Citation Nr: 21074235 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 16-55 258 DATE: December 14, 2021 ORDER New and material evidence having been received, the claim of entitlement to service connection for arthritic pain in the hands, arms, back, and legs is reopened. To that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection a low back disability is reopened. To that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for a right knee disability is reopened. To that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for a left knee disability is reopened. To that extent only, the appeal is granted. New and material evidence having been received, the claim of entitlement to service connection for hepatitis C is reopened. To that extent only, the appeal is granted. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for Parkinson's disease is denied. Entitlement to service connection for essential tremor is denied. REMANDED Entitlement to service connection for arthritic pain in the hands, arms, back, and legs is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for cirrhosis of the liver is remanded. Entitlement to service connection for hepatitis C is remanded. FINDINGS OF FACT 1. A July 2008 rating decision denied service connection for arthritic pains in the hands, arms, back, and legs; right knee disability; and left knee disability. 2. The Veteran did not perfect an appeal of the July 2008 rating decision. 3. The evidence received since the July 2008 rating decision is neither cumulative nor redundant of evidence previously of record and raises a reasonable possibility of substantiating the claims of entitlement to service connection for arthritic pains in the hands, arms, back, and legs; right knee disability; and left knee disability. 4. A July 2011 rating decision denied service connection for discogenic degenerative disease at L3-L4 and L4-L5 (claimed as chronic low back pain) and hepatitis C. 5. The Veteran did not perfect an appeal of the July 2011 rating decision. 6. The evidence received since the July 2011 rating decision is neither cumulative nor redundant of evidence previously of record and raises a reasonable possibility of substantiating the claims of entitlement to service connection for discogenic degenerative disease at L3-L4 and L4-L5 (claimed as chronic low back pain) and hepatitis C. 7. The preponderance of the evidence weighs against associating a low back disability with any incident of service. 8. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of Parkinson's disease. 9. The preponderance of the evidence weighs against associating essential tremor with any incident of service. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim of entitlement to service connection for arthritic pains in the hands, arms, back, and legs. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. New and material evidence has been received to reopen a claim of entitlement to service connection for a low back disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. New and material evidence has been received to reopen a claim of entitlement to service connection for a left knee disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. New and material evidence has been received to reopen a claim of entitlement to service connection for hepatitis C. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303, 3.309. 7. The criteria for entitlement to service connection for Parkinson's disease have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 8. The criteria for entitlement to service connection for essential tremor have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to August 1979. In March 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. An October 2020 Agency of Original Jurisdiction (AOJ) rating decision established service connection for a psychiatric disability, a right shoulder disability, a left shoulder disability, and a total disability rating based on individual unemployability (TDIU). As the benefits sought on appeal with regard to those claims have been granted in full, the issues of entitlement to service connection a psychiatric disability, a right shoulder disability, a left shoulder disability, and TDIU are no longer before the Board. This case was previously remanded for further development. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the AOJ, the Board finds that there has been substantial compliance with the prior remand requests concerning the issues of whether new and material evidence has been received to reopen claims of entitlement to service connection for arthritic pain in the hands, back, legs, and arms; a lumbar spine disability; a bilateral knee disability; hepatitis C; and entitlement to service connection for a Parkinson's disease and essential tremor. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). New and Material Evidence Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. VA rating decisions that are not timely appealed are final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as evidence not previously submitted to agency decision-makers. 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 be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of the claim has been fulfilled. 38 U.S.C. § 5108; Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321 (1999). The claim to reopen does not require the submission of new and material evidence as to each previously unproven element of a claim for that claim to be reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new evidence is material, the credibility of the new evidence, although not its weight, is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). 