Citation Nr: 21069153 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 18-25 940 DATE: November 17, 2021 ORDER As new and material evidence has been received, the petition to reopen a previously denied claim for service connection for a right shoulder trauma is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disability is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. FINDING OF FACT An unappealed March 1997 rating decision denied entitlement to service connection for right shoulder trauma; new and material evidence was not received prior to expiration of the appeal period; subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. CONCLUSION OF LAW The March 1997 rating decision denying claim for service connection for right shoulder trauma is final; new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156(a), 3.160(d), 20.1103. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from August 1972 to August 1975 and from March 1976 to May 1978. He had full-time Active Guard/Reserve (AGR) status in the Indianapolis Army National Guard from September 1981 to May 1996. This duty was authorized under 32 U.S.C. § 502 (f) and is considered as active duty for training (ACDUTRA) for the VA compensation purposes. See 38 C.F.R. § 3.6 (c)(3). As the Veteran has been service-connected for his right knee disability incurred during this period of ACDUTRA, "veteran status" has been established for that period. See Hill v. McDonald, 28 Vet. App. 243 (2016). In April 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) during a virtual hearing. A copy of the hearing transcript has been associated with claims folder. The psychiatric claim on appeal has been characterized to include any acquired psychiatric disorder pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran submitted an August 2021 waiver of initial consideration of additional evidence associated with the claims folder since an April 2018 statement of the case (SSOC). Whether new and material evidence has been received to reopen the previously denied claim for service connection for right shoulder trauma. The Board concludes that a March 1997 rating decision denying the claim for entitlement to service connection for right shoulder trauma is final; and that new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), 20.1103. A claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. Generally, a claim that has been denied in an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of whether the RO found that new and material evidence had been submitted to reopen a claim for service connection, it is well established that the Board must determine on its own whether new and material evidence has been submitted to reopen a claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). A March 1997 rating decision originally denied service connection for right shoulder trauma on the basis that the evidence failed to show a current right shoulder disability or chronic disease since service. VA notified the Veteran of this decision by letter and how to appeal. VA received no appeal or new and material evidence prior to expiration of the appeal period. Therefore, the rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.1103. Evidentiary submissions received since the March 1997 rating decision includes new and material evidence. Specifically, additional private treatment records show treatment for complaints of right shoulder pain and an assessment of rotator cuff disorder. See Medical Treatment Record - Non-Government Facility (November 2017) and (June 2021). In addition, the Veteran has provided testimony that he has experienced recurrent right shoulder problems since his in-service injury when he fell down a flight of stairs in 1987, which has progressively worsened since service. See Hearing Transcript (April 2021). Together, this additional evidence demonstrates a current disability as well as continuity of symptoms since in-service injury, which constitutes new and material evidence necessary to reopen the previously denied claim. Further, considering the "low threshold" standard for reopening endorsed by the Court in Shade, this additional evidence raises a reasonable possibility of substantiating the underlying claims. Accordingly, the Board finds that new and material evidence has been received, and that the claim of service connection for right shoulder trauma is reopened. REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. Indeed, the Board expressly defers a credibility determination in this appeal until the development has been completed to the extent feasible. The Veteran had full-time (State) National Guard Duty in AGR status under 32 U.S.C. § 502(f) from September 1981 to May 1996. As full-time National Guard duty performed pursuant to orders issued under Title 32, United States Code, is specifically excluded from the definition of "active duty," this period qualifies as active duty for training (ACDUTRA) service. 38 C.F.R. § 21.9505; see 38 U.S.C. §§ 101 (21), (22)(C) (likewise defining "active duty" to exclude full-time duty in the National Guard under 32 U.S.C. § 502); 38 C.F.R. § 3.6 (c)(3) (defining full-time duty performed by members of the National Guard of any State under 32 U.S.C. § 502 as "active duty for training"). Service connection may only be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA. 38 U.S.C. §§ 101 (24), 106, 1110, 38 C.F.R. §§ 3.6, 3.303, 3.304. As noted above, the Veteran is service-connected for right knee disability which was incurred during his ACDUTRA from September 1981 to May 1996. Accordingly, because he has already established "veteran" status for this ACDUTRA period, any applicable presumptions will be considered for that period. Smith v. Shinseki, 24 Vet. App. 40 (2010); Donnellan v. Shinseki, 24 Vet. App. 167 (2010). 