Citation Nr: 21067564 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 15-41 496 DATE: November 4, 2021 ORDER Entitlement to service connection for degenerative disc disease of the lumbar spine is granted. Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS) and/or ulcerative colitis, is denied. REMANDED Entitlement to service connection for arthritis of the right foot is remanded. Entitlement to service connection for arthritis of the left foot is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, the competent and credible evidence of record indicates the Veteran sustained back injuries in service that resulted in degenerative disc disease of the lumbar spine. 2. Resolving all doubt in the Veteran's favor, the competent and credible evidence of record indicates the Veteran's migraine headache disorder had its onset in service. 3. The competent of the evidence does not establish that the Veteran's diagnosed ulcerative colitis had its onset during service or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative disc disease of the lumbar spine are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for migraine headaches are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a gastrointestinal disorder, to include IBS and ulcerative colitis, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1990 to March 1994; he was then a member of the Reserves with periods of active duty from February 2003 to May 2004 and from November 2006 to July 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision by an Agency of Original Jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA). The Veteran testified at a February 2019 hearing before the undersigned Veterans Law Judge (VLJ) held at the AOJ. A transcript of the proceeding is associated with the claims file. The Veteran's claim of entitlement to service connection for IBS has been recharacterized to broadly reflect that the scope of the claim includes any gastrointestinal disorder, pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The issues were previously before the Board in June 2019, at which time they were remanded for additional development. As discussed in more detail below, the Board finds there was not substantial compliance with is June 2019 remand orders pertaining to the issues of entitlement to service connection for arthritis of the right foot, arthritis of the left foot, bilateral hearing loss and tinnitus, and another remand of these issues is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). Duty to Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. 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). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Arthritis and organic diseases of the nervous system, each with a presumptive period of one year following separation from service, are listed conditions. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the 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; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Degenerative Disc Disease of the Lumbar Spine The Veteran is seeking service connection for degenerative disc disease of the lumbar spine. The Veteran's service treatment records (STRs) are negative for treatment for complaints of back pain or for a back injury in service. There is no record of a back disability on his separation physical examination. In August 2012, the Veteran submitted a lay statement from CG, who was assigned to the same engineering battalion and who was deployed with the Veteran in Kuwait from April 2003 to 2004. CG stated that he witnessed the Veteran slip off a truck and that afterwards he noticed the Veteran would be in a lot of pain, but that the Veteran did not complain about it. CG stated that prior to deployment in Kuwait, they would play basketball 2 to 4 times a week. After returning home, the games were cut back to once a month. CG stated that the Veteran "would be in so much pain, and when we would ask him what was the matter, he would say nothing." CG stated that, to the best of his knowledge, ever since the Veteran slipped off that truck he has been suffering. A letter dated February 6, 2013, was received from the Veteran's private physician, Dr. BAC. Dr. BAC stated that the Veteran suffered from "low back pain which is also consistent with physical activities and physical strain sustained while he was deployed to Kuwait in 2003-2004." Private medical records from Dr. BAC were received in April 2013. These records reflected visits in September 2011, May 2012, and June 2012. At his September 2011 visit, the Veteran reported that he had not seen any medical provider since his last visit in 2007; he did not complain of back symptoms at this visit. At his May 2012 visit, the Veteran reported experiencing intermittent, lumbar back pain which he described as aching and related to his military duties. Dr. BAC noted normal range of motion and strength