Citation Nr: 21068385 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-34 227 DATE: November 10, 2021 ORDER The appeal for entitlement to service connection for bilateral hearing loss is dismissed. The appeal for entitlement to service connection for erectile dysfunction is dismissed. The appeal for entitlement to service connection for a personality disorder is dismissed. The appeal for entitlement to a rating in excess of 10 percent for right knee chondromalacia is dismissed. The appeal for entitlement to a rating in excess of 10 percent for right hand minimal motor and mild sensory loss (previously characterized as laceration scar of the right fifth finger) is dismissed. New and material evidence having been received, the appeal to reopen service connection for a low back disability is granted. Service connection for headaches is denied. Service connection for a right wrist disability is denied. Service connection for a left knee disability is denied. REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for temporomandibular joint (TMJ) disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and/or posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a kidney condition is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to an initial rating in excess of 10 percent for left ankle retrocalcaneal achilles tendon repair with edema and tendonitis is remanded. FINDINGS OF FACT 1. In a June 2021 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran testified that he wished to withdraw the appeals of entitlement to service connection for bilateral hearing loss, erectile dysfunction, and a personality disorder, and increased ratings for right knee chondromalacia and the right hand disability. 2. Service connection for a low back condition was denied in a November 1993 rating decision and the Veteran did not appeal the decision. 3. Evidence received since the November 1993 rating decision is new in that it is not cumulative and was not previously considered by decision makers, and it is material because it raises a reasonable possibility of substantiating the claim for service connection for a low back disability. 4. The preponderance of the evidence is against finding that the current headache diagnosis began during active service, or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that any current right wrist diagnosis began during active service, or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that any current left knee diagnosis began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for service connection for bilateral hearing loss by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the appeal for service connection for erectile dysfunction by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of the appeal for service connection for a personality disorder by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of the appeal for an increased rating for right knee chondromalacia by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The criteria for withdrawal of the appeal for an increased rating for right hand minimal motor and mild sensory loss by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 6. New and material evidence has been received to reopen the claim for service connection for a low back disability. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 3.159, 20.1103. 7. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for a right wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 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 Air Force from March 1983 to January 1984, and in the Marine Corps from July 1986 to July 1991. In June 2021, the Veteran testified at a virtual hearing before the undersigned, and a transcript of that hearing is of record. Withdrawal of Appeals 1. Withdrawal of appeal for service connection for bilateral hearing loss. 2. Withdrawal of appeal for service connection for erectile dysfunction. 3. Withdrawal of appeal for service connection for a personality disorder. 4. Withdrawal of appeal for an increased rating for right knee chondromalacia. 5. Withdrawal of appeal for an increased rating for the right hand disability. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran indicated in his June 2021 Board hearing that he wished to withdraw the claims for entitlement to service connection for bilateral hearing loss, erectile dysfunction, and a personality disorder, and increased ratings for the right knee chondromalacia and right hand disability. The Veteran's representative was with him in the hearing, and the Veteran stated that he understood that nothing further would happen with these issues. In light of this, the Veteran has withdrawn the appeals; hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the issues of entitlement to service connection for bilateral hearing loss, erectile dysfunction, and a personality disorder, and increased ratings for the right knee chondromalacia and right hand disability, and they are dismissed. New and Material Evidence Rating decisions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § § 20.1103. An appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § § 20.200. To reopen a claim that has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened; and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). The claim for service connection for a low back condition was denied in a November 1993 rating decision. The Regional Office (RO) noted that the although the Veteran was treated in service for after falling down some stairs, his back pain was acute and transitory in nature with no residual disability shown. He also did not have an objective diagnosis, and there was no evidence that his subjective complaints were related to his in-service fall. The