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression and PTSD. The Veteran contends that he has a current acquired psychiatric disorder as a result of his period of service. He reports that his depression and anxiety symptoms first manifested during his military service and has led to the development of his current acquired psychiatric disorder. See Correspondence (March 2015). He also asserts that he has PTSD as result of in-service stressors events. See Hearing Transcript (April 2021). In the alternative, the Veteran contends that his acquired psychiatric disorder is secondary to his service-connected disabilities. See Buddy/ Lay Statement (September 2020). The record reflects that the Veteran has alleged the following in-service stressor events: (1) being shot at and fearing for his safety on two occasions while on active duty when he was stationed in Subic Bay, Philippines; (2) being part of a National Guard unit while on ARG status that responded to a civilian airline crash on October 31, 1994 and was responsible for the recovery of the bodies; (3) being a member of a ceremonial unit for over 150 military funerals during his National Guard service while on ARG status. See VA 21-0781, Statement in Support of Claim for PTSD (March 2021), C&P Exam (March 2021), and Hearing Transcript (April 2021). The Veteran's service treatment records (STR) from his periods of Marine Corps service do not reflect any complaints or findings of mental health symptomatology. His May 1978 report of medical examination (ROME) prior to separation shows he received a normal psychiatric evaluation. See Military Personnel Record (April 2015). The Veteran's STRs from his National Guard service while on ARG status from September 1981 to May 1996 do not contain an entrance examination. These records do document that he was voluntarily admitted for inpatient treatment from September 20, 1986 to October 1, 1986 for psychiatric symptomatology. At that time, he was evaluated as suffering from marital stress with adjustment reaction with resultant disturbance of mood and conduct. He was initially admitted to a private hospital and then transported to VA hospital for further evaluation. See STR Medical (October 1996). In March 1992, the Veteran presented with complaints chest pain, and it was noted that he felt "nervous" about his career ending. Diagnostic testing ruled out a cardiac etiology for his symptomatology, and his symptomatology was felt to be stress-related. His February 1996 retirement report of medical history (ROMH) documents a positive history of depression and excessive worry, which the examining physician noted as work-related stress and concerns about finding a new job. See STR - Medical (May 2015). The available post-service medical records indicate that the Veteran did not seek treatment for mental health symptoms until 2012. See Medical Treatment Record - Non-Government Facility (March 2015). The current medical evidence of record reflects that the Veteran has current diagnoses of major depressive disorder, PTSD, and somatic disorder with depression and anxiety. See CAPRI (September 2020), Disability Benefits Questionnaire (September 2020), and C&P Exam (March 2021). To ensure that VA's duty to assist has been satisfied, a remand is needed to attempt to verify the Veteran's alleged in-service stressor events, to obtain an addendum VA medical opinion, and to obtain relevant outstanding treatment records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. First, a remand is necessary to complete the development of in-service stressor verification, as the Veteran has not reported combat-related events. Although the Veteran has a current diagnosis of PTSD, it has not been related to a verified in-service stressor necessary to support an award of service connection as required by 38 C.F.R. § 3.304. The Veteran cannot establish the occurrence of a noncombat in-service stressor through lay testimony alone-rather, VA must have credible supporting evidence in corroborating the claimed event. See Doran v. Brown, 6 Vet. App. 283, 290 (1996). His service personnel records do confirm that the Veteran was a member of a ceremonial unit during his National Guard service in ARG status; however, the March 2021 VA examination report shows that the VA examiner felt that this claimed stressor did not satisfy Criterion A for PTSD diagnosis. See C&P Exam (March 2021). The record does not reflect that development of in-service service stressor verification has been completed with respect to the Veteran's reports of being shot at while in the Philippines or his participation in the October1994 airplane crash recovery. As such, a remand for stressor verification is necessary. Next, a remand is needed to obtain an addendum VA medical opinion on whether the Veteran has a current diagnosed acquired psychiatric disorder that is related to an in-service injury, event, or disease. The record contains the March 2021 VA medical opinion, in which the VA examiner provided a favorable nexus that the Veteran's major depressive disorder was a result of his service, and specifically noted that his depressed mood was more likely than not due to the in-service traumas he experienced. See C&P Exam (March 2021). However, the VA examiner failed to identify which of the Veteran's reported traumas was the source of his current major depressive disorder. Again, as noted above, the VA examiner noted that the Veteran's assignment to the ceremonial unit did not satisfy the stressor criterion and his other claimed stressors have not been verified. Clarification is needed regarding which claimed in-service stressor incident(s) is the source of the Veteran's current major depressive disorder. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); see also Bowling v. Principi, 15 Vet Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). In addition, the Veteran has submitted a private PTSD evaluation report completed by D.D., PhD., which included a current diagnosis of somatic disorder with depression and anxiety symptoms, which was considered proximately due to or aggravated by his service-connected disabilities. See Disability Benefits Questionnaire (September 2020). However, no further explanation was provided in support of this medical conclusion, and therefore, it contains very limited, if any, probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that "most of the probative value of a medical opinion comes from its reasoning"); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (stating that to be adequate, a medical opinion" must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions"). Regardless of the deficiencies in this private medical opinion, it does trigger the need for addendum VA medical opinion on whether the Veteran has a current acquired psychiatric disorder that is secondary to a service-connected disability. See 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Finally, a remand is required to obtain outstanding relevant treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, including making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159 (c)(1). At the April 2021 Board hearing, the Veteran testified that he received annual and/or biannual physical evaluations in conjunction with his employment with the State of Indiana Department of Transportation (DOT). On remand, the Veteran should be requested to complete a VA Form 21-4142, Authorization and Consent to Release Information to VA, for the release of his records from State of Indiana DOT. 2. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disability is remanded. The Veteran asserts entitlement to service connection for his current left knee disorder as secondary to his service-connected right knee disability. In the alternative, he contends that his left knee disorder had an onset during service, and he is current left knee disorder is a result of the physical demands of his military service, to include marching, running, and physical training exercises. See Correspondence (March 2015), and Hearing Transcript (April 2021). To ensure that VA's duty to assist has been satisfied, a remand is needed to obtain a new VA examination and medical opinion. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's National Guard STRs show that in August 1990, the Veteran complained of bilateral knee pain, worse on right, and he was assessed with patellofemoral pain syndrome and received physical therapy treatment. A September 1993 STR shows an assessment of probable arthritis associated with the Veteran's complaints of bilateral knee pain, but a bilateral knee x-ray report revealed no abnormalities. See STR Medical (October 1996). The Veteran's knees were evaluated as normal on a June 1994 periodic ROME and February 1996 retirement ROME, and he only indicated a history of right knee problems on his February 1996 retirement ROMH. See STR Medical (May 2015). Post-service medical records include diagnostic imaging of degenerative changes in the left knee as of September 2015. A remand is needed to afford the Veteran with an adequate VA examination and medical opinion in conjunction with his claim. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). The record contains an August 2015 VA examination and medical opinion report, but it is inadequate. The VA examiner determined that there was no current diagnosis as the Veteran only had subjective complaints of left knee pain without objective or radiologic findings to support a diagnosis and concluded that the left knee complaints were less likely than not secondary to his service-connected right knee disability without further discussion. However, the VA examination report does show evidence of reduced range of motion in the left knee as well as the Veteran's reports of increased symptomatology on repeated use and during periods of flare-ups, which resulted in functional impairment that is sufficient to demonstrate a current disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Moreover, only a month after the VA examination, a September 2015 private left x-ray report contains findings of minor degenerative changes in the left knee, and a more recent May 2021 VA knee examination report contains diagnoses of left knee patellofemoral and medial compartment osteophyte. The August 2015 VA examiner failed to provide a meaningful rational statement that considered whether Veteran's left knee disorder was secondary to his service-connected right knee disability. Given the absence of rationale that explains the basis for the conclusion reached, the Board finds that the VA medical opinion is inadequate. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 120. Therefore, a remand is necessary to obtain an adequate medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, no VA medical opinion has been obtained on whether the Veteran's current left knee disorder is directly related to his military service, to include complaints shown during his period of ACDUTRA. To the extent that there is competent evidence of degenerative arthritis of the knee, the examiner should consider whether it was shown as chronic in service, manifested to a compensable degree within a presumptive period following separation from service, or was noted in service with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Again, as the Veteran has already established "veteran" status for his period of ACDUTRA, the presumption for chronic diseases is applicable to that period. See Smith, supra; Donnellan, supra. On remand, VA should obtain a new VA medical opinion to address whether the Veteran has a current left knee disorder had an onset during service, is etiologically related to his military service or is secondary to his service-connected right knee disability. Also, a remand is required to allow VA to obtain relevant private treatment records. See 38 C.F.R. § 3.159 (c)(1). 