Citation Nr: 21077102 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 13-16 163 DATE: December 28, 2021 REMANDED The claim of entitlement to service connection for a right knee disorder is remanded. The claim of entitlement to service connection for a left knee disorder is remanded. The claim of entitlement to service connection for a right ankle disorder is remanded. The claim of entitlement to service connection for a left ankle disorder is remanded. The claim of entitlement to service connection for a back disorder is remanded. The claim of entitlement to service connection for bilateral arthritis, unspecified is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1977 to September 1977 and again from April 1980 to July 1980. These matters come before the Board of Veterans' Appeals (Board) from March 2012, November 2012, and July 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The March 2012 rating decision, in part, denied service connection for bilateral ankle/knee disabilities. The November 2012 rating decision, in part, denied service connection for bilateral arthritis. The July 2014 rating decision denied service connection for a back disorder. With regard to the bilateral arthritis issue, the Veteran testified before the undersigned Veterans Law Judge at a Board videoconference hearing in February 2016. A transcript of this proceeding has been associated with the claims file. The bilateral arthritis issue was previously before the Board in February 2019. At that time it was noted that, following the February 2016 Board hearing, the Veteran perfected an appeal regarding, in part, claims for service connection for bilateral knee disorders, bilateral ankle disorders, and a low back disorder. However, these issues were awaiting the scheduling of a requested Board hearing and were not be addressed at this time. Significantly, the Board found that the bilateral arthritis issue was intertwined with the joint issues awaiting a Board hearing and remanded the bilateral arthritis issue for additional development and so that the issues could be adjudicated together at a later date. Subsequently, in February 2020 correspondence, the Veteran withdrew the pending Board hearing request and, the issues awaiting a hearing were remanded by the Board in June 2020 to complete the development requested in the February 2019 Board remand, specifically obtaining outstanding service treatment records (STRs), VA treatment records, and private treatment records. Pursuant to the February 2019 and June 2020 Board remands, additional attempts were made to obtain outstanding STRs, VA treatment records, and private treatment records from the 1980s as, during the February 2016 Board hearing, the Veteran's attorney argued that there were missing Reserve records dated from 1980 to 1984. Additional VA treatment records dated as early as May 1993 were obtained and a request for outstanding STRs was made through PIES (Personnel Information Exchange System) in July 2020 but a November 2020 memorandum indicates that no additional records had been received. Notably, the June 2020 Board decision/remand used the docket number 17-05 010 instead of 13-16 163 which was used in the February 2019 Board decision/remand. As the development requested with regard to both sets of issues has been completed, the Board will now adjudicate all nine issues using the earlier docket number, 13-16 163. In March 2021, the Board, in part, reopened the previously denied claim of entitlement to service connection for a back disorder and remanded this issue along with the bilateral knee, bilateral ankle, and unspecified arthritis issues for additional development. The Board also remanded the issue of entitlement to service connection for a bilateral foot disorder, to include pes planus, and, by rating decision dated in October 2021, the RO granted service connection for pes planus. As such, the bilateral foot disorder issue is no longer on appeal. 1. The claims of entitlement to service connection for bilateral knee disorders are remanded. The Veteran contends that service connection is warranted for bilateral knee disorders. With regard to the left knee, in his February 2011 claim, the Veteran wrote that he injured his left knee in October 2010 when he fell due to his service-connected left wrist disability. Also, during a December 2016 VA knee examination, the Veteran reported that his knee symptoms began in the 1980s, during basic training marching exercises. The Veteran's available STRs are silent as to any bilateral knee condition or complaints. While a separation examination is not of record, a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, shows normal lower extremities and, in a February 1980 report of medical history, the Veteran specifically denied "'trick' or locked knee," "arthritis, rheumatism, or bursitis," and "bone, joint, or other deformity." Post-service VA treatment records show a request for magnetic resonance imaging (MRI) scan of the knees as early as January 2000, however, it appears that the requested MRI was not completed at that time. The Veteran complained of left knee pain in September 2001 and was assessed with "joint tenderness." In October 2003, the Veteran reported a history of swelling in his left knee which had resolved. In February 2009, the Veteran reported a history of right knee pain for the past two to three weeks. The impression was right knee arthralgia, likely OA (osteoarthritis) since he favors his right side post surgery to his left foot and it appears that the Veteran underwent arthroscopic meniscectomy of the right knee sometime in 2009. There is an impression of arthralgia of the bilateral knees as early as February 2010 and X-ray evidence of left knee arthritis as