Citation Nr: 21075272 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 17-13 412 DATE: December 20, 2021 ORDER Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for a migraine headache disorder is granted. REMANDED Entitlement to service connection for acid reflux disease is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for acid reflux is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. FINDING OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his obstructive sleep apnea is proximately due to or aggravated beyond its natural progression by his service-connected deviated nasal septum. 2. Resolving reasonable doubt in the Veteran's favor, his migraine headache disorder began during active service or are otherwise related to his active service. CONCLUSION OF LAW 1. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for migraines have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1988 to February 1993. This matter comes before the Board of Veterans' Appeals (Board) from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The RO granted service connection for an acquired psychiatric disorder and a low back condition in July 2020 and October 2020 rating decisions, and assigned initial disability ratings and effective dates, which is a full grant of the benefit sought with regard to those issues. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). To date, the Veteran has not expressed disagreement with the initial disability ratings or effective dates assigned. Accordingly, those issues are no longer before the Board. Additional VA-generated evidence was also associated with the claims file after the appeal was certified and transferred to the Board. In August 2021, the Veteran's representative agreed to waive RO consideration. Therefore, the Board may review the evidence in the first instance. See 38 C.F.R. § 20.1304 (c). 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, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Additionally, secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 1. Obstructive Sleep Apnea The Veteran seeks service connection for obstructive sleep apnea. The Board finds service connection for obstructive sleep apnea is warranted as secondary to his service-connected deviated septum. Service connection is currently in effect for a deviated nasal septum and other specified depressive disorder with anxious distress. A November 2010 private treatment record notes the Veteran has been a heavy snorer in the past and still snores when sleeping on his back. He reported having a sleep study done seven years ago with unremarkable results. He also reported waking with problems breathing. A December 2017 VA examination shows the Veteran has a current disability of obstructive sleep apnea. The December 2017 VA examiner opined that his sleep apnea is less likely than not proximately due to or the result of his service-connected condition. The examiner indicated that his sleep apnea is a multifactorial condition. While his service-connected deviated septum would contribute to and aggravate sleep apnea, he is also obese, has insomnia, and has violent kicking during his sleep that has injured his spouse, the window frame, and the wall structures. The December 2017 examiner additionally opined that the Veteran's sleep apnea was at least as likely as not aggravated beyond its natural progression by his service-connected deviated septum. The examiner noted that a deviated septum usually causes an obstructed or partially obstructed airway. The Veteran would be forced to open his mouth in his sleep to get enough air while sleeping, which increases snoring with the uvula obstructing the airway and can contribute to the violent leg movements. The examiner noted that a repeat sleep study would be needed to establish the pressure needed to open the airway for maximum effect; however, his report of sleep symptoms suggests that his obstructive sleep apnea has been exacerbated. Additionally, the Board notes that an October 2020 rating decision granted service connection for other specified depressive disorder with anxious distress. Both a July 2018 private mental disorders disability benefits questionnaire and an October 2020 VA examination indicate that the Veteran's service-connected psychiatric disorder includes chronic sleep impairment and/or disturbances. As the December 2017 VA examiner indicated that the cause of the Veteran's sleep apnea was multifactorial, including due to the Veteran's insomnia, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current obstructive sleep apnea is proximately due to or aggravated beyond its natural progression by his service-connected disabilities, to include his deviated septum and his acquired psychiatric disorder. The Board finds the December 2017 VA etiology opinion to be highly probative. This opinion had clear conclusions and supporting data, as well as reasoned medical explanations connected the Veteran's obstructive sleep apnea to his service-connected deviated septum and unspecified depressive disorder, namely, his insomnia. Nieves-Rodriguez v. Peake, supra. This opinion is being afforded great probative weight. There is no contrary probative opinion of record. In sum, the Veteran has a current diagnosis of obstructive sleep apnea. There is only one probative etiology opinion of record, which is in support of the Veteran's claim for entitlement to service connection. 