Citation Nr: 21069778 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 16-32 115 DATE: November 19, 2021 ORDER Entitlement to service connection for disability due to generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales (claimed as painful, achy joints over entire body) as due to undiagnosed illness is granted. Entitlement to service connection for bilateral pes planus disability is granted. Entitlement to service connection for degenerative arthritis and degenerative disc disease of the lumbar spine disability is granted. REMANDED Entitlement to service connection for bilateral foot disorders, other than pes planus disability, is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a right wrist disorder is remanded. Entitlement to service connection for a left elbow disorder is remanded. Entitlement to service connection for a right elbow disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. FINDINGS OF FACT 1. The Veteran served on active duty in in the Southwest Asia Theater of operations during the Persian Gulf War from February 13, 1991, to April 30, 1991. 2. The evidence is at least in equipoise as to whether the Veteran's chronic generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales cannot be attributed to a known clinical diagnosis and has required continuous medication. 3. The evidence is at least in equipoise as to whether the Veteran's bilateral pes planus had its onset in service. 4. The Veteran currently has degenerative arthritis and degenerative disc disease of the lumbar spine, and he has experienced continuous symptoms pertaining to his back since an injury in service. CONCLUSIONS OF LAW 1. The criteria for service connection for generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. 2. The criteria for service connection for bilateral pes planus disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for degenerative arthritis and degenerative disc disease of the lumbar spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training (ADT) with the Army Reserves from September 1982 to November 1982, and he served on active duty in the United States Army from November 1983 to June 1991, April 2008 to August 2008, and March 2009 to October 2009. He had additional service in the Army National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a June 2019 hearing. A hearing transcript is associated with the claims file. In November 2019, the Board remanded all the issues on appeal for additional development, to include VA examinations and medical opinions. In January 2021, the Board determined that there had not been substantial compliance with the remand directives, and again instructed for additional development. Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to those remand directives, the Veteran was afforded with additional June 2021 VA examinations and medical opinions. Although the Board notes that additional development is still required concerning the remaining the issues on appeal, given the favorable decisions regarding the claims for generalized body aches with tender points, lumbar spine, and bilateral pes planus disability, the Veteran is not prejudiced by the Board proceeding with adjudication of those claims herein. The remaining claims are addressed in the remand portion below. REFERRED The Veteran initiated a claim for service connection for venous insufficiency of the lower extremities on his June 2011 Veterans Application for Compensation or Pension. See VA Form 21-526 (June 2011). This claim was deferred in an October 2012 rating decision and remains pending. See Rating Decision (October 2012). As such, the claim for service connection for venous insufficiency of the lower extremities is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) 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). 1. Entitlement to service connection for generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales (claimed as painful, achy joints over entire body) due to an undiagnosed illness The Veteran asserts that he has experienced painful, achy joints and muscles all over his body due to his military service. He believes that he has a current joint and muscle disorder as a result of the physical demands of his military service, to include marching, running, jumping, and carrying heavy equipment. Alternatively, he contends that he has painful joints and muscle as result of his service in Southwest Asia. See NOD (March 2014), and Hearing Transcript (June 2019). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Here, the record confirms that the Veteran has service in Southwest Asia Theater of operations during the Persian Gulf War from February 13, 1991, to April 30, 1991. See Military Personnel Record (January 2012). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi- symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. An undiagnosed illness requires that the illness, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(4). There is no burden on a veteran to demonstrate that a medical professional has eliminated all possible diagnoses before the veteran can be compensated for a disability stemming from an undiagnosed illness. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014). For purposes of Gulf War undiagnosed illness claims, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). The Board concludes that the evidence of record is at least in equipoise as to whether the Veteran's disability manifested by generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales is due to an undiagnosed illness as a result of Persian Gulf War service. 