early as August 2010. An October 2010 VA treatment record shows that the Veteran fell out of a truck on his right arm and twisted his left knee. The Veteran submitted an initial claim for service connection for bilateral knee disorders in February 2011. In connection with this claim, he was afforded a VA knee examination in June 2013. Significantly, the examiner diagnosed status post right knee arthroscopy as well as bilateral knee degenerative arthritis and the Veteran reported that his bilateral knee symptoms began in 1981, during basic training marching exercises. The examiner also opined that the bilateral knee disabilities were less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected [left wrist] disability as it was "medically impossible to relate the two." The Veteran was afforded a second VA knee examination in December 2016. This examination also shows a diagnosis of bilateral knee degenerative arthritis and the Veteran reported that he first experienced bilateral knee symptoms in the 1980s during basic training when he fell down on some rocks. Significantly, the examiner opined that it was less likely than not that (less than 50 percent probability) that the Veteran's current bilateral knee disabilities were incurred in or caused by the Veteran's military service. As rationale for this opinion, the examiner noted that a review of the records did not reveal any supportive evidence to make such a connection. In its March 2021 remand, the Board found that the June 2013 and December 2016 VA medical opinions were inadequate. First, while the June 2013 VA examiner found that it was "medically impossible to relate" the Veteran's left wrist disability to his bilateral knee disabilities, the examiner never explained why this was the case. Significantly, the Veteran does have a history of falls, claimed as due to his service-connected left wrist disability, and, as above, a medical professional has related a right elbow disorder to a fall caused by the Veteran's service-connected left wrist disability, so it is unclear why it is impossible that a fall related to the Veteran's left wrist disability could cause injury to the knees. (Notably, the falls appear to happen when he attempts to brace himself with the weakened arm.) With regard to the December 2016 opinion, the examiner did not provide a reasoned rationale for the opinion provided supported by the medical evidence discussed above. As such, the case was remanded to obtain a new medical opinion. Pursuant to the March 2021 Board remand, the Veteran was afforded another VA knee examination in September 2021. This examination report shows diagnoses of right knee meniscal tear, bilateral knee osteoarthritis, bony sclerotic lesion right lower femur, bony sclerotic lesion left upper tibia, status post right knee ligament repair. Significantly, the September 2021 VA examiner opined that it was less likely than not that a disorder of either knee was related to the Veteran's active service on either a direct and/or secondary basis. As rationale for these opinions, the examiner noted that there was a significant lapse of time between the Veteran's military service and his development of bilateral knee problems. The examiner also noted that there was no anatomical connection between the Veteran's knees and his service-connected left wrist disability. Unfortunately, the Board finds that the September 2021 VA opinion is also inadequate. First, with regard to direct service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations of continuity of knee symptoms since his military service as directed in the March 2021 Board remand. Second, with regard to secondary service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations that a knee disability is secondary to falls caused by his service-connected left wrist disability as directed in the March 2021 Board remand. As such, addendum medical opinions should be obtained on remand. 2. The claims of entitlement to service connection for bilateral ankle disorders are remanded. The Veteran contends that service connection is warranted for bilateral ankle disorders. Specifically, during a December 2016 VA knee examination, the Veteran reported that his ankle symptoms began in the 1980s, during basic training marching exercises. The record also suggests that the Veteran's service-connected left wrist disability has caused him to fall on multiple occasions, (due to bracing himself with the weakened arm and falling), resulting in additional disability. STRs from the Veteran's first period of service are negative for ankle complaints. A September 1979 VA examination, in between the Veteran's first and last periods of service, shows that the Veteran sprained his left ankle playing basketball two days earlier. STRs from the Veteran's last period of service show an isolated history of prior bilateral ankle pain in June 1980. While a separation examination is not of record, a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, shows normal lower extremities and, in a February 1980 report of medical history, the Veteran specifically denied "arthritis, rheumatism, or bursitis" and "bone, joint, or other deformity." Significantly, the Veteran submitted a claim for service connection for a bilateral foot disorder in February 1994. In connection with this claim, he was afforded a VA examination in August 1994 which showed normal ankles. Post-service VA treatment records show a history of ankle problems as early as November 1998. Specifically, a November 1998 record shows a history of ankle trauma and that the Veteran was "run over" as a child. However, in December 2000, October 2001, July 2002, the Veteran specifically denied experiencing ankle pain. A July 2010 X-ray of the ankles reveals