Citation Nr: 21076994 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-35 178A DATE: December 28, 2021 ORDER Service connection for a cervical spine disorder is denied. Service connection for a right shoulder disorder is denied. Service connection for a left shoulder disorder is denied. Service connection for a right hip disorder is denied. Service connection for right upper extremity radiculopathy, claimed as secondary to a service-connected disability, is denied. Service connection for left upper extremity radiculopathy, claimed as secondary to a service-connected disability, is denied. Service connection for right wrist carpal tunnel, claimed as secondary to a service-connected disability, is denied. service connection for left wrist carpal tunnel, claimed as secondary to a service-connected disability, is denied. REMANDED The claim of entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected lumbar spine disability, is remanded. The claim of entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for sleep disturbances, to include as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of cervical degenerative arthritis, that manifested many years after service, and is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 2. The Veteran has current diagnoses of impingement syndrome of the right shoulder status post SLAP (superior labrum anterior and posterior) repair with capsulitis status post tenotomy and lysis of adhesions, as well as degenerative arthritis of the right shoulder that manifested many years after service, but such disorders are not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 3. The Veteran has a current diagnosis of degenerative arthritis of the left shoulder, that manifested many years after service, and is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 4. The Veteran has a current diagnosis of mild degenerative arthritis of the right hip, that manifested many years after service, and is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 5. The Veteran has a current diagnosis of right upper extremity radiculopathy, but such disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 6. The Veteran has a current diagnosis of left upper extremity radiculopathy, but such disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 7. The Veteran has a current diagnosis of right wrist carpal tunnel, but such disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. 8. The Veteran has a current diagnosis left wrist carpal tunnel, but such disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service, or caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for right upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for left upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for right wrist carpal tunnel have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 8. The criteria for service connection for left wrist carpal tunnel have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board of Veterans' Appeals (Board) from March 2014 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Specifically, the March 2014 rating decision, in part, denied service connection for erectile dysfunction, sleep disturbances, bilateral carpal tunnel syndrome, radiculopathy of the upper extremities, and GERD. The May 2014 rating decision, in part, denied service connection for a cervical spine disability, bilateral shoulder disabilities, and a right hip disability. The Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in June 2019. A transcript of this proceeding has been associated with the claims file. This case was previously before the Board in September 2019 at which time the Board, in pertinent, reopened a previously denied claim of entitlement to service connection for GERD and remanded this claim along with the other issues noted on the cover page of this decision for additional development. The above issues were remanded by the Board again in May 2021 for additional development. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service injury, event, or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 1. Service connection for a cervical spine disorder, bilateral shoulder disorders, and a right hip disorder is denied. The Veteran contends that cervical spine, bilateral shoulder, and right hip disorders are related to his military service. Specifically, during the June 2019 Board hearing, the Veteran testified that he was a paratrooper during his military service and has experienced neck, shoulder, and right hip pain since his military service due to jumping out of planes and carrying heavy bags in service. The Veteran's service treatment records are negative for complaints regarding the neck, shoulder, or right hip. Significantly, the Veteran's May 1993 separation examination shows a normal spine, upper extremities, as well as lower extremities and in a May 1993 report of medical history, the Veteran specifically denied a history of "arthritis, rheumatism, or bursitis," "bone, joint, or other deformity," as well as "painful or 'trick' shoulder or elbow." Furthermore, a post-service September 1997 VA joints examination is negative for complaints regarding the neck, shoulders, and/or right hip. Post-service treatment records are silent for complaints regarding the neck until approximately 2010. Significantly, a