38 U.S.C. §§ 1110, 1117, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317. VA and private treatment records show that the Veteran has complained of pain over his entire body, and he has been prescribed pain medication (tramadol and ibuprofen) to help alleviate his symptoms. See Medical Treatment Record - Government Facility (March 2020), and CAPRI (December 2019). The Veteran testified that he experiences pain all over his body ranging from his shoulders to his feet, which increases with activity, and he takes ibuprofen daily to help with pain. See Hearing transcript (June 2019). The Veteran was evaluated by VA in June 2021 and the examiner noted that the Veteran's complaints manifests in widespread musculoskeletal pain, stiffness, sleep disturbances, and anxiety, and with tender points, bilaterally, involving the second rib, trapezius muscle, lateral epicondyle, and gluteal. He had stiffness in his knees, elbows, wrists, and generalized body aches. The examiner determined that the Veteran's symptomatology did not meet criteria for a diagnosis of fibromyalgia, and that clinical evaluation did support diagnoses of lateral epicondylitis and medial epicondylitis in his elbows, and chronic bilateral wrist sprains. The medical evidence of record also shows that the Veteran has known diagnosed disorders, including degenerative arthritis, involving his lumbar spine, knees, shoulders, and feet. These diagnosed disorders are addressed separately herein as well as in the remand portion below. In addition, the Veteran's service-connected anxiety disability already contemplates his symptomatology involving sleep impairment and anxiety. However, the competent evidence does not otherwise show that the Veteran's signs and symptoms of generalized body aches and identified tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales, are attributable to a known clinical diagnosis by history, physical examination, or laboratory testing. There is no affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War. See 38 C.F.R. § 3.317(a)(7)(i)-(iii). Throughout the pendency of the appeal, the Veteran has reported signs and symptoms of painful joints and muscles all over his body, and thus, they are considered chronic under the regulatory definition. Moreover, the signs and symptoms have manifested to a degree of 10 percent or more as the Veteran has required continuous medication to manage his symptomatology due painful joints and muscle as required under 38 C.F.R. § 4.71a, Diagnostic Code 5025 for fibromyalgia. In this regard, the VA and private treatment records reflect that the Veteran has been prescribed pain medication, including tramadol and ibuprofen, to take as needed and the Veteran has credibly reported that he takes pain medication daily to help alleviate his symptomatology. Such symptomatology closely approximates a compensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5025 by analogy to fibromyalgia. For the above reasons, the evidence is at least in equipoise as to whether the Veteran's disability manifested by generalized body aches with tender points are due to undiagnosed illness. As the reasonable doubt created by relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for generalized body aches with tender points involving the second ribs, trapezius muscles, lateral epicondyles, and gluteales due to undiagnosed illness is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for bilateral pes planus The Veteran contends that his current bilateral foot disorders are a result of his military service. He reports that his bilateral foot problems had an onset during service, and he believes that his current foot problems are a result of an in-service injury when he fell into a hole and landed hard on his feet. See VA examination (February 2012). He further contends that his foot problems were further aggravated by the physical demands of military service, to include marching, running, jumping, and carrying heavy equipment. Alternatively, he contends that his bilateral foot pain is a result of his Persian Gulf War service. See NOD (March 2014), and Hearing Transcript (June 2019). The Board concludes that the Veteran has a current pes planus disability that began during his first period of active duty service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran's service treatment records (STR) from his first period of active duty service from November 1983 to June 1991 have not been associated with the claims folder. However, the record does contain the report of a July 1991 report of medical examination (ROME) for enlistment into Army National Guard (ANG) service, which occurred only one month after his separation from his first period of active duty. The July 1991 ROME shows findings of abnormal feet and evidence of pes planus, moderate, asymptomatic. See STR-Medical (July 2012). The Board acknowledges that subsequent periodic ANG ROME in January 2003 and January 2005 both show the Veteran received normal foot and arch evaluation. See STR-Medical (August 2011). However, August 2008 private treatment records show he presented with complaints of pain on the bottom of his feet, worse with waking and improved with footwear, during his second period of active. See Medical