Citation Nr: 21071340 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 19-11 498 DATE: November 30, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to service connection for adjustment disorder with mixed emotional reaction (claimed as depression) remanded. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 11, 2020, and in excess of 50 percent thereafter, is remanded. Entitlement to an initial disability rating in excess of 20 percent for lumbar strain is remanded. Entitlement to an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome (hereinafter "right knee disability") is remanded. Entitlement to service connection for a cervical spine disability (claimed as a neck condition) is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a bilateral eye disability is remanded. FINDING OF FACT The Veteran does not have a right or left ear hearing loss disability for VA purposes. CONCLUSION OF LAW The criteria for the establishment of service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1131, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 2007 to April 2012. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision, which, in pertinent part, granted service connection for a right knee disability, evaluated at 10 percent, effective April 20, 2012, and denied service connection for an adjustment disorder with mixed emotional reaction, bilateral eye condition, bilateral hearing loss, right and left hip, left knee, left shoulder, and neck disabilities. These matters also come to the Board on appeal from an October 2017 rating decision which, in pertinent part, granted service connection for PTSD, evaluated at 30 percent, effective April 20, 2012; granted service connection for lumbar strain, evaluated at 10 percent, effective April 20, 2012; and denied service connection for a right shoulder disability. The evidence of record that the Veteran filed a timely notice of disagreement and VA issued a statement of the case (SOC) on January 17, 2020. On a VA Form 9 (Appeal to Board of Veterans' Appeals) postmarked March 16, 2020, the Veteran indicated he wanted to appeal the increased rating claims for PTSD and lumbar strain and service connection claim for a right shoulder disability to the Board. While this form was not received by VA until March 23, 2020, and the appeal closed out for failure to respond, the Board finds that this VA 9 was postmarked prior to the expiration of 60 days from the date of the January 17, 2020 SOC; thus, it is timely. As such, the Board has added these issues to the appeal. In November 2020, the Veteran and D.R. testified before the undersigned Veterans Law Judge (VLJ) at a Board Central Office hearing in Washington, D.C. A copy of the transcript is of record. In a March 2021 rating decision, VA granted an increased 50 percent evaluation for PTSD, effective November 11, 2020. In an April 2021 rating decision, VA continued a 20 percent evaluation for lumbar strain. As the grant of a 50 percent evaluation for PTSD and continuation of a 20 percent evaluation for lumbar strain do not represent the maximum grant of the benefit sought on appeal, these increased rating claims remain pending before the Board. As it pertains to the increased rating claim for the right knee disability, subsequent to the February 2019 statement of the case (SOC), and certification of the appeal to the Board, additional VA treatment records and a VA examination report were added to the claims file. Although initial Agency of Original Jurisdiction (AOJ) review is automatically waived for evidence submitted by the Veteran or his representative when the VA Form 9 is received after February 2, 2013, as is the case here, the automatic waiver does not apply to VA-generated evidence not submitted by the Veteran. 38 U.S.C. § 7105(e). Further, waiver of a supplemental statement of the case is only applicable to evidence submitted by the Veteran or his representative. See 38 C.F.R. § 20.1304. However, as the Board is remanding this claim, the AOJ will have an opportunity to review the records in the first instance such that no prejudice results to the Veteran as a result of the Board's consideration of this evidence for the limited purpose of issuing a comprehensive and thorough remand. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of a "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With a chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Specific to claims of service connection for hearing loss, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In evaluating claims of service connection for hearing loss, it is observed that the threshold for normal hearing is from zero to 20 decibels, with higher threshold levels indicating some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). Entitlement to service connection for bilateral hearing loss. The Veteran contends that service connection is warranted for bilateral hearing loss. Specifically, he contends that he was exposed to hazardous noise during service and that he has difficulty hearing and has to ask others to repeat themselves. The Veteran's DD Form 214 reflects that his military