May 2010 magnetic resonance imaging (MRI) scan of the cervical spine shows an impression of degenerative disc disease at C5-6. A February 2011 neurosurgery note shows a 5 month history of neck pain which first began after hitting a bump on the road while driving his truck. Post-service records are silent for complaints regarding the left shoulder until a September 2000 VA physical therapy note showing some mild left shoulder pain secondary to possible degenerative joint disease with possible mild supraspinatus tendonitis. Post-service records are silent for complaints regarding the right shoulder until May 2010 when the Veteran underwent MRI of the right shoulder which showed a partial tear of the anterosuperior labrum. Post-service records are silent for complaints regarding the right hip until April 2014 when an X-ray of the hips revealed right hip degenerative joint disease (DJD). The Veteran submitted an initial claim for service connection for neck, shoulder, and right hip disabilities in March 2013. In connection with this claim, he was afforded VA neck, shoulder, and hip examinations in May 2014. The neck examination shows a diagnosis of cervical degenerative arthritis. The shoulder examination shows diagnoses of impingement syndrome of the right shoulder status post SLAP repair with capsulitis status post tenotomy and lysis of adhesions and includes complaints of left shoulder pain but is negative for a diagnosed left shoulder disorder. The hip examination shows a diagnosis of mild degenerative arthritis of both hips. Significantly, the examiner reviewed the claims file and opined that such disabilities were not secondary to the Veteran's in-service parachute jumping. Pursuant to the September 2019 Board remand, the Veteran was afforded additional VA neck, shoulder, and hip examinations in January 2020. The shoulder examination shows disabilities of both shoulders diagnosed as right shoulder impingement syndrome, bilateral degenerative arthritis, and status post SLAP tear with capsulitis s/p tenotomy and lysis of adhesions. The January 2020 examiners opined that it was less likely than not that the Veteran's claimed cervical spine, bilateral shoulder, and right hip disabilities are due to the Veteran's military service. As rationale for these opinions the examiner wrote that there was no documentation of these conditions or pain in service in the claims file. The Veteran's testimony that neck/shoulder/right hip pain is secondary to carrying heavy bags and jumping out of planes does not create a nexus because pain would have manifested during service and (other than left shoulder pain which was an acute strain) this was not reported in the claims file and many years have passed since the veteran's service and reporting neck pain. The examiner noted that arthritis occurs with aging and is not secondary to jumping out of planes and carrying heavy bags in service. Furthermore, the Veteran did not seek post-service treatment for the right shoulder until 1998. However, in a separate medical opinion, also dated in January 2020, regarding the Veteran's claim for service connection for a lumbar spine disability, also claimed as due to in-service jumping out of planes and carrying heavy bags, the examiner opined that it was at least as likely as not that the Veteran's claimed lumbar spine disability was due to his military service. As rationale for this opinion, the examiner noted that, to be certified as a Senior Parachutist, soldiers must participate in a minimum of 30 jumps, including at least 15 jumps with combat equipment. The 30 jumps must also include two night jumps, and one of these jumps must be as the jumpmaster of a group of jumpers. There is also a requirement for two mass tactical jumps. Graduation from the Army's Jumpmaster Course and 24 months of service with an airborne unit are also required for Senior Parachutist certification. Paratroopers can exit the plane at speeds up to 180 knots with a landing speed around 15 kilometers per hours. The Veteran earned a Senior Parachutist badge during his active service and complained of back pain in 1997, approximately four years after his discharge from service. Airborne operations entail high impact activity as well as carrying at least 70 pounds of gear. Although the Veteran did not complain of back pain while in service nor get evaluated for a back condition, it is conceivable that his current back pain had its origin while in service. The amount of weight the Veteran carried worth of combat equipment and/or parachute equipment along with the repetitive jumps more than likely causes back pain and it is within the realm of medical possibility that the Veteran's lumbar spine disability was caused by his active service. In May 2021, the Board noted the disparity between the January 2020 VA lumbar spine examiners' medical opinion as compared to the medical opinions of the January 2020 VA cervical spine, shoulder, and hip examiners pertaining to the damage caused by the Veteran's in-service parachute jumping and carrying heavy bags. Given this disparity, the Board remanded these issues for an addendum medical opinion regarding the etiology of the Veteran's claimed cervical spine, bilateral shoulder, and right hip disorders that considers the extensive reasoning in favor of orthopedic problems