arthritis. In October 2010, after a fall primarily onto his right elbow and forearm, the Veteran reported experiencing pain in his ankle and foot. In March 2011, the Veteran reported experiencing left ankle pain since July 2007 when he injured his left foot while stepping out of a truck. He was diagnosed with arthritis of the bilateral ankles. An April 2011 record also shows enthesopathic changes at the Achilles tendon insertions, bilaterally. A September 2011 record shows a diagnosis of left Achilles tendinitis. The Veteran submitted an initial claim for service connection for bilateral ankle disorders in February 2011. In connection with this claim, he was afforded a VA ankle examination in June 2013. Significantly, the examiner found that the Veteran did not currently have nor had he ever had an ankle disorder. The Veteran reported that his bilateral ankle symptoms began in 1981, during basic training marching exercises. The examiner also opined that the claimed bilateral ankle disabilities were less likely than not (less than 50 percent probability) incurred in or caused by the Veteran's in-service injury, event, or illness because there was no current ankle disorder. The Veteran was afforded a second VA ankle examination in December 2016. This examination also shows a diagnosis of bilateral ankle strain and the Veteran reported that he first experienced bilateral ankle symptoms in the 1980s during basic training when he participated in road marches and prolonged standing. Significantly, the examiner opined that it was less likely than not that (less than 50 percent probability) that the Veteran's current bilateral ankle disabilities were incurred in or caused by the Veteran's military service. As rationale for this opinion, the examiner noted that there was insufficient evidence to relate the Veteran's bilateral ankle strain to an event claimed to have occurred while in service. In its March 2021 remand, the Board found that the June 2013 and December 2016 VA medical opinions were inadequate. First, while the June 2013 VA examiner provided a negative nexus opinion, this opinion was premised on the Veteran having no current ankle disability. Significantly, the Veteran has been diagnosed with several disabilities of the ankles during the appeal period. With regard to the December 2016 opinion, the examiner did not provide a reasoned rationale for the opinion provided supported by the medical evidence discussed above. Also, the Veteran has a history of falls, claimed as due to his service-connected left wrist disability and, as above, a medical professional has related a right elbow disorder to a fall caused by the Veteran's service-connected left wrist disability. As such, the case was remanded to obtain a new medical opinion. Pursuant to the March 2021 Board remand, the Veteran was afforded another VA ankle examination in September 2021. This examination report shows diagnoses of bilateral degenerative arthritis and calcaneal spur. Significantly, the March 2021 VA examiner opined that it was less likely than not that a disorder of either ankle was related to the Veteran's active service on either a direct and/or secondary basis. As rationale for these opinions, the examiner noted that there was a significant lapse of time between the Veteran's military service and his development of bilateral ankle problems. The examiner also noted that there was no anatomical connection between the ankles and the Veteran's service-connected left wrist disability. Unfortunately, the Board finds that the September 2021 VA opinion is also inadequate. First, with regard to direct service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations of continuity of ankle symptoms since his military service as directed in the March 2021 Board remand. Second, with regard to secondary service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations that an ankle disability is secondary to falls caused by his service-connected left wrist disability as directed in the March 2021 Board remand. As such, addendum medical opinions should be obtained on remand. 3. The claim of entitlement to service connection for a back disorder is remanded. The Veteran contends that service connection is warranted for a back disorder. Specifically, during a December 2016 VA back examination, the Veteran reported that his back symptoms began in 1980, during basic training marching exercises. The record also suggests that the Veteran's service-connected left wrist disability has caused him to fall on multiple occasions, resulting in additional disability. STRs from the Veteran's first period of service are negative for back complaints. As above, the Veteran submitted an initial claim for service connection for a back disorder in July 1979, in between his first and last periods of active service. In connection with this claim, the Veteran was afforded a VA examination in September 1979. At the time of this examination, the Veteran reported that he first began experiencing low back pain shortly after his discharge in 1977. The impression was history of chronic low back pain. STRs from the Veteran's last period of service show complaints of low back pain in June 1980 since falling off a pickup truck one year earlier. While a separation examination is not of record, a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, shows a normal spine and, in a February 1980 report of medical history, the Veteran specifically denied "recurrent back pain," "arthritis, rheumatism, or bursitis," and "bone, joint, or other deformity." As above, the Veteran submitted a second claim for service connection for a back disorder in February 1998. In connection with this claim, the RO obtained records from SSA showing that the Veteran injured