Citation Nr: 21011453 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 16-53 574A DATE: March 1, 2021 ORDER Entitlement to service connection for bilateral leg disability is denied. Entitlement to service connection for lumbar spine disability is denied. Entitlement to service connection for right flank/rib disorder is denied. REMANDED Entitlement to an initial compensable rating for headache disability is remanded. Entitlement to service connection for bilateral hip disability is remanded. Entitlement to service connection, to include on a secondary basis, for obstructive sleep apnea (OSA) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have a diagnosed bilateral leg disability other than a bilateral knee, hip or ankle condition. 2. The Veteran’s lumbar spine disability did not originate in service, within a year of service, and is not otherwise etiologically related to his active service. 3. The Veteran does not have a diagnosed right flank/rib condition that originated in service, within a year of service, or otherwise etiologically related to his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral leg condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for service connection for lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for service connection for right flank/rib condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to June 1996. This matter is before the Board of Veterans’ Appeals (Board) on appeal from April 2013 (service connection claims; TDIU) and August 2015 (increased rating – headache condition) rating decisions by a Department of Veterans Affairs Regional Office (RO). In September 2020, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. During the Board hearing, the Veteran only testified about his claim for an increased rating for his service-connected headaches and their effect on his employment. It was noted that the Veteran was unaware that his other claims were part of the appeal. The undersigned asked if he wished to have another hearing where he could discuss his other claims. The Veteran replied that he did not, and the undersigned noted that those claims would be decided without his testimony. See hearing transcript p.11. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Bilateral Leg Condition The Veteran seeks entitlement to service connection for a bilateral leg condition. Specifically, the Veteran asserts that he developed an arthritic bilateral leg condition due to wear and tear caused by performing parachute jumps, ski training, cold weather survival training and road marches. See January 2012 VA Form 21-4138, Statement in Support of Claim, and January 2012 VA Form 21-0820, Report of General Information. Initially, the Board notes that in addition to the Veteran’s service connection claim for bilateral leg condition, the April 2013 rating decision additionally denied service connection for bilateral ankle condition, bilateral hip condition (addressed in the Remand section below), and noted that service connection claims for bilateral knee condition were currently under appeal and would be addressed in a separate correspondence. In this regard, a prior December 2011 rating decision denied entitlement to service connection for right knee disability, and denied reopening the previously denied service connection claim for left knee disability. The Veteran filed a timely notice of disagreement (NOD) in February 2012. A statement of the case (SOC) was issued in October 2015, however, the Veteran did not perfect his appeal of these claims to the Board. Additionally, a subsequent November 2016 rating decision granted service connection for bilateral ankle disability. Therefore, the issue currently before the Board is whether the Veteran has a bilateral leg condition other than bilateral ankle, hip or knee condition, that is etiologically related to service. The evidence of record includes the Veteran’s service treatment records (STRs) which show the Veteran complained of left leg pain in July 1986. He denied any injury. He was assessed with a strained hamstring. An April 1988 periodic examination noted normal lower extremities and the Veteran denied any swollen or painful joints. Thereafter, a February 1991 retirement examination noted normal lower extremities, and an August 1991 periodic examination also noted normal lower extremities and the Veteran denied any swollen or painful joints. During his September 1991 overseas screening examination, the Veteran denied any swollen or painful joints. The Veteran’s March 1996 separation examination shows he reported having swollen or painful joints and having cramps in his legs. In this regard, he stated that he experienced intermittent leg cramps in the morning and at night. Post-service medical records show that in May 2006, the Veteran underwent an ultrasound study due to reports of left leg pain. The ultrasound was normal. See Private Medical Records Received August 2015. In a January 2012 VA Form 21-4138, Statement in Support of Claim, the Veteran asserted that his musculoskeletal conditions were due to his military service including service with the 82 Airborne and conducting parachute jumps, deployments to Korea, and attending several ski training and cold weather survival courses. The Veteran underwent a VA knee and lower leg examination in August 2015. The examiner noted a diagnosis for bilateral knee osteoarthritis. The Veteran denied any flare-ups of leg pain. The examiner noted that the Veteran did not have any shin splints, stress fractures, or any other tibial and/or fibular impairments. No other pertinent physical findings, complications, conditions, signs or symptoms were found. A September 2016 VA ankle examination noted diagnoses for bilateral ankle arthritis. The examiner noted normal ROM, and normal muscle strength. The examiner determined that the Veteran did not have any shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus to talus, or that the Veteran had had a talectomy. No other pertinent physical findings, complications, conditions, signs or symptoms were found. After a review of the evidence of record, the Board finds that entitlement to service connection for a bilateral leg condition is not warranted. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that “‘disability’ pursuant to 38 U.S.C. § 1110 refers to the functional impairment of earning capacity” and “pain in the absence of a presently-diagnosed condition can cause functional impairment,” en route to its conclusion that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability.” See also Wait v. Wilkie, 33 Vet. App. 8 (2020). However, apart from his diagnosed bilateral knee, ankle and hip conditions, the Veteran does not have a diagnosed bilateral leg condition, nor does the record show that he had reported bilateral leg pain other than pain related to his bilateral knee, ankle or hip. In this regard, the Board finds most probative both the August 2015 VA knee and lower leg and September 2016 VA ankle examinations as the examiners noted no other bilateral leg conditions apart from his bilateral knee and ankle arthritis, including any shin splints, stress fracture, tibial and/or fibular impairment, achilles tendonitis, achilles tendon rupture, malunion of calcaneus to talus, or that the Veteran had had a talectomy. The Board finds equally probative the fact that the Veteran has not identified any bilateral leg condition other than those affecting his knee, hip or ankle. As noted above, a necessary element for establishing entitlement to service connection is the existence of a current disability. Additionally, for VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Absent a current diagnosis for a bilateral leg condition other than a bilateral knee, ankle and hip condition, the Board finds that the first Shedden requirement has not been met and the probative evidence is against the Veteran’s claim for service connection for a bilateral leg condition. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for a bilateral leg condition. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). 2. Lumbar Spine Disability The Veteran seeks entitlement to service connection for lumbar spine disability. Specifically, the Veteran asserts that he developed a lumbar spine disability due to wear and tear caused by performing parachute jumps, attending ski and cold weather survival training and road marches. See January 2012 and February 2012 VA Statements in Support of Claim. The evidence of record includes a July 1976 STR showing the Veteran complained of right sided back pain the past three days, the cause of which was unknown. Pain was described as a sharp mid-axillary line pain. He was assessed with a non-specific ache. An August 1982 periodic examination noted a normal spine and the Veteran denied any recurrent back pain or swollen or painful joints. An April 1988 periodic examination also noted a normal spine and the Veteran again denied any recurrent back pain or swollen or painful joints. The Veteran reported having a hernia condition and that he had undergone hernia operations in 1984 and 1988. Thereafter, February 1991 retirement and September 1991 overseas screening examinations show the Veteran denied any recurrent back pain, and an August 1991 periodic examination noted a normal spine and the Veteran denied any recurrent back pain. A June 1992 STR noted complaints of back, neck and right shoulder pain. The Veteran reported that his neck pain was recurrent. Pain was noted from the neck to the right shoulder. No specific area of back pain was noted. In March 1995, the Veteran complained of a possible pulled back and groin muscle. He reported that his symptoms occurred while stretching his right leg with sharp pain in his right testicle and right inguinal area. He was assessed with right inguinal/scrotal tenderness. The Veteran’s March 1996 separation examination shows he reported having swollen or painful joints and having cramps in his legs. He denied any recurrent back pain. The Veteran did report having a hernia condition and that he had undergone two hernia operations. Post-service evidence of record includes a December 2007 VA medical record showing the Veteran reported left knee pain over the past year. He denied any lower back or hip pain. See VA Medical Records Received November 2016. A July 2008 private medical record shows the Veteran was not found to have any myalgia, muscle weakness, joint or back pain. See Private Medical Records Received April 2016. February, April and August 2009 VA medical records show the Veteran reported having had chronic joint pain affecting his back, shoulders and knees dating back to his time in service. He also reported having taken ibuprofen for many years. The Veteran was assessed with chronic pain and arthralgias. The August 2009 record noted a normal lumbar spine examination. See VA Medical Records Received November 2016. In a January 2012 Statement in Support of Claim, the Veteran asserted that his musculoskeletal conditions were due to his military service including serving with the 82 Airborne and conducting parachute jumps, deployments to Korea, and attending several ski training and cold weather survival courses. In a February 2012 Statement in Support of Claim, the Veteran asserted that his back pain was due to injuries sustained during parachute jumps, snow skiing, ski training, and numerous tactical road marches with heavy equipment. The Veteran underwent a VA lumbar spine examination in December 2012. The examiner