Citation Nr: 21071305 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-37 581 DATE: November 30, 2021 ORDER New and material having been received, the petition to reopen a claim of entitlement to service connection for low back pain is granted to that extent only. Entitlement to service connection for a lumbar spine disorder is granted. Entitlement to service connection for any acquired psychiatric disorder as due to military sexual trauma is granted. REMANDED Entitlement to service connection for arthritis to include as secondary to service-connected pseudofolliculitis barbae is remanded. Entitlement to service connection for anterior cruciate ligament tear (ACL), claimed as an ACL tear, to include as secondary to service-connected pseudofolliculitis barbae is remanded. FINDINGS OF FACT 1. An appealed October 2001 rating decision denied the claim of entitlement to service connection for low back pain; the petition to reopen the claim was subsequently denied in rating decisions dated in May 2010, March 2011, August 2012, March 2013 and July 2014. 2. The evidence associated with the claims file subsequent to the July 2014 rating decision is not cumulative nor redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for low back pain. 3. Resolving all doubt in favor of the Veteran, the preponderance of the evidence supports a finding that the Veteran's lumbar spine disorder was due to service. 4. Resolving all doubt in favor of the Veteran, the preponderance of the evidence supports a finding that the Veteran's current acquired psychiatric disorder was due to service to include military sexual trauma. CONCLUSIONS OF LAW 1. The July 2014 rating decision denying the petition to reopen the claim for service connection for low back pain is final and new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for low back pain. 38 U.S.C. §§ 5108, 7104, 7105; 38 C.F.R. § 3.156. 2. The criteria for service connection for a lumbar spine disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for any acquired psychiatric disorder, to include as due to military sexual trauma have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1974 to January 1975. The matters come to the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by the Department of Veterans (VA) Affairs Regional Office (RO). In his November 2017 Substantive Appeal (on a VA Form 9), the Veteran requested a Board hearing. In a subsequent letters dated in March 2020 and July 2021, the Veteran stated that he wished to withdraw his request for a Board hearing. Thus, this hearing request is considered to be withdrawn. 38 C.F.R. § 20.704(e). New and Material Evidence As a threshold matter, the Board must determine whether new and material evidence has been submitted to reopen a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial) A rating decision becomes final when it has not been appealed within the prescribed time period and when no additional material evidence was received within a year of the decision; the decision is not subject to revision on the same factual basis. 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In order to reopen a claim, there must be added to the record "new and material evidence." 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing 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 neither be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. The law provides that new and material evidence necessary to reopen previously and finally disallowed claims must be secured or presented since the time that the claims were finally disallowed on any basis, not only since the time the claims were last disallowed on the merits. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). 38 C.F.R. § 3.156(a), which defines new and material evidence, requires that evidence raise a reasonable possibility of substantiating the claim in order to be considered "new and material," and defines material evidence as evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. The Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). By the way of history, the claim of entitlement for service connection for low back pain was originally denied in October 2001. The rating decision found that while the Veteran did suffer from back concerns while in service, the condition was not shown to be chronic, and therefore, lacked the nexus element to establish service connection. Evidence consisted of service medical records, several treatment records from 1998 to 2001, private medical letter from August 1999 and imaging correspondence from August 1999. The Veteran was notified of this denial in an October 2001 letter. There was no further communication regarding his claim of entitlement to service connection for a back condition until March 2010, when VA received his petition to reopen such claim in a statement in support of claim. Therefore, the October 2001 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no relevant evidence pertaining to the Veteran's claim for service connection was received prior to the expiration of the appeal period stemming from the October 2001 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). In a March 2010 statement in support of the claim, the Veteran sought to reopen his claim for service connection for the back condition. An April 2010 rating decision found that no new and material evidence had been received as no additional information has been received as of the date of the rating decision. The Veteran was notified of this denial in an April 2010 letter. The Veteran then submitted a private etiology opinion in April 2010. A May 2010 rating decision readjudicated the claim and found that the evidence does not show that the Veteran's low back pain that is related to service. The Veteran was notified of this denial in a May 2010 letter. In March 2011, the Veteran submitted a December 2010 private etiology opinion. A March 2011 rating decision found that the evidence does not relate to an unestablished fact necessary to substantiate the claim and does not raise a reasonable possibility of substantiating the claim. The Veteran was notified of this denial in a March 2011 letter. There was no further communication regarding his claim of entitlement to service connection for a back condition until June 2012, when VA received his petition to reopen such claim in a statement in support of claim. Therefore, the March 2011 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no relevant evidence pertaining to the Veteran's claim for service connection was received prior to the expiration of the appeal period stemming from the March 2011 rating decision. See also Bond v. Shinseki, supra; Roebuck v. Nicholson, supra; Muehl v. West, supra. Evidence received since the March 2011 rating decision includes updated VA treatment records. An August 2012 rating decision found that new and material evidence had not been received. The Veteran