in the January 2020 medical opinion pertaining to the etiology of the Veteran's lumbar spine disability. Furthermore, given the anatomical proximity between the newly service-connected lumbar spine disability and the claimed cervical spine/bilateral shoulder disabilities, a medical opinion regarding whether the claimed cervical spine/bilateral shoulder disabilities are secondary to the Veteran's service-connected lumbar spine disability was requested. Pursuant to the May 2021 Board remand, addendum medical opinions were obtained in August 2021. Specifically, the August 2021 VA examiner opined that it was less likely than not (less than 50 percent probability) that either a cervical spine disorder, a disorder of either shoulder, and/or a right hip disorder was incurred in or caused by the claimed in-service injury, event, or illness. Notably, the examiner reviewed the entire claims file, including the Veteran's lay statements regarding conducting parachute jumps during service and carrying heavy loads during service, conceded that such events had occurred. With regard to the cervical spine, the August 2021 VA examiner noted that the Veteran's STRs were silent for complaints of or treatment for a cervical spine condition during service. Specifically, October 1987 and May 1993 reports of medical history were negative for complaints regarding the neck. Also, the Veteran's May 1993 separation examination shows a normal spine. Furthermore, a post-service September 1997 VA joints examination is negative for complaints regarding the neck. Post-service records are silent for complaints regarding the neck until approximately 2010. Significantly, a February 2011 neurosurgery note shows a 5 month history of neck pain which first began after hitting a bump on the road while driving his trucking. An MRI scan of the cervical spine at that time showed annular tear at C3/C4, C4/C5, and C5/C6 disc protrusion with a diagnosis of cervical radiculitis. The examiner noted that it was less likely than not that the cervical spine condition is the result of accumulated trauma sustained during active duty service given the lack of complaints regarding the neck in service, the significant gap between the Veteran's discharge from service and the first complaints regarding the neck, as well as the Veteran's post-service occupation as a truck driver. Significantly, it was noted that medical literature shows an increased prevalence of neck pain due to prolonged sitting, poor posture, and road vibrations. With regard to the shoulders, the August 2021 VA examiner noted that, while the Veteran's STRs do show a diagnosis of left muscle strain after falling off a rope in July 1887, STRs are silent for continued care and treatment for the left shoulder and are silent for any complaints regarding the right shoulder. Significantly, in a May 1993 report of medical history , the Veteran specifically denied a history of "painful or 'trick' shoulder." Furthermore, a post-service September 1997 VA joints examination is negative for complaints regarding the shoulders. While a post-service March 1998 treatment record shows a history of injury to a shoulder while lifting a heavy box-chronic shoulder pain (right vs. left not denoted) sometime in the 1990s, physical examination at that time was negative. The earliest indication of a left shoulder disorder is a September 2000 VA physical therapy note showing some mild left shoulder pain secondary to possible degenerative joint disease with possible mild supraspinatus tendonitis. The examiner noted that it was less likely than not that a shoulder disorder is the result of accumulated trauma sustained during active duty service given the lack of complaints regarding the shoulders in service, the significant gap between the Veteran's discharge from service and the first complaints regarding the shoulders, as well as the Veteran's post-service occupation as a truck driver. Significantly, it was noted that medical literature shows an increased prevalence of shoulder pain due to repetitive motions among truck drivers which is second only to back pain among this population. With regard to the right hip, the August 2021 VA examiner noted that STRs are silent for complaints of or treatment regarding the right hip in service. Significantly, October 1987 and May 1993 reports of medical history are negative for complaints regarding the right hip and the Veteran's May 1993 separation examination shows normal lower extremities. Furthermore, a post-service September 1997 VA joints examination is negative for complaints regarding the right hip. Post-service records are silent for complaints regarding the right hip until April 2014 when an X-ray of the hips revealed right hip DJD. The examiner noted that it was less likely than not that a right hip disorder is the result of accumulated trauma sustained during active duty service given the lack of complaints regarding the shoulders in service, the significant gap between the Veteran's discharge from service and the first complaints regarding the right hip, as well as the Veteran's post-service occupation as a truck driver. Significantly, it was noted that medical literature shows an increased prevalence of hip pain among truck drivers. With regard to secondary service connection, the August 2021 VA examiner also found