noted a diagnosis for degenerative disc disease (DDD) and degenerative joint disease (DJD). The Veteran reported that his lumbar spine pain began in 1975 when he became a paratrooper. The Veteran also reported that he believed his back pain was caused by wear and tear due to being in the infantry and carrying rucksacks. He further reported being treated for back pain when he was stationed in Korea, but could not recall what that treatment consisted of. The Veteran denied having sought treatment for his back since he separated from service. The examiner opined that it was “less likely than not (less than 50 percent probability)” that the Veteran’s lumbar spine disability was etiologically related to service. In support of this opinion, the examiner noted a July 1976 STR noting evaluation of “sharp pain mid axillary line right side when bending to the right side” and that the Veteran was diagnosed with a nonspecific ache. The examiner further noted that a September 1991 overseas screening examination showed the Veteran indicated he did not have any recurrent back pain. Additionally, the examiner noted that there was no indication in the record that the Veteran had sustained any back injury or had chronic back pain that started during service. While noting the July 1976 STR, the examiner found that it did not constitute a diagnosis for back pain. Instead, the examiner referred to medical literature which noted that DDD was due to gradual aging. Accordingly, the examiner found it less likely than not that the Veteran’s current lumbar spine disability was due to service, and more likely the result of the normal aging process and not an isolated incidence of right sided pain that occurred 36 years prior. In a March 2014 statement, the Veteran asserted that he had been continuously treated for back pain beginning in the 1980s, and that he had been treated with pain medication since that time. In addition, the Veteran asserted that there were numerous entries missing from his STRs. After a review of the evidence of record, the Board finds that entitlement to service connection for lumbar spine disability is not warranted. In this regard, the Board finds the December 2012 VA examination the most probative evidence of record. The examiner considered the STRs, including the July 1976 STR showing complaints of right-sided back pain. However, the examiner noted that the record did not evidence any diagnosed lumbar spine disability. This finding is supported by the July 1976 STR which noted “non-specific pain.” Additionally, this finding is supported by the STRs which are silent for any complaints of recurrent back pain or any diagnosed lumbar spine disability, as well as his in-service examinations which show the Veteran specifically denied having any recurrent back pain. Instead, the only STR that mentions any condition affecting his back is a June 1992 record which noted complaints of back, neck and right shoulder pain. However, when detailing the Veteran’s symptoms, the clinician only found pain that stretched from the Veteran’s right shoulder to his neck. No back pain was documented. Additionally, the March 1995 STR showing a reported possible pulled back and groin muscle instead diagnosed the Veteran with a right inguinal/scrotal tenderness. In this regard, a review of the Veteran’s March 1996 separation examination shows he reported having a hernia condition resulting in two operations, but no recurrent back pain. Accordingly, the Board finds that the June 1992 and March 1995 STRs do not evidence a lumbar spine disability. The examiner’s opinion is further bolstered by the fact that the Veteran first complained of chronic pain affecting his back in February 2009, and that post-service treatment records dated within two years prior to this record show he specifically denied any lower back pain at that time. Accordingly, the record does not support a finding that the Veteran had chronic back pain prior to February 2009. The Board recognizes the Veteran’s lay statements linking his current lumbar spine disability to service. The Veteran is competent to report purported symptoms such as experiencing chronic pain during and after service. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the Board finds the Veteran to be an inaccurate historian. While in a March 2014 statement, the Veteran has asserted being continuously treated for back pain beginning in the 1980s, and that he had been treated with pain medication since that time, during his December 2012 VA lumbar spine examination, he specifically denied having sought treatment for his back since separation from service. Additionally, as noted above, there are no STRs documenting treatment, let alone continual treatment, for a back condition. Instead, during each of his in-service examinations, the Veteran specifically denied having any recurrent back pain. It stands to reason that if the Veteran had been treated continuously due to recurrent back pain, such would have been noted during one of his in-service examinations. The Veteran’s lay statements are further contradicted by the December 2007 VA medical record showing he denied any lower back pain, as well as the July 2008 private medical record in which the Veteran was not found to have any myalgia joint or back pain. Accordingly, the Board finds the Veteran to be an inaccurate historian and provides his lay statements little probative value. Accordingly, the Board finds the Veteran’s lay assertions in the present case are outweighed by the December 2012 VA medical examiner’s opinion who determined that the there was no nexus between the Veteran’s lumbar spine disability and service. There is no competent evidence to the contrary. The Board further recognizes that the Veteran has reported that his STRs are incomplete. See March 2014 Statement. In this regard, the Veteran asserts that his STRs are incomplete because they fail to document continuous treatment for back and knee pain during service. However, the claims file includes a February 2000 VA memorandum which notes that all of the Veteran’s STRs were found, and that if any additionally STRs were received that would be automatically associated with the claims file. A review of the STRs also shows that they are extensive, detailed and cover the Veteran’s entire period of active duty service. Accordingly, the Board finds the Veteran’s assertion that his STRs are incomplete is not supported. Thus, the Board finds that the first and third Shedden requirements have not been met. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for lumbar spine disability. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). 3. Right Flank/Rib Condition The Veteran seeks entitlement to service connection for a right rib/flank condition. Specifically, the Veteran asserts that he sustained a right rib injury in November 1982. See February 2012 Statement in Support of Claim. The evidence of record includes a November 1982 STR showing the Veteran became pinned by a wheel of a car resulting in an injury to his right flank. He complained or right rib and flank pain. An X-ray study was negative for any fracture. He was assessed with a muscle contusion. A subsequent April 1988 periodic examination shows the Veteran denied any pain or pressure in his chest or broken bones. Thereafter, a February 1991 retirement examination noted a normal chest and a normal chest X-ray study. An August 1991 periodic examination also noted a normal chest and negative chest X-ray study and the Veteran denied any pain or pressure in his chest or broken bones. Additionally, a September 1991 overseas screening examination shows the Veteran denied any chest pain or pressure or broken bones. The Veteran’s March 1996 separation examination shows he reported having swollen or painful joints but denied any pain or pressure in his chest or broken bones. A July 2008 private medical record shows the Veteran was not found to have any myalgia, muscle weakness, joint or back pain. An examination revealed normal ROM for all extremities which were non-tender to palpation. See Private Treatment Records Received April 2016. The Veteran underwent a VA muscle injury examination in September 2016. The examiner noted that the Veteran had sustained blunt trauma to his right flank in November 1982, when he became pinned by the wheel of an automobile, and that the Veteran was diagnosed with a muscle contusion. The Veteran reported that he was working under the car when it rolled backwards onto his right flank and ribs. X-ray studies at that time were normal. The Veteran currently complained of right-sided pain. The examiner opined that it was “less likely (less than 50% probability)” that the Veteran had a diagnosis for right sided pain that was etiologically related to service. In support of this opinion, the examiner noted that while the Veteran was diagnosed with a chest wall contusion during service, he did not sustain any fractured bones and that STRs and post-service medical records were silent regarding any muscle wall pain. Accordingly, the examiner found that a nexus had not been established between the 1982 chest wall contusion and his 2016 right-sided abdominal pain. In September 2016, the Veteran also filed a service connection claim for gallstones which was denied in an unappealed December 2016 rating decision. The Veteran filed another service connection claim for gallstones and gallbladder removal in May 2017, and in an accompanying Statement in Support of Claim, the Veteran reported that in 2012, his gallstone condition resulted in intermittent extremely sharp pains on his right side. Additionally, the Veteran reported that in November 2016, he had his gall bladder removed and a lesion was found on his stomach wall at that time. The Veteran underwent subsequent VA gallbladder and stomach examinations in June 2017. A review of those examination reports show the Veteran reported developing right upper quadrant pain in approximately 2016. He further reported that a chest CT scan revealed an unknown spot/lesion on his stomach lining which he asserted was caused by taking ibuprofen. The Veteran further reported that diagnostic testing had revealed gallstones and that he underwent a cholecystectomy in November 2016. Thereafter, an unappealed July 2017 rating decision denied service connection for gallstones, gallbladder removal and unknown spot/lesion on stomach lining. After a review of the evidence of record, the Board finds that entitlement to service connection for right rib/flank condition is not warranted. In this regard, the Board finds the September 2016 VA muscle injury examination the most probative evidence of record. The examiner considered the evidence, including the Veteran’s lay statements regarding his in-service muscle contusion, but found that the Veteran’s current symptoms were not etiologically related to a muscle condition. The Board finds the examiner’s opinion is well supported, including based on findings that the evidence of record did not show any current muscle wall complaints or conditions. The examiner additionally noted that the Veteran had not sustained a broken rib as a result of his in-service blunt force trauma as X-ray studies at that time were normal. The examiner’s negative nexus opinion is further supported by the record, including the Veteran’s STRs which show that each subsequent in-service examination conducted following his November 1982 injury noted a normal chest and chest X-ray study, and the Veteran specifically denied any