occupational specialty (MOS) was that of a motor vehicle operator, which has a moderate probability of hazardous noise exposure. The Veteran's service treatment records are silent for complaints of or diagnosis of hearing loss. On a December 2007 Report of Medical history upon entrance to service, the Veteran denied hearing loss and an associated audiogram revealed right ear pure tone thresholds of 10, 10, 5, 0, and 5, and left ear pure tone thresholds of 20, 0, 0, 0, and 0 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. On a May 2010 Report of Medical History associated with the Veteran's Medical Board proceedings, he denied hearing loss and an associated audiogram revealed right ear pure tone thresholds of 5, 0, 0, 0, and 5, and left ear pure tone thresholds of 5, 0, -5, 0, and 5 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. A June 2010 audiogram revealed right ear pure tone thresholds of 0, 0, -5, 0, and -10, and left ear pure tone thresholds of 5, -5, -5, 0, and -5 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. On a July 2011 Report of Medical History associated with the Veteran's separation from service, he denied hearing loss and an audiogram revealed right ear pure tone thresholds of 5, 0, 0, 5, and 0, and left ear pure tone thresholds of 10, 5, 0, 5, and 0 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. A January 2017 VA examination report shows right ear pure tone thresholds of 15, 5, 5, 0, and 5, and left ear pure tone thresholds of 15, 15, 5, 15, and 20 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition was 96 percent in the right ear and 100 percent in the left ear. A May 2018 VA audiology note summarized the Veteran's hearing as normal hearing thresholds across the Hertz range, bilaterally. Speech recognition was 100 percent bilaterally using the CNC word list. The VA audiologist indicated that the Veteran was not a candidate for amplification. Upon review of the evidence of record, audiometric testing fails to show that the Veteran's bilateral hearing loss has reached a level of severity sufficient to be considered a disability for VA purposes. 38 C.F.R. § 3.385. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Notably, the Veteran is not shown by the probative evidence of record to have bilateral hearing loss in accordance with 38 C.F.R. § 3.385 at any time during service or the pendency of the appeal. To the extent that the Veteran has reported hearing loss, such evidence is probative insofar as it describes observable symptomatology, such as hearing difficulty. See Layno v. Brown, 6 Vet. App. 465 (1994). However, such reports are not probative insofar as they attempt to diagnose hearing loss according to VA regulations, to include whether the Veteran's hearing loss manifested to a compensable degree during active service, within one year after discharge from service, or after service. In certain unique instances, lay testimony may be competent to establish medical diagnosis or etiology. See Jandreau v. Nicholson, 492 F.3d at 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, the diagnosis of a hearing disability for VA purposes is based on objective audiometric testing and is not simply determined based on mere personal observation by a layperson. 38 C.F.R. § 3.385. Thus, the question of whether the Veteran has a bilateral hearing loss disability for VA purposes does not lie within the range of common experience or common knowledge but requires special experience or special knowledge in the field of audiology, including audiometric testing. As such, the most probative evidence regarding whether the Veteran has a current bilateral hearing loss disability is the objective medical evidence of record discussed above. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Such evidence weighs against the Veteran's claim of entitlement to service connection for bilateral hearing loss. There is no additional probative evidence of record that the Veteran has a current bilateral hearing loss disability for VA purposes for any period on appeal. As the preponderance of the evidence is against the Veteran's claim, there is no reasonable doubt to be resolved, and the claim of service connection for bilateral hearing loss must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Upon review of the Veteran's April 2018 VA Form 21-0958 (Notice of Disagreement), it appears that an incomplete copy of the notice of disagreement is associated with the record. Specifically, handwritten correspondence on notebook paper reflects that the Veteran's contentions are continued on the opposite side; however, only the front side of the page is associated with the record. As the Board is remanding these claims for further development, a complete copy of the Veteran's notice of disagreement and his contentions should be associated with the record. 1. Entitlement to service connection for adjustment disorder with mixed emotional reaction (claimed as depression) remanded. 2. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 11, 2020, and in excess of 50 percent thereafter, is remanded. The Veteran contends that service connection is warranted for an adjustment disorder. Specifically, he contends that he became depressed during boot camp due to military life. Alternatively, he contends that he suffers from depression due to pain from his injuries and being unable to exercise. The Veteran was afforded a VA examination in January 2017. After examining the Veteran and reviewing the claims file, the examiner provided a diagnosis of adjustment disorder with mixed emotional reaction. The examiner indicated that such caused symptoms of depressed mood, anxiety, and chronic sleep impairment resulting in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner did not provide an etiological opinion as to whether the Veteran's adjustment disorder was incurred in or was otherwise related to or aggravated by service or service-connected disabilities. In April 2017, VA denied service connection for an adjustment disorder on the basis that such was not shown to have been incurred in or caused by service and the Veteran filed a timely notice of disagreement. The Veteran was afforded a VA PTSD examination in April 2017. After examining the Veteran and reviewing the claims file, the examiner provided diagnoses of PTSD and adjustment disorder with mixed emotional reaction. The examiner indicated that it was possible to differentiate which symptoms were attributable to each diagnosis, with the Veteran's PTSD causing intrusive thoughts, nightmares, irritability, and social withdrawal, and his adjustment disorder causing depressive and anxious moods in response to poor life adjustment to relationships, military life, and the working world. The Veteran reported difficulty with life adjustments since high school. The examiner indicated that the Veteran's psychiatric conditions caused symptoms of depressed mood, anxiety, near continuous panic or depression affective the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, suicidal ideation, and impaired impulse control resulting in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner opined that the Veteran's PTSD was incurred in or otherwise related to service but did not provide an etiological opinion as to the Veteran's adjustment disorder. In an October 2017 rating decision, VA granted service connection for PTSD and assigned a 30 percent evaluation based on impaired impulse control and chronic sleep impairment. Under the ratings schedule, all psychiatric disabilities other than eating disorders are rated together under the General Rating Formula for Mental Disorders based on the level of social and occupational impairment detailed at 38 C.F.R. § 4.130. As not all of the Veteran's psychiatric symptoms are attributable to his PTSD, the question remains whether service connection is warranted for the Veteran's adjustment disorder. A remand is necessary so that a medical opinion as to the nature and etiology of the Veteran's adjustment disorder can be obtained. Finally, because a decision on the remanded issue of entitlement to service connection for an adjustment disorder could significantly impact a decision on the issue of entitlement to an increased rating for PTSD, the issues are inextricably intertwined. A remand of the increased rating claim for PTSD is required. 3. Entitlement to an initial disability rating in excess of 20 percent for lumbar strain is remanded. As discussed above, an October 2017 rating decision granted service connection for lumbar strain, evaluated at 10 percent, effective April 20, 2012. The Veteran filed a timely notice of disagreement and VA issued a statement of the case (SOC) on January 17, 2020. The Veteran filed a timely VA Form 9; however, the appeal was erroneously closed out for failure to respond. As such, this issue was never certified to the Board. Subsequent to the January 2020 SOC on this issue, additional relevant evidence was added to the claims file, including VA treatment records and a VA examination report. When additional evidence pertinent to the issue on appeal is submitted prior to certification to the Board, the Agency of Original Jurisdiction (AOJ) must furnish a SSOC. 38 C.F.R. § 19.31. Thus, the Veteran's claim of entitlement to an increased rating for a lumbar spine disability must be remanded for AOJ consideration of the evidence and issuance of an updated SSOC. 4. Entitlement to an initial disability rating in excess of 10 percent for right knee patellofemoral pain syndrome (hereinafter "right knee disability") is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to an increased rating for a right knee disability at this time. While the record contains a contemporaneous March 2021 VA examination regarding the Veteran's right knee disability, the examination appears inconsistent with the other evidence of record. Specifically, prior examinations and treatment records have shown limitation in range of motion of the knee due to pain, even when not during a flare-up, and that the Veteran receives injections to his knee to treat his pain. The Veteran testified during his November 2020 Board hearing that his right knee gives out, locks up, and he has limited range of motion. During the March 2021 VA examination, the