1. Whether new and material evidence has been submitted to reopen a claim for service connection for arthritic pains in the hands, arms, back, and legs Service connection for arthritic pains in hands, back, legs, and arms was originally denied in a July 2008 AOJ decision. The AOJ noted that the service medical records did not contain a diagnosis of arthritis in the hands, back, legs, and arms. It was further noted that there was no current evidence of arthritis in the Veteran's hands, legs, or arms. Evidence associated with the claims file since the July 2008 RO decision includes additional lay statements, VA treatment records, and the transcript from the Veteran's March 2020 Board hearing. In particular, a September 2020 VA examination report contains a diagnosis of degenerative arthritis of both hands. That evidence provides evidence of a current diagnosis, which was lacking in July 2008. The credibility of the newly submitted evidence is presumed in determining whether or not it is material to warrant reopening a claim. Justus v. Principi, 3 Vet. App. 510 (1992). As the September 2020 examination report provides a current diagnosis, that evidence raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Accordingly, the new evidence is also material. As new and material evidence has been received, the claim for service connection for arthritic pains in hands, back, legs, and arms is reopened. Although the new evidence is adequate for the limited purpose of reopening the claim, that does not necessarily make it sufficient to allow the grant of the benefits sought. That will be discussed in the remand below. 2. Whether new and material evidence has been submitted to reopen a claim for service connection for a low back disability Service connection for discogenic degenerative disease at L3-L4 and L4-L5 (claimed as chronic low back pain) was originally denied in a July 2011 AOJ decision. The AOJ noted that the service medical records showed no treatments, evaluations, or a diagnosis of a back condition. Although current treatment records showed a history of back pain assessed as discogenic degenerative disease at L3-L4 and L4-L5, the evidence did not show that the back disability occurred in or was caused by service. Evidence associated with the claims file since the July 2011 RO decision includes additional lay statements, VA treatment records, and the transcript from the Veteran's March 2020 Board hearing. In particular, at a March 2020 Board hearing, the Veteran stated that he injured his back from falling from a pole on two separate occasions while on active duty. That evidence provides a possible in-service incurrence of a back disability, which was lacking in July 2011. The credibility of the newly submitted evidence is presumed in determining whether or not it is material to warrant reopening a claim. Justus v. Principi, 3 Vet. App. 510 (1992). As the March 2020 Board hearing transcript suggests a possible in-service incurrence of a back disability, that evidence raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Accordingly, the new evidence is also material. As new and material evidence has been received, the claim for service connection for a low back disability is reopened. Although the new evidence is adequate for the limited purpose of reopening the claim, that does not necessarily make it sufficient to allow the grant of the benefits sought. That will be discussed below. 3. Whether new and material evidence has been submitted to reopen a claim for service connection for a right knee disability 4. Whether new and material evidence has been submitted to reopen a claim for service connection for a left knee disability Service connection for bilateral knee degenerative joint disease was originally denied in a July 2008 AOJ decision. The AOJ noted that while the Veteran had a current diagnosis of degenerative joint disease of the knees, the service medical records showed no treatment or diagnosis of a bilateral knee condition. Evidence associated with the claims file since the July 2008 RO decision includes additional lay statements, VA treatment records, and the transcript from the Veteran's March 2020 Board hearing. In particular, at a March 2020 Board hearing, the Veteran stated that he injured his knees from falling from a pole on two separate occasions while on active duty. That evidence provides a possible in-service incurrence of a bilateral knee disability, which was lacking in July 2008. The credibility of the newly submitted evidence is presumed in determining whether or not it is material to warrant reopening a claim. Justus v. Principi, 3 Vet. App. 510 (1992). As the March 2020 Board hearing transcript suggests a possible in-service incurrence of bilateral knee disabilities, that evidence raises a reasonable possibility of substantiating the claims. 38 C.F.R. § 3.156(a). Accordingly, the new evidence is also material. As new and material evidence has been received, the claims for service connection for right and left knee disabilities are reopened. Although the new evidence is adequate for the limited purpose of reopening the claims, that does not necessarily make it sufficient to allow the grant of the benefits sought. That will be discussed in the remand below. 5. Whether new and material evidence has been submitted to reopen a claim for service connection for hepatitis C Service connection for hepatitis C was originally denied in a July 2011 AOJ decision. The AOJ noted that the Veteran had not reported having any risk factors for hepatitis C. The AOJ found that the Veteran's claimed hepatitis C neither occurred in nor was caused by service. Evidence associated with the claims file since the July 2011 RO decision includes additional lay statements, VA treatment records, and the transcript from the Veteran's March 2020 Board hearing. In particular, at a March 2020 Board hearing, the Veteran explained that while he was on active duty, a friend of his was doing drugs and stuck him with a needle. That evidence provides a possible risk factor in service for hepatitis C, which was lacking in July 2011. The credibility of the newly submitted evidence is