of the back with pain on palpation of the lumbar paraspinal muscles on the left side; full range of motion with minimal pain; no radiation of pain and 5 out of 5 strength in the lower extremities. At his June 2012 visit, Dr. BAC noted the Veteran had paperwork to be filled out that addresses his back pain and that the Veteran needed the diagnosis to be related to his time in Kuwait. Musculoskeletal examination showed normal range of motion and strength. Low back pain was noted, and the Veteran was given range of motion and strengthening exercises for his lower back. The Veteran underwent a VA back examination with a nurse practitioner in July 2013. The VA examiner noted the Veteran's diagnosis of lumbago degenerative disc disease of the lumbar spine in 2009. The Veteran reported that he fell off a truck in 2004 during active military duty. He was seen at family doctor in 2006 with low back pain. Current symptoms consist of low, sharp back pain for which he takes ibuprofen. He had no limitations on walking or standing. He reported flare-ups as occurring with exercise three times a week. Physical examination revealed range of motion as follows: flexion of the spine was to 90 degrees with objective evidence of painful motion at 90 degrees; extension to 30 degrees, with objective evidence of painful motion at 30 degree; bilateral lateral flexion was to 30 degrees, respectively, with objective evidence of painful motion at 30 degrees; bilateral lateral rotation was to 30 degrees, respectively, with objective evidence of painful motion at 30 degrees. The Veteran was noted to have functional loss and/or functional impairment of the thoracolumbar spine. Contributing factor of disability was identified as pain on movement. No localized tenderness to pain to palpation for joints, nor any guarding or muscle spasm was noted. X-rays of the spine revealed lumbago. The lumbar spine was noted to be in normal alignment and there were minimal endplate degenerative changes at L4-5. Intervertebral disc spaces and vertebral body heights are otherwise well-maintained. No displace fractures were identified. In September 2013, a negative nexus opinion was rendered by a different nurse practitioner. The doctor reasoned there was "no evidence of chronicity or continuity of back pain...." She also noted that, contrary to lay assertions of continuity, treatment records from 2006, 2007, 2010, and 2011 were silent with regard to the back. At his hearing, the Veteran testified that he hurt his back in service due to lifting heavy equipment. He testified that his back has continually hurt from service until the present. He testified that his back never fully resolved. In its June 2019 decision, the Board remanded the issue for an opinion as to whether it is at least as likely as not that the Veteran's degenerative disc disease of the lumbar spine is related to service, to include as due to the heavy lifting he was required to do as part of his duties as a wheel mechanic and/or as due to his reported fall from a tank in service. An addendum opinion was received in October 2019. The VA examiner stated that it was less likely than not that the Veteran's current back disability was incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that the Veteran's private medical records dated September 30, 2011 document that the Veteran had not seen any other provider since his last visit in 2007. He was not on any medication. The Veteran mentioned low back pain, although it was not noted in the history of present illness. X-rays taken in July 2013 reflected normal alignment of the spine; minimal endplate degenerative changes at L4-L5; intervertebral disk spaces and vertebral body heights are otherwise well-maintained. The Veteran reported experiencing a fall from a truck in 2004, but the VA examiner noted he was able to deploy from 2006 to 2007 with no residuals from the 2004 injury. The Veteran reported he was seen in 2006 for a strain and was treated with motrin; however, treatment records from 2011 note he had not been seen since 2007. The VA examiner noted this reflects a 3-year period without any complaints or treatment for a back condition and when seen in 2011, the plan was to evaluate at a later date if persistent. Based on this and the x-ray results, the VA examiner determined that it is less likely than not that the low back condition is due to heavy lifting and the reported fall in 2004. The Board notes that the Veteran has been consistent in reporting that he injured his back in service, as well as in his reports of the circumstances of his injury. He has been consistent in reporting the continuity of symptoms of back pain he has experienced since service. As a lay person he is competent to report his symptoms and there is no reason to doubt his credibility. The Veteran has repeatedly stated he was seen in 2006, has continued to experience back pain since his