that it was less likely than not (less than 50 percent probability) that either a cervical spine disorder, a disorder of either shoulder, and/or a right hip disorder is proximately due to or the result a service-connected disability, particularly the Veteran's service-connected lumbar spine disability. As rationale for this opinion, the examiner noted that the Veteran's cervical spine, bilateral shoulder, and right hip disorders are separate and unrelated to the service-connected lumbosacral strain with intervertebral disc syndrome (IVDS) as they are separate conditions anatomically from one another. Furthermore, specific to the right hip, the examiner noted that there was no evidence of a Trendelenburg gait or gait disturbance from the service-connected lumbar spine disability and does not suggesting right hip degenerative joint disease (DJD) as a compensatory condition. With regard to aggravation, the examiner also found that these disorders were not aggravated by the service-connected lumbar spine disability as the conditions are anatomically separate from one another. Also of record are VA treatment records dated through September 2021. These records show treatment for the Veteran's cervical spine, bilateral shoulder, and right hip disorders but do not discuss the etiology of the disorders. Upon review of the above evidence, the Board finds that service connection for cervical spine, bilateral shoulder, and/or right hip disorders is not warranted. Initially, the Board notes that the Veteran has current diagnoses regarding the cervical spine, bilateral shoulders, and right hip. However, a causal relationship cannot be presumed and is not at least as likely as not. With regard to presumptive service connection, the Board notes that DJD is a form of arthritis which is a chronic condition under 38 C.F.R. § 3.309(a). However, there is no indication of arthritis of the cervical spine, either shoulder, and/or the right hip within one year of the Veteran's discharge from military service. As above, a post-service September 1997 VA joints examination is negative for complaints regarding the neck, shoulders, and or right hip. As such, presumptive service connection on the basis of continuity of symptomatology is not warranted for the Veteran's arthritis. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. The claims are also denied on a direct basis. Significantly, as above, the Veteran's STRs are negative for cervical spine, right shoulder, and right hip complaints and, while there are complaints regarding the left shoulder, these complaints have been found by medical professionals to be acute. Furthermore, post-service treatment records are negative for cervical spine problems until 2010, shoulder problems until 2000, and right hip problems until 2014. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Finally, the probative evidence in the record does not link the Veteran's current cervical spine, bilateral shoulder, and/or right hip disorders to an incident of the Veteran's active military service. Significantly, while the Veteran contends that his current disorders are related to his military service, he is not competent to render opinions on matters that are inherently medical in nature. The August 2021 VA examiner found that the Veteran's claimed disorders are not related to his military service and are, instead, related to the Veteran's post-service occupation as a truck driver. As the August 2021 VA examiner offered a clear conclusion with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to the opinions. See Nieves-Rodriguez v, 22 Vet. App. at 295; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, the claims are denied on a secondary basis. While the Veteran contends that cervical spine, bilateral shoulder, and/or right hip disorders may be related to his service-connected lumbar spine disability, he has not submitted any evidence supporting this theory. Significantly, the August 2021 VA examiner opined that the Veteran's cervical spine, bilateral shoulder, and right hip disorders are not related to his service-connected lumbar spine disability on either a secondary or aggravation basis as medical treatise evidence does not support such an association. The examiner noted that there was no anatomical correlation between the cervical spine/shoulders/right hip and the lumbar spine. Instead, the August 2021 VA examiner found that the Veteran's cervical spine, bilateral shoulder, and right hip disorders were most likely related to his post-service occupation as a truck driver. As above, since the August 2021 VA examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to these opinions. See Nieves-Rodriguez v, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. While the Veteran has alleged that his cervical spine, bilateral shoulder, and right hip disorders are related to his military service, the Board finds that the question regarding the potential relationship between these disorders and any instance of his military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). Furthermore, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation of these disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for cervical spine, bilateral shoulder, and right hip disorders. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for bilateral upper extremity radiculopathy as well as bilateral carpal tunnel syndrome of the wrists, claimed as secondary to a service-connected disability, is denied. The Veteran has alleged that he has neurological disorders of the upper extremities, specifically bilateral upper extremity radiculopathy and wrist carpal tunnel, which are related to his military service. Specifically, he contends that such disabilities are due to a cervical spine disorder which was incurred during his service. The Veteran's service treatment records are negative for complaints regarding the upper extremities. Significantly, the Veteran's May 1993 separation examination shows normal upper extremities and in a May 1993 report of medical history, the Veteran specifically denied a history of "painful or 'trick' shoulder or elbow" as well as "neuritis." Furthermore, a post-service September 1997 VA joints examination is negative for neurological deficits. Post-service treatment records show an impression of bilateral carpal tunnel syndrome as early as May 2002. As above, post-service treatment records are silent for complaints regarding the neck until approximately 2010. Significantly, a May 2010 MRI scan of the cervical spine shows an impression of degenerative disc disease at C5-6. A February 2011 neurosurgery note shows a 5 month history of neck pain which first began after hitting a bump on the road while driving his truck causing hyperextension of his neck. Since this injury, he had experienced occasional shooting pain in his right arm, especially with rotation of his head to the right. The Veteran submitted an initial claim for service connection for various disabilities, to include neck and bilateral upper extremity disabilities in March 2013. In connection with this claim, he was afforded a VA neck examination in May 2014. Significantly, the May 2014 VA neck examination shows a diagnosis of cervical degenerative arthritis and the examiner noted that the Veteran experienced radiculopathy of the upper extremities, described as mild intermittent pain. Initially, the Board has considered whether service connection is warranted on a presumptive basis. However, neither radiculopathy nor carpal tunnel are listed as a presumptive condition under 38 C.F.R. § 3.309. As such, presumptive service connection is not warranted pursuant to 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The claim must also be denied on a direct basis. As above, service treatment records are negative for both radiculopathy and/or carpal tunnel and the Veteran does not contend that such began in service. In fact, a review of the record shows that his carpal tunnel did not begin until 2002, approximately 9 years after his discharge from military service, and that his radiculopathy did not begin until 2010, approximately 17 years after his discharge from military service. With regard to the Veteran's claim for service connection for a neurological disorder of the upper extremities as secondary to a cervical spine disorder, the Board notes that service connection for a cervical spine disorder is not in effect. Therefore, service connection for a neurological disorder of the upper extremities on a secondary basis is also not warranted. While neither a VA examination nor medical opinion has been obtained with regard to these issues, the Board finds that the threshold criteria under McLendon v. Nicholson, 20 Vet. App. 79 (2006) for obtaining an examination and/or medical opinion have not been met. Significantly, a conclusory generalized lay statement alleging nexus between a current disability and service does not meet the standard to warrant a VA examination. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). That is all there is in the present case. The Veteran claims that service connection is warranted for a neurological disorders of the upper extremities, but did not submit evidence or make lay statements indicating that he had persistent or recurrent symptoms of the disability or that he had symptoms in and since service. Thus, a VA examination under McLendon is not warranted. As the Board finds that the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.§ 5107. REASONS FOR REMAND 3. The claim of entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected lumbar spine disability, is remanded. The Veteran alleges that he experiences erectile dysfunction as a result of his military service. Specifically, during the June 2019 Board hearing, he testified that such is due to his service-connected lumbar spine disability. In connection with this claim, the Veteran was afforded a VA male reproductive examination in December 2020. This examination report shows a diagnosis of erectile dysfunction. At that time, the Veteran reported that the condition began in 1993, after starting psychiatric and pain medication. Notably, the examiner opined that it was less likely than not that the Veteran's erectile dysfunction was either secondary to and/or aggravated by a service-connected disability. As rationale for this opinion, the examiner noted that there was no mention in the Veteran's medical records by his medical providers that his erectile dysfunction was due to his back condition. Although there is medical literature suggesting spinal conditions can cause erectile dysfunction, it is not universally thought to cause