Treatment Record - Non-Government Facility (November 2012). In addition, a January 2011 VA foot x-rays reports shows evidence of bilateral pes planus, which comes only fourteen months after his separation from his last period of active duty service. See CAPRI (October 2012). The medical evidence demonstrate that the Veteran suffered bilateral pes planus during active service and corroborates his lay reports of continuity of foot problems. Both February 2012 and March 2020 VA foot examination reports contain a diagnosis of bilateral pes planus. See VA examination (February 2012) and C&P Exam (March 2020). As the competent evidence demonstrates a current bilateral pes planus and abnormal feet findings of moderate pes planus within one month of his separation from his first period of active duty, as well as and complaints of bilateral foot pain in later periods of active service, the remaining questions is whether there is competent evidence establishing a nexus between the current disability and in-service disease. VA medical opinions (VAMO) obtained in February 2012 and March 2020 were previously determined to be inadequate. See BVA Decision (November 2019) and (January 2021). More recently, in a June 2021 VAMO report, the VA examiner concluded the Veteran's bilateral pes planus was less likely than not incurred in or caused by service, including physical demands such as marching, running, jumping, and carrying heavy gear, and his disorder was more likely age-related. However, the Board finds this VA medical opinion that the Veteran's bilateral pes planus disorder is not related to service contains no probative value as it is based on an inaccurate factual premise. See Reonal, 5 Vet. App. at 461. Specifically, the examiner failed to address the STRs that shows findings of pes planus only a month after his separation from his first period of active duty as well as private medical records that show complaints of bilateral foot problems during his second period of active service. While the Board could remand the case for an additional medical opinion, such action could be construed as a request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304 (c) (The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination); Gardner-Dickson v. Wilkie, 33 Vet. App. 50, 62 (2020) (denying petition for a writ of mandamus challenging a remand but agreeing with the petitioner that it would not be permissible for VA to undertake... additional development if a purpose was to obtain evidence against an appellant's case.' (citing Mariano v. Principi, 17 Vet. App. 305, 312 (2003) and Hart v. Mansfield, 21 Vet. App. 505, 508 (2007)). The above evidence is sufficient to decide the claim. There is competent evidence of current bilateral pes planus disability, and medical records show that moderate pes planus was assessed in July 1991, which comes only one month after his separation from his first period of active service. Further, a relationship between the two has been established through the Veteran's competent, credible statements of onset of bilateral foot problems in 1991 and continuity of bilateral foot problems since then, which are consistent with the treatment records during and after service. See Layno, 6 Vet. App. a 465; see also Falzone, 8 Vet. App. at 403. Moreover, there is no competent opinion to the contrary. Based on the evidence of record, and resolving reasonable doubt in his favor, the Board finds that the Veteran's current bilateral pes planus was incurred during his active service. Thus, service connection for bilateral pes planus disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for lumbar spine disorder The Veteran contends that he has a current lumbar spine disorder as a result of his military service. He reports that his low back pain had an onset during service, and he believes that his current low back problems are a result of an in-service injury when he fell into a hole and landed hard on his feet. He further contends that his low back pain was aggravated by the physical demands of military service, to include marching, running, jumping, and carrying heavy equipment. Alternatively, he contends that his low back pain is a result of his Persian Gulf War service. See NOD (March 2014), and Hearing Transcript (June 2019). The Board concludes that the Veteran's degenerative arthritis and degenerative disc disease of the lumbar spine was incurred during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A March 2020 VA spine examination report shows that the Veteran has current diagnoses of degenerative joint disease and degenerative disc disease of the lumbar spine. See C&P Exam (March 2020). Although degenerative changes are not specifically referenced as a chronic disease in 38 U.S.C. § 1101 (3) or 38 C.F.R. § 3.309 (a), degenerative joint disease, as form of arthritis, qualify as a "chronic disease" under 38 C.F.R. § 3.309 (a). See Dorland's Illustrated Medical Dictionary (1344 (32d ed. 2012); see also Giglio v. Derwinski, 2 Vet. App. 560, 561 (1992) (nonprecedential decision citing medical authority to show that degenerative joint is a form of arthritis). The Veteran's June 1982 report of medical examination (ROME) for enlistment into the Army Reserves shows that his spine was evaluated as normal, and he did not complain of any back problems on the associated report of medical history (ROMH). An October 1982 STR shows that the Veteran