injuries in service, and testified that the original injury never resolved. His assertions are supported by the lay statement of CG. The July 2013 VA back examination reflects the Veteran was diagnosed with "lumbago DDD of lumbar spine" in 2009, though the VA examiner does not indicate what is the basis for this diagnosis. In her October 2019 addendum opinion, the VA examiner bases her negative opinion, in part, on the fact that the Veteran had not been treated since 2007. However, she indicates he was diagnosed with "lumbago DDD of lumbar spine" in 2009. In light of the evidence of record, including the Veteran's lay statements and testimony, post-service medical records and VA examination, the Board concludes that the evidence is in equipoise as to whether or not the Veteran's degenerative disk disease of the lumbar spine is related to his in-service back injuries. When the totality of the evidence supports the Veteran's claim or is in relative equipoise, the Veteran prevails on his claim. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, resolving any doubt in favor of the Veteran, the Board concludes service connection for degenerative disk disease of the lumbar spine is warranted. Migraine Headaches The Veteran asserts that his migraine headache disability is related to his time in service, to include as due to his conceded exposure to chemicals. The Veteran's STRs are negative for treatment for complaints of headaches or a diagnosis of a headache disorder in service. There is no record of a headache disorder on his separation physical examination. Private treatment records from Dr. BAC and Dr. DRC dated August 2007 indicate the Veteran was treated for chronic headaches and increased stress. Records dated September 2011 indicate the Veteran was seen to re-establish care as he had not seen any other provider since 2007. The Veteran complained of dizziness and headaches. He described onset of symptoms as 3 days earlier. Dizziness was described as disequilibrium and spinning. Duration was described as intermittent and acute. Frequency of attacks was several times per day. He denied a history of dizzy spells. He was taking Motrin for his headaches. His symptoms worsen with rising from sitting position, sudden head/body movements, and turning in bed. He reported onset of headaches as gradual and starting 2 weeks earlier. Location was generalized and in the frontal region. Duration was acute, severe pain. He stated his symptoms do not improve with rest. The Veteran's blood pressure was noted to be elevated. Dr. BC submitted a letter dated July 2012 which stated that the Veteran has migraines. In August 2012, the Veteran submitted statements from a friend, SJM, and from his wife, BD, in support of his claim. SJM stated that the Veteran frequently complains about severe headaches and is unable to attend some family engagements due to migraines. The Veteran has had to leave events such as dinners out due to his headaches. SJM stated that she witnessed the Veteran cry on occasion due to the severity of his pain. BD stated that she has been married to the Veteran for 16 years. BD stated that since the Veteran returned home from Kuwait in 2004, he has constantly suffered from severe and frequent migraine headaches. BD stated that the Veteran must be in a room with lights off during these attacks which are accompanied by visual disturbances, vomiting, dizziness, and extreme light sensitivity. She stated that light and noise seem to intensify his pain. In February 2013, the Veteran submitted a VA headaches disability benefits questionnaire completed by Dr. BAC. Dr. BAC stated that the diagnosis of the Veteran's migraine headaches was in August 2007. Dr. BAC noted that the Veteran reported his migraine headaches first occurred during Kuwait deployment in 2003 -2004 due to increased stress. Treatment included Excedrin migraine PM, Relpax prn, and stress reduction/time off from work. The Veteran underwent a VA headaches examination in July 2013. The VA examiner noted a diagnosis of tension headaches in 2006. The Veteran reported he was seen by his primary care provider with headaches. He stated he was diagnosed with migraine headaches by Dr. BAC. He stated he is treated with Motrin, Advil, and Tylenol. The Veteran states he gets headaches two to three times per week. He stated stress triggers his headaches. He experienced sensitivity to light. At his hearing, the Veteran testified that he had chronic migraines. Private medical records dated May 2018 include a report of a CT scan indicating mild white matter disease, nonspecific, possibly related to migraine headaches or chronic microangiopathy. A January 2019 medical record notes the Veteran's diagnosis of migraines. In its June 2019 decision, the Board remanded this issue for a new VA examination and opinion because it found the July 2013 VA opinion was inadequate for adjudication purposes