erectile dysfunction unless there is a severe spinal injury or surgeries affecting the spinal cord, which the Veteran has no history of nor does the Veteran have MRI findings of any severe spinal condition. Erectile dysfunction is a common condition for men over 40 years old and the Veteran is well over 40. As suggested in the article below, 40 percent of men over the age of 40 have erectile dysfunction. Specifically, with regard to aggravation, the examiner noted that the Veteran does not have a spinal condition such as spinal surgery, severe stenosis or spinal injury that would lead to aggravation of erectile dysfunction. The Veteran is of the age of typical erectile dysfunction. Making a statement that the Veteran's erectile dysfunction was aggravated by his spinal condition would only be based on speculation. In May 2021 the Board remanded this issue for additional development. Specifically, it was noted that while the December 2020 medical opinion discusses the possible connection between the Veteran's erectile dysfunction and his service-connected lumbar spine disability, the opinion does not discuss whether the Veteran's erectile dysfunction may be related to medications used to treat the Veteran's service-connected joint disabilities. As above, during the December 2020 VA examination, the Veteran reported that his erectile dysfunction began in 1993, after starting psychiatric and pain medication. As such, this issue was remanded once again to obtain an addendum medical opinion that provides an adequate discussion as to whether the Veteran's claimed erectile dysfunction can be related to medications used to treat his service-connected disabilities. Pursuant to the May 2021 Board remand, an additional medical opinion was obtained in August 2021. Significantly, the examiner reviewed the claims file and opined that it was at least as likely as not that the Veteran has erectile dysfunction that is aggravated by medication taken for depression. However, the Veteran is not service connected for depression and no medical opinion was obtained regarding whether the Veteran's claimed erectile dysfunction can be related to medications used to treat his service-connected disabilities. As such, an additional medical opinion should be obtained on remand. Stegall v. West, 11 Vet. App. 268, 270-71 (1998) (holding that a remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand, and that the Board itself commits error as a matter of law in failing to ensure this compliance). 4. The claim of entitlement to service connection for GERD, to include as secondary to a service-connected disability, is remanded. The Veteran alleges that he experiences GERD as a result of his military service. As was noted in the September 2019 Board remand, the Veteran submitted an original claim for service connection for stomach problems in November 1997. In connection with this claim, he was afforded a VA general examination in June 1998 and was diagnosed with GERD. The Veteran was treated for stomach problems (usually assessed as gastroenteritis) on several occasions in service but was not treated for GERD until September 1997, several years after his discharge from service. A January 2016 VA treatment record shows diagnoses of bulbar duodenitis, gastritis, and GERD and suggests that these three disorders are related. The Veteran is currently service connected for chronic gastritis and hemorrhoids. Pursuant to the September 2019 Board remand, the Veteran was afforded a VA GERD examination in January 2020. Significantly, the examiner continued a diagnosis of GERD, noting an onset in 1998, and opined that it was less likely than not that the Veteran's GERD is related to the Veteran's military service on a direct, secondary, or aggravation basis. As rationale for the opinion on a direct basis, the examiner wrote that there was no documentation in the claims file of "heartburn" during service. As rationale for the opinion on a secondary basis, the examiner wrote that the Veteran's GERD, gastritis, and hemorrhoids are not medically related. As per medical literature, GERD is a separate entity entirely from the service-connected conditions and unrelated to them. Specifically, GERD involves reflux of the esophageal valve, gastritis is inflammation of the stomach, and hemorrhoids are small swollen veins in the anus and rectum. These conditions and the treatment of the conditions are unrelated. Finally, as rationale for the opinion on an aggravation basis, the examiner wrote that gastritis is a separate condition that affects the stomach lining, is unrelated, and does not cause or aggravate GERD which is reflux of the lower esophageal sphincter. In May 2021 the Board remanded this issue for additional development. Specifically, it was noted that the January 2020 VA anus/rectum examiner's finding that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation suggested that the Veteran's GERD may be secondary to medications used to treat his service-connected disabilities. As such, this issue was remanded again to determine whether the Veteran's claimed GERD can be related to medications used to treat his service-connected disabilities. Pursuant to the May 2021 Board remand, an additional medical opinion was obtained in August 2021. Significantly, the examiner reviewed the claims file and