his back performing physical labor at work in April 1996 resulting in an assessment of severe injury to the low back, very minor disk herniation at the L5-S1 level, probable mild and minor left L5-S1 radiculopathy. The RO also obtained updated VA treatment records showing that the Veteran underwent discectomy in October 1998, was involved in motor vehicle accidents in August 1999 and October 1999. The Veteran submitted the current claim for service connection for a back disorder in February 2011. In connection with this claim, the Veteran was afforded a VA back examination in December 2016 and the examiner diagnosed lumbosacral degenerative disc disease status post surgery (noting an onset of December 2016). At that time, the Veteran reported that his back symptoms back in 1980 during basic training. Significantly, the examiner opined that the Veteran's claimed back disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness as the records did not reveal any supportive evidence to make such a connection at that time. In its March 2021 remand, the Board found that December 2016 VA medical opinion was inadequate. First, the examiner failed to opine whether the Veteran's claimed back disorder is secondary to his service-connected left wrist disability. As above, the Veteran does have a history of falls, claimed as due to his service-connected left wrist disability, and, as above, a medical professional has related a right elbow disorder to a fall caused by the Veteran's service-connected left wrist disability. As such, an opinion regarding secondary service connection is warranted. Furthermore, the examiner did not provide a reasoned rationale for the opinion provided supported by the medical evidence discussed above. As such, the case was remanded to obtain a new medical opinion. Pursuant to the March 2021 Board remand, the Veteran was afforded another VA spine examination in September 2021. This examination report shows diagnoses of degenerative arthritis, intervertebral disc syndrome (IVDS), and spinal fusion. Significantly, the March 2021 VA examiner opined that it was less likely than not that a disorder of the back was related to the Veteran's active service on either a direct and/or secondary basis. As rationale for these opinions, the examiner noted that there was a significant lapse of time between the Veteran's military service and his development of back problems. The examiner also noted that there was no anatomical connection between the back and the Veteran's service-connected left wrist disability. Unfortunately, the Board finds that the September 2021 VA opinion is also inadequate. First, with regard to direct service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations of continuity of back symptoms since his military service as directed in the March 2021 Board remand. Second, with regard to secondary service connection, the Board notes that the September 2021 VA examiner does not appear to consider the Veteran's allegations that a back disability is secondary to falls caused by his service-connected left wrist disability as directed in the March 2021 Board remand. As such, addendum medical opinions should be obtained on remand. 4. The claim of entitlement to service connection for bilateral arthritis, unspecified is remanded. As noted in the February 2019 and March 2021 Board remands, during the February 2016 Board hearing, the Veteran testified that he began experiencing problems with his knees and feet during his military service due to the rigors of military life including falling to the floor, marching, and hauling equipment. As above, VA treatment records show diagnoses of bilateral knee and foot arthritis and the Board has remanded these issues for additional development. Given the above, the Veteran's claim for service connection for bilateral arthritis is inextricably intertwined with the issue of entitlement to service connection for bilateral knee/foot disorders, which has been remanded for additional development. Therefore, a final decision on the issue of entitlement to service connection for bilateral arthritis cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Also, with regard to all of the remanded issues, the Veteran should be provided with an opportunity to identify any VA or non-VA healthcare provider who has treated him for his claimed bilateral knee/ankle disorders, back disorder, and bilateral arthritis since his discharge from military service. Also, there are likely outstanding VA treatment records as the Veteran has consistently sought treatment at VA since May 1993, but the most recent VA medical records in the claims file are dated in July 2021. Therefore, all outstanding VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Afford the Veteran an opportunity to identify any healthcare provider who has treated him for his claimed bilateral knee/ankle disorders, back disorder, and bilateral arthritis since his discharge from military service. After obtaining any necessary authorization from the Veteran, obtain all identified records, to include updated VA treatment records dated from July 2021 to the present. 