as no opinion was provided as to the nature and etiology of the Veteran's headache condition. The Board notes that an opinion was actually secured in September 2013; the examiner stated that there was no evidence of continuity or chronicity of migraine headache complaints, citing progress notes reporting tension headaches over the years. The Veteran underwent a VA headaches examination in November 2019. The VA examiner noted the Veteran's diagnosis of migraines. An opinion was provided in August 2020. The VA examiner determined that it was less likely than not that the Veteran's migraine headache condition was less likely than not incurred in or caused by service. The VA examiner determined that there was no evidence of a migraine headache condition while in service. "It was not diagnosed until 2012. Any headache arising due to exposures of chemicals would almost certainly arise during the time of exposure or proximate to them. This is established medical knowledge. Migraine headaches are a vascular phenomenon caused by multiple triggers. Or exposure in service responsible for the veterans headaches a headache would have 'triggered' during this time. Therefore it is less likely than not that the veterans headaches had their nexus in service, to include possible chemical exposure." The Board notes that the Veteran has been consistent in reporting that he has experienced migraine headaches since his time in Kuwait. As a lay person he is competent to report the onset of his headaches and chronicity of his symptoms since service and the Board finds his statements and the statements of SJM and BD to be competent, credible, and highly probative of the fact that these symptoms started in service and persisted. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's assertions are supported by the medical records of Dr. BAC. On the other hand, the August 2020 VA opinion notes the Veteran was diagnosed with migraine headaches in 2012. In light of the evidence of record, including the Veteran's lay statements and testimony, post-service medical records and VA examinations, the Board concludes that the evidence is in equipoise as to whether or not the Veteran's migraine headaches had onset during service. When the totality of the evidence supports the Veteran's claim or is in relative equipoise, the Veteran prevails on his claim. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, resolving any doubt in favor of the Veteran, the Board concludes service connection for migraine headaches is warranted. Gastrointestinal Disorder The Veteran asserts his gastrointestinal disorder, to include IBS and ulcerative colitis, is related to his time in service, to include as due to his conceded exposure to chemicals. The Veteran's STRs are negative for treatment for complaints of irritable bowel syndrome and/or a diagnosis of irritable bowel syndrome. A single, undated STR reflects treatment for 2 days of watery, crampy, diarrhea and nausea. The diagnosis was diarrhea. There is no record of irritable bowel syndrome or diarrhea noted on his separation physical examination. The Veteran's wife, BD, submitted a statement in support of the Veteran's claim in August 2012. BD stated that after the Veteran's return home from his deployment in Kuwait, he constantly complained about his severe/chronic abdominal pain, gas, and bloating. BD stated that the Veteran also complained of severe and frequent diarrhea and other times complains of constipation. Private treatment records dated September 30, 2011, from Dr. DRC, note the Veteran's complaints of diarrhea within one hour after eating. The Veteran was given a spastic colon diet. On May 29, 2012, Dr. BAC noted the Veteran "feels he may have IBS. He has frequent BMs per day. He states sometimes they are formed and sometimes diarrhea. Episodes frequently happen after he eats and is sometimes accompanied by abd cramping." Records dated May 29, 2012 from astate In August 2012, the Veteran submitted a VA intestinal conditions disability benefits questionnaire completed by Dr. BAC. Dr. BAC noted the Veteran's diagnosis of irritable bowel syndrome. Dr. BAC stated that the Veteran's irritable bowel syndrome symptoms started during Kuwait deployment in 2003 2004 due to increased stress. Dr. BAC noted that continuous medication was not required for control of the Veteran's intestinal condition, nor has he had any surgical treatment for an intestinal condition. In February 2013, the Veteran submitted a letter from Dr. SK, gastroenterologist, from the Digestive Disease Center, which stated the Veteran was a patient who suffered from severe gastrointestinal problems and experienced chronic diarrhea and abdominal cramps. In February 2013, the Veteran submitted a letter from Dr. BAC stating the Veteran suffers from irritable bowel syndrome. The Veteran underwent a VA intestinal conditions examination in July 2013. The VA