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 obstructive sleep apnea as secondary to service-connected disabilities is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Migraine Headache Disorder The Veteran seeks service connection for migraines. The Veteran contends his migraines onset after a 1989 in-service motor vehicle accident. Alternatively, the Veteran contends his migraines are secondary to his neck condition and service-connected back condition. For the reasons that follow, the Board finds entitlement to service connection is warranted. The Veteran is currently diagnosed with a migraine headache disorder. See, e.g., May 2015 VA examination. The question for the Board is whether the Veteran's migraines began during service or are at least as likely as not related to an in-service injury, event, or disease. The Veteran endorsed a history of head injury on his December 1982 enlistment report of medical history. The examiner noted a scalp laceration without concussion. His service treatment records reveal a May 1989 motor vehicle accident. The Veteran struck his nose on the steering wheel and knees of the dash. He reported no loss of consciousness but had slightly slurred speech. He also reported a history of head injury on his January 1993 separation report of medical history, about which the examiner noted 'nasal fracture, healed' and not currently disabling (NCD). A March 1997 private treatment record notes headaches. A January 1999 private treatment record notes the Veteran has a history of migraines that he treated at home with Tylenol and ibuprofen, which has not worked this time. A February 1999 private treatment record reflects complaints of migraines with a negative magnetic resonance image (MRI) of the brain. Subsequent private treatment records continue to reflect chronic intermittent migraines. See, e.g., August 2006 private treatment record. A September 2000 private treatment record notes a two-year history of right frontal headaches. A June 2002 private treatment record notes headaches were not very much of a problem until 1997 when they started increasing in intensity and severity. An April 2004 private treatment record notes chronic intermittent right-sided neck pain that radiates up into his eye occasionally and a tendency to get migraines on the right. An October 2010 VA treatment record notes the Veteran was advised if his migraines are worsening he could discuss with his mental health provider to see if his poor sleep or depression could be worsening them. A December 2010 VA treatment record notes he was awakened by his headaches, which raised a concern that sleep apnea may be a trigger. See also November 2010 private neurologic consultation. March 2013 and July 2014 VA treatment records suggest his migraine headaches may be related to his neck pain, including a diagnosis of chronic cervicogenic migraines with aura. An October 2014 private treatment record notes headaches for 20 plus years. An additional October 2014 VA treatment record also notes chronic cervical spine pain with associated cervicogenic migraines. A March 2015 administrative decision found the Veteran's injuries related to his May 1989 motor vehicle accident were incurred in the line of duty. A May 2015 VA examiner opined that the Veteran's migraines are less likely than not related to service because there is no evidence to link his migraines to his time in service. The Board finds the May 2015 VA opinion inadequate to decide the claim. In this regard, the examiner failed to provide adequate rationale for the conclusions reached. Additionally, the May 2015 VA examiner failed to address the October 2014 VA treatment record indicating his migraine headache disorder may be secondary to his psychiatric disorder. This opinion is therefore afforded little, if any, probative weight. A June 2015 private correspondence from the Veteran's chiropractor, T.V., notes treatment for back pain, neck pain, and headaches. T.V. notes that his headaches remain somewhat under control in that they are decreasing in frequency and intensity, with treatment he is able to be a little more active and feels better. A September 2016 private treatment record notes the Veteran's headaches were decently controlled as long as he was on Zonisamide and received an occipital nerve block. A November 2016 VA examiner opined that the Veteran's migraines were less likely than not the consequence of his service-connected May 1989 motor vehicle accident. The November 2016 examiner noted that the Veteran states he developed headaches in 1989 after his 1989 motor vehicle accident. However, a May 1989 service treatment record and his January 1993 report of medical history notes the Veteran suffered a fracture and laceration of nose, a laceration of the left knee, and a bruise to the right side of his back with a complaint of recurrent back pain. The examiner noted there is no mention of headaches in these records and his January 1993 report of medical history notes the absence of frequent or severe headaches. A February 1999 MRI of the brain was normal. The MRI of the brain was repeated in April 2000 and was normal except for evidence of right frontal sinusitis. An August 2003 computed tomography (CT) of the sinuses performed showed mild rightward septal deviation but no evidence of obstruction or sinusitis. He was seen for a complaint of migraines in July 2003 at which time it was noted that his migraine had begun 7 years earlier in 1996, 3 years following separation from military service and 7 years following his motor vehicle accident in 1989. He was tried on Imitrex nasal spray, amitriptyline, and indomethacin without benefit. A suboccipital block was performed, trigger