3. Entitlement to service connection for a low back disorder is remanded. The Veteran asserts that his current low back disorder is a result of his military service. He reports that he injured his low back while lifting heavy equipment and performing his duties as wireman during his Marine Corps periods of service. He further believes that his low back disorder was further aggravated by the physical demands of his military service, to include marching, running, and physical training exercises. The Veteran contends that he has a current low back disorder as result of in-service injury, and he has continued to experience back pain since service. See Correspondence (March 2015), and Hearing Transcript (April 2021). To ensure VA's duty to assist has been satisfied, a remand is needed to obtain a VA examination and medical opinion as VA's duty has been triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006) (a VA examination and/or opinion is warranted when there is an indication in the record that a current disability is related to military service; the threshold for an indication is low). A March 1978 Marine Corps STR shows the Veteran presented with complaints of low back pain as result of an injury from lifting a heavy box from a truck. He reported that he noticed sharp back pain immediately, and had passed large clot that night, and he continued to have some flank pain. See STR Medical (April 2015). His May 1978 separation ROME shows that his spine was evaluated as normal. See Military Personnel Record (April 2015). Next, his National Guard STRs show that in November 1987, the Veteran fell down some stairs and injured his tailbone. A pelvis x-ray revealed a non-displaced fracture of the coccyx. He was placed on a physical profile. He again injured his tailbone in September 1989 when he fell down a flight of stairs, but a pelvis x-ray revealed no abnormalities. See Medical Treatment Record - Government Facility (October 2015). His February 1996 retirement ROME shows that his spine was evaluated as normal, and he had full range of motion and a negative Patrick's test for evidence of sacroiliac joint dysfunction. He denied any history of recurrent back pain on the associated ROMH. See STR Medical (May 2015). Post-service medical records include a September 2015 private lumbar spine x-ray which reflects findings of mild spondylosis, and an April 2018 VA lumbar spine x-ray reflects grade 1 anterolisthesis and multilevel degenerative changes. Given the evidence showing a current diagnosis of degenerative changes in the lumbar spine and the evidence of in-service back injury and complaints of low back pain, a remand is needed to afford the Veteran with a VA examination and medical opinion in conjunction with his claim. See McLendon, supra. The examiner should also address the Veteran's contention that his current low back disorder is a result of his in-service back injury in 1978 as well as result of physical demands of military service, to include marching, running, and physical training exercises. Also, a remand is required to afford the Veteran an opportunity to authorize release of relevant outstanding private treatment records to VA. See 38 C.F.R. § 3.159(c)(1). 4. Entitlement to service connection for a neck disorder is remanded. 5. Entitlement to service connection for a right shoulder disorder is remanded. Remanded Issues 4-5: The Veteran asserts this current neck and right shoulder problems are a result of injury he sustained when he fell down a flight of stairs in September 1989 while on ARG status in the National Guard. He reports that he continued to experience recurrent neck and right shoulder problems through the remainder of his National Guard service, and he continued to have similar problems since service which have progressively worsened. He further believes that his neck and right shoulder disorders were further aggravated by the physical demands of his military service, to include marching, running, and physical training exercises. See Correspondence (March 2015), and Hearing Transcript (April 2021). To ensure VA's duty to assist has been satisfied, a remand is needed to afford the Veteran with VA examinations and medical opinions in conjunction with his claims. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's National Guard STRs show that in September 1989, the Veteran fell down a flight and presented with complaints of right side neck and shoulder pain. He was placed in neck brace and treated with Motrin. X-ray of the shoulder and neck were normal, and impression cervical muscle spasms was provided. See STR Medical (October 1996). Three weeks later, the Veteran reported that his neck and right shoulder pain persisted, and he was assessed with sprain and contusion of the neck and right shoulder. Next, STRs dated in March 1994 and April 1994 show that the Veteran presented with recurring neck and right shoulder pain with numbness and tingling down his right arm. A March 1994 cervical spine x-ray for complaints of right upper extremity problems revealed no abnormalities, and the Veteran was assessed with right trapezoid spasms. He was provided with physical therapy treatment for cervical muscle spasms in Apri 1994, which provided excellent pain relief. See STR Medical (March 2015). The Veteran's February 1996 retirement ROME shows that his upper extremity was evaluated as normal, although he reported a positive history of shoulder problems related to his right shoulder injury on the associated ROMH. See STR-Medical (May 2015). Shortly after his separation from his full-time National Guard duty, the Veteran initiated a claim for service connection for right shoulder trauma, however, a February 1997 VA general medical examination report showed the Veteran has a normal right shoulder evaluation and x-ray film was negative for abnormalities, despite his reports of minor symptoms. See VA Examination (February 1996). Subsequent private medical records show complaints of neck and right shoulder pain since service, as well as diagnostic imaging of cervical spondylosis and assessment of rotator cuff disorder. See Medical Treatment Record - Non-Government Facility (October 2015). Given the evidence showing current cervical spine and right shoulder disorders and the evidence of in-service injury and complaints of persistent neck and right shoulder pain during his period of ACDUTRA, a remand is needed to afford the Veteran with a VA examination and medical opinion in conjunction with his claims. See McLendon, supra. The examiner should also address the Veteran's contention that his current neck and right shoulders are a result of his in-service injury in September 1989 as well as result of physical demands of military service, to include marching, running, and physical training exercises. Also, a remand is required to afford the Veteran an opportunity to authorize release of relevant outstanding private treatment records to VA. See 38 C.F.R. § 3.159(c)(1). The matters are REMANDED for the following action: 1. Attempt to verify the Veteran's reported stressors while being stationed in Subic Bay, Philippines, to the extent feasible along with his participation in an airplane crash recovery in October 1994. If the search for corroborating records leads to negative results, the RO must notify the Veteran and his representative of this fact, explaining the efforts taken, describing further action, if any, to be taken, and affording them the opportunity to respond. The RO should also follow up on any additional action suggested by each appropriate source contacted. 