Veteran did not appeal the November 1993 rating decision and it is final. The Veteran requested to reopen the claim in May 2010. The additional relevant evidence received since the November 1993 rating decision includes VA examinations and treatment records, private medical treatment records, and the Veteran's Board hearing testimony. A February 2017 VA examination report indicates that the Veteran has a diagnosis of thoracolumbar spine degenerative joint disease (DJD), and an opinion from a private physician, Dr. A.R., indicates that the degenerative changes are more likely than not caused by the Veteran's military service. Presumed credible, the examination report and medical opinion are probative evidence that the Veteran has a low back disability that could be related to service. Accordingly, new and material evidence has been received to reopen the claim for service connection for a low back disability. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). Certain disease, including arthritis, are listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 6. Service connection for headaches. 7. Service connection for a right wrist disability. 8. Service connection for a left knee disability. The Veteran asserts that his claimed headaches, right wrist, and left knee conditions all began in service. With regard to the headaches, the Veteran contends that he was kicked in the head in 1983 during his first period of service while playing a football game. He was diagnosed with a concussion and he started having headaches. During his second period of service, the headaches got worse. The Veteran also got a concussion during a training exercise in France in 1989 or 1990 when he fell through a roof. He fell 18 feet and landed on his back. He was seen at a hospital where he thinks a CAT scan was done. The Veteran currently worked at VA, got 3-4 migraine headaches per month, and had called out due to the headaches. With regard to the right wrist, the Veteran contends that he got into a fight with a Marine in 1988. The Marine hit the Veteran and the Veteran hit back, breaking his right wrist in the process. He was in a cast for a few months, and since then his had felt tingly and numb when he locked his wrist or bent it in any way. With regard to the left knee, the Veteran contends that service connection is warranted. In the Board hearing, however, the Veteran indicated that while doing the training exercise in France, he jumped from one rooftop to another with full gear on. When he landed, he fell to his knees and went through the roof down to through the first floor. Medical treatment records indicate that the Veteran has current diagnoses of migraine headaches including migraine variants, history of healed right wrist fracture, right wrist strain by personal history, left knee chondromalacia, and left knee degenerative arthritis. See the March 2012, June 2013, and February 2017 VA examination reports. Thus, the current disability requirement for service connection for headaches, right wrist strain, and left knee chondromalacia is satisfied. The question for the Board is whether the Veteran's current diagnoses either began during active service, or are etiologically related to service. The Board finds that probative evidence of record does not establish that any headache, right wrist, or left knee diagnosis is etiologically related to the Veteran's active service. Service treatment records (STRs) from the Veteran's first period of service indicate that in August 1983, the Veteran was seen in an emergency department the day after being kicked in the head during a football game. He reported having a headache and impaired right eye vision. Results of a neurologic examination were normal, and he was noted to have a labyrinth contusion. The next day, he reported feeling worse. A neurological examination was again within normal limits and there were no focal findings. Two days later, he was seen in an emergency department with complaints of a headache and dizziness. In September 1983, the Veteran was seen for another follow-up visit for posttraumatic headache syndrome. He reported continuing headaches, but was "much improved over the last 8 days." The treatment record indicates "no further follow-up appointment required." In a January 1984 separation examination and report of medical history, the Veteran's head was found to be clinically normal, and he was noted to be neurologically normal. He reported having a history of head injury, but reported that his present health was good. He was noted to have had a "minor concussion" in 1983, with no loss of consciousness, treated with Tylenol, with no complications and no sequalae (NCNS). STRs from the Veteran's second period of service indicate that in a May 1986 enlistment examination, the Veteran's head, upper extremities, and lower extremities were found to be clinically normal and he was also found to be neurologically normal. In an accompanying report of medical history, the Veteran indicated that he had a history of a head injury, but that he was in "excellent" present health. In Aril 1988, the Veteran was seen for pain in his right wrist. He was noted to have injured it five weeks ago, and had been in a cast since then. He was noted to have mild tendonitis due to the placement of the cast. In a September 1988 treatment record, the Veteran stated that his wrist was still "a little sore." A new cast was applied, and he was put on light duty for three weeks. In October 1989, the Veteran was seen after slipping down a flight of stairs the night before. He reported injuring his left arm, back, left buttock, left thigh, and left heel, and did not report any right wrist or left knee injury. In January 1990, the Veteran reported trauma