point injections were performed, and he was started on gabapentin and Labetalol. His medical records show treatment of migraines dating back to February 1999 and a variety of medications including Zomig, Imitex, Labetalol, propranolol, Topamax, gabapentin and various antidepressant medications. An August 2006 MRI of the brain obtained was normal. He was seen by an allergist who excluded allergic causes for his headaches. Presently, his headaches are treated with diclofenac, Zonisamide, and Imitrex tablets. The examiner noted his headaches occur every 3 to 4 days and will last for 1 to 2 days. They are right hemi-cranial in location and are described as a throbbing type of headache. They are associated with both nausea and vomiting, visual aura, and sensitivity to light and sound. Finally, the examiner noted the diagnosis of migraine headaches is correct, but it is less likely than not that the Veteran's migraine headaches are consequent to the service-connected motor vehicle accident that occurred in May 1989. The Board finds the November 2016 VA opinion inadequate to decide the claim. In this regard, the examiner failed to provide adequate rationale for the conclusions reached. Namely, the November 2016 VA examiner noted the Veteran's treatment history, but did not provide an explanation or elaboration as to why his migraine headache disorder is not etiologically related to active service. Rather, the November 2016 VA examiner merely provided a conclusory statement that such disorder was not related to service. This opinion is therefore afforded little, if any, probative weight. In March 2018, the Veteran's brother reported the Veteran's neck issues caused him to have headaches. In March 2018, the Veteran's father reported that he was complaining of migraines when he returned from service. In March 2018, the Veteran's mother reported his headaches began in service. In August 2018, the Veteran's private physician, M.B., opined that the Veteran's migraine headaches more likely than not began in service and continued uninterrupted to this day. M.B. further opined that the Veteran's migraine headaches are more likely than not both caused and permanently aggravated by his back and neck conditions. In formation of the opinion, M.B. discussed the Veteran's service and post-service medical treatment records, his VA examinations, and the lay statements of record. The Board finds the August 2018 private etiology opinion to be highly probative. This opinion had clear conclusions and supporting data, as well as reasoned medical explanations connected the Veteran's migraine headache disorder to his service. Nieves-Rodriguez v. Peake, supra. This opinion is being afforded great probative weight. There is no contrary probative opinion of record. The Veteran underwent a VA examination in August 2019. During the examination, the Veteran indicated his headaches started during service, but he thought they were related to drinking. He indicated they continued after service. The August 2019 examiner noted there are no records of treatment for headaches until 1997 but also noted that the Veteran began treatment for migraine headaches in 1996. The examiner indicated that the etiology of his migraines is not known. However, there were no complaints of migraines while on active duty, and he did not report any headaches until 3 years after he left the military. The examiner opined that his headaches less likely than not resulted from his 1989 motor vehicle accident. The Board finds the August 2019 VA opinion inadequate to decide the claim. In this regard, the examiner failed to provide adequate rationale for the conclusions reached. Namely, the August 2019 VA examiner noted the Veteran's treatment history, but did not provide an explanation or elaboration as to why his migraine headache disorder is not etiologically related to active service. Rather, the August 2019 VA examiner merely provided a conclusory statement that such disorder was not related to service. This opinion is therefore afforded little, if any, probative weight. After a review of the evidentiary record, resolving any doubt in the favor of the Veteran, the Board concludes that the Veteran's migraine headache disorder is related to service. He has a current diagnosis of a migraine headache disorder, and his service treatment records show a May 1989 motor vehicle accident. He has competently reported experiencing headaches during service that continued after discharge from service. While his service treatment records do not necessarily support the Veteran's assertion that he continued to have headaches after the 1989 motor vehicle accident up until the time of his discharge from service in 1993, the Veteran's competent and credible lay statements reflect that he experienced headaches in service that gradually increased in severity until approximately 1997 when he sought treatment. Thus, the competent lay statements of record support onset of headaches in service and recurrence thereafter. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Additionally, while the May 2015, November 2016, and August 2019 VA examiners found the Veteran's migraines to be less likely than not related to his active service, the Board notes the opinions seemingly rely on the lack of in-service medical records corroborating or documenting in-service migraines or for three years post-service and a lack of a temporal relationship. See generally Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). However, the Board observes that there is nothing that significantly impugns the credibility of the Veteran's assertion that he experienced recurrent headaches after service discharge, which he was able to self-manage until they worsened in severity and frequency in approximately 1997. To the extent the examiners were relying on the absence of post-service treatment for several years as the rationale for the negative nexus opinions, this would render their opinions of little probative weight. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In contrast, the Veteran's private physician, M.B., addresses the competent medical and lay evidence of record and opined that his migraine headaches are related to his service. These conflicting nexus opinions, which were supported by rationale and based upon the clinicians' review of the Veteran's clinical history and their clinical expertise, serve to place the matter of causal nexus in at least relative equipoise. Therefore, resolving all reasonable doubt in the Veteran's favor, the cumulative evidence is sufficient to establish a nexus between his current migraine headaches and his active service. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, service connection for a migraine headache disorder is warranted. REASONS FOR REMAND 1. Service Connection Hypertension The Veteran seeks service connection for hypertension. As noted in the April 2019 Board remand, the August 2017 VA examiner indicated that the Veteran's hypertension may be related to his service-connected migraine medication. As of the date of this decision, service connection is currently in effect for a migraine headache disorder. Thus, the Board cannot make a fully-informed decision on the issue of hypertension because no VA examiner has opined whether the Veteran's hypertension was caused or aggravated by his service-connected migraine headache disorder. Additionally, the Board notes the September 2017 examiner indicated an inability to 'confirm' whether the Veteran's hypertension is related to his one hypertensive notation that occurred during service without resorting to mere speculation. The Board acknowledges that the United States Court of Appeals for Veterans Claims has held that generally, where an examiner is unable to give an opinion without resorting to mere speculation, there is no opinion offered. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008). As the examiner determined that they were unable to form an opinion without resorting to mere speculation, the Board further finds an addendum direct service connection opinion is necessary. Accordingly, on remand, an addendum opinion should be obtained. 2. Service Connection - Acid Reflux The Veteran seeks service connection for acid reflux. In compliance with the Board's prior remand directives, a VA examination and opinion was obtained in August 2019. The examiner noted there were no medical records that indicated any gastroesophageal reflux disease (GERD) until June 2001 when the Veteran was diagnosed and placed on Axid. The examiner indicated indigestion was not noted on any military records. As there were no medications or reports of GERD while in the military or on exit exams, the examiner opined that GERD was less likely than not to related to the Veteran's military service. The Board finds this opinion is inadequate as it fails to address the January 1990 service treatment record indicating treatment for gastritis. Moreover, the opinion does not consider the lay statements of record competently reporting in-service indigestion with continuity after service and appears to be based solely on the lack of in-service medical records corroborating or documenting in-service indigestion. See generally Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). Accordingly, on remand, an addendum opinion should be obtained. 3. Service Connection - Neck Disorder The Veteran seeks service connection for a neck disorder. In compliance with the Board's April 2019 remand directives, an addendum examination was obtained in August 2019. The examiner opined that the Veteran's neck condition is less likely than not related to his 1989 in-service motor vehicle accident. The examiner reasoned that the Veteran was first treated for neck pain after a motor vehicle accident in 200511 years after the motor vehicle accident on active duty. Although the Veteran reported his pain started in 1989, the examiner noted that there is no indication of neck pain in his medical records until his second motor vehicle accident in 2005. The examiner opined that his 2005 motor vehicle accident caused injury leading to degeneration of his cervical spine. However, the Board notes the evidence of record reflects complaints of neck pain prior to his November 2005 motor vehicle accident. See, e.g., December 2003 VA treatment record. Additionally, the August 2019 opinion does not reflect consideration and discussion of the medical significance of the September 2018 private opinion as instructed by the prior remand directives. As the August 2019 VA opinion was based on an inaccurate factual premise and does not comply with the prior remand directives, remand is necessary to obtain an addendum opinion. See Reonal v. Brown, 5 Vet. App. 458 (1993); see also Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). 