Citation Nr: 21066290 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 17-08 626 DATE: October 29, 2021 ORDER Entitlement to a rating in excess of 20 percent for left knee degenerative joint disease with limited flexion is denied. Entitlement to a separate 10 percent rating for left knee degenerative joint disease with recurrent subluxation is granted. Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease with limited extension is denied. Entitlement to a rating in excess of 30 percent for right shoulder mild acromioclavicular (AC) joint degenerative joint disease is denied. Entitlement to an initial rating in excess of 10 percent for hypertension is denied. Entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU) is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for sleep disturbances is remanded. Entitlement to service connection for a left shoulder disorder is remanded. FINDINGS OF FACT 1. The Veteran's left knee degenerative joint disease with limited flexion is manifested by flexion to 90 degrees. 2. The Veteran has a left knee disability manifested by slight subluxation. 3. The Veteran's left knee degenerative joint disease with limited extension is manifested by extension to 10 degrees. 4. The Veteran's right shoulder mild AC joint degenerative joint disease is manifested by flexion to 50 degrees and abduction to 45 degrees of the major extremity. 5. During the appeal period, the Veteran's hypertension did not manifest in diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 6. The Veteran is service connected for headaches, right shoulder, left knee, lung cancer, right knee, tinnitus, hypertension, right elbow, and scars disabilities; he meets the schedular criteria for consideration for TDIU. 7. The Veteran has not been able to maintain substantially gainful employment during this appeal; his service-connected disabilities preclude substantially gainful employment consistent with his educational background and occupational experience. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for left knee degenerative joint disease with limited flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 2. The criteria for a separate 10 percent rating for left knee degenerative joint disease with recurrent subluxation are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for a rating in excess of 20 percent for left knee degenerative joint disease with limited extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 4. The criteria for a rating in excess of 30 percent for right shoulder mild AC joint degenerative joint disease are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 5. The criteria for a rating in excess of 10 percent for hypertension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101. 6. The criteria for TDIU are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from August 1969 to July 1971, and from August 2008 to February 2010. This matter is on appeal from July and September 2016 rating decisions and was previously remanded by the Board of Veterans' Appeals (Board) in July 2020. The Board also remanded the issue of service connection for a right knee disorder, which was granted in a July 2021 rating decision. In light of the grant, that issue is no longer on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In making the below determinations, the Board notes that neither the Veteran nor his representative has raised any other issues, nor has the record reasonably raised any other issues. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). 1. Entitlement to a rating in excess of 20 percent for left knee degenerative joint disease with limited flexion The Veteran contends that he is entitled to a higher rating. The Veteran's left knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Effective February 7, 2021, VA amended certain rating criteria for disabilities of the knee and leg. However, Diagnostic Code 5260 was unchanged. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the left knee disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, less movement than normal, disturbance of locomotion, interference with sitting and standing, and stiffness. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experienced flare-ups five to six times per day with his knee getting red and popping, as well as having increased pain, would not result in limitation of motion more nearly approximating flexion limited to 15 degrees. The June 2016 VA examination shows that the Veteran reported flare-ups as noted above. He had flexion from 10 to 30 degrees at that examination. He also experienced functional loss in being unable to squat. The examiner opined that they were not able to objectively quantitate symptoms or range of motion changes associated with repeated use over time and with flare-ups without resorting to mere speculation. The May 2021 VA examination shows that the Veteran reported monthly flare-ups lasting about 20 minutes, and were moderate in severity. He had flexion to 100 degrees with active and passive motion. There was pain with active and passive motion that caused functional loss. Functional loss included not being able to run, only being able to walk about half a mile, and only standing for about 15 minutes. There was no additional limitation following repetition. The examiner opined that with repeated use over time and during flare-ups, flexion was limited to 90 degrees with pain. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The June 2016 examination shows favorable ankylosis in slight flexion at ten degrees, although no ankylosis was shown at the 2021 examination. Ankylosis of the knee is, in essence, a form of limitation of flexion. Assigning a separate rating for ankylosis shown in 2016 would constitute pyramiding, as the Veteran's symptomatology is compensated for with the 20 percent rating for limitation of flexion. Therefore, a separate rating under Diagnostic Code 5256 for ankylosis is not warranted. The examinations and treatment records do not reflect dislocated semilunar cartilage, removal of semilunar cartilage, impairment of tibia and fibula, or genu recurvatum. Therefore, separate ratings under Diagnostic Codes 5258, 5259, 5262, or 5263 are not warranted. However, the evidence does support a separate 10 percent rating for slight recurrent subluxation under Diagnostic Code 5257, which evaluates other impairment of the knee. Diagnostic Code 5257 was amended effective February 7, 2021. The old criteria provides for a 10 percent rating for slight recurrent subluxation or lateral instability. The amended criteria provides for ratings with sprain, incomplete ligament tear, or complete ligament tear, which has not been shown. The 2016 examination specifically shows a history of recurrent subluxation, which the examiner indicated was slight in severity. No recurrent subluxation or persistent instability was shown at the 2021 examination. However, based on the 2016 examination findings, the Board concludes that a separate 10 percent rating under Diagnostic Code 5257, though not more, is warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for left knee limitation of flexion. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. However, the Board also finds that the preponderance of the evidence supports the assignment of a separate 10 percent rating under Diagnostic Code 5257 for slight recurrent subluxation. To that extent, the appeal is granted. 2. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease with limited extension The Veteran contends that he is entitled to a higher rating. The Veteran's left knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5261, for limitation of extension of the leg. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Effective February 7, 2021, VA amended certain rating criteria for disabilities of the knee and leg. However, Diagnostic Code 5261 was unchanged. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the left knee disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, less movement than normal, disturbance of locomotion, interference with sitting and standing, and stiffness. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experienced flare-ups five to six times per day with his knee getting red and popping, as well as having increased pain, would not result in limitation of motion more nearly approximating extension limited to 15 degrees. The June 2016 VA examination showed extension of 30 to 10 degrees. The May 2021 VA examination revealed extension to 5 degrees with pain for active and passive motion. There was no change in motion following repetition. The examiner opined that with repeated use over time and during flare-ups, extension would be limited to 5 degrees with pain. Functional impairment for both examinations was discussed above in rating limitation of flexion, and will not be repeated. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62. The Veteran is already in receipt of separate ratings for limitation of flexion under Diagnostic Code 5260, and now for recurrent subluxation under Diagnostic Code 5257. As discussed above, a separate rating under Diagnostic Code 5256 for ankylosis would constitute pyramiding, and the criteria for separate ratings under Diagnostic Codes 5258, 5259, 5262, and 5263 are not met. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for left knee limitation of extension. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a rating in excess of 30 percent for right shoulder mild AC joint degenerative joint disease The Veteran contends that he is entitled to a higher rating. The Veteran's right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. 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). Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for the right shoulder disability. The evidence of record shows that the Veteran is right-handed, as per a June 2016 VA examination. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the Veteran experienced severe flare-ups with increased pain occurring two to three times a day and lasting for 15 to 30 minutes, would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the major extremity. The 2016 VA examination showed that he had flexion to 50 degrees and abduction to 45 degrees. The examiner opined that they were not able to objectively quantitate symptoms or range of motion changes associated with repeated use over time and with flare-ups without resorting to mere speculation. A May 2021 VA examination revealed flexion and abduction both to 90 degrees in active and passive motion with pain noted on motion. There was no additional loss of motion following repetition. With repeated use over time and during flare-ups, flexion and abduction were each reported to be limited to 80 degrees with pain. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The examinations and treatment records all fail to show ankylosis, impairment of humerus, or impairment of clavicle or scapula. Therefore, higher ratings under Diagnostic Codes 5200, 5202, and 5203 are not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 30 percent for the right shoulder disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to an initial rating in excess of 10 percent for hypertension The Veteran contends that he is entitled to a higher rating. Hypertension is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension). Under Diagnostic Code 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. For the reasons that follow, the Veteran's hypertension has manifested in continuous medication being required for control, corresponding to the criteria for a 10 percent rating under Diagnostic Code 7101. A June 2016 VA examination shows that the Veteran reported being prescribed medication for his hypertension. The examination, as well as treatment records during this appeal, have not shown diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 10 percent for the hypertension disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to TDIU The Veteran seeks a TDIU. He contends that his disabilities render him unemployable. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has the following disabilities that are service connected: headaches, right shoulder, left knee, lung cancer, right knee, tinnitus, hypertension, right elbow, and scars. The Veteran's headaches are associated with his hypertension, and are rated as 30 percent disabling from February 26, 2016, to December 3, 2018, and as 50 percent from December 3, 2018. The Veteran's hypertension is rated as 10 percent throughout this appeal. The combined disability rating for those disabilities is at least 40 percent since February 26, 2016. 