examiner noted the Veteran had been diagnosed with IBS in September 2011. The Veteran reported that his primary care provider diagnosed him with IBS and referred him to the Digestive Disease Center. No diagnosis of IBS was given from the Digestive Disease Center. Subjective complaints included chronic diarrhea with bm 4 to 5 times per day with abdominal bloating. Medical records from Dr. BAC dated November 2014 indicate the Veteran sought treatment for blood in his stool. Dr. BAC noted that the Veteran needed a colonoscopy. Private treatment records from Dr. SSS indicate the Veteran was seen in November 2014 for blood in his stool. Dr. SSS assessed the Veteran with hematochezia, flatulence, eructation and gas pain, and functional diarrhea. Colonoscopy was noted as treatment. The Veteran was counseled to follow a high fiber diet, increase fluids in diet. Follow up was noted on an as need basis. Examination of the abdomen revealed no guarding, no rigidity, soft, non-tender/non-distended, bowel sounds present. A November 2014 colonoscopy revealed active chronic colitis/proctitis. Recommendation wat to resume previous diet, await pathology results and repeat colonoscopy in 5 years. benign large bowel mucosa, no colitis, In July 2016, the Veteran had a colonoscopy which revealed inflammation from the rectum to the sigmoid colon, in the ascending colon and in the cecum secondary to ulcerative colitis. Treatment records dated September 2016 indicate the Veteran was diagnosed with left-sided ulcerative colitis, without complications; ulcerative proctitis for which the Veteran has been noncompliant with his medication. Current colonoscopy reveals inflammation in the cecum along with proctosigmoiditis. PH colon polyps were noted. The Veteran had a third colonoscopy in November 2017 which revealed non-bleeding internal hemorrhoids and normal mucosa. A repeat colonoscopy was recommended for July 2018. Physical examination of the abdomen revealed no guarding, no rigidity, soft, non-tender/non-distended, bowel sounds present. At his hearing, the Veteran testified that he had been diagnosed with ulcerative colitis. In its June 2019 decision, the Board remanded this issue for a new VA examination and opinion because it found the July 2013 VA opinion was inadequate for adjudication purposes as no opinion was provided as to the nature and etiology of the Veteran's chronic diarrhea. In fact, an addendum opinion was secured in September 2013. A VA nurse practitioner opined negatively, stating there was no evidence of continuity or chronicity of complaints. However, she noted complaints and symptoms in treatment in 2006, 2007, 2011, and 2012. The Veteran underwent a VA intestinal conditions examination in November 2019. The VA examiner noted the Veteran's diagnosis of ulcerative colitis in November 2014. The Veteran reported that he was diagnosed with IBS in 2006. He is on medication every day for diarrhea with abdominal cramps. In a July 2020 opinion, the VA examiner noted that all medical records had been reviewed. The VA examiner determined that it was less likely than not that the Veteran's IBS was incurred in service or caused by service. The VA examiner noted that while the Veteran was initial treated for his GI symptoms with an IBS diet in 2011, the diagnosis was changed to Inflammatory Bowel Disease (IBD or Ulcerative Colitis) after a colonoscopy in 2014 and 2017. The VA examiner opined that "while there is some overlap of symptoms between IBS and IBD, the conditions are distinct and with different etiologies. Inflammatory bowel disease is a disease with a clear and specific diagnosis usually by colonoscopy. The etiology is associated with a high fat diets, a genetic predisposition and an immune response to bowel infections such as gastroenteritis." The VA examiner determined there is no objective evidence which supports an etiology due to service. There is no scientific research which supports an etiology due to the burn pits and/or chemical exposure during service." The VA examiner further noted that the opinion by Dr. BAC was considered but found to be insufficient. Dr. BAC associated the Veteran's GI condition and symptoms with Irritable Bowel Syndrome which was incorrect. The VA examiner further noted that the definitive diagnosis of the Veteran's intestinal condition was made in 2014 by colonoscopy and that the diagnosis of ulcerative colitis or inflammatory bowel disease was also confirmed on the colonoscopy in 2017. The VA examiner determined that there is no established medical nexus related to service. After a careful review of the evidence of record, the Board finds the preponderance of the evidence is against the claim. Although the Veteran as expressed his belief in a connection, he lacks the knowledge and training required to render a nexus opinion on a cause-and-effect relationship unobservable to a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran has simply asserted his opinion, without a clear rationale or support; no probative value is given his statements beyond their worth as physical observations. There is no medical evidence associated with the file that establishes a link between the Veteran's in-service episode of acute diarrhea, or his conceded exposure to chemical in service and his claimed IBS or diagnosed ulcerative colitis. The competent evidence of record does not show that the Veteran's claimed gastrointestinal disorder to include IBS and ulcerative colitis was either caused or aggravated by service. Simply put, there is no competent evidence linking his claimed gastrointestinal disorder to service. There is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, at 1 Vet. App. 49 (1990). Service connection for a gastrointestinal disorder, to include IBS or ulcerative colitis is not warranted. REASONS FOR REMAND The issues of entitlement to service connection for arthritis of the right foot, for arthritis of the left foot, for bilateral hearing loss, and for tinnitus are remanded for additional development. The Veteran underwent a VA foot examination in August 2013. The VA examiner noted that x-rays revealed degenerative arthritis of the Veteran's feet. Degenerative changes were noted and described as "mild/minor right 1st mtp and bilateral midfoot." The VA examiner determined it was less likely than not that the Veterans degenerative arthritis of the feet was incurred in or caused by claimed in-service injury, event, or illness. The Board found that this examination was inadequate for adjudication purposes because the examiner relied on the lack of treatment in service to form his opinion and did not discuss the Veteran's account of his in-service experiences nor his statements regarding the continuity of his symptoms since service. The matter was remanded in June 2019 for a new examination and opinion. The VA examination was conducted in November 2019. In August 2020, an addendum opinion was provided. The VA examiner determined it was less likely than not that the Veteran's bilateral degenerative arthritis of the feet was incurred in or caused by service. The VA examiner noted that the Veteran had not issues or foot conditions while in service or proximate to service. The Veteran's first noted foot complaints occurred approximately August 2013, six years post service. The VA examiner opined that therefore it is less likely than not that the Veteran's foot conditions, to include arthritis and pes planus, are due to or incurred in service. Unfortunately, this opinion did not address the Veteran's accounts of his in-service experiences nor his statements regarding the continuity of his symptoms since service. On remand, a new opinion must be provided as to the etiology of the Veteran's currently diagnosed arthritis of the feet to comply with the Board's prior remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issues of entitlement to service connection for bilateral hearing loss and tinnitus was remanded in June 2019 for a new VA hearing loss examination. The Veteran was afforded a VA hearing loss examination in November 2019. The VA examiner noted that the test results were not valid for rating purposes because his SRTs were not in agreement with pure tone responses. The VA examiner noted that "an occupational hearing screening obtained on 09/23/19 indicated the following normal results" and included the results for puretone threshold and speech discrimination score (Maryland CNC word list). However, the 9/23/19 screening report itself is not associated with the claims file. On remand, this report should be obtained and associated with the claims file. The matters are REMANDED for the following action: 1. Return the file to the VA examiner who provided the August 2020 VA foot opinion, or, if not available, another qualified clinician. The claims file must be reviewed by the examiner. If the examiner is not available, another appropriate medical professional may be consulted. If the examiner determines another VA examination is necessary, one should be scheduled. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's arthritis of the feet is related to military service, to include as due to the Veteran's accounts of his in-service experiences of jumping down from tanks, marching in military boots, and addressing his statements regarding the continuity of his symptoms since service. A full and complete rationale for all opinions expressed is required. 2. Obtain a copy of the September 23, 2019, occupational hearing screening referred to by the VA examiner who conducted the November 2019 hearing loss examination and associate it with the claims file. 3. Then, readjudicate the remanded issues. If the benefits sought remain denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, 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.