2. After obtaining any outstanding records, to the extent possible, return the claims file to the September 2021 VA knee examiner for an addendum opinion. If the examiner who drafted the September 2021 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the reviewing examiner is requested to provide opinions as to: (a) whether it is at least as likely not (50 percent probability or greater) that a disorder of either knee is caused by or is otherwise related to the Veteran's active duty service, to include basic training marching exercises. (b) whether it is at least as likely not (50 percent probability or greater) that a disorder of either knee (to include arthritis and/or a disability of the meniscus) is caused by, or aggravated by, the Veteran's service-connected left wrist disability, to include documented July 2007 and October 2010 falls claimed to have been caused by the Veteran's service-connected left wrist disability, in so far as the Veteran was falling, attempted to brace himself with his left arm, which gave out because of his service-connected disability. Note that aggravation in this context means any incremental increase in the non-service-connected disability (i.e., any additional impairment of earning capacity) caused by the service-connected disability. In doing so, the examiner should address the following:(i) a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, which shows normal lower extremities and a February 1980 report of medical history, wherein the Veteran specifically denied "'trick' or locked knee," "arthritis, rheumatism, or bursitis," and "bone, joint, or other deformity." (see VBMS, document labeled STR - Medical, receipt date 8/6/2014, pages 6 and 8); (ii) post-service VA treatment records showing complaints of knee pain as early as January 2000, arthroscopic meniscectomy of the right knee sometime in 2009 (likely secondary to a left foot disability), X-ray evidence of arthritis of the left knee as early as August 2010, and the Veteran falling out of a truck on his right arm and twisting his left knee in October 2010 (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 9/20/2000, page 6; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 3/19/2009, page 16; VBMS, document labeled VA Examination, receipt date 12/1/2011, page 83; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 12/14/2010, page 1); (iii) an April 2009 treatment record including a statement from the Veteran's VA treating physician wherein she opined that the Veteran's left wrist disability caused the Veteran to fall to the floor as he was pushing himself out of a chair in 2007 resulting in a right elbow injury (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 7/8/2011, page 1); (iv) the Veteran's December 2016 allegations regarding an onset of knee symptoms in the 1980s during basic training (see VBMS, document labeled C&P Exam, receipt date 12/30/2016, pages 27) and (v) the June 2013, December 2016, and September 2021 VA knee examinations, showing diagnoses of status post right knee arthroscopy, bilateral knee degenerative arthritis, right knee meniscal tear, bony sclerotic lesion right lower femur, and bony sclerotic lesion left upper tibia, status post right knee ligament repair with negative nexus opinions on a direct and secondary basis (see VBMS, document labeled C&P Exam, receipt date 6/25/2013, pages 14, 41, and 46; VBMS, document labeled C&P Exam, receipt date 12/30/2016, pages 24, 102, 106, 110, and 114; and VBMS, documents labeled C&P Exam, receipt date 10/13/2021, various pages). Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner 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 it is to find against it. 3. After obtaining any outstanding records, to the extent possible, return the claims file to the September 2021 VA ankle examiner for an addendum opinion. If the examiner who drafted the September 2021 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the reviewing examiner is requested to provide opinions as to: (a) whether it is at least as likely not (50 percent probability or greater) that a disorder of either ankle (to include arthritis, Achilles tendinitis, or strain) is caused by or is otherwise related to the Veteran's active duty service, to include basic training marching exercises. (b) whether it is at least as likely not (50 percent probability or greater) that a disorder of either ankle is caused or aggravated by the Veteran's service-connected left wrist disability, to include documented July 2007 and October 2010 falls claimed to have been caused by the Veteran's service-connected left wrist disability, in so far as the Veteran was falling, attempted to brace himself with his left arm, which gave out because of his service-connected disability. Note that aggravation in this context means any incremental increase in the non-service-connected disability (i.e., any additional impairment of earning capacity) caused by the service-connected disability. In doing so, the examiner should address the following:(i) STRs from the Veteran's first period of service which are negative for ankle complaints; a September 1979 VA examination, in between the Veteran's first and last periods of service, showing that the Veteran sprained his left ankle playing basketball two days earlier; STRs from the Veteran's last period of service showing an isolated history of prior bilateral ankle pain in June 1980; a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, showing normal lower extremities and, in a February 1980 report of medical history, the Veteran specifically denying "arthritis, rheumatism, or bursitis" and "bone, joint, or other deformity." (see VBMS, document labeled VA Examination, receipt date 9/21/1979, page 7; VBMS, document labeled STR - Medical, receipt date 8/6/2014, page 5; VBMS, document labeled STR - Medical, receipt date 8/6/2014, pages 6 and 8); (ii) a post-service VA examination dated in August 1994 which shows normal ankles (see VBMS, document labeled VA Examination, receipt date 8/10/1994, page 2); (iii) post-service VA treatment records dated in November 1998 showing a history of ankle trauma and that the Veteran was "run over" as a child.; a July 2010 X-ray of the ankles revealing arthritis; an October 2010 record showing that, after a fall primarily onto his right elbow and forearm, the Veteran reported experiencing pain in his ankle