2. With the assistance of the Veteran as necessary, identify and obtain his medical records from State of Indiana the Department of Transportation, and associate them with the Veteran's electronic claims file. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's acquired psychiatric disorder, to include the alleged PTSD. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any acquired psychiatric disorder. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. The clinician must opine on: (a) Whether it is at least as likely as not that the Veteran has, or has had, PTSD at any time during the pendency of the claim or recent to the filing of the claim. Attempt to reconcile, or account for, medical evidence showing negative and positive findings for PTSD. Explain. (b) If the Veteran is diagnosed with PTSD, the clinician must explain how the diagnostic criteria are met and opine on whether it is at least as likely as not related to any VA conceded in-service stressor. (c) For all other diagnosed mental disorders, to include major depressive disorder, shown during this appeal, the clinician must opine on whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to performing duties in the ceremonial unit, his 1986 hospitalization treatment for mental health symptoms, and complaints of "depression and excessive worry" on his 1996 retirement ROMH during his National Guard service while on ARG status, or result of another verified stressor event identified by the RO. (d) Whether the Veteran has a current acquired psychiatric disorder that is at least as likely as not (1) proximately due to a service-connected disability, or (2) aggravated beyond its natural progression by a service-connected disability. Provide a rationale that deals with causation and aggravation as independent concepts. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? NOTE (3): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 4. Schedule the Veteran for a VA examination for a left knee disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any left knee disorder. The clinician must opine on: (a) Whether the Veteran's current left knee disorder is at least as likely as not related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to in-service complaints of knee pain as well as physical demands of military service, to include running, marching, and physical training exercise. (b) Whether the Veteran's arthritis involving his left knee at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Consider and expressly address the Veteran's lay statements concerning continuity of left knee symptomatology. (c) Whether the Veteran's left knee disorder is at least as likely as not (1) proximately due to service-connected right knee disability, or (2) aggravated beyond its natural progression by service-connected right knee disability. Provide a rationale that deals with causation and aggravation as independent concepts. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? NOTE (3): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 5. Schedule the Veteran for a VA examination for a low back disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any low back disorder. The clinician must opine on: (a) Whether the Veteran's current low back disorder is at least as likely as not related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to in-service back injury in 1978, and tailbone injuries in 1987 and 1989, as well as physical demands of military service, to include running, marching, and physical training exercise. (b) Whether the Veteran's arthritis involving his lumbar spine at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Consider and expressly address the Veteran's lay statements concerning continuity of back symptomatology. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 6. Schedule the Veteran for a VA examination for a right shoulder disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any right shoulder disorder. Note that if a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider that there exists a "disability" for VA purposes. The clinician must opine on: (a) Whether any current right shoulder disorder is at least as likely as not related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to in-service injury in September 1989 and complaints of persistent shoulder pain, as well as the physical demands of military service, to include running, marching, and physical training exercise. (b) If there is evidence of arthritis involving the right shoulder, the address whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. Consider and expressly address the Veteran's lay statements concerning continuity of right shoulder symptomatology. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 7. Schedule the Veteran for a VA examination for a neck disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any neck disorder. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician must opine on: (a) Whether the Veteran's current neck disorder at least as likely as not related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to in-service injury in 1989 1989 and complaints of persistent neck pain and right upper extremity numbness, as well as physical demands of military service, to include running, marching, and physical training exercise. (b) Whether the Veteran's arthritis involving his cervical spine at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Consider and expressly address the Veteran's lay statements concerning continuity of neck symptomatology. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 8. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Murray, 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.