presented with a history of recurrent back pain for the past three to four years, but he had been advised to not reported any problems at enlistment physical. He underwent a few sessions of physical therapy which provided him with much improvement. His spine was evaluated as normal on his November 1982 separation ROME as well as on his January 2003 and January 2005 periodic ROME during his National Guard service. See STR-Medical (July 2012). During the Veteran's second period of active duty service from April 1, 2008 to August 31, 2008, private treatment records dated in August 2008 show that the Veteran presented with complaints of low back pain for the past few months, which had worsened due to increased activity, especially sit-ups. An August 13, 2008 private lumbar spine x-ray and MRI lumbar spine reports showed evidence of mild degenerative spondylitic changes throughout the lumbar spine most pronounced at L4-L5. He underwent physical therapy evaluation which determined SI joint abnormalities and received physical therapy treatment with some improvement. See Medical Treatment Record - Government Facility (March 2020). Here, the record first demonstrates diagnostic evidence of degenerative disc disease in the Veteran's lumbar spine comes during his second period of active duty service. While this evidence is not definitive that the Veteran's back disability included degenerative joint disease during service, the Board finds that there is sufficient evidence of continuity of symptomatology of that chronic disease since service. During his final period of active duty service, an April 2009 STR shows complaints of back pain. See STR Medical (July 2012). Then, in January 2011, just fourteen months following his separation from his final period of active service, the Veteran initiated VA care and he complained of low back discomfort since his military service. A March 2011 VA lumbar spine x-ray showed evidence of mild degenerative changes with alight disc space narrowing at L4-L5 level. See CAPRI (July 2012). Based on those x-ray results, the February 2012 VA back examiner marked that there was diagnostic evidence of arthritis in the lumbar spine. See VA examination (February 2012). Further, a November 2012 private MRI of the lumbar spine revealed evidence of minimal bulging annulus fibrosis L4-5 with foraminal narrowing, which was considered unchanged when compared to the August 13, 2008 MRI results, and further tends to demonstrate continuity of lumbar spine symptomatology since service. See Medical Treatment Record - Non-Government Facility (May 2016). The Board has also considered the lay evidence of record. The Board initially notes that a lay person is competent to report observable symptoms and these statements must be taken in account. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 403 (1995). Here, the Veteran has consistently reported the onset of his low back pain during active duty service, and that his back problems have continued since service. The Board finds that the objective evidence supports the Veteran's statements as evidenced by the onset of back pain following increased activity noted in August 2008 during his second period of active duty service, and subsequent treatment, thereafter, including after discharge. As such, the Board finds the Veteran's reports of continuous back symptoms to be competent and credible as they are consistent with the contemporaneous medical records. With regard to the most recent June 2021 VA medical opinion (VAMO), in which the examiner concluded that the Veteran's the current lumbar spine disorder was less likely than not incurred in or result of his periods of service, the Board finds the opinion is inadequate as it is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). Specifically, the examiner failed to address the private medical records that show complaints of back injury and physical therapy treatment during his second period of active duty service. Moreover, the examiner failed to address whether the August 2008 diagnostic evidence of degenerative disc disease shown during the Veteran's second period of active duty marked the onset of his current lumbar spine disability. Given the totality of the lay and medical evidence above, the Board finds that, for the purpose of establishing continuity, the weight of the service treatment records, private treatment records, and lay statements of record sufficiently demonstrate the onset of a chronic disease during the Veteran's second period of service and continuity of low back symptomatology since then. The medical evidence first shows diagnostic evidence of degenerative disc disease in August 2008 during the Veteran's second period of active duty service, which had remained unchanged when later evaluated after service. Further, the preponderance of evidence shows that the Veteran injured his back during his second period of service which required physical therapy treatment, and that he continued to have back problems during his final period of active duty service. The preponderance of evidence also shows that after discharge, the Veteran continued to have problems with his back resulting in diagnostic evidence of degenerative arthritis of the lumbar spine only three years after the first diagnostic evidence of a lumbar spine disorder. Thus, continuity of symptoms has been established. In light of the evidence above, the Board finds that the criteria for entitlement to service connection for degenerative disc disease and degenerative joint disease of the lumbar spine, pursuant to the continuity of symptomatology provisions of 38 C.F.R. § 3.303 (b), have been met. Accordingly, the claim for service connection for degenerative disc disease and degenerative joint disease of the lumbar spine is granted. 