examiner indicated that the Veteran described flare-ups of the right knee that were severe and required rest. However, the examiner indicated that the examination was being conducted after repeated use over time and during a flare-up, and that the Veteran maintained full range of motion of the right knee. A review of the Veteran's VA treatment records reflects that he had an injection to his right knee in June 2020 after reporting approximately nine months of improvement after his last injection. Thus, it is not clear from the record whether there was a continuing ameliorative effect from the June 2020 injection during the March 2021 VA examination. As the rating criteria under 38 C.F.R. § 4.71a do not explicitly contemplate the ameliorative effects of such injections, the Board finds that a new VA examination is necessary in order to properly assess the severity of the Veteran's right knee disability. 5. Entitlement to service connection for a cervical spine disability (claimed as a neck condition) is remanded. The Veteran contends that service connection is warranted for a cervical spine disability, to include as due to the rigors of service or as secondary to his lumbar spine disability. The Veteran was afforded a VA examination in January 2017. The Veteran reported onset of a cervical spine disability starting with neck cramps during service. After examining the Veteran and reviewing the claims file, the examiner provided a diagnosis of cervical strain. The examiner did not provide an etiological opinion and VA denied the claim on the basis that the Veteran's service treatment records were silent for complaints of, treatment for, or diagnosis of this condition. The mere absence of service treatment records showing complaints of, treatment for, or diagnosis of a cervical spine disability during service is not sufficient to deny the Veteran's claim. The Veteran states that he did not seek treatment during service for this condition because he was focused on his lumbar spine and right knee conditions. Additionally, VA did not address whether his cervical spine disability is otherwise related to service, to include the rigors of service, or are secondary to his service-connected lumbar spine disability. As such, the Board finds that a remand is warranted so that a medical opinion addressing the nature and etiology of the Veteran's cervical spine disability can be obtained. 6. Entitlement to service connection for a right hip disability is remanded. 7. Entitlement to service connection for a left hip disability is remanded. The Veteran contends that service connection is warranted for a bilateral hip disability, to include as due to the rigors of service. The Veteran was afforded a VA examination in January 2017. The Veteran reported onset of a bilateral hip disability after injuring his knee in service. After examining the Veteran and reviewing the claims file, the examiner provided a diagnosis of bilateral hip strain. The examiner did not provide an etiological opinion and VA denied the claim on the basis that the Veteran's service treatment records were silent for complaints of, treatment for, or diagnosis of this condition. The mere absence of service treatment records showing complaints of, treatment for, or diagnosis of a bilateral hip disability during service is not sufficient to deny the Veteran's claim. The Veteran states that he did not seek treatment during service for such conditions because he was focused on his lumbar spine and right knee conditions. Additionally, VA did not address whether his bilateral hip disability was otherwise related to service, to include the rigors of service. As such, the Board finds that a remand is warranted so that a medical opinion addressing the nature and etiology of the Veteran's bilateral hip disability can be obtained. 8. Entitlement to service connection for a right shoulder disability is remanded. 9. Entitlement to service connection for a left shoulder disability is remanded. The Veteran contends that service connection is warranted for a bilateral shoulder disability, to include as due to the rigors of service. The Veteran was afforded a VA examination in January 2017. The Veteran reported onset of a bilateral shoulder disability due to the rigors of service, including exercises and shooting stances. After examining the Veteran and reviewing the claims file, the examiner provided a diagnosis of right rotator cuff syndrome. The examiner indicated that there was no pathology to render a diagnosis for the left shoulder. As to the right shoulder, the examiner opined that it was less likely than not that the Veteran's right rotator cuff syndrome was incurred in or caused by service as the Veteran's service treatment records were silent for complaints of shoulder pain. The examiner did not provide an etiological opinion on the left shoulder. In an April 2017 addendum opinion, the examiner indicated there was no change in the right shoulder opinion based on the Veteran filing a claim of service connection for a right shoulder disability upon separation from service as the problem was not described at the time