Citation Nr: 21067260 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-63 689 DATE: November 3, 2021 ORDER Entitlement to service connection for bilateral shin splints is granted. Entitlement to service connection for colon cancer to include as due to exposure to contaminated water at Camp Lejeune is denied. Entitlement to a 10 percent rating prior to September 12, 2018 for umbilical hernia is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 20 percent from September 12, 2018 for umbilical hernia is denied. Entitlement to a separate 10 percent rating during the appeal period for painful residual scar due to the umbilical hernia is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for a bilateral ankle disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left eye disability is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for benign paroxysmal positional vertigo (BPPV) is remanded. Entitlement to service connection for diabetes mellitus, type 2 is remanded. Entitlement to service connection for ischemic heart disease is remanded. FINDINGS OF FACT 1. Bilateral shin splints are attributable to service. 2. Colon cancer was not manifest in service or to a degree of 10 percent within one year of separation and is otherwise unrelated to service, including exposure to herbicides or exposure to contaminated water at Camp Lejeune. 3. Prior to September 12, 2018, the Veteran's umbilical hernia was well supported by truss or belt; from September 12, 2018, the Veteran's umbilical hernia remained well supported by truss or belt. 4. During the appeal, the Veteran's umbilical hernia was manifest by one healed scar which was painful. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral shin splints are met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.306. 2. The criteria for service connection for colon cancer are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309. 3. Prior to September 12, 2018, the criteria for a 10 percent rating prior to September 12, 2018 for umbilical hernia are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, 4.118, Diagnostic Codes 7338, 7339. 4. From September 12, 2018, the criteria for a rating in excess of 20 percent for umbilical hernia are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7339. 5. For the appeal period, the criteria for a separate 10 percent rating for one painful residual scar due to the umbilical hernia are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Marine Corps from November 13, 1972 to September 30, 1995. Shin Splints Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service treatment records (STRs) show that the Veteran was treated on multiple occasions for bilateral shin splints in the mid-1970s. He has credibly indicated that he continued to experience shin splints thereafter. The Veteran has a lay person is capable of stating that he has shin splints as they are observable by him, particularly after his initial diagnoses. A VA examiner indicated the following: "The Veteran's c-file lacks objective medical evidence to confirm diagnosis or treatment for shin splints during military service. A nexus is not established." This is factually incorrect. Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In affording the Veteran reasonable doubt, the Board finds that service connection for bilateral shin splints is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Colon Cancer The Veteran had service at Camp Lejeune during a period of time associated with exposure to contaminated water at that base. Accordingly, the Regional Office (RO) conceded the Veteran's exposure to the contaminated water. The Veteran seeks service connection for colon cancer, which he asserts is related to his military service when he was exposed to contaminated water at Camp Lejeune. STRs do not show that the Veteran received treatment for complaints or symptoms associated with his colon. Post-service treatment records reflect that the Veteran was diagnosed as having colon cancer in 2015, decades after he retired from service in 1995. The Veteran's file to include his presumed inservice contaminated water exposure, was provided to a VA Subject Matter Expert (SME) Reviewer to determine if the Veteran's colon cancer is linked to an event, injury or illness in service, to include the exposure to the contaminated water at Camp Lejeune. In February 2017, the VA examiner opined that the Veteran's colon cancer and finding of appendicular carcinoid was not related to service. The examiner noted that in reviewing the specifics of the Veteran's claim to include the duration of exposure, the causation for the diagnosis is less likely than not a result of the Veteran's past exposure to Camp Lejeune contaminated water, as it is not a recognized presumptive condition and accordingly not supported by the associated VA evidence. The examiner indicated that there is no nexus supported by a sufficient medical explanation identified in support of the Veteran's claimed non-presumptive condition. The examiner indicated that the Veteran was exposed to Camp Lejeune contaminated water for a period of 525 days. He was subsequent diagnosed with the condition claimed in April 2015 at age 61; and approximately 38 years after service at Camp Lejeune. The claimed condition is not Camp Lejeune contaminated water presumptive. The medical records document a history of obesity and tobacco abuse, both risk factors for colon cancer. The examiner stated that the negative opinion was based on the lack of information in the world medical literature definitively linking low dose Camp Lejeune contaminated water exposures and colon cancer at the low levels measured in Camp Lejeune, and given the alternate non-Camp Lejeune contaminated water risk factors of age, tobacco smoking and BMI greater than 30. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307 (a)(7). The following diseases are deemed associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309 (f). As noted above, the Veteran is presumed to have been exposed to contaminated water during his military service at Camp Lejeune. However, colon cancer is not a disease for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. 38 C.F.R. § 3.309 (f). Therefore, a nexus linking the Veteran's colon cancer and military service cannot be presumed under this law, regardless of the Veteran's confirmed exposure to contaminated water during service. Notwithstanding the foregoing presumption provisions for exposure to contaminated water at Camp Lejeune, a claimant is not precluded from establishing service connection with proof of direct causation. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran has also indicated that he was exposed to Agent Orange during service. However, he does not contend that colon cancer resulted from the claimed exposure and there is no medical evidence of record suggesting a link between any diagnosis of colon cancer any claimed herbicide agent exposure. Moreover, colon cancer is not among those medical conditions for which presumptive service connection is warranted. 38 C.F.R. § 3.309 (e). Since it is not a presumptive disease, service connection would need to be shown on a direct basis. Combee. Therefore, the remaining questions for the Board are whether the claimed colon cancer disorder is directly related to service, or whether under the legal criteria for chronic diseases, the Veteran has a disease that was chronic in service, or manifested within the applicable presumptive period, or whether the onset was in service with a continuity of symptomatology since service. The Board finds that, while the Veteran has been diagnosed with colon cancer, a type of malignant tumor, which is a chronic disease under 38 U.S.C. § 1101 (3); 38 C.F.R. § 3.309 (a), it did not manifest in service and as such, was not chronic in service nor did it manifest to a compensable degree within one year of service. 38 U.S.C. §§ 1101 (3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.307, 3.309(a). Colon cancer is first shown decades after the Veteran's military service. Although service connection may be established for a disability that was incurred in or aggravated by military service or a malignant tumor may be presumed if manifested within a year of service, service connection for colon cancer is not warranted since this condition neither occurred in nor was caused by service. This condition is not one of the conditions shown to be related to contaminated water exposure at Camp Lejeune. A review of all the objective medical evidence does not show a reasonable possibility that this condition is caused by contaminated water exposure at Camp Lejeune. Moreover, colon cancer was not shown during service, manifest within a year of service, first arose decades after service, and it not shown to be etiologically related to service. In determining the weight assigned to this evidence, the Board looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the February 2017 VA medical opinion constitutes highly probative evidence against the claim. The VA medical opinion is based on a review of the entire medical record and review of medical literature. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The VA examiner sufficiently discussed the underlying medical rationale of the opinion, rather than a mere review of the claims file. Also probative are the medical records which initially document and show that the Veteran's colon cancer began many years after he retired from service. While the Veteran believes his colon cancer is related to an in-service injury, event, or disease, including exposure to contaminated water at Camp Lejeune, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Thus, while the Veteran believes his colon cancer is related to service the Board affords more probative weight to the opinion provided by the VA examiner. It is based on a review of the medical records and extensive review of the medical literature. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean, supra. The record is absent of any medical evidence supporting the assertion that the Veteran's colon cancer is etiologically related to his exposure to contaminated water at Camp Lejeune. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran's colon cancer and service. For these reasons, the Board finds that the preponderance of the probative evidence of record is against the Veteran's claim of service connection for colon cancer, to include as due to exposure to contaminated water at Camp Lejeune, on a direct or presumptive basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Rating for Umbilical Hernia, Status Post-Surgical Repair, with Scar Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In deciding the Veteran's higher rating claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. The Veteran's umbilical hernia was originally rated as noncompensable under Diagnostic Code 7338. Under that code, a zero percent disability rating is assigned for a small hernia, reducible, or without true protrusion; or for a hernia that is not operated but remedial. A 10 percent disability rating is assigned for a postoperative recurrent, readily reducible hernia, and well supported by truss or belt. A 30 percent disability rating is assigned for small, postoperative recurrent, or unoperated irremediable hernia, not well supported by truss, or not readily reducible. A 60 percent disability rating is assigned for large, postoperative, recurrent hernia, not well supported under ordinary conditions and not readily reducible, when considered inoperable. 