and foot; a March 2011 record wherein the Veteran reported experiencing left ankle pain since July 2007 when he injured his left foot while stepping out of a truck and was diagnosed with arthritis of the bilateral ankles; and a September 2011 record showing a diagnosis of left Achilles tendinitis (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 7/24/2000, page 3; VBMS, document labeled CAPRI, receipt date 3/6/2012, page 37; VBMS, document labeled VA Examination, receipt date 12/1/2011, pages 79 and 111; VBMS, document labeled CAPRI, receipt date 1/5/2017, page 1550); iv) an April 2009 treatment record including a statement from the Veteran's VA treating physician wherein she opined that the Veteran's left wrist disability caused the Veteran to fall to the floor as he was pushing himself out of a chair in 2007 resulting in a right elbow injury (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 7/8/2011, page 1); (v) the Veteran's December 2016 allegations regarding an onset of ankle symptoms in the 1980s during basic training (see VBMS, document labeled C&P Exam, receipt date 12/30/2016, page 39) and (vi) the June 2013, December 2016, and September 2021 VA ankle examinations, showing a diagnosis of bilateral ankle strain, with negative nexus opinions on a direct basis (see VBMS, document labeled C&P Exam, receipt date 6/25/2013, pages 21, 49, and 53; VBMS, document labeled C&P Exam, receipt date 12/30/2016, pages 36, 81, and 85 and VBMS, documents labeled C&P Exam, receipt date 10/13/2021, various pages). Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner 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 it is to find against it. 5. After obtaining any outstanding records, to the extent possible, return the claims file to the September 2021 VA back examiner for an addendum opinion. If the examiner who drafted the September 2021 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the reviewing examiner is requested to provide opinions as to: (a) whether it is at least as likely not (50 percent probability or greater) that a back disorder is caused by or is otherwise related to the Veteran's active duty service, to include basic training marching exercises. (b) whether it is at least as likely not (50 percent probability or greater) that a back disorder is caused by or is otherwise related to the Veteran's service-connected left wrist disability, to include documented July 2007 and October 2010 falls claimed to have been caused by the Veteran's service-connected left wrist disability, in so far as the Veteran was falling, attempted to brace himself with his left arm, which gave out because of his service-connected disability. Note that aggravation in this context means any incremental increase in the non-service-connected disability (i.e., any additional impairment of earning capacity) caused by the service-connected disability. In doing so, the examiner should address the following:(i) a September 1979 VA examination, in between the Veteran's first and last periods of active service, wherein Veteran reported that he first began experiencing low back pain shortly after his discharge in 1977 and the examiner diagnosed history of chronic low back pain; June 1980 STRs from the Veteran's last period of service showing complaints of low back pain since falling off a pickup truck one year earlier; a February 1980 Reserve examination, conducted in between the Veteran's two periods of active service and five months prior to his discharge from his second period of active service, showing a normal spine; and, a February 1980 report of medical history wherein the Veteran specifically denied "recurrent back pain," "arthritis, rheumatism, or bursitis," and "bone, joint, or other deformity" (see VBMS, document labeled VA Examination, receipt date 9/21/1979, page 4; VBMS, document labeled STR - Medical, receipt date 8/6/2014, pages 23 and 24; VBMS, document labeled STR - Medical, receipt date 8/6/2014, pages 6 and 8); (ii) post-service SSA records showing that the Veteran injured his back performing physical labor at work in April 1996 resulting in an assessment of severe injury to the low back, very minor disk herniation at the L5-S1 level, probable mild and minor left L5-S1 radiculopathy; VA treatment records showing that the Veteran underwent discectomy in October 1998, was involved in motor vehicle accidents in August 1999 and October 1999 (see VBMS, document labeled Correspondence, receipt date 9/26/2000, page 5; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 6/14/1999, page 5; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 9/26/2000, page 6); (iii) an April 2009 treatment record including a statement from the Veteran's VA treating physician wherein she opined that the Veteran's left wrist disability caused the Veteran to fall to the floor as he was pushing himself out of a chair in 2007 resulting in a right elbow injury (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 7/8/2011, page 1); (iv) the Veteran's December 2016 allegations regarding an onset of back symptoms in the 1980s during basic training (see VBMS, document labeled C&P Exam, receipt date 12/30/2016, page 61); and (v) the December 2016 and September 2021 VA back examination reports, showing diagnoses of lumbosacral degenerative disc disease status post surgery, degenerative arthritis, IVDS, and spinal fusion with a negative nexus opinion on a direct basis (see VBMS, document labeled C&P Exam, receipt date 12/30/2016, pages 59 and 98 and VBMS, documents labeled C&P Exam, receipt date 10/13/2021, various pages). Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner 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 it is to find 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.