to determine if it was related to his present complaints. VA denied service connection for a right and left shoulder disability, in part, on the basis that the Veteran's service treatment records were silent for complaints of, treatment for, or diagnosis of this condition. The mere absence of service treatment records showing complaints of, treatment for, or diagnosis of a bilateral shoulder disability during service is not sufficient to deny the Veteran's claim. The Veteran states that he did not seek treatment during service for such conditions because he was focused on his lumbar spine and right knee conditions. Additionally, VA did not address whether his bilateral shoulder disability was otherwise related to service, to include the rigors of service. As to the examiner's finding that there was no pathology of the left shoulder to render a diagnosis, the Board notes that pain alone can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Finally, the Board finds that the April 2017 addendum opinion is inadequate. While the examiner indicated that a nexus could not be made between his current right shoulder complaints and those upon separation from service due to lack of description of the shoulder complaints at the time of separation, such information could have been obtained by asking the Veteran to describe the history of his right shoulder symptoms, to include whether the pain he experiences now is similar to the pain experienced then. As such, the Board finds that a remand is warranted so that a new VA examination and medical opinion addressing the nature and etiology of the Veteran's bilateral shoulder disability can be obtained. 10. Entitlement to service connection for a left knee disability is remanded. The Veteran contends that service connection is warranted for a left knee disability, to include as due to the rigors of service or as secondary to his service-connected right knee disability. The Veteran was afforded a VA examination in January 2017. The Veteran reported onset of left knee pain during service. After examining the Veteran and reviewing the claims file, the examiner provided a diagnosis left knee strain. The examiner opined that it was less likely than not that the Veteran's left knee strain was incurred in or caused by service as the Veteran's service treatment records were silent for complaints of left knee pain. The examiner also opined that it was less like than not that the Veteran's left knee strain was secondary to his service-connected right knee disability, explaining that while there was one notation of slight antalgic gain during a February 2010 physical therapy session, the record was otherwise silent for compensatory gait changes due to the right knee disability. The mere absence of service treatment records showing complaints of, treatment for, or diagnosis of a bilateral shoulder disability during service is not sufficient to deny the Veteran's claim. The Veteran states that he did not seek treatment during service for this condition because he was focused on his lumbar spine and right knee conditions. Additionally, VA did not address whether his left knee disability was otherwise related to service, to include the rigors of service. As such, the Board finds that a remand is warranted so that an addendum medical opinion addressing the nature and etiology of the Veteran's left knee disability can be obtained. 11. Entitlement to service connection for a bilateral eye disability is remanded. The Veteran contends that service connection is warranted for a bilateral eye disability. Specifically, he contends that he developed night blindness while driving during service and that it has continued since. Service treatment records reflect that in November 2011, the Veteran requested a night vision check as he was experiencing blurred vision at night. The Veteran was noted to be wearing eyeglasses. An eye examination, including dilation of the eyes, was normal. The Veteran's vision bilaterally was 20/20 without correction and the clinician noted there was no ocular condition upon examination that would worsen vision at night. Post-service treatment records are silent for complaints related to the Veteran's vision. A January 2017 VA examination report reflects the Veteran reported onset during service of trouble seeing in the dark while driving when there was oncoming traffic. He also reported occasional muscle spasms of the eye. The examiner provided diagnoses of bilateral photophobia, convergence insufficiency, and blepharospasm. Upon examination, uncorrected and corrected distance and near vision was 20/40 or better bilaterally. Pupils were round and reactive to light and there was no afferent pupillary defect. There was no anatomical loss, light perception only, or extremely poor vision or blindness, astigmatism, or diplopia. Eye pressure was 20 bilaterally. The eyes were internally and externally normal except for minor eye twitching. While a visual field defect was noted, there was no contraction or loss of visual field, scotoma, or legal blindness. No eye conditions were found except for the noted near point convergence and