to both knees when he fell through a roof in combat town. He was assessed as having rule-out contusions to the bilateral knees, and told to return if his condition worsened. In a June 1990 periodic examination, the Veteran's head, upper extremities, and lower extremities were again found to be clinically normal. In an August 1990 medical examination, the Veteran's musculoskeletal system was found to be within normal limits. In December 1990, the Veteran reported having constant bilateral knee pain for the last five years, and that he was told he was developing calcium deposits over both knees. Finally, in a July 1991 separation examination, the Veteran's head and upper extremities were found to be clinically normal, and his lower extremities were found to be clinically normal except for his right knee. In a March 2012 VA wrist conditions examination, the Veteran reported being in an altercation with another service member and striking the service member with his right hand. He was put in a cast and did not have any problems with his right wrist over the years until recently when he started to notice some numbness in the wrist region, especially while typing. On examination, the right wrist had 75 degrees of palmar flexion (with objective evidence of painful motion at 70 degrees or greater), and 65 degrees of dorsiflexion (with objective evidence of painful motion at 60 degrees). After repetitive-use testing, palmar flexion was still to 75 degrees and dorsiflexion was to 65 degrees. There was localized tenderness or pain on palpation and muscle strength testing was normal. The diagnoses were healed fracture and strain by personal history. The examiner noted that the Veteran was instructed to obtain radiographs of the right wrist at the time of the examination, but he did not show at radiology department. The examiner opined that it was less likely than not that the claimed current right wrist condition was related to the Veteran's military service. Although there was documentation in STRs of a right wrist fracture, an absence of relevant medical records from 1988 to 2012 did not document chronicity of a right wrist condition since separation from service. In a June 2013 VA knee conditions examination, the Veteran reported falling from a roof in service in approximately 1989. He had current symptoms of instability, throbbing pain, and edema in the left knee. On examination, the Veteran had 130 degrees of flexion (with objective evidence of painful motion at 120 degrees) and zero degrees of hyperextension (no limitation of extension). Crepitus in flexions and extension was consistent with chondromalacia and increased bony prominence at the proximal tibia. After repetitive-use testing, range of motion remained the same. There was localized tenderness or pain on palpation, muscle strength testing was normal, and there was no instability. X-rays showed minor lateral joint space narrowing. The diagnosis was left knee chondromalacia. The examiner opined that it was less likely than not that the claimed current left knee condition was related to the Veteran's military service, although the examiner was unable to find STRs documenting the in-service fall through the roof. In a February 2017 VA knee conditions examination, the Veteran reported that he had been experiencing episodes of bilateral knee pain since his last evaluation. On examination, the left knee range of motion was normal (140 degrees of flexion to zero degrees of extension), with evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation. There was no additional functional loss or range of motion loss after three repetitions of movement. Muscle strength testing was normal and there was no instability. X-rays showed minimal degenerative changes. The examiner diagnosed degenerative arthritis and chondromalacia, which he opined was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. STRs showed that the Veteran reported trauma to both knees when he fell, but they did not show any left knee pain chronicity, and there was no evidence of left knee minor lateral joint space narrowing, which is a sign of chondromalacia patellae, until June 2013, which was 22 years after separation from service. In a February 2017 VA headaches examination, the Veteran reported experiencing headaches since 1992 with associated episodes of dizziness. The examiner indicated that the Veteran had pain and dizziness, which lasted for less than one day typically. A head CT done in September 2015 showed no acute intracranial process. The examiner opined that the claimed headache condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, as the Veteran himself denied that the headaches were secondary or related to being kicked in the head in service, and that he had been experiencing headaches since 1992. The headache description as reported by the Veteran was not typical of posttraumatic headaches, and the symptoms attributed to postconcussion syndrome (PCS) are greatest within the first 7-10 days for the majority of patients, that the vast majority of PCS patients have largely recovered by three months, and that the symptoms reported by the Veteran were consistent with the typical presentation of migraine. The Board finds the March 2012 and February 2017 VA medical opinions to be of at least some probative value. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinions were rendered after reviewing the Veteran's STRs and other medical records, soliciting a medical history from the Veteran, and physical examination of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The opining examiners provided the facts and rationale on which their opinions were based. Specifically, the March 2012 examiner acknowledged the STRs showing a right wrist fracture, but noted that there were no records of further right wrist complaints or treatment for 24 years (from 1988 to 2012); the February 2017 examiner noted that STRs showed a report of trauma to both knees when the Veteran fell, but did not show any left knee pain chronicity and there was no sign of chondromalacia until 22 years after separation from service; and the February 2017 examiner also noted that the Veteran himself denied that the headaches were due to being kicked in the head in service, and that his symptom presentation was not typical of posttraumatic headaches but were consistent with the typical presentation of migraines. Furthermore, neither the Veteran nor his representative has produced a medical opinion to contradict the conclusions of the VA examiners. There is no evidence suggesting that any portion of the current degree of degeneration of the left knee was attributed to any cause other than aging. As such, there is no competent evidence that relates the current left knee diagnosis to military service, to include as secondary to or aggravated by the service-connected right knee disability. The Board also finds that although the Veteran can describe observable symptoms including pain, his statements cannot be used to determine whether a headache condition, right wrist diagnosis, or left knee diagnosis is related service or to an in-service injury. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. Moreover, the Veteran has been inconsistent in his statements. Specifically, he reported in the March 2012 wrist examination that he had only recently begun feeling pain in his right wrist, and he denied that his headaches were secondary to being kicked in the head in service in the February 2017 examination. As such, the Board finds the Veteran's statements probative with regard to establishing his current symptoms, but finds little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has expertise and training pertinent to brain and head injuries, and musculoskeletal diagnoses. Finally, the earliest evidence of complaints or treatment for the right wrist condition was in 2011 and the earliest evidence of complaints or treatment for the left knee was in 2013, which was 20 years after the Veteran's separation from service. This lengthy period of time without diagnosis or treatment weighs against the finding that any current right wrist or left knee diagnosis has existed since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As noted above, STRs indicate that the Veteran fractured his wrist in 1988 and reported trauma to both knees and knee pain in 1990. However, he denied having any right wrist or left knee problems in examinations conducted in June 1990, August 1990, and July 1991; there is no medical evidence showing relevant symptoms or a diagnosis within one year from service separation; and the competent and credible evidence does not establish chronic and continuous symptoms of any right wrist or left knee condition. As such, service connection on a presumptive basis under 38 C.F.R. § 3.303 (a) or (b) is not warranted. In sum, the weight of the competent and credible evidence of record weighs against the claims for service connection for headaches, a right wrist disability, and a left knee disability. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a neck disability is remanded. 2. Entitlement to service connection for a low back disability is remanded. 3. Entitlement to service connection for a right shoulder disability is remanded. 4. Entitlement to service connection for a left shoulder disability is remanded. 5. Entitlement to service connection for a right hip disability is remanded. 6. Entitlement to service connection for temporomandibular joint (TMJ) disorder is remanded. The Veteran contends that his neck, back, bilateral shoulders, and right hip were injured in service when he fell down some metal stairs on the USS Iwo Jima, and a few weeks later, he fell through the rooftop during a training exercise in France. He also contends that his TMJ started in service, although he was not treated for it in service. See the June 2021 Board hearing transcript. The Veteran asserted in the Board hearing that he was seeing a private physician, Dr. R., at Florida Orthopedics. He stated that records from Dr. R. had been provided, but the claims file does not currently contain any such records. The Board acknowledges that the there is a short letter from Dr. A.R. indicating that the Veteran had degenerative changes in his neck, back, and hips, which were more likely than not caused by his military service. There is also a statement from another private physician, Dr. R.C., indicating that the Veteran had a diagnosis of TMJ that was most likely due to two in-service injuries. The Board finds that the statements from Dr. A.R. and Dr. R.C. are insufficient bases on which to adjudicate the claims for service connection for the neck, back, bilateral shoulders, right hip and TMJ, as they do not indicate that either doctor reviewed any relevant STRs, do not include any treatment records or x-rays, and do not adequately explain the rationale for the conclusions. As such, remand is necessary to obtain any relevant treatment records. See 38 C.F.R. § 3.159(c). 7. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, is remanded. The Veteran contends that he was diagnosed with posttraumatic stress disorder (PTSD) at VA in January or February 2021. See the June 2021 Board hearing transcript. The most recent VA treatment records currently associated with the claims file are dated in September 2015. As such, remand is necessary to obtain any outstanding relevant records. See 38 C.F.R. § 3.159(c). 