Citation Nr: 21076798 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-46 362 DATE: December 27, 2021 ORDER As new and material evidence has been received, the petition to reopen the claim for service connection for an acquired psychiatric disorder is granted. As new and material evidence has been received, the petition to reopen the claim for service connection for a left knee disability is granted. As new and material evidence has been received, the petition to reopen the claim for service connection for a right ankle disability is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder, is remanded. Entitlement to service connection for a left knee disability, to include as due to the service-connected right knee disability, is remanded. Entitlement to service connection for a right ankle disability, to include as due to the service-connected left ankle disability, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as due to the right knee disability, left ankle disability, and obesity, is remanded. Entitlement to service connection for diabetes mellitus, to include as due to the right knee disability, left ankle disability, and obesity, is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for a left lower extremity sciatica, to include as due to the service-connected lumbar spine disability, is remanded. FINDING OF FACT The evidence received since the last prior final denial, to include on August 9, 2021, in the form of lay testimony, is new, because it had not been previously associated with the file, and material, because it was lay evidence of an in-service occurrence and continued symptomatology regarding the right ankle disability, left knee disability, and acquired psychiatric disorder. CONCLUSION OF LAW The criteria for reopening the previously denied claims of service connection for a right ankle disability, left knee disability, and acquired psychiatric disorder are met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1992 to September 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. The record was held open for 60 days for additional evidence to be submitted. However, the record does not show that additional evidence was submitted. A July 2017 rating decision granted the claim for service connection for a migraine disability. As such, this matter is no longer on appeal due to the full grant of the benefit sought and it will not be discussed. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Service Connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d). Service connection requires evidence showing: (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 condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent lay or medical evidence of (1) a current diagnosed disability or persistent or recurrent symptoms of disability; (2) evidence establishing that the veteran suffered an event, injury or disease in-service; and (3) an indication that the claimed disability or symptoms may be associated with the established event, injury, or disease in-service or with another service-connected disability; and (4) insufficient competent medical evidence for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Furthermore, the threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). 1. New and material evidence to reopen the claim for service connection for an acquired psychiatric disorder. 2. New and material evidence to reopen the claim for service connection for a left knee disability. 3. New and material evidence to reopen the claim for service connection for a right ankle disability. New and Material Evidence Where a claim has been finally adjudicated, a claimant must present new and material evidence in order to reopen the previously denied claim. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Wakeford v. Brown, 8 Vet. App. 239 (1995). New evidence is that which was not previously submitted to agency decision makers. Material evidence is that which by itself, or when considered with previous evidence of record, relates to an unestablished fact that is 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 final denial, and it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of reopening, evidence received is generally presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). There is a low threshold for finding new evidence that raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). VA should consider whether the newly received evidence could reasonably substantiate the claim were the claim to be reopened, including whether VA's duty to provide a VA examination is triggered. There must be new and material evidence as to at least one of the bases of the prior disallowance to warrant reopening. Shade, 24 Vet. App. at 117-20. The Veteran initially filed his claim for a right ankle disability in December 1996. An April 1997 rating decision denied his claim. It noted that the record did not show a diagnosis for a right ankle disability. A notice of disagreement was not filed and new and material evidence was not received within a year of this decision. As such the April 1997 decision became final. 38 U.S.C. § 7104; 38 C.F.R. § 3.156(b). Subsequently, the Veteran filed a claim for a right ankle disability and an acquired psychiatric disorder in May 2012. A November 2012 rating decision denied his claims. Regarding the claim for a right ankle disability, it noted that the Veteran did not file new and material evidence to reopen the claim. It stated that his STRs showed a diagnosis of or treatment for the right ankle, but there was not new evidence showing a diagnosis of or treatment for it. Regarding the acquired psychiatric disorder, it noted that the record did not show a diagnosis for PTSD and that he had a stressful event in service, to include fear of hostile military or terrorist activity. Subsequently, the Veteran submitted a timely NOD in December 2012 and the agency of original jurisdiction (AOJ) denied his claim via an October 2013 Statement of the Case (SOC). A substantive appeal was not perfected. As such the November 2012 decision became final. 