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. 1. Entitlement to service connection for a left ankle disorder is remanded. 2. Entitlement to service connection for a right ankle disorder is remanded. 3. Entitlement to service connection for a left knee disorder is remanded. 4. Entitlement to service connection for a right knee disorder is remanded. 5. Entitlement to service connection for a left wrist disorder is remanded. 6. Entitlement to service connection for a right wrist disorder is remanded. 7. Entitlement to service connection for a left elbow disorder is remanded. 8. Entitlement to service connection for a right elbow disorder is remanded. 9. Entitlement to service connection for a left shoulder disorder is remanded. 10. Entitlement to service connection for a right shoulder disorder is remanded. 11. Entitlement to service connection for a left hip disorder 12. Entitlement to service connection for a right hip disorder 13. Entitlement to service connection for bilateral foot disorder, other than pes planus disability, is remanded. Remanded Issues 1-13: Initially, as noted above, the Veteran's service treatment records (STR) appear to be incomplete as the record is devoid of any treatment records from the Veteran's first period of active duty service dated from November 1983 to June 1991. Therefore, remand is required for the Agency of Original Jurisdiction (AOJ) to attempt to secure the service treatment records. If unable to do so, a Memorandum of Formal Finding of Unavailability of service treatment records must be prepared and sent to the Veteran. See 38 C.F.R. § 3.159 (c). Second, the Board finds that there has not been substantial compliance with the Board's previous remand directive regarding the appeals of left ankle disorder and other diagnosed bilateral foot disorders (metatarsalgia, osteoarthritis, and hammertoes). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board finds that an addendum medical opinion is required with respect the Veteran's claim for a left ankle disorder. On remand, the AOJ obtained a June 2021 VAMO report as related to the Veteran's left ankle, which denied any disability related to his ankle joints. However, a VA x-ray reports of the left ankle showed changes at the medial malleolus of one ankle, which was noted as possibly due to an old injury, which was confirmed as degenerative joint disease in a February 2012 VA examination. Hence, the February 2012 VA examination and June 2021 VAMO are incongruous as to the presence of a current left ankle disability during the appellate period. A remand is necessary to obtain an addendum opinion that addresses the etiology of the Veteran's left ankle degenerative arthritis noted in the February 2012 VA examination report. As noted above, the Board finds that the June 2021 VAMO regarding the Veteran's bilateral foot disorders was inadequate because it was based on an inaccurate factual premise. See Reonal, 5 Vet. App. at 461. Again, the VAMO does not appear to consider the August 2008 private medical records that show complaints of bilateral foot problems during his second period of active service. A remand is necessary to obtain an addendum opinion that addresses whether the Veteran's diagnosed foot disorders, other than pes planus, were incurred in or result of his military service, to include physical demands such as marching, running, jumping, and carrying heavy gear. Third, a remand is needed to obtain VAMOs that addresses whether the Veteran's claimed his left ankle, knees, hips, and feet (other than pes planus) disorders are secondary to his now service-connected disabilities. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, the Board must supplement the record by seeking an advisory opinion or ordering a medical examination.) In this regard, the Veteran has indicated that his current left ankle and bilateral knee disorders are secondary to his now service-connected bilateral pes planus disability. He asserted that he has experienced knee and ankle problems since he injured his feet when he fell into a hole and landed hard on his feet. See NOD (March 2014). In addition, the current medical evidence is insufficient to determine whether the Veteran's other diagnosed bilateral foot disorders (metatarsalgia, osteoarthritis, and hammertoes) are secondary to his now service-connected bilateral pes planus disability. The record also demonstrates that the Veteran has reported recurrent bilateral pain throughout the pendency of this case. The March 2020 VA hip examination report shows that the Veteran has described the pain as located on lateral pelvis near iliac crest, bilaterally, which the VA examiner noted involved the muscle of his pelvis and not hip joint. However, there was evidence of some limited range of motion on clinical examination in both hips as well as reports of increased symptomatology due flare-ups, which demonstrates functional impairment necessary to establish a current bilateral hip disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The March 2020 VA examiner