was notified in an August 2012 letter. Additional evidence, to include updated VA treatment records and lay statements, were received by VA within one year of the August 2012 rating decision. A March 2013 rating decision found that new and material evidence had not been received. The Veteran was notified in a March 2013 letter. Additional evidence, to include updated VA treatment records and a January 2014 private etiology opinion, were received by VA within one year of the March 2013 rating decision. A July 2014 rating decision found that new and material evidence had not been received. The Board has also considered the applicability of 38 C.F.R. § 3.156(c) as additional personnel records were associated with the record in November 2014 and July 2015. In this regard, such provides that, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of the same section (which defines new and material evidence). The regulation further identifies service records related to a claimed in-service event, injury, or disease as relevant service department records. 38 C.F.R. § 3.156(c)(1)(i). As such, new and material evidence is not needed to reopen a previously denied claim when relevant service treatment records and/or any other relevant service department records are received after a prior final denial. Rather, the claim is simply reviewed on a de novo basis. Here, the service personnel records are not relevant as they are not related to a claimed in-service event, injury, or disease. Therefore, the provisions of 38 C.F.R. § 3.156(c) are not applicable to this case. The pertinent evidence that has been received since the July 2014 rating decision includes continuing post-service treatment records and a private etiology opinion. Presuming the credibility of the private etiology opinion, the Board finds that the evidence is new and material. In this regard, it has not been previously considered by VA and it raises a reasonable possibility of substantiating the claim of entitlement to service connection for low back pain. The claim for service connection for low back pain was previously denied because there was no evidence showing that the back condition was chronic or otherwise etiologically related to active service nor aggravated beyond its natural progression by service. However, the May 2020 private etiology opinion, the examiner opined a positive nexus between that the Veteran's lumbar spine disorder and service. Accordingly, reopening of the claim of entitlement to service connection for low back pain is warranted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for posttraumatic stress disorder (PTSD) requires: (1) medical evidence establishing a diagnosis of the condition; (2) credible supporting evidence that the claimed inservice stressor occurred; and, (3) a link established by medical evidence, between current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). Lay testimony alone can establish the occurrence of the claimed in-service stressor in certain circumstances, which include: when PTSD is diagnosed during service and the claimed stressor is related to that service, when the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, when the stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and certain other conditions are met, and when the veteran was a prisoner-of-war and the claimed stressor is related to that prisoner-of-war experience. Id. In other cases, the claimed stressor must be corroborated by credible supporting evidence. In addition to the regulations cited above, 38 C.F.R. § 3.304(f)(5) provides that if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to, records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a lumbar spine disorder is granted. The Veteran seeks to establish service connection for a lumbar spine disorder. Specifically, in the March 2010 statement in support of claim form, the Veteran reported that he has back problems due to his time in the service. Service treatment record shows that the Veteran complained of low back pain in September and November 1974. However, in the November 1974 discharge examination, the Veteran was found to have normal clinical evaluation of the back. There is no corresponding report of medical history by the Veteran. Post-service treatment records are negative for any treatments associated with the back until September 1997, when the Veteran received a work-related injury to the back. In July 1999, the Veteran sought state welfare based on an assertion that due to a work-related injury, he cannot stand or walk for long periods of time. The Veteran did not specify the source with regards to his back injury. However, in the August 1999 private imaging study, the Veteran was diagnosed with degenerative disease at C5-6 with bulging of intervertebral disc and spinal stenosis. In a June 2001 private medical opinion, the examiner explained that the Veteran suffers from a work injury dating back to April 1997, when he was lifting a patient and was injured. In the letter, the provider explained that the Veteran was found to have degenerative changes at L4-5 and L5-S1 with free fragment disc herniation at L4-5 with fragment behind the body at L5. Turning to the question of whether there is an etiological relationship between the Veteran's service and his diagnosed lumbar spine disorder, the Board notes that the record contains multiple etiology opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board will consider each of these opinions below. In an April 2010 private opinion, the physician noted the in-service complaints of back pain in 1974 and that the Veteran continued to experience pain until his work-related injury in 1997. The physician considered after a physical examination and the Veteran's own historical recall, that the Veteran was reliable historian and that his back pain was related to both his time in service and the work-related injury which caused disc herniation, disc bulge, and nerve damage. In support of this opinion, the physician explained that the chronological history provided by the Veteran and the natural history of discogenic diseases are consistent in terms of cause and effect. The Veteran also submitted a private opinion in September and December 2010 stating that while the physician could not guarantee that his injury when he was 18 was responsible for the progressive degenerative disc disease but could state with reasonable certainty that the Veteran's back pain began with injury in the military. However, no rationale was provided for this opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") As such, this opinion is being afforded little, if any, probative weight. The Veteran submitted a private medical opinion in January 2014, where the physician explained that the Veteran suffered an initial injury while in the service and subsequently developed low back pain, which has been lifelong and without periods of remission. The physician opined that the lumbar pain had its onset due to service. However, no rationale was provided for this opinion. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded little, if any, probative weight. In August 2015, the Veteran reported for a VA examination to determine the nature and etiology of his claimed back condition. The examiner confirmed the current diagnosis of lumbosacral strain and degenerative arthritis of the spine. The VA examiner opined that it is at least as likely as not, that the Veteran's back conditions had its onset in service. However, no rationale was provided for this opinion. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded little, if an\y, probative weight. In a May 2020 private medical opinion, the physician provided a brief history with regards to the onset of the Veteran's back conditions and opined that the Veteran was unable to access medical care after separation until 1997, although he continued to experience back pain. The Veteran had reported to the physician that he had self-medicated due to lack of health insurance. With regards to the argument that the Veteran's condition was not chronic after service, the physician referred to the various statements provided by the Veteran's family and friends, who stated that he did struggle with back conditions prior to the diagnosis in April 1997. The physician gave a positive nexus opinion and agreed with the previous expert opinion which stated that based on the extent of the disease and the diffuse degree of arthritis in the spine at the time of the surgery, the likelihood of the back condition being a problem since service was highly likely. The Board affords significant weight this opinion because it includes a thorough review of the Veteran's treatment; it specifically addresses the question of service connection without speculation; and, it includes a detailed, articulate analysis supported by medical rationale. This opinion had a clear conclusion, supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded probative weight. In sum, the Veteran has competently and credibly reported symptoms of back pain that began during active service and have continued since; such symptoms are documented in his service treatment records. The Veteran has a current diagnosis of lumbosacral strain and degenerative disc arthritis of the spine. There is no competent medical opinion of record against the claim. Rather, there are probative private opinions indicating the Veteran's back condition is more likely than not as a result of his active service. Moreover, there is no sufficient basis for the Board to reject this supportive opinion and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Accordingly, the Board finds that the preponderance of the evidence is for the claim and entitlement to service connection for a lumbar spine disorder is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to service connection for any acquired psychiatric disorder to include as due to military sexual trauma The Veteran asserts that he has PTSD due to his service to include military sexual trauma. Specifically, in a November 2014 statement, the Veteran reported that he was sexually assaulted while in the military. Post-service treatment records reflect diagnoses of major depressive disorder and PTSD. The Veteran's recount of the events associated with the claim of military sexual trauma and the records are in conflict in one instance. Specifically, in a February 2017 clinical report, the Veteran reported to the counselor that he had been sexually abused while in service and when he sought assistance at the hospital, the nurse gave him new pants because the back of his pants were heavily blooded. However, the Veteran's service treatment records do not show that he reported for any treatment related to this incident. Furthermore, the November 1974 report of medical examination shows clinical evaluation to be normal. The Veteran reported that he was in good condition. The Veteran's military personnel record shows that the Veteran had received an Article 15 for misconduct in October 1974 and found to be absent without leave (AWOL) between December 12 and December 27, 1974, which is the time period the Veteran asserted was a period when the Veteran had left as due to the impact of dealing with military sexual trauma. The military personnel records do show that the Veteran's undesirable discharge status was changed to honorable post-service. Post-service the Veteran sought and received mental health assistance as early as December 2013, when the Veteran reported for a mental health group session. The Veteran was noted to have to have a diagnosis of depression. Turning to the question of whether there is an etiological relationship between the Veteran's service and his diagnosed acquired psychiatric disorder, the Board notes that the record contains multiple etiology opinions which must be considered and weighed. See Hayes v. Brown, supra. When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, supra. The Board will consider each of these opinions below. The Veteran reported for an initial PTSD VA examination in August 2015. The examiner reported that the Veteran did not have PTSD under Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria but that he did have a current diagnosis of persistent depressive disorder. During this examination, the Veteran reported that he did not have any problems with alcohol or drugs for the past 20 years. With regards to the military sexual trauma incident, the Veteran reported that a commanding officer had inappropriately touched him and grabbed him by the neck after threatening to cause bodily harm. The examiner opined that based on the Veteran's recount of the events, it appeared more likely than not that his persistent depressive disorder was caused by the highly distressing events described with regards to the event that occurred in the military. In a December 2015 VA addendum opinion, the physician reviewed the documents on file and explained that based on the review of the examination and the claims file, to include changing the Veteran's undesirable discharge to an honorable discharge showed that the Veteran's current persistent depressive disorder is a result of his stressor events as described in the August 2015 report. This opinion had a clear conclusion, supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded probative weight. The Veteran then reported for an April 2016 VA examination, where the Veteran was diagnosed with severe recurrent major depressive disorder. However, in this examination, the physician provided a negative nexus opinion with regards to being secondary to a service-connected disability and provided a rationale that the Veteran's major depressive disorder is more likely to be due to the Veteran's allegation of being sexually assaulted in service than to the service-connected