38 U.S.C. § 7104. Furthermore, the Veteran filed a claim for acquired psychiatric disorder in February 2014 and for a left knee disability in November 2014. A March 2015 rating decision denied his claims. Regarding the acquired psychiatric disorder, it noted that the Veteran did not file new and material evidence to reopen the claim. Regarding the left knee disability, it noted that the record did not show a diagnosis for a left knee disability. A notice of disagreement was not filed and new and material evidence was not received within a year of this decision. As such, the March 2015 decision became final. 38 U.S.C. § 7104; 38 C.F.R. § 3.156(b). The current appeal began when the Veteran submitted a formal claim for an acquired psychiatric disorder, a right ankle disability, and a left knee disability, among others, in August 2016. Since at that time his decision was final, he needed to submit new and material evidence to reopen the claims. The Board finds that the Veteran submitted new and material evidence to reopen his claims in the form of lay testimony evidence in August 2021. In support, the Veteran testified about his in-service incident where he hurt his knee and suffered psychological traumatic events. Further, he raised the theory of secondary service connection for his right ankle disability, to include as due to the service-connected left ankle disability. See 5/19/2021 Hearing Transcript, at pages 4, 5, 6, 7, 22, 23, 24, and 26. Moreover, VA treatment records showed that the Veteran was diagnosed with PTSD, major depressive disorder, and generalized anxiety disorder, discussed below. This evidence is new because it was not previously associated with the file, and material, because it tends to support the Veteran's contention of a diagnosed disability, an in-service injury or event, and continued symptomatology, the basis of his prior denials. Before adjudication on the merits, the Board finds that additional development is necessary, as discussed below. REASONS FOR REMAND 1. Service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, and generalized anxiety disorder. The Veteran contends service connection for an acquired psychiatric disorder. See 5/8/2017 NOD. Service connection for PTSD, depression, severe anxiety/panic attacks, and memory loss will be discussed under the umbrella of an acquired psychiatric disorder. Clemons, 23 Vet. App. at 4-6. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Post-service medical records showed that the Veteran was diagnosed with PTSD, major depressive disorder, and generalized anxiety disorder. See 9/30/2016 Medical Treatment Record Non-Government Facility, at page 11; see also 10/31/2016 CAPRI, at pages 34, 78, and 85. Regarding the in-service incident, the Veteran testified, at the Board hearing, that during service, a coworker threatened to kill him. He reported it to his supervisor, who dismissed and scolded him for it. Additionally, he testified that a sergeant asked him to work on things he was not qualified, he explained so, and the sergeant started picking on him and got him court martialed. The Veteran testified the sergeant stated things that were not true and the Veteran did not get a chance to respond or defend himself. Moreover, the Veteran testified that during a game of tag football, the same sergeant indicated to other people to "get [him]," he got "dog piled" for five minutes, he was scared that he was going to die because he could not breathe, and he almost passed out. After that, he was anxious and depressed because whenever he saw the sergeant, he was afraid that something was going to happen, and he would get in trouble. In addition, he testified that he still experiences psychiatric symptoms since service. Finally, he testified that Dr. M. from La Jolla VA attributed the above-mentioned incidents to his diagnosis of PTSD. See 8/9/2021 Hearing Transcript, at pages 5, 6, 7, and 9. The AOJ did not obtain a VA examination regarding whether PTSD, major depressive disorder, and generalized anxiety disorder are due to his active service. However, based on the evidence associated with the claims file showing diagnoses for the above-mentioned disorders and the Veteran's testimony regarding Dr. M.'s attributing the above-mentioned incidents to his diagnosis of PTSD, the Board finds that a VA examination/medical opinion is required. See 8/9/2021 Hearing Transcript, at page 9. However, the Board notes that the VA treatment records from Dr. M. appear to be not associated from the Veteran's claims file. Based on this factual scenario, the Board finds that a remand is necessary for the AOJ to attempt are to obtain the VA records from La Jolla from 2015, as such records would likely be pertinent to the Veteran's disability picture. Finally, as noted above, the Veteran has not undergone a VA examination to determine the nature and etiology of any current mental health disability and the record now reflects that VA's duty to assist in this regard has been triggered. As such, on remand, the AOJ should take appropriate action to obtain records and schedule a VA psychiatric examination. 2. Service connection for a left knee disability, to include as due to the service-connected right knee disability. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for a left knee disability, to include as due to the right knee disability. Specifically, at the Board hearing, the Veteran testified that they were running together as a group in file and then some guys behind him tripped each other, and one landed on him and hurt his knees. Additionally, he testified that because of the service-connected right knee disability, he changed his gait and now he experiences pain, swelling, and a loss of range of motion of his left knee. Further, he testified that due to his service-connected right knee disability and left ankle disability, he was told by VA doctors to stop exercising, which contributed to his weight gain, and another VA doctor told him that his weight was worsening his left knee disability. See 8/9/2021 Hearing Transcript, at pages 4, 19, and 24. Service treatment records showed an incident where the Veteran tripped during bootcamp in December 1992 and had pain on both knees. Additionally, they showed an additional incident in April 1993 where the Veteran hit his left knee on the street while running and he fell straight down on his knees. Further, he finished the run but the next day he walked with a limp. The objective examination showed an abrasion on the left patella and a contusion of the left knee. Moreover, the record showed that the Veteran experienced tightness behind his knees when squatting or standing up and had ongoing complaints of bilateral knee pain, popping, and clicking. See 11/5/2013 STR, at pages 22, 31, 40, 42, and 70. The Veteran underwent VA knee and lower leg conditions disability benefits questionnaires in June 2015, October 2016, and May 2018. All the examiners reported no diagnosis for a left knee disability. As such, no nexus opinions were rendered. The Board finds these examinations inadequate because they do not show adequate consideration of all relevant evidence, to include the above-mentioned in-service incidents or his complaints of bilateral knee pain. See 10/31/2016 CAPRI, at page 121. Additionally, they do not show adequate consideration of the Veteran's lay statements that due to his service-connected right knee disability, he changed his gait and now he experiences pain, swelling, and a loss of range of motion of his left knee throughout his active duty and to this day. Furthermore, concerning the Veteran's contentions of left knee pain, swelling, and loss of range of motion in the absence of proof of a present disability, there can be no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is generally satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 318, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that the Veteran satisfies the current disability requirement when a disability exists at the time the claim is filed or during its pendency, even if it resolved itself prior to adjudication). The Board also notes that the Court of Appeals for the Federal Circuit found that pain alone can constitute a "disability" under § 1110, because pain can cause functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). In light of Saunders, the Board finds that the Veteran's reports of left knee pain and swelling may indicate chronic pain and/or a persistent disability. Based on this factual scenario, the Board finds that a remand is necessary for the AOJ to can schedule an in-person VA examination to gather evidence as to whether the Veteran has a current diagnosed left knee disability, or in the alternative, symptoms including pain which reach to the level of functional impairment of earning capacity. If there is a finding of functional impairment, then a medical nexus opinion must be rendered. 3. Service connection for a right ankle disability, to include as due to the service-connected left ankle disability. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for a right ankle disability. Specifically, at the Board hearing, the Veteran testified that his right ankle disability is due to his service-connected left ankle disability. Additionally, he testified that his service-connected left ankle disability left him more susceptible to further injuries to his right ankle due to overuse and having to keep weight off his left ankle. Further, the change in gait and walking with a limp caused his right ankle to swell and give out. Moreover, those injuries exacerbated the ones suffered in service. See 8/9/2021 Hearing Transcript, at pages 22 and 23. The Veteran underwent a VA ankle conditions examination in September 2012, which reported no diagnosis for a right ankle disability and, as such, did not render a nexus opinion. On the other hand, the October 2016 VA ankle examination diagnosed the Veteran with bilateral Achilles' tendon tendonitis, but it did not render a nexus opinion. See 10/17/2016 C&P Examination. However, the Board finds these examinations inadequate because they do not show consideration of all relevant evidence, to include the above-mentioned Veteran's lay statements that due to his service-connected left ankle disability, he had to change his gait and walk with a limp, which caused his right ankle to swell and give out. Additionally, those injuries exacerbated the ones suffered in service. Based on the evidence of record, the Board finds that a VA examination/medical opinion that considers the entire record is necessary before an adjudication on the merits. Based on this factual scenario, the Board finds that a remand is required for the AOJ to schedule an in-person VA examination be conducted to determine the nature and etiology of the Veteran's right ankle disability. 