38 C.F.R. § 4.114, Diagnostic Code 7338. The Veteran's rating was increased to 20 percent effective September 12, 2018 under Diagnostic Code 7339. Diagnostic Code 7339 provides ratings of zero, 20, 40, and 100 percent for postoperative ventral hernia. A noncompensable rating is warranted when the postoperative wounds are healed, there is no disability, and a belt is not indicated. A 20 percent is warranted for postoperative ventral hernia that is small, not well supported by a belt under ordinary conditions, or healed ventral hernia or postoperative wounds with weakening of the abdominal wall and indication for a supporting belt. A 40 percent rating is warranted for a postoperative ventral hernia which is large, not well supported by belt under ordinary conditions. See 38 C.F.R. § 4.114, Diagnostic Code 7339. Prior to September 12, 2018, the evidence shows that on examination in February 2016, there were no current residuals of the umbilical hernia, although the Veteran reported a painful scar which was confirmed on physical examination. Otherwise, the scar was asymptomatic. The examiner indicated that the hernia was surgically corrected and there was no need for a supporting truss or belt. At his Board hearing, the Veteran indicated that he has required a supporting truss or belt since the inservice surgery. In October 2018, the Veteran was examined and was noted to have a persistent umbilical hernia measuring 8 centimeters by 6 centimeters surrounding the naval. The examiner indicated that the hernia could be well supported by truss or belt. It was noted that the scar was inferior to the umbilicus. The Veteran reported having discomfort in the area of the scar/hernia. The Board notes that the earlier examination showed a painful scar, but no other residuals. However, the Veteran credibly reported wearing a belt for years at his hearing. Under Diagnostic Code 7338, a 10 percent disability rating is assigned for a postoperative recurrent, readily reducible hernia, and well supported by truss or belt. Since the Veteran reported that he required a belt and affording all reasonable doubt, a 10 percent rating is warranted. A 30 percent disability rating is not warranted as the Veteran did not have a small, postoperative recurrent, or unoperated irremediable hernia, not well supported by truss or belt, or not readily reducible. The Veteran also had a painful scar. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note 1. If one or more scars are both unstable and painful, the Board must add 10 percent to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note 2. The Veteran had one painful scar thereby warranting a separate 10 percent rating under Diagnostic Code 7804. On September 12, 2018 (the date of correspondence from the Veteran), the RO increased the disability rating to 20 percent per the findings on the second examination under Diagnostic Code 7339. Although the 20 percent rating under this code contemplates that the hernia is not well supported by a belt under ordinary conditions, the examiner indicated that the hernia was well supported by a truss or belt. The Board will not alter this rating under Diagnostic Code 7339 as that is not advantageous to the Veteran. Nonetheless, the Veteran's umbilical hernia as of that date does not warrant a higher rating under either Diagnostic Code 7338 or 7339 because the hernia was in fact able to be well supported by a truss or belt and higher ratings require that it not be well supported by truss or belt. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, prior to September 12, 2018, the evidence supports a 10 percent rating for the Veteran's umbilical hernia, During the appeal period, the evidence supports a separate 10 percent rating for a painful scar. From September 12, 2018, a preponderance of the evidence is against a rating in excess of 20 percent. REASONS FOR REMAND 1. Increased rating for hearing loss is remanded. The Veteran testified that his bilateral hearing loss had increased in severity and has not been assessed in several years. The Veteran should be afforded a current VA examination. 2. Service connection for a left shoulder disability is remanded. 3. Service connection for a lumbar spine disability is remanded. 4. Service connection for a cervical spine disability is remanded. 5. Service connection for a bilateral knee disability is remanded. 6. Service connection for a bilateral ankle disability is remanded. 