Conditions i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left and/or right knee conditions are related or attributable to his military service? In answering this question, the reviewing clinician is asked to specifically address the Veteran's statement at his May 2015 VA examination that his right knee pain began in basic training, and at his November 2019 and October 2020 VA examinations that his bilateral knee conditions are due to strenuous jumping and carrying heavy equipment and the physical training in service. ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left and/or right knee conditions are caused by a service-connected disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left and/or right knee conditions are aggravated (i.e., any increase in the severity beyond its natural progression) by a service-connected disability? If the Veteran's left and/or right knee conditions have been aggravated by a service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. (d.) Bilateral Plantar Fasciitis i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's bilateral plantar fasciitis is related or attributable to his military service? In answering this question, the reviewing clinician is asked to specifically address the Veteran's statement at his October 2020 VA examination that his bilateral plantar fasciitis is due to prolonged marching in service. ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's bilateral plantar fasciitis is caused by a service-connected disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's bilateral plantar fasciitis is aggravated (i.e., any increase in the severity beyond its natural progression) by a service-connected disability? If the Veteran's bilateral plantar fasciitis has been aggravated by a service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. (e.) Cervical Spine Condition i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine condition is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine condition is caused by his service-connected right shoulder disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's cervical spine condition is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected right shoulder disability? If the Veteran's bilateral cervical spine condition has been aggravated by a service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering the opinions requested in (a.) through (e.), the reviewing clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the development requested in item 1, obtain a medical opinion from an appropriate reviewing clinician for the Veteran's sinusitis claim. The electronic claims file must be made available to the medical professional for review in connection with the request for an opinion. If the reviewing clinician determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the reviewing clinician should address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed sinusitis (see November 2019 VA examination report) is related or attributable to his military service? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sinusitis is caused by his service-connected deviated nasal septum disability or any other service-connected disability? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's sinusitis is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected deviated nasal septum disability or any other service-connected disability? In addressing questions (b.) and (c.), the reviewing clinician is asked to specifically address the medical literature submitted on February 27, 2017 regarding a deviated nasal septum and sinusitis. If the Veteran's sinusitis has been aggravated by a service-connected disability, the reviewing clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering these opinions, the reviewing clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. After completing the development requested in item 1, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible) to determine the nature, extent, and etiology of any right ankle condition. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: (a.) Does the Veteran have a diagnosis of any right ankle condition or any symptoms that cause functional impairment of earning capacity? (b.) For any right ankle condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is related or attributable to his military service, to include the October 1983 in-service diagnosis of "bruised right ankle?" (c.) For any right ankle condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is caused by a service-connected disability? (d.) For any right ankle condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is aggravated (i.e., any increase in the severity beyond its natural progression) by a service-connected disability? If the Veteran's right ankle condition/functional loss has been aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 5. After completing the development requested in item 1, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible) for his erectile dysfunction claim. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction is caused by his service-connected posttraumatic stress disorder (PTSD) or any other service-connected disability? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected PTSD or any other service-connected disability? If the Veteran's erectile dysfunction has been aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 6. After completing the development requested in item 1, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible) for his sleep condition claim. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: (a.) Does the Veteran have a diagnosis of any sleep condition, to include sleep apnea, or any symptoms that cause functional impairment of earning capacity? (b.) For any sleep condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is related or attributable to his military service? (c.) For any sleep condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is caused by his service-connected PTSD, traumatic brain injury (TBI), tinnitus, and/or deviated nasal septum? (d.) For any sleep condition/functional loss, is it at least as likely as not (50 percent or greater probability) that such is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected PTSD, traumatic brain injury (TBI), tinnitus, and/or deviated nasal septum? In addressing questions (c.) and (d.), the examiner is asked to specifically address the medical literature submitted on September 7, 2018 regarding acquired psychiatric disorders and sleep apnea and on December 13, 2019 regarding a deviated nasal septum and sleep apnea. If the Veteran's sleep condition/functional loss has been aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Breitbach, 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.