presumed in determining whether or not it is material to warrant reopening a claim. Justus v. Principi, 3 Vet. App. 510 (1992). As the March 2020 Board hearing transcript suggests a possible incurrence of a risk factor for hepatitis C in service, that evidence raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Accordingly, the new evidence is also material. As new and material evidence has been received, the claim for service connection for hepatitis C is reopened. Although the new evidence is adequate for the limited purpose of reopening the claim, that does not necessarily make it sufficient to allow the grant of the benefits sought. That will be discussed in the remand below. Service Connection In general, service connection may be established for disability due to disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish a service connection for a disability, a Veteran must show: (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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163(Fed. Cir. 2004). A disability may be service-connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or that was chronic as defined by regulation with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for a low back disability The Veteran asserts that he has a current low back disability due to falling from a pole on two separate occasions while on active duty. The service medical records do not contain any signs, symptoms, or diagnoses of a low back disability. The service separation examination report shows that the Veteran had a normal spine, and the Veteran marked on an accompanying Report of Medical History that he did not experience back pain. At a September 2020 VA examination, the examiner recorded the Veteran's self-report of falling from a pole and injuring his back while on active duty. The examiner also recorded the Veteran's report of injuring the back in a motor vehicle accident in 1977. The Veteran stated that he worked as a wireman which involved climbing poles and trees on a regular basis. The Veteran stated that while he was on active duty, he had to carry heavy bags, and physical training bothered his knees, feet, hips, and his back. The examiner diagnosed degenerative arthritis of the spine and intervertebral disc syndrome. The examiner opined that it was not at least as likely as not that the Veteran's low back disability was incurred in or caused by service. The examiner considered the Veteran's reports of experiencing low back pain after falling from a pole during service. The examiner also noted that the Veteran was in multiple car accidents in 1982 and 1988. The examiner further noted that the Veteran experienced a back injury at work around 1997 to 1999. The examiner opined that it was more likely that the Veteran's current lumbar spine disabilities were due to work-related back injuries in the 1990s and multiple car accidents which occurred after service separation. The Veteran has a current diagnosis of a low back disability. However, service connection on a presumptive basis for arthritis is not warranted. As the evidence is negative for signs, symptoms, or diagnoses of arthritis of the low back during service, or to a compensable level during the Veteran's first post-service year, service connection for a low back disability cannot be granted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. The Board further finds that the preponderance of evidence is against a finding that a current low back disability was caused or aggravated by active service. The Veteran has sought ongoing medical treatment with VA. However, none of the medical treatment providers has given any indication that the Veteran's low back disability could be related to service. The only evidence which provides any connection between the Veteran's low back disability and service comes from the Veteran's own statements. It is to be noted that the Board is not free to substitute its own judgment for a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to the evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran's lay statements. Although laypersons are competent to provide opinions on some medical issues, as to the specific issue in this case, whether the Veteran's low back disability was caused by active service, that issue falls outside the realm of common knowledge of a layperson due to the presence of multiple possible etiologies. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide an etiology opinion, and there are no competent etiology opinions are of record that support the claim. The Board places the most probative weight on the opinion offered by the September 2020 VA examiner. The VA examiner is an objective medical professional, who has the medical training and knowledge to perform and interpret the necessary medical tests. The examiner considered the Veteran's statements regarding his low back disability. Significantly, the examiner attributed the Veteran's low back disability to non-service-related etiologies; namely, work-related back injuries in the 1990s and multiple car accidents which occurred after the Veteran's service separation. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for a heart disability, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Entitlement to service connection for Parkinson's disease The Board concludes that the Veteran does not have a current diagnosis of Parkinson's disease and has not had one at any time during the pendency of the claim or contemporary to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). While the Veteran may believe that he has a current diagnosis of Parkinson's disease, the Board notes that the Veteran has sought consistent medical treatment from VA. However, despite that consistent treatment, the VA treatment records do not contain a diagnosis of Parkinson's disease at any time during the pendency of the claim or contemporary to the filing of the claim. At a September 2020 VA examination, a VA examiner specified that the Veteran did not have Parkinson's disease. The examiner attributed the Veteran's reported shaking and tremors to a different diagnosis, essential tremor. The diagnosis of essential tremor will be discussed below. The Board gives more probative weight to the competent medical evidence, as the medical records were created by objective professionals who have the education, training, and expertise to be able to determine diagnoses. Absent competent and credible evidence of a diagnosis of Parkinson's disease, the Board concludes that the claim of entitlement to service connection for Parkinson's disease must be denied because the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 8. Entitlement to service connection for essential tremor The Veteran asserts that he has essential tremor generally due to his active duty. The service medical records do not contain any signs, symptoms, or diagnoses of essential tremor. The service separation examination report found that the Veteran had a normal neurological system, and the Veteran marked on an accompanying Report of Medical History that he did not experience neuritis or paralysis. At a September 2020 VA examination, the examiner diagnosed essential tremor. The Veteran reported having developed tremors in the early 1980s. It was noted that in 2018, the Veteran was prescribed Propranolol for tremors. A brain SPECT scan was normal, which ruled out Parkinson's disease. The examiner reiterated that the Veteran did not have Parkinson's disease. The examiner opined that it was not at least as likely as not that the Veteran's essential tremors were incurred in or caused by service. The examiner explained that essential tremor often did not have a known etiology except for family history in some cases. The examiner found no events, injuries, illnesses, or exposure to hazardous or infectious agents which may have caused tremors in the service records. The examiner also noted that the interim records between service and the diagnosis of tremors around 2017 did not show complaints of tremors. Although the Veteran has a current diagnosis of essential tremor, the Board concludes that the preponderance of the evidence is against a finding of a relationship of that disability to service. The Board further finds that the preponderance of evidence is against a finding that essential tremor was caused or aggravated by active service. Again, the Veteran has sought ongoing medical treatment with VA. However, none of the medical treatment providers has given any indication that the Veteran's essential tremor could be related to service. The only evidence which provides any connection between the Veteran's essential tremor and service comes from the Veteran's own statements. The Board is not free to substitute its own judgment for a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to the evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran's lay statements. Although laypersons are competent to provide opinions on some medical issues, as to the specific issue in this case, whether the Veteran's essential tremor was caused by active service, that issue falls outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide an etiology opinion concerning a neurological disability, and there are no competent etiology opinions are of record that support the claim. The Board places the most probative weight on the opinion offered by the September 2020 VA examiner. The VA examiner is an objective medical professional, who has the medical training and knowledge to perform and interpret the necessary medical tests. In particular, the VA examiner discussed the nature of essential tremor and what the treatment records did and did not show in relation to the nature of essential tremor. The VA examiner also specifically considered the Veteran's contentions. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for essential tremor, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for arthritic pain in the hands, arms, back, and legs is remanded. 2. Entitlement to service connection for a right hip disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. 4. Entitlement to service connection for a left knee disability is remanded. The Veteran asserts that he has arthritic pain, a right hip disability, a right knee disability, and a left knee disability as a result of sleeping on the ground and difficult field duty while he was on active duty. At a September 2020 VA examination, the examiner diagnosed arthritis of both hands, arthritis of the right hip, and arthritis of both knees. The examiner stated that as the service medical records did not show complaints of hand, hip, and knee pain, it was less likely than not that the degenerative arthritis of the hands, right hip, and knees was related to service. The Board notes that the VA examiner's negative etiology opinion was based on the lack of treatment in service. However, the lack of treatment or complaints of a disability in service is not persuasive evidence that a current disability was not caused by active service. An examination is inadequate where the examiner does not comment on the Veteran's reports, but instead relies on an absence of medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, remand is required to schedule the Veteran for a VA examination for an etiology opinion that is supported by sufficient rationale. 