7. Service connection for a right foot disability is remanded. The Board initially notes that the STRs document that the Veteran was in a car accident in 1974. The STRS document neck, back, knee, and other right-sided complaints following the accident. The Veteran also, in 1975, reported foot pain which was noted to be related to improper footwear. In May 1975, the Veteran fell and injured his right shoulder, but the Veteran indicates that his left shoulder, as well as his other joints were also bruised or injured in that fall. In February 1976, the STRs show that the Veteran injured his ankles in the field. He was also treated for foot complaints including plantar warts. In August 1976, he strained a ligament and tendon in the left knee. The Veteran testified that he was in two additional subsequent accidents, in 1991, and in 1995, before he separated from service. His commanding officer submitted a statement confirming the last accident which then necessitated 8 weeks of rehabilitation. He basically asserts that his neck, back, knees, and shoulder were affected. The rehabilitation records are not of record. On his retirement examination in 1995, the Veteran reported current complaints involving his left shoulder (noted by the examiner to be left shoulder impingement syndrome), upper lumbar spine, and his left knee. The Veteran additionally indicated that his ankles and feet were negatively impacted by the impairments to the other joints. The Veteran was afforded VA examinations in May 2016. Although the initial car accident was acknowledged, the examiner basically concluded that there is no evidence of chronicity of care and that a nexus has not been established. There was no commentary regarding the subsequent car accidents, rehabilitation, or the complete findings in the STRs, including on the retirement examination. Accordingly, the Board finds that an attempt must be made to obtain the rehabilitation records and a medical addendum should be obtained. 8. Service connection for a left eye disability is remanded. The Veteran contends that his left eye was injured during the car accident(s). There are negative VA opinions regarding the Veteran's chalazion, canaliculitis, hordeolum, and kerato-conjunctivitis. The examiner indicated that all are infectious etiologies and not related to trauma. Additionally, he has blepharochalasis which is age-related and had ptosis surgery. The STRs note on the retirement examination a left eye water spot on lens and myopia. Generally refractive errors of the eyes are congenital or developmental defects and not diseases or injuries within the meaning of the applicable legislation (38 C.F.R. §§ 3.303 (c), 4.9; 38 U.S.C. § 1110; and in the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service. The Board therefore finds that an addendum is needed to specifically indicate whether the incurred any superimposed disease or injury on such congenital defect during active duty service resulting in a current eye disability. The matter of the left eye water spot should also be addressed. 9. Service connection for allergic rhinitis is remanded. The Veteran contends that he has allergic rhinitis which was negatively impacted by his exposure to contaminated water at Camp LeJeune. A medical addendum is needed in that regard. 10. Service connection for hypertension is remanded. Elevated blood pressure readings were noted on multiple occasions during service, particularly in conjunction with anxiety in February 1994. On the February 1995 retirement examination, the Veteran complained of having high blood pressure readings. The VA examination opinion indicated that the Veteran's file lacks objective medical evidence to confirm diagnosis or treatment for hypertension during military service and a nexus is not established. The Board notes that the inservice findings were inadequately addressed. 11. Service connection for a disorder manifested by dizziness and to include BPPV is remanded. The VA examination opinion of record indicates that the Veteran's dizziness, with a diagnosis of BPPV, is not etiologically related to his hearing loss or the initial car accident. The Board notes that dizziness was reported on the retirement examination. In addition, in April 2013. Dr. J.V., dental examiner, indicated that his service-connected temporomandibular joint disease (TMJ) may possibly be causing the dizziness. The Veteran has also asserted the dizziness is secondary to hypertension, a matter still on appeal. Accordingly, a medical addendum is needed. 12. Service connection for diabetes mellitus, type 2 is remanded. The Veteran's STRs reflect that he had an elevated glucose reading in February 1995, before the Veteran separated from service. On a March 1995 Chronological Record of Medical Care noted diabetes on an eye examination. There is no medical opinion on this matter. 13. Service connection for ischemic heart disease is remanded. The STRs reflect that in November 1991, the Veteran complained of chest pain and sinus tachycardia was noted. The electrocardiogram was normal. The examiner indicated that coronary artery disease should be considered, but stated that the examiner doubted that it would be confirmed. The retirement examination indicated that the Veteran complained of chest pain and pressure. The Board finds that a VA examination should be afforded the Veteran with the appropriate cardiovascular testing. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA audiological examination to determine the current severity of service-connected bilateral hearing loss. Any indicated tests should be accomplished. The examiner should obtain the Veteran's auditory thresholds at frequencies of 1000, 2000, 3000, and 4000 Hertz, as well as speech recognition scores based on the Maryland CNC tests. 2. Attempt to obtain the Veteran's medical rehabilitation records following his 1995 car accident. If these inservice records cannot be obtained, the RO should indicate such in an unavailability memorandum. 