pain or pressure in his chest or having broken bones. The Board has considered the Veteran’s lay statements. In this regard, he has not provided any lay statements with regard to any continuity of symptomatology with regard to a right rib or right flank condition. Instead, the Veteran has since asserted that he developed right-sided abdominal pain due to the development of gallstones resulting in a gallbladder removal procedure, as well as the discovery of an unknown lesion on his abdominal wall. However, as noted above, an unappealed July 2017 rating decision denied service connection for those conditions. Therefore, those claims are not currently before the Board. Importantly, with regard to the Veteran’s claim for a right rib/flank condition, there is no medical evidence to the contrary. Accordingly, the Board finds that the preponderance of the evidence is against the claim for entitlement to service connection for a right rib/flank condition. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). REASONS FOR REMAND 1. Increased Rating - Headache Condition The Veteran seeks entitlement to an initial compensable rating for a headache condition. The Veteran last underwent a VA headache examination in August 2015. The examiner noted a diagnosis for tension headaches. The examiner also noted that the Veteran had a temporomandibular joint (TMJ) condition, and that he developed headaches when his jaw locked and opened. The following symptoms were noted: pulsating or throbbing pain on both sides of the head, with duration of typical head pain less than one day. The examiner noted that the Veteran did not have characteristic prostrating attacks of migraine headache pain. Evidence added to the record since the August 2015 VA examination includes an October 2015 notice of disagreement in which the Veteran reported suffering from 3 to 4 severe headaches per month and, at times, 2 to 3 headaches per week. In a January 2016 Statement in Support of Claim, the Veteran asserted that he had been hospitalized and/or seen in emergency rooms due to the severity of his headaches, and that he sometimes became incapacitated by them. A July 2016 VA medical record show the Veteran complained of headaches averaging 2 per week. See VA Medical Records Dated November 2016. An April 2018 private medical record shows the Veteran reported that his headaches occurred mostly at night, that he would wake up with them, and that his headaches prevented him from going to work. In addition, the Veteran reported having been hospitalized for headaches a few times over the years. Associated symptoms included nausea, photophobia and phonophobia. The physician noted that the Veteran’s headaches occurred 3 times per month with symptoms totalling 4 to 5 days. He was assessed with migraine headaches without aura. See Private Treatment Records Received August 2018. Lastly, at a September 2020 Board hearing, the Veteran testified that with regard to his current symptomatology, that if he woke-up with a headache, he could not go into work. In addition, the Veteran reported that his headaches sometimes lasted two days. Since he moved to North Carolina, he reported having been hospitalized twice. The Board finds that a Remand is necessary to obtain a new VA headache examination. In this regard, evidence of a change in the condition or allegation of worsening of the condition renders an examination inadequate for rating purposes. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007); see also Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Given the Veteran’s assertion that his headache condition consists of symptoms more severe that those indicated in his August 2015 VA examination report, and recently added medical records evidencing that his condition had worsened, a remand is warranted for a new VA examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board further finds that efforts should be made to obtain updated private treatment records, or any private treatment records identified by the Veteran. 2. Service Connection - Bilateral Hip The Veteran seeks entitlement to service connection for bilateral hip disability. Specifically, the Veteran asserts that he developed a bilateral hip disability due to wear and tear caused by performing parachute jumps, attending ski training and cold weather survival, road marches. See January 2012 Statement in Support of Claim and the Veteran’s September 2012 Letter. The Veteran’s STRs include a March 1996 separation examination showing the Veteran reported having swollen or painful joints. Post-service records contain SSA records which include a December 2011 private treatment record noting a right hip X-ray study revealing degenerative disease. The Veteran underwent a right total hip replacement in February 2012. See SSA Records. In a July 2012 letter, the Veteran’s physician, Dr. Dobzyniak, noted the Veteran had severe end stage right hip osteoarthritis and that he had undergone a hip replacement. Dr. Dobzyniak stated that he believed the Veteran’s hip arthritis was related to repetitive use and repetitive injury during service. No rationale was provided. See Private Treatment Records Received August 2015. An August 2012 VA medical record shows the Veteran reported having bilateral hip arthritis. See VA Medical Records Received October 2016. In a September 2012 letter, the Veteran asserted that his bilateral hip condition was caused by wear and tear due to his active duty service, including carrying heavy loads for extended periods of time, making parachute jumps, road marches, laying in ambush positions, walking guard duty in extreme cold, snow, and rain, running and skiing. In a November 2013 letter, Dr. Dobzyniak stated that he believed the Veteran’s hip osteoarthritis was