38 C.F.R. § 4.25. The Veteran's combined disability rating during this appeal is 80 percent from February 26, 2016, and 90 percent from December 3, 2018. Since the Veteran's service-connected headaches are secondary to his service-connected hypertension, the combined 40 percent rating is sufficient to satisfy the requirements for TDIU because the disabilities resulted from a common etiology and are therefore considered one disability in combination for the purpose of meeting the percentage thresholds for TDIU. Based on the forgoing, the Veteran has at least one disability rated at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). For the reasons that follow, the Board finds that a TDIU is warranted. The Veteran last worked as in the National Guard as a warehouse material handler in 2011. He completed two years of college. See August 2019 VA Form 21-8940. The Veteran's ability to secure and follow a substantially gainful occupation is impacted by the physical effects of his service-connected headache and orthopedic disabilities. The June 2016 VA examination for his knees shows that the Veteran had increased pain with prolonged standing, sitting, and walking. He reported that his left knee felt unstable. The June 2016 VA examination for his right shoulder reveals that lifting his arms in front of him or above his head was not possible, and that he had very restricted range of motion. A December 2018 private evaluation for his headaches shows that he experienced prostrating headaches three to four times daily requiring him to lie down in a dark room for 15 to 20 minutes each time. He was opined to be unable to sustain adequate concentration, and was not productive during prostrating episodes. A private December 2018 evaluation discussing all of the Veteran's disabilities shows that he was unemployable due to symptoms from his right shoulder, left knee, right elbow, lung, and hypertension disabilities. A thorough rationale discussing the disabilities was provided. Given the forgoing, the Veteran's service-connected disabilities preclude him from the ability to secure and follow a substantially gainful occupation consistent with his education, skills, training, and work history. As noted above, the Veteran last worked as a warehouse material handler. His service-connected right shoulder disability, his dominant hand, renders him unable to lift his arm in front of him or above his head. His knee disabilities impact his ability to stand, sit and walk. Further, his headaches impair his concentration. From December 3, 2018, his headaches alone are rated as 50 percent disabling, which contemplates attacks productive of severe economic adaptability. 38 C.F.R. § 4.124(a), Diagnostic Code 8100. Throughout this appeal, the Veteran's combined disability rating has been at least 80 percent. Considering the overall impact of his service-connected disabilities, along with his employment and education background, the Veteran is unemployable due to his disabilities. Accordingly, TDIU is warranted. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected disabilities, is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of service connection for an acquired psychiatric disorder. Stegall v. West, 11 Vet. App. 268, 271 (1998). The July 2020 remand directed that medical opinions be obtained as to whether an acquired psychiatric disroder is caused by or aggravated by service-connected disabilities. Opinions were obtained in May 2021. The examiner opined that the acquired psychiatric disorder was not caused or aggravated by service-connected disabilities. However, the rationale for both opinions addressed service-connection on a direct basis. Indeed, the examiner provided the same exact rationale for service connection on both direct and secondary bases. Therefore, the opinions regarding whether a psychiatric disorder is secondar to service-connected disabilities are not adequate, and another remand is required. 2. Entitlement to service connection for sleep disturbances is remanded. The May 2021 psychiatric examination lists chronic sleep impairment as a symptom of the diagnosed depressive disorder. The Board finds that the issue of service connection for sleep disturbances is related to the issue of service connection for an acquired psychiatric disorder, and must also be remanded. 3. Entitlement to service connection for a left shoulder disorder is remanded. The Veteran was provided a VA examination in May 2021 and was diagnosed with a left shoulder strain. The Veteran reported incurring an in-service injury when he was hit by the door of a five ton cargo truck. No medical opinion was obtained regarding whether the currently diagnosed strain is related to the reported in-service injury. A remand for a medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from the May 2021 VA mental disorders examiner (or, if unavailable, from a medical professional with appropriate expertise) to determine the etiology of any diagnosed acquired psychiatric disorder and sleep disturbances. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that any diagnosed acquired psychiatric disorder is caused or is aggravated by service-connected disabilities. (If an acquired psychiatric disorder is found to have been aggravated by service-connected disabilities, the examiner should quantify the approximate degree of aggravation.) The examiner should also opine as to whether the Veteran has a separately diagnosed sleep disorder, or whether sleep disturbances are a symptom of his acquired psychiatric disorder. A complete rationale should be given for all opinions and conclusions expressed. 2. Obtain an addendum medical opinion from the May 2021 VA shoulder and arm conditions examiner (or, if unavailable, from a medical professional with appropriate expertise) to determine the etiology of the diagnosed left shoulder strain. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that the diagnosed left shoulder strain is related to the Veteran's service, including his reported injury of being hit by the door of a five ton cargo truck. A complete rationale should be given for all opinions and conclusions expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Barstow, 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.