opined that it was less likely than not (less than 50 percent probability) that the Veteran's GERD is proximately due to and/or aggravated by a service-connected disability. As rationale for this opinion, it was noted that EGD (esophagogastroduodenoscopy) dated in September 2013 and January 2016 shows evidence of gastritis. Also, upper gastrointestinal series (UGI) dated in September 1997 as well as EGDs dated in September 2013 and January 2016 are negative for GERD. The literature supports that GERD is the result of poor esophageal motility, a dysfunctional lower esophageal sphincter, delayed gastric emptying, or a hiatal hernia. The literature does not support NSAID medication as a cause of GERD. Unfortunately, the Board finds that the August 2021 VA opinion is inadequate. As above, in May 2021 this issue was remanded to obtain a medical opinion regarding whether the Veteran's claimed GERD can be related to medications used to treat his service-connected disabilities, particularly Tramadol. Significantly, while the August 2021 VA examiner noted that the literature does not support NSAID medication as a cause of GERD, Tramadol is not an NSAID. As such, an additional medical opinion should be obtained on remand which considers whether the Veteran's claimed GERD can be related to medications used to treat his service-connected disabilities, including Tramadol. Stegall, 11 Vet. App. at 270-71. 5. The claim of entitlement to service connection for sleep disturbances, to include as secondary to a service-connected disability, is remanded. The Veteran contends that he experiences sleep disturbances secondary to chronic pain experienced due to his service-connected disabilities. As was noted in the September 2019 Board remand, VA treatment records show complaints of sleep disturbances as early as November 2001. The Veteran was afforded a sleep study in May 2011 which was negative for sleep apnea. A July 2016 VA treatment record shows that the Veteran sleeps with a pillow between his knees, suggesting that the Veteran's service-connected bilateral knee disorders may aggravate his sleep. Pursuant to the September 2019 Board remand, the Veteran was afforded a VA respiratory examination in January 2020. Significantly, the examiner diagnosed obstructive sleep apnea based on a January 2020 sleep study and opined that it was less likely than not that the Veteran's sleep apnea is related to the Veteran's military service on a direct, secondary, or aggravation basis. As rationale for the opinion on a direct basis, the examiner wrote that as there was no record of sleep complaints during service, a nexus could not be established. As rationale for the opinion on a secondary basis, the examiner wrote that sleep apnea and right knee patellofemoral joint pain syndrome are not medically related as they are separate entities and medical literature does not support a medical relationship. Specifically, obstructive sleep apnea is a sleep disorder that is characterized by periodic narrowing and obstruction of the pharyngeal airway during sleep. Patellofemoral pain syndrome is characterized by insidious onset diffuse pain originating from the anterior knee, most commonly in young active athletes, especially runners. The etiology is likely multifactorial and may include patellar maltracking, hip strength deficits, dynamic knee valgus alignment, and altered foot mechanics. Knee pain does not cause upper airway collapse; therefore the two conditions are not related. As rationale for the opinion on an aggravation basis, the examiner wrote that the Veteran's service-connected disabilities of patellofemoral pain syndrome of the right knee, scar right knee, seborrheic dermatitis, left knee chondromalacia patella, septal deviation with vasomotor rhinitis, left ankle degenerative arthritis, tinnitus, and gastritis do not result in upper airway collapse and therefore do no contribute to sleep apnea or aggravate the condition. In May 2021 the Board remanded this issue for additional development. Specifically, it was noted that while the January 2020 VA examiner opined that the Veteran's service-connected disabilities, particularly septal deviation with vasomotor rhinitis, do not aggravate the Veteran's sleep apnea, the only rationale for this opinion is that the Veteran's service-connected disabilities do not "result in upper airway collapse." The word "result" does not appear to contemplate the word "aggravate" and, given the physical proximity of the Veteran's septal deviation with vasomotor rhinitis to the upper airway, the Board found that additional medical opinion would be helpful to resolve this issue. As such, this issue was remanded once again to determine whether the Veteran's claimed sleep disturbances can be related to a service-connected disability, particularly the Veteran's service-connected septal deviation with vasomotor rhinitis on an aggravation basis. Pursuant to the May 2021 Board remand, an additional medical opinion was obtained in September 2021. Significantly, the examiner reviewed the claims file and opined that it was less likely than not (less than 50 percent probability) that the Veteran's insomnia is proximately due to or the result of a service-connected disability. As rationale for this opinion, the examiner noted that the Veteran has a diagnosis of depression