pseudofolliculitis barbae. The examiner provided a limited rationale; therefore, this opinion is being afforded some probative weight. The Veteran submitted a February 2017 examination diagnosing the Veteran with PTSD with major depressive disorder secondary to military sexual trauma. However, the examination is incomplete. With the incomplete examination is a private evaluation in February 2017, where the physician explained that although there are no records of his sexual assault, the Veteran's post-service medical history and military records supported a finding that the Veteran's life was impacted by the alleged military sexual trauma event, to include the use of alcohol and drugs as self-medications, going absent without leave after the event, receiving an Article 15, difficulty maintaining a relationship with women or in general, becoming violent, and expressing suicide attempts and hospitalizations. The examiner argued that the Veteran had a current diagnosis of PTSD and symptoms that were enough to diagnose the Veteran with PTSD per DSM-IV and DSM-5. This opinion had a clear conclusion, supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded probative weight. The Veteran reported for a VA examination in April 2017. The examiner reported that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria but explained that the Veteran does have another mental disorder diagnosis. The Veteran was diagnosed with major depressive disorder with anxious distress during this examination. The examiner summarized the various medical treatment records but explained that while the Veteran's claims file included numerous entries with regards to medical treatment during service, the records did not reflect any treatment with regards to injuries consistent with the Veteran's report of having been physically assaulted by the four men in November 2004. That being said, the Veteran was not in service in November 2004. The examiner opined that the Veteran's acquired psychiatric disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the examiner explained that while the Veteran's current major depressive disorder diagnosis meets the DSM criteria, there is an insufficient evidence that this diagnosis is related to the Veteran's military service. This opinion had a clear conclusion, supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded probative weight. In May 2020, the Veteran submitted two private opinions regarding the Veteran's major depressive disorder and its connection to service. In the opinion, the physician explained that based on the review of records, the Veteran's major depressive disorder did not preexist service due to lack of evidence. The physician asserted that while the Veteran's medical treatment records do not support a finding that the Veteran was sexually assaulted as he reported, the military personnel records to include Article 15, the absent without leave and the resulting premature discharge from service were all indicative of military sexual trauma, especially as these are considered reasonable from an individual following a personal assault. Based on the symptoms the Veteran suffers from and the military personnel records on file showing several disturbances after the alleged attack, the physician opined that the Veteran's major depressive disorder is the direct result of the military sexual trauma the Veteran experienced during service. This opinion had a clear conclusion, supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. As such, this opinion is being afforded probative weight. In sum, the Board finds that the evidence presently before the Board is sufficient to grant the appeal as the Veteran has been diagnosed with an acquired psychiatric disorder due to military sexual trauma and the evidence is at least evenly balanced as to whether the Veteran suffered in-service military sexual trauma during his military service and as to whether his acquired psychiatric disorder is related to such in-service military sexual trauma. Although some of the VA opinions contain only a brief rationale, the Board notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, supra. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for an acquired psychiatric disorder, to include as due to military sexual trauma is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to service connection for arthritis to include as secondary to service-connected pseudofolliculitis barbae is remanded. 2. Entitlement to service connection for anterior cruciate ligament tear, claimed as an ACL tear, to include as secondary to service-connected pseudofolliculitis barbae is remanded. The Board finds that a remand is warranted to further develop the issue of arthritis and anterior cruciate ligament tear, claimed as ACL tear, to include as secondary to service-connected pseudofolliculitis barbae. Specifically, in the July 2017 Notice of Disagreement and the December 2015 Supplemental Claim for Compensation, the Veteran claimed entitlement for the issues of arthritis and anterior cruciate ligament tear, to include as secondary to service-connected pseudofolliculitis barbae. The VA did not obtain a VA examination or opinion to address either of these concerns. Therefore, on remand, the RO should provide the Veteran with either VA examination or opinion and address these theories of entitlement raised by the Veteran. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, provide the Veteran with a VA examination to determine the etiology of his claimed arthritis. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, to include the Veteran's lay statements, the VA examiner must provide the following opinions: (A) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's arthritis was incurred in or caused by his active duty service? (B) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's arthritis was caused or aggravated by his service-connected pseudofolliculitis barbae? Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate 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. 3. Following the receipt of outstanding records, provide the Veteran with a VA examination to determine the etiology of his claimed anterior cruciate ligament tear. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, to include the Veteran's lay statements, the VA examiner must provide the following opinions: (A) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's anterior cruciate ligament tear was incurred in or caused by his active duty service? (B) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's anterior cruciate ligament tear was caused or aggravated by his service-connected pseudofolliculitis barbae? Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate 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. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.J. Kim, Associate 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.