8. Entitlement to service connection for a kidney condition is remanded. The Veteran contends that he has kidney failure and chronic nephritis, which was diagnosed in 2009. He was asked if he was taking Motrin, and he stated that he took it from 1986 (when he injured his right knee) to 1991. The cause of the kidney condition was "listed as unknown." See the June 2021 Board hearing transcript. In July 2021, a letter from Veteran's VA physician, Dr. D.G., was received in which Dr. D.G. opined that the Veteran's use of Motrin to treat his service-connected conditions caused his chronic kidney disease. The Board finds the statement from Dr. D.G. is an insufficient basis on which to adjudicate the claim for service connection for a kidney condition. The doctor did not explain whether use of Motrin for five years, nearly 20 years before the kidney disease diagnosis, was sufficient to cause kidney disease. The opinion also does not address VA treatment records indicating that the Veteran has a history of anabolic steroid use from 2002 to 2004 or 2005. See Black v. Brown, 5 Vet. App. 177, 180 (1993) (finding medical opinions inadequate when they are not supported by medical evidence); Swann v. Brown, 5 Vet. App. 229, 232 (1993) (noting that the weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated). As such, the Board finds that a VA medical opinion is needed on the issue of service connection for a kidney condition. 9. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran contends that although he was not diagnosed with sleep apnea in service, he had symptoms in service. He noted that he would wake up gasping for air periodically during the night and his roommates complained that he snored very loudly. See the June 2021 Board hearing transcript. In February 2017, a VA physician opined that the obstructive sleep apnea was less likely than not proximately due to or the result of any psychiatric disorder, including anxiety and narcissistic personality disorder. The rationale was that the weight of the medical literature was against a relationship between obstructive sleep apnea and anxiety or narcissistic personality disorder, and the Veteran was not prescribed any psychotropic medication. The examiner did not, however, opine on whether the sleep apnea was related to service on a direct basis. As such, the Board finds that a VA medical opinion should be obtained to determine the nature and etiology of the sleep apnea. 10. Entitlement to an increased rating for the left ankle is remanded. The Veteran was most recently examined for his left ankle disability in February 2017. He reported that he had severe, sharp pain in the left ankle. Range of motion included 15 degrees of dorsiflexion and 35 degrees of plantar flexion. In the June 2021 Board hearing, the Veteran testified that his symptoms had worsened. His ankle was extremely painful, and he could not move his foot up or down. The only way it moved was when he walked and put pressure on it. Thus, due to evidence of potentially worsening symptomatology, the Board finds that a new VA examination is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide sufficient information and, if necessary, authorization to enable the AOJ to obtain any relevant outstanding non-VA treatment records, to include any treatment at Florida Orthopedics. The AOJ should make an attempt to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. 2. Obtain from the VA healthcare system all outstanding relevant treatment records dated from September 2015 to present. All records/responses received should be associated with the claims file. If any records sought are not obtained, a written statement to that effect should be incorporated into the record. 3. Obtain a medical opinion on the current nature and likely etiology of any diagnosed kidney condition. The claims folder, including a copy of this REMAND, must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the kidney condition is causally related to and/or increased in severity by any service-connected disability(s), to include as due to Motrin taken from 1986 to 1991 for any service-connected disability(s). A thorough rationale should be provided for all opinions expressed, to include consideration and discussion of the Veteran's history of anabolic steroid use. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. 4. Obtain a medical opinion on the current nature and likely etiology of the obstructive sleep apnea. The claims folder, including a copy of this REMAND, must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the obstructive sleep apnea had its origin during, or is in some way the result of, the Veteran's periods of active military service, to include consideration and discussion of the Veteran's statements regarding symptoms in service. A thorough rationale should be provided for all opinions expressed. If the VA examiner determines that an examination is necessary in order to render the requested medical opinion(s), the AOJ should schedule the Veteran for such an examination. 5. Schedule the Veteran for a VA examination to determine the current severity and manifestations of the service-connected left ankle disability. The examiner should review the claims file and should note that review in the report. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Based on this review, the examiner is asked to provide an assessment of the current nature of the left ankle disability, including all symptoms attributable to the condition and their severity. The examiner should also describe the functional impact of the disability. Range of motion (ROM) should be tested actively and passively, in weight-bearing and nonweight-bearing, and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. If for any reason the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.