sensitivity to light. The examiner did not opine as to the nature and etiology of the Veteran's eye conditions. During the November 2020 Board hearing, the Veteran reported he was told to wear reading glasses during service to improve focus. He reported wearing over-the-counter reading glasses but that he felt they were too strong. Refractive error of the eyes is one of the specific conditions that VA does not grant service connection for, as it is not considered a disability for VA purposes. See 38 C.F.R. §§ 3.303(c), 4.9. Such a condition is part of a life-long defect and is normally a static condition which is incapable of improvement or deterioration. See VAOGCPREC 67-90 (1990). However, bilateral photophobia, convergence insufficiency, and blepharospasm are not refractive errors of the eyes. A remand is warranted so that a medical opinion can be obtained as to the nature and etiology of the Veteran's diagnosed bilateral photophobia, convergence insufficiency, and blepharospasm. The matters are REMANDED for the following actions: 1. Obtain and associate with the record a complete copy of the Veteran's April 2018 notice of disagreement, to include the second page of handwritten contentions on notebook paper. 2. Obtain the Veteran's VA treatment records from March 2021 to present. 3. Obtain a medical opinion as to the nature and etiology of the Veteran's adjustment disorder. The examiner must review the claims file. An in-person examination is not required unless deemed so by the examiner. The examiner is asked to provide a response to the following: Did the Veteran's adjustment disorder clearly and unmistakably (undebatable) preexist the Veteran's service? If the examiner finds the Veteran's adjustment disorder did clearly and unmistakably preexist service, was it clearly and unmistakably not aggravated by service? If the examiner finds that the Veteran's adjustment disorder either did not clearly and unmistakably preexist service or was not clearly and unmistakably not aggravated by service, the examiner must opine whether it is at least as likely as not related to service. If the examiner finds that the Veteran's adjustment disorder preexisted service and was not aggravated by service or was not incurred in or otherwise related to service, is the Veteran's adjustment disorder at least as likely as not (1) proximately due to service-connected disability, to include PTSD or pain from service-connected disabilities, or (2) aggravated, i.e., worsened beyond its natural progression, by PTSD or pain from service-connected disabilities? Provide a rationale to support the opinion(s). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right knee disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria, to include a discussion on whether the Veteran is experiencing any ameliorative effects from Synvisc injections. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, 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). 5. Obtain an opinion from an appropriate clinician as to the nature and etiology of the Veteran's cervical spine, bilateral hip, and left knee disabilities. The examiner must review the claims file. An in-person examination is not required unless deemed so by the examiner. The examiner is asked to provide a response to the following: Is it at least as likely as not that the Veteran's cervical spine, bilateral hip, and/or left knee disabilities (1) began during active service, to include related to the rigors of service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? If the examiner finds that the Veteran's cervical spine disability was not incurred in or is not otherwise related to service, is the Veteran's cervical spine disability at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated, i.e., worsened beyond its natural progression, by service-connected disability? Provide a rationale to support the opinion(s). 6. Schedule the Veteran for a VA examination for his bilateral shoulder disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is it at least as likely as not that a right and/or left shoulder disability (1) began during active service, to include related to the rigors of service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. 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 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. Obtain an opinion from an appropriate clinician as to the nature and etiology of the Veteran's bilateral eye disability, diagnosed as bilateral photophobia, convergence insufficiency, and blepharospasm. The examiner must review the claims file. An in-person examination is not required unless deemed so by the examiner. The examiner is asked to provide a response to the following: Is the Veteran's bilateral photophobia, convergence insufficiency, and/or blepharospasm at least as likely as not related to service, including his reports of blurred vision while driving at night and that he was advised to wear reading glasses to improve focus? Provide a rationale to support the opinion(s). 8. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, 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.