indicated that the Veteran's bilateral hip symptomatology was likely a result of his now service-connected lumbar spine disability; however, it remains unclear whether the Veteran has a separate and distinct bilateral hip/pelvis disability secondary to his service-connected lumbar spine disability (as opposed to symptoms associated with the lumbar spine disability). Notably, muscle group XVI, pelvic girdle group, under 38 C.F.R. § 4.73, Diagnostic Code 5315, involves function of hip flexion, which may not be considered in the diagnostic criteria applicable for rating the now service-connected lumbar spine disability. A remand is needed to obtain a medical opinion that addresses the claim on secondary basis. The Board cannot make a fully-informed decision on the issue, and a remand is needed to obtain a medical opinion on whether the Veteran may have a bilateral hip/pelvis condition secondary to now service-connected lumbar spine disability. Finally, the Veteran's right ankle swelling, instability, and pain has been associated with his diagnosed bilateral lower extremity venous insufficiency. See C&P Exam (March 2020). The claim for service connection for lower extremity venous insufficiency remains pending and has been referred above for appropriate action by the AOJ, and the Board finds that these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim). The Board's consideration of the merits of the Veteran's claim for service connection for ankle disability is deferred pending any necessary development and adjudication of issue of entitlement to service for bilateral lower extremity venous insufficiency. The matters are REMANDED for the following action: 1. Undertake all appropriate action to obtain any outstanding STRs from the Veteran's first period of active duty service dated from November 1983 to June 1991 from the appropriate source(s). If no records are obtained, prepare a Memorandum of Formal Finding of Unavailability for the STRs outlining the steps taken to retrieve the Veteran's STR, and notify the Veteran. A copy of the memorandum should be associated with the claims file. 2. If additional STRs are obtained and associated with the claims folder, determine if addendum VA medical opinions should be obtained with regard to the remaining issues on appeal. 3. Obtain an addendum VA opinion from an appropriate clinician regarding the Veteran's left ankle degenerative arthritis on the following: (a.) Whether the arthritis involving the left ankle 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 ankle symptomatology. (b.) Whether any left ankle degenerative arthritis 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 the physical demands of military service including marching, running, jumping, and carrying heavy gear. (c.) Whether the Veteran's left ankle degenerative arthritis is at least as likely as not proximately due to service-connected disability/aggravated beyond its natural progression by service-connected bilateral pes planus 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): 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. Obtain an addendum VA opinion from an appropriate clinician regarding whether the Veteran's current bilateral knee are at least as likely as not proximately due to service-connected disability/aggravated beyond its natural progression by service-connected bilateral pes planus disability. Provide a rationale that deals with causation and aggravation as independent concepts. NOTE: 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. Obtain an addendum VA opinion from an appropriate clinician regarding whether the Veteran's other diagnosed foot disorders (metatarsalgia, osteoarthritis, and hammertoes) on the following: (a.) Whether it is at least as likely as not any of the other diagnosed foot disorders (metatarsalgia, osteoarthritis, and hammertoes) incurred in or related to an in-service injury, event, or disease. Consider and expressly address whether the disability is related to the physical demands of military service including marching, running, jumping, and carrying heavy gear. (b.) Whether the arthritis involving the feet 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 feet symptomatology. (c.) Whether the Veteran's other diagnosed foot disorders (metatarsalgia, osteoarthritis, and hammertoes) are at least as likely as not proximately due to service-connected disability/aggravated beyond its natural progression by service-connected bilateral pes planus 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): 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. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the claimed bilateral hip/pelvis disorder. The examiner is asked to address each of the following: (a.) The examiner must provide a diagnosis for any pelvis conditions found extant. (b.) If a current pelvis diagnosis is not present, the examiner should nevertheless address the Veteran the functional impairment in the bilateral hip (recurrent pain with limitation of motion). (c.) If any pelvis condition is diagnosed, and/or for the functional impairment of bilateral hip present, opine whether the current condition 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: 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. 7. Ensure that the VA medical opinion 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 opinions 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.