related to repetitive use and injury during service. No rationale was provided. See Private Medical Records Received August 2015. After a review of the evidence of record, the Board finds that a VA examination is necessary to adequately adjudicate this issue on appeal. The Veteran asserts that his bilateral hip arthritis is etiologically related to in-service wear and tear, including due to parachute jumps, and cold weather and ski training. A review of his DD 214 shows he was the recipient of the parachutist badge and was an infantryman for 21 years. The record also includes medical opinions by the Veteran’s physician; however, those medical opinions are unsupported by any rationale and, therefore, inadequate. A medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). Accordingly, the Board finds that a duty to assist exists in order to provide the Veteran with a VA examination to determine the nature and etiology of any diagnosed bilateral hip disability. 3. Service Connection - OSA The Veteran seeks entitlement to service connection for OSA. Specifically, the Veteran asserts that his OSA is secondary to his service-connected TMJ condition. See August 2012 Claim. The evidence of record includes a February 2011 polysomnography study revealing a diagnosis for OSA. An April 2018 private medical record notes a diagnosis for OSA and that the Veteran’s sleep was poor. In this regard, the physician noted the Veteran’s OSA was untreated, that he grinded his teeth and that he had a history of TMJ issues. The Board notes that the Veteran has not been provided with a VA examination with regard to this claim on appeal. VA’s duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4). Accordingly, in order to properly adjudicate this claim on appeal, a Remand is necessary to obtain a VA examination to determine the nature and etiology of the Veteran’s OSA condition, to include whether the condition was caused or aggravated by his service-connected TMJ condition. 4. TDIU The Veteran seeks entitlement to service connection for a TDIU. The evidence of record includes a January 2013 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The Veteran reported that he last worked in January 2012. However, a July 2014 VA medical record noted that the Veteran currently worked in commercial sales. See VA Medical Records Received May 2017. Additionally, during his September 2020 Board hearing, the Veteran testified that he currently worked for VA. As such, further development of the TDIU claim is necessary to adequately adjudicate this issue on appeal. Therefore, the Veteran should be afforded an opportunity to furnish information about his employment history during the period on appeal to include income he earned or currently earns from any such employment, the number of hours worked and any special circumstances (i.e. protected environment such as a family business or sheltered workshop), so that the Board may make a determination about whether this employment constitutes marginal employment for VA purposes. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Provide the Veteran with a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, with instructions to complete and return the form as to the period of time to the present the Veteran has been working. The Veteran should be specifically requested to provide information as to the income earned from his employment, specify the number of hours per week for any part-time employment, and any special circumstances attendant to such employment. 3. Then, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected headache disorder (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner is asked to consider the Veteran’s lay statements as to the severity of his headaches, to include statements that they occasionally interfere with his ability to work. The examiner should review pertinent documents in the Veteran’s claims file and this Remand in connection with the examination. All indicated studies should be completed, and all pertinent symptomatology and findings must be reported in detail. 4. After the development in 1-2 has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed bilateral hip disability (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that the Veteran has a diagnosed bilateral hip disability that is etiologically related to his period of service? The examiner is asked to consider the lay statements and Dr. Dobzyniak’s finding that the Veteran osteoarthritis is related to wear and tear caused by in-service activities including parachute jumps, skiing, cold weather training, road marches, carrying heavy equipment, and duties as an infantry soldier. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 5. After the development in 1-2 has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his diagnosed OSA (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed OSA is etiologically related to his period of service? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed OSA was caused by a service-connected disability, to include his TMJ condition? Please explain why or why not. (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed OSA was aggravated by a service-connected disability, to include his TMJ condition? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. The examiner is asked to consider the April 2018 private treatment record noting the Veteran was a poor sleeper due to his untreated OSA, teeth grinding and history of TMJ issues. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 6. Then, the AOJ must readjudicate the remaining issues on appeal, to include the claim for a TDIU. If the benefits sought remain denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lamb, 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.