4. Service connection for OSA, to include as due to the right knee disability, left ankle disability, and obesity. 5. Service connection for diabetes mellitus, to include as due to the right knee disability, left ankle disability, and obesity. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for diabetes and OSA. Specifically, at the Board hearing, the Veteran testified that due to his service-connected left ankle and right knee disabilities, he was told by VA doctors to stop exercising, which contributed to weight gain, and subsequently contributed to the development of his diabetes and OSA disabilities. Regarding his OSA disability, the Veteran testified that while in-service, his roommates told him that he was snoring. Additionally, he testified that after he gained weight, he started waking up in the middle of the night shocked and taking a deep breath at the same time. Further, he testified that in 2016 he underwent a sleep study and was diagnosed with OSA by a VA doctor in La Jolla. See 8/9/2021 Hearing Transcript, at pages 11, 18, 19, and 20. Initially, the Board notes that the Veteran is currently service connected for a right knee disability and a left ankle disability per the November 2012 rating decision. Additionally, post-service treatment records showed that the Veteran was diagnosed with diabetes mellitus and OSA. See 10/31/2016 CAPRI, at pages 132-33. Furthermore, the record showed that the Veteran received education regarding the health risk associated with being overweight/obese, such as heart disease, diabetes, and sleep apnea, among others. See 4/13/2018 CAPRI, at page 22. As noted above, the Veteran has suggested that his OSA disability started in-service and that in the alternative, his OSA disability is due to the service-connected right knee disability and left ankle disability, by way of obesity as an intermediate step. Regarding the Veteran's diabetes, the Veteran has suggested that his diabetes disability is due to the service-connected right knee disability and left ankle disability, by way of obesity as an intermediate step. VA may service connect the current disability on a secondary basis under 38 C.F.R. § 3.310(a) to include aggravation of a non-service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300, 304, 306 (2020) (explaining service connection may be granted on a secondary basis where the claimed disability would not have occurred but for obesity caused or aggravated by a service-connected disability). To determine whether obesity is an intermediate step between a service-connected disability and the development of a current disability that may be service connected on a secondary basis, the following criteria must all be satisfied: 1) the service-connected disability must have caused the Veteran to become obese; 2) the obesity, as a result of the service-connected disability must have been a substantial factor in causing the potential secondary disability; and 3) the potential secondary disability would not have occurred but for the obesity caused by the service-connected disability. The AOJ did not obtain a VA examination regarding whether the Veteran's diabetes and OSA disabilities are due to his active service or to his service-connected right knee disability and left ankle disability, by way of obesity as an intermediate step. However, based on the evidence of record, the Board finds that VA examinations and medical opinions are required. As mentioned above, at the Board hearing, the Veteran testified that in 2016 he underwent a sleep study and was diagnosed with OSA by a VA doctor in La Jolla. See 8/9/2021 Hearing Transcript, at page 20. However, the Board notes that these VA treatment records have not been associated with the Veteran's claims file. Based on this factual scenario, the Board finds that a remand is required for the AOJ to attempt to obtain the VA records from La Jolla of 2016, as such records would likely be pertinent to the Veteran's disability picture and take appropriate action to schedule VA examinations for his diabetes and OSA disabilities. 6. Service connection for a heart disability. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for a heart disability. Specifically, at the Board hearing, the Veteran testified that 4 months before separation he started feeling a rapid heart rate, heart palpitations, an irregular heartbeat, pressure in his chest, and shortness of breath. Additionally, he testified that in 1999, shortly after separation from active service, he had a panic attack that put him in the hospital, they found that his heart rate was fast, and he was diagnosed with tachycardia. See 8/9/2021 Hearing Transcript, at pages 14 and 16. Post-service treatment records show that the Veteran has a history of arrhythmia. See 10/31/2016 CAPRI, at page 34. The record showed that the Veteran received education regarding the health risk associated with being overweight/obese, such as heart disease, diabetes, and sleep apnea, among others. See 4/13/2018 CAPRI, at page 22. As noted above, the Veteran has suggested that his heart disability started in-service. Additionally, the theory that his heart disability is due to the service-connected right knee disability and left ankle disability, by way of obesity as an intermediate step was reasonable raised by the record. Further, the theory that his heart disability is due to his acquired psychiatric disorder for panic attacks was reasonable raised by the record. The AOJ did not obtain a VA examination regarding whether the Veteran's heart disability is due to his active service or due to his service-connected right knee disability and left ankle disability, by way of obesity as an intermediate step. However, based on the evidence of record, the Board finds that a VA examination/medical opinion is required. Furthermore, as noted above, at the Board hearing, the Veteran testified that in 1999, shortly after separation from active service, he had a panic attack that put him in the hospital, they found that his heart rate was fast, and he was diagnosed with tachycardia. However, these records have not been associated with the Veteran's claims file. Based on this factual scenario, the Board finds that a remand is required for the AOJ to take appropriate action to schedule a VA examination and medical opinion(s) for his heart disability. 