5. Entitlement to service connection for hepatitis C is remanded. For service connection to be established for hepatitis C, the evidence must show that a hepatitis C infection, risk factors of hepatitis C, or symptoms were incurred in, present in, or aggravated by service. The evidence must further show by competent evidence that there is a relationship between the claimed in-service injury and the current hepatitis C. Risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine use, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, and shared toothbrushes or razor blades. . A VA Fast Letter (FL) issued in June 2004 (FL 04-13, June 29, 2004) identified key points that included the fact that hepatitis C is spread primarily by contact with blood and blood products, with the highest prevalence of hepatitis C infection among those with repeated, direct percutaneous (through the skin) exposure to blood (such as intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). Another key point was the fact that hepatitis C can potentially be transmitted with the reuse of needles for tattoos, body piercing, and acupuncture. It was concluded that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. In this case, the Veteran has stated that he was exposed to hepatitis C as a result of being stuck with a dirty needle as a joke by a fellow soldier who was doing drugs while the Veteran was asleep while he was on active duty. Additionally, the Veteran's accredited representative has suggested that the Veteran was exposed to hepatitis C as a result of receiving numerous shots with an air gun while the Veteran was in basic training. The Board observes that the service treatment records document that the Veteran had gonorrhea while he was on active duty, which shows one sexually transmitted disease. The Veteran is competent to describe the circumstances surrounding inoculations in service and high-risk sexual activity because that comes to him through his senses and requires only personal knowledge rather than medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). At a September 2020 VA examination, the examiner opined that the Veteran's hepatitis C was less likely than not incurred in or caused by service. The examiner stated that the Veteran first reported the alleged experience in service of being stuck by a dirty needle by a fellow serviceman over 35 years after service, and there was nothing in the service medical records to indicate any event, illness, or injury that would otherwise be a risk factor for hepatitis C. The Board appreciates the efforts made by the VA examiner, but examiner did not comment on the service medical records which show that the Veteran was treated for gonorrhea in 1977. The examiner also did not comment on the theory that the Veteran was exposed to hepatitis C as a result of being inoculated with an air gun while in basic training. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Remand is necessary for an adequate etiology opinion which includes full consideration of all of the Veteran's risk factors in service for hepatitis C. 6. Entitlement to service connection for cirrhosis of the liver is remanded. A March 2016 ultrasound of the Veteran's abdomen found hepatic cirrhosis. In light of the above, the claim for service connection for cirrhosis is inextricably intertwined with the issue of entitlement service connection for hepatitis C. Harris v. Derwinski, 1 Vet. App. 180 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Therefore, further consideration of the claim for service connection for tinnitus must be deferred. The matters are REMANDED for the following action: 1. With any necessary authorization from the Veteran, obtain all outstanding VA and private treatment records. All attempts to locate those records must be documented in the claims folder. 2. After all available records have been obtained and associated with the claims file, schedule the Veteran for a VA examination to determine the etiology of any arthritis of the hands, arms, and legs; right hip; and bilateral knee disabilities. The examiner must review the record and should note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any disability of the hands, arms, legs, right hip, and bilateral knees had its onset in or are otherwise related to service or any event, injury, or disease during service. If it is determined that there is another more likely etiology for any arthritis of the hands, arms, and legs; right hip; and bilateral knee disabilities, that should be stated. The examiner should discuss how the disabilities generally present or develop in most cases. The examiner should consider the Veteran's assertions regarding the onset of pain in the joints under consideration, claimed as resulting from sleeping on the ground and arduous field training during service, or falling from a pole twice during service. A complete rationale for all opinions expressed should be clearly provided. The examiner must consider the Veteran's statements and all lay statements regarding onset in service and statements regarding the continuity of symptomatology. The examiner should not base the opinion solely on the lack of treatment or complaint in service. The rationale for all opinions expressed should be provided. 3. Schedule the Veteran for a VA examination to determine the etiology of any hepatitis C. Any indicated tests and studies are to be performed. The examiner must review the claims file and should note that review in the report. The examiner is requested to consider all possible risk factors that may be relevant to hepatitis C infection. The examiner is to be informed that the Board finds the Veteran's assertions of receiving in-service inoculations with an air gun and engaging in high-risk sexual activity to be credible. The Board notes that treatment in service for gonorrhea is documented. Following a review of the claims folder and an examination of the Veteran, the examiner is requested to provide an opinion as to whether it is as least as likely as not (50 percent probability or greater) that hepatitis C was caused by risk factors associated with active service. The examiner is requested to explain the usual incubation period and onset of symptoms for hepatitis C. A rationale should be given for any opinion provided. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Layton, 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.