and that, while sleep disturbance is a symptom of depression, it does not meet DSM-5 diagnostic criteria for a separate or distinct disorder. The examiner noted that, while the Veteran has a diagnosis of obstructive sleep apnea (OSA), a breathing-related sleep disorder, the DSM-5 diagnostic criteria for insomnia states that "insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia)." Therefore, there is no diagnosis of insomnia disorder which makes it less likely than so that the sleep disturbance is proximately due to a service-connected disability. With regard to whether the Veteran's claimed sleep disturbances can be related to a service-connected disability, particularly the Veteran's service-connected septal deviation with vasomotor rhinitis on an aggravation basis, the examiner indicated that it was outside the scope of the examiners expertise to comment on the cause or aggravation of the Veteran's sleep apnea. Unfortunately, the Board finds that the September 2021 VA opinion is inadequate. As above, in May 2021 this issue was remanded to obtain a medical opinion regarding whether the Veteran's claimed sleep disturbances can be related to a service-connected disability, particularly the Veteran's service-connected septal deviation with vasomotor rhinitis on an aggravation basis. The September 2021 VA examiner did not address this question with respect to the Veteran's sleep apnea and, instead, indicated that it was outside the scope of the examiners expertise to comment on the cause or aggravation of the Veteran's sleep apnea. As such, an additional medical opinion should be obtained on remand from an examiner who does have the expertise to comment on the cause or aggravation of the Veteran's sleep apnea as to whether the Veteran's claimed sleep disturbances can be related to a service-connected disability, particularly the Veteran's service-connected septal deviation with vasomotor rhinitis on an aggravation basis. Stegall, 11 Vet. App. at 270-71. Finally, with regard to all of the remanded issues, the Board notes that there are likely outstanding VA treatment records as the most recent VA medical records in the claims file are dated in September 2021. Therefore, all outstanding VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated since September 2021. 2. Request an addendum from the December 2020/August 2021 VA male reproductive examiner regarding the etiology of the Veteran's claimed erectile dysfunction. Access to the electronic claims file should be made available to the examiner. If the December 2020/August 2021 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's erectile dysfunction is (i) caused, or (ii) aggravated by his medications used to treat his service-connected disabilities. Significantly, the examiner is advised that the Veteran is service connected for back and knee disabilities, for which he believes his medications cause his ED. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The opinion should address the Veteran's history in the December 2020 VA examination report that his erectile dysfunction began in 1993, after starting psychiatric and pain medication. See VBMS, document labeled C&P Exam, receipt date 1/13/2021, page 3. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. Request an addendum from the January 2020/August 2021 VA GERD examiner regarding the etiology of the Veteran's claimed GERD. Access to the electronic claims file should be made available to the examiner. If the January 2020/August 2021 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's GERD is (i) caused, or (ii) aggravated by his medications used to treat his service-connected disabilities, particularly Tramadol. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The opinion should address the January 2020/August 2021 VA anus/rectum medical opinion wherein the examiner noted that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation. See VBMS, document labeled C&P Exam, receipt date 1/24/2020, page 2. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. Request an addendum from the January 2020/September 2021 VA respiratory examiner regarding the etiology of the Veteran's claimed sleep disorder. Access to the electronic claims file should be made available to the examiner. If the January 2020/September 2021 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's sleep apnea is (i) caused, or (ii) aggravated by a service-connected disability (particularly the Veteran's service-connected septal deviation with vasomotor rhinitis). Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The Board recognizes that the January 2020 VA respiratory examiner did opine that the Veteran's service-connected disabilities, including septal deviation with vasomotor rhinitis, do not aggravate the Veteran's sleep apnea; however, the only rationale for this opinion is that the Veteran's service-connected disabilities do not "result in upper airway collapse." See VBMS, document labeled C&P Exam, receipt date 1/24/2020, page 3. The word "result" does not appear to contemplate the word "aggravate" and, given the physical proximity of the Veteran's septal deviation with vasomotor rhinitis to the upper airway, the Board finds that additional medical opinion would be helpful to resolve this issue The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.