3. Obtain VA medical addenda for the Veteran's claimed orthopedic disabilities (left shoulder, lumbar spine, cervical spine, bilateral knees, bilateral ankles, and right foot). The examiner(s) should review the record prior to providing the addendum(s). The examiner should note that there is credible lay evidence that the Veteran was involved in three car accidents during service, in 1974, 1991, and 1995. The examiner(s) should review the Board's remand with regard to inservice medical findings pertaining to claimed left shoulder, lumbar spine, cervical spine, bilateral knees, bilateral knees, bilateral ankles, and right foot disabilities. The findings on the Veteran's retirement examination with regard to the Veteran's complaints as well as the physical findings should be addressed. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current left shoulder, lumbar spine, cervical spine, left knee, right knee, left ankle, right ankle, and/or right foot disabilities had a clinical onset during service or are related to any in-service disease, event, or injury. If arthritis is present, the examiner should indicate if it was manifest within a year of the Veteran's retirement. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current left or right ankle/foot disability(ies) is proximately due to, or the result of, the spine or knee disabilities. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current ankle/feet disability(ies) is aggravated by the Veteran's spine or knee disabilities. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 4. Obtain a medical addendum from an appropriate examiner to determine the etiology of the Veteran's claimed left eye disability. The examiner should review the record prior to providing the addendum. The examiner should determine whether the Veteran's diagnosed refractive error (myopia and any other refractive error) is a congenital defect (as opposed to disease) and if so, whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran incurred any superimposed disease or injury on such congenital defect during service resulting in a current eye disability. The examiner should note that the Veteran reported that he injured his eye in a car accident. The examiner should also address the matter of the left eye water spot reported on the retirement examination. If the Veteran has current eye disability which is etiologically related to that finding, the examiner should so indicate. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 5. Obtain a medical addendum from an appropriate examiner to determine the etiology of the Veteran's claimed allergic rhinitis. The examiner should review the record prior to providing the addendum. The examiner should indicate if the Veteran has allergic rhinitis which was due to or aggravated by his exposure to contaminated water at Camp LeJeune. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current allergic rhinitis had its clinical onset during service or is related to any in-service disease, event, or injury to include his multiple reports of hay fever. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 6. Obtain a medical addendum from an appropriate examiner to determine the etiology of the Veteran's claimed hypertension. The examiner should review the record prior to providing the addendum. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that hypertension had its clinical onset during service, manifest within one year of retirement from service, or is related to any in-service disease, event, or injury to include his elevated blood pressure readings in February 1994, and his report of high blood pressure at retirement. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 7. Obtain a medical addendum from an appropriate examiner to determine the etiology of the Veteran's claimed BPPV/dizziness. The examiner should review the record prior to providing the addendum. The examiner should indicate if the Veteran has BPPV/dizziness which was due to or aggravated by his exposure to contaminated water at Camp LeJeune. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that BPPV/dizziness had its clinical onset during service or is related to any in-service disease, event, or injury to include his multiple reports of dizziness during service and on his separation examination. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current BPPV/dizziness disability is proximately due to, or the result of, the Veteran's TMJ and/or hypertension. The examiner should also provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current BPPV/dizziness is aggravated by the Veteran's TMJ and/or hypertension. The examiner should address the April 2013 letter of Dr. J.V., a dental examiner, who stated that the Veteran possibly had dizziness due to TMJ. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 8. Schedule the Veteran for a VA examination to determine the nature and etiology of any current heart and DM disabilities. All indicated tests should be accomplished. The examiner should review the record prior to examination. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that a current heart disability and/or DM had its clinical onset during service, manifest within a year of service, or is otherwise related to any in-service disease, event, or injury to include claimed Agent Orange exposure. With regard to the heart, the examiner should address the cardiac testing performed in November 1991 (including the notation that coronary artery disease should be considered) and on the retirement examination when the Veteran reported chest pain and pressure. With regard to DM, the examiner should address the elevated glucose reading in February 1995 as well as the March 1995 Chronological Record of Medical Care which noted diabetes on an eye examination. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Connolly, 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.