4. Service Connection - Left and Right Knee Disorders The Veteran seeks service connection for right and left knee disorders. In compliance with the Board's prior remand directives, an addendum opinion was obtained in August 2019. The examiner opined that the Veteran's right knee was less likely than not related to his 1989 motor vehicle accident because there was no evidence of any knee pain until 2013. The examiner noted not knowing the etiology of the medial meniscal tear but opined that it is unlikely that it occurred in 1989 and the Veteran did not report the discomfort for 24 years because the Veteran has been treated intermittently for many other issues since he left the military. Similarly, the examiner opined that the Veteran's left knee was less likely than not related to his in-service motor vehicle accident because there was no treatment for the left knee for 22 years. The examiner found it is unlikely the meniscal tearing and fraying was from an injury that occurred in 1989. Finally, the examiner noted that the Veteran has treated frequently over the years but did not report left knee concerns for 22 years after the original injury. The Board finds the opinion inadequate as it fails to address the lay statements of record competently reporting in-service knee pain with continuity post-service and appears to be based solely on the lack of in-service medical records corroborating or documenting in-service knee pain or knee pain for several years thereafter. See generally Dalton, 21 Vet. App. at 23; see also Buchanan, at 1336. Additionally, the August 2019 opinion does not reflect consideration and discussion of the medical significance of the September 2018 private opinion as instructed by the prior remand directives. See Stegall, 11 Vet. App. at 271. Accordingly, on remand, addendum opinions must be obtained. 5. Service Connection Left Shoulder, Right Shoulder, and Right Hip Disorders The Veteran seeks service connection for right and left shoulder disorders and a right hip disorder. In compliance with the Board's prior remand directives, addendum opinions were obtained in August 2019. However, the opinions do not reflect consideration and discussion of the medical significance of the September 2018 private opinion as instructed by the prior remand directives. See Stegall, 11 Vet. App. at 271. Accordingly, on remand, an addendum opinion must be obtained. Additionally, while the Veteran generally contends his right hip pain is related to his May 1989 in-service complaint of right pelvic pain following the May 1989 in-service motor vehicle accident, the Board acknowledges the Veteran has also asserted his right hip condition is secondary to his right knee condition, which is being remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991). Moreover, the evidence of record also reflects the Veteran's service-connected low back condition causes pain to radiate down his right leg. See, e.g., June 2015 private treatment record. Thus, on remand, an addendum opinion must also be obtained to determine whether the Veteran's right hip condition is secondary to his service-connected low back disability. 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 claim 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 his 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. Then, schedule the Veteran for VA examinations with an appropriate clinician(s) to determine the etiology of the Veteran's claimed hypertension. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. Further physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: (A) Is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension had its onset during any period of service, or is otherwise related to such period of service, to include his January 1993 elevated blood pressures? (B) Is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused and or permanently worsened by any service-connected disability, namely, his service-connected migraine headache disorder? A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 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. Then, schedule the Veteran for VA examinations with an appropriate clinician(s) to determine the etiology of the Veteran's claimed acid reflux. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. Further physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: (A) Is at least as likely as not (50 percent or greater probability) that the Veteran's acid reflux had its onset during any period of service, or is otherwise related to such period of service, to include his January 1990 in-service treatment for viral gastritis. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 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. 4. Then, schedule the Veteran for VA examinations with an appropriate clinician(s) to determine the etiology of the Veteran's claimed neck, right knee, left knee, right shoulder, left shoulder, and right hip disorders. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. Further physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: (A)Is at least as likely as not (50 percent or greater probability) that the Veteran's neck, right knee, left knee, right shoulder, left shoulder, and right hip disorders had its onset during any period of service, or is otherwise related to such period of service, to include his 1989 motor vehicle accident? (B)Is at least as likely as not (50 percent or greater probability) that the Veteran's neck, right knee, left knee, right shoulder, left shoulder, and right hip disorders was caused and or permanently worsened by any service-connected disability, namely, his service-connected back disorder? A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 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. Mariah N. Sim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, 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.