7. Service connection for a left lower extremity sciatica, to include as due to the service-connected lumbar spine disability. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for left lower extremity sciatica. Specifically, at the Board hearing, the Veteran testified that his left lower extremity sciatica is due to his service-connected lumbar spine disability. Additionally, he experiences nerve pain, tingling, numbness, and burning sensation. He further testified that he cannot walk for more than 5 minutes. Moreover, he testified that his disability changed the way he walked; he cannot stand up straight when he is in pain. In addition, he testified that in 2015 he was diagnosed with sciatic nerve pain due to his service-connected lumbar spine disability by a VA doctor in La Jolla. See 8/9/2021 Hearing Transcript, at pages 27, 28, and 29. However, the Board notes that these VA treatment records are missing from the Veteran's claims file. Based on this factual scenario, the Board finds that a remand is required for the AOJ to attempt to obtain the VA records from La Jolla of 2015, as such records would likely be pertinent to the Veteran's disability picture. These matters are REMANDED for the following actions: 1. Obtain any and all of the Veteran's outstanding VA records from appropriate repositories, to include all VA treatment records from the La Jolla VA treatment facility from 2015 to the present. All records and/or responses received should be associated with the claims file. 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 the records. 2. Ask the Veteran to submit, or provide authorization for VA to obtain, all non-VA treatment records from 1999, onward, related to his heart disability, to include the records mentioned in his hearing testimony that shortly after separation from active service, he had a panic attack that put him in the hospital, they found that his heart rate was fast, and he was diagnosed with tachycardia. Document all requests for information as well as responses in the claims file. If the records are unavailable, then notify the Veteran and his representative. 3. After completion of step # 1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any currently mental health disorder. The clinician is to review the virtual file, including a copy of this Remand. The examiner is to identify any current psychiatric disorders, to include PTSD, major depressive disorder, generalized anxiety disorder, or any other psychiatric disorder since the period on appeal (shortly before and/or since May 29, 2012). The examiner must make clear whether the Veteran has or has not had any acquired psychiatric disorder during the period on appeal (since mid-2016). Additionally, if the examiner disagrees with any diagnosis or lack thereof during the period on appeal, the examiner must explain why. After a review of the claims file, the examiner must address: (a.) Compile a list of all psychiatric disorders. (b.) For EACH psychiatric disorder identified on the current examination, state whether it is at least as likely as not (probability of approximately 50 percent or more), that any of the Veteran's current psychiatric disorders, in whole or part, had their onset in service. A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. All pertinent evidence, including both lay and medical, should be considered. If medical literature is reference, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After completion of step # 1, schedule the Veteran for a VA musculoskeletal examination by an appropriate clinician to determine the nature and etiology of any current left knee disability. The examiner is to provide a diagnosis which accounts for the Veteran's present symptoms for his left knee. If a medical diagnosis cannot be given, the examiner must state whether the Veteran has any functional impairment, such as loss of range of motion, pain, or instability. Complete the "Functional Impact" section of the report. The clinician is to review the virtual file, including a copy of this Remand. After a review of the claims file, the examiner is to specifically address: (a.) Whether it is at least as likely as not (probability of approximately 50 percent or more) that the Veteran's current left knee disability is related to an in-service injury, event, or disease. (b.) Whether it is at least as likely as not (probability of approximately 50 percent or more) that the current left knee disability has been (1) caused by OR (2) aggravated (i.e., worsened beyond the normal progression of that disease) by the service-connected right knee disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. The examiner is asked to provide specific evidence of record to support his conclusions, such as references from this Veteran's relevant medical history and/or medical literature. All pertinent evidence, including both lay and medical, should be considered. If medical literature is reference, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. After completion of step # 1, schedule the Veteran for a VA musculoskeletal examination by an appropriate clinician to determine the nature and etiology of any current right ankle disability. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: (a.) Whether it is at least as likely as not (probability of approximately 50 percent or more) that the Veteran's current right ankle disability is related to an in-service injury, event, or disease. (b.) Whether it is at least as likely as not (probability of approximately 50 percent or more) that the Veteran's current right ankle disability has been (1) caused by OR (2) aggravated (i.e., worsened beyond the normal progression of that disease) by the service-connected left ankle disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. (c.) **In responding to the above, please address the in-service incident where the Veteran tripped during bootcamp in December 1992 and had pain on both knees. Service records showed an additional incident in April 1993 where the Veteran hit his left knee on the street while running and he fell straight down on knee. Additionally, he finished the run but next day he walked with limp. The examination showed an abrasion on the left patella and a contusion of the left knee. Further, the record showed that the Veteran experienced tightness behind his knees when squatting or standing up. Moreover, service records showed ongoing complaints of bilateral knee pain, popping, and clicking. See 11/5/2013 STR, at pages 22, 31, 40, 42, and 70. Additionally, please address the Veteran's contentions that they were running together as a group in file and then some guys behind him tripped each other, and one landed on him and hurt his knees. Additionally, he testified that because of the service-connected right knee disability, he changed his gait and because of it he experiences pain, swelling, and a loss of range of motion of his left knee. Further, he testified that due to his service-connected right knee disability and left ankle disability, he was told by VA doctors to stop exercising, which contributed to his weight gain, and another VA doctor told him that his weight was worsening his left knee disability. See 8/9/2021 Hearing Transcript, at pages 4, 19, and 24.** A comprehensive rationale for all opinions is to be provided. The examiner is asked to provide specific evidence of record to support his conclusions, such as references from this Veteran's relevant medical history and/or medical literature. All pertinent evidence, including both lay and medical, should be considered. If medical literature is reference, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 6. After completion of step # 1 and 2, schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of his diabetes disability. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: (a.) Whether the obesity/weight gain as a result of the musculoskeletal service-connected disabilities was a substantial factor in causing his diabetes. (b.) Whether his diabetes would not have occurred but for the obesity/weight gain caused by the musculoskeletal service-connected disabilities, such as right knee disability and left ankle disability. (c.) If no to the above questions (a)-(b), is it at least as likely as not (probability of approximately 50 percent or more) that his diabetes was either (1) proximately due to OR 2) aggravated by any service-connected disability, to include his right knee disability and left knee disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. All pertinent evidence, including both lay and medical evidence, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 7. After completion of step # 1, 2, and 3, schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of his OSA disability. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: (a.) Whether the obesity/weight gain as a result of the musculoskeletal service-connected disabilities was a substantial factor in causing his OSA disability. (b.) Whether his OSA disability would not have occurred but for the obesity/weight gain caused by the musculoskeletal service-connected disabilities, such as right knee disability and left ankle disability. (c.) If no to the above questions (a)-(b), is it at least as likely as not (probability of approximately 50 percent or more) that his OSA disability was either (1) proximately due to OR (2) aggravated by any service-connected disability, to include his right knee disability and left knee disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. All pertinent evidence, including both lay and medical evidence, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). 8. After completion of step # 1 and 2, schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of his heart disability. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: (a.) Compile a list of all heart disabilities. (b.) For EACH heart disability identified on the current examination, state whether the obesity/weight gain as a result of the musculoskeletal service-connected disabilities was a substantial factor in causing his heart disability. (c.) Whether his heart disability would not have occurred but for the obesity/weight gain caused by the musculoskeletal service-connected disabilities, such as right knee disability and left ankle disability. A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. (Continued on the next page) All pertinent evidence, including both lay and medical evidence, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.F., 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.