Citation Nr: 21021228 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 18-08 481 DATE: April 12, 2021 ORDER Entitlement to service connection for a lumbar spine disability is granted. Entitlement to service connection for left lower extremity radiculopathy is granted. Entitlement to service connection for right knee medial collateral ligament (MCL) laxity is denied. Entitlement to service connection for right quadriceps atrophy is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is granted from October 7, 2012, subject to the laws and regulations governing payment of monetary benefits. REMANDED Entitlement to service connection for benign prostate hypertrophy (BPH) is remanded. Entitlement to service connection for a right shoulder disability, to include as due to a service-connected disability, is remanded. Entitlement to service connection for a cervical spine muscle disability is remanded. Entitlement to service connection for a chronic pain syndrome disability is remanded. FINDINGS OF FACT 1. The Veteran’s lumbar degenerative disc disease (DDD) and spondylosis/arthritis had its onset during active service. 2. The Veteran’s left lower extremity radiculopathy is proximately due to service-connected lumbar spine disability. 3. The preponderance of the evidence of record is against finding that the Veteran has had right knee MCL laxity at any time during or approximate to the pendency of the claim. 4. The preponderance of the evidence of record is against finding that the Veteran has had right quadriceps atrophy at any time during or approximate to the pendency of the claim. 5. From October 7, 2012, the Veteran’s service-connected disabilities as likely as not prevent him from maintaining substantially gainful employment CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar degenerative disc disease (DDD) and spondylosis/arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left lower extremity radiculopathy as secondary to service-connected lumbar spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for right knee MCL laxity have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for right quadriceps atrophy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. From October 7, 2012, the criteria for a TDIU due to service-connected disabilities have been met. 38 U.S.C. § 1155; 38C.F.R. §§ 3.340, 3.341, 3.400, 4.1, 4.7, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1969 to June 1994. This matter is before the Board of Veterans’ Appeals (Board) following a Board Remand in June 2019. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a lumbar spine disability The Veteran contends that his lumbar spine disorder had its onset during service. In a Statement in Support of Claim received in January 2014, the Veteran stated, “In the military I had chronic low back pain and sought care for my pain on multiple occasions. I had a couple of x-rays. The x-rays showed narrowing between L4-5 and arthritis in the form of a “spur” at L4.” The Veteran’s service treatment records indicate that in April 1972, he complained of a four-day history of low back pain without trauma or heaving lifting; impression was strain. In June 1979, the Veteran complained of back problems since his neck operation in August; assessment was back disorder. In October 1979, the Veteran was noted to have had back problems for one year with DDD and mild dorsolumbar scoliosis. In January 1982, the Veteran was noted to have had a history of DDD and was experiencing low back pain for two days after twisting; impression was acute low back pain. In January 1982, the Veteran complained of muscle spasm and low back pain for three days; he was noted to have a history of DDD with sudden onset of low back pain with radiation down left thigh; assessment was low back pain rule out disc. Lumbar spine x-ray in March 1984 indicated a possible slight disc space narrowing at L4-5 and a small spur off the anterior aspect of L4. The provider noted a significant history of back and neck pain and experiencing pain at L4-5 with radiation into left buttock and leg, questionable straight leg raising with left leg at 90 degrees, and unchanged x-ray since 1982; assessment was acute exacerbation of chronic low back pain with radiation to left buttock. The Veteran was seen a few days later at which time neurological evaluation was negative including straight leg raising. In 1984, the Veteran was seen in April, May, June, and July; in July 1984, the findings were suggestive of left S1 radiculopathy. On the February 1994 Report of Medical History completed by the Veteran in conjunction with his retirement physical, he denied ever having recurrent back pain. The Veteran underwent VA examination in October 1994, only four months after retirement from service. At that time, the Veteran stated that he had low back stiffness and spasms for about six to eight years. He denied a history of trauma to his back and noted that he underwent several “negative” evaluations in the past. He stated that he had no radiation or discomfort into his lower extremities. After physical examination and x-ray which showed small nonmarginal osteophyte formation noted at the mid-lumbar spine (minimal spondylosis) and minimal osteopenia, otherwise normal lumbar spine. The VA examiner diagnosed the Veteran as having chronic low back discomfort. The Veteran underwent VA examination in September 2001 at which time he was diagnosed as having radiculitis L2-L3 secondary to degenerative changes, lumbar spine DDD L2-L3 (retrolisthesis L2-4, left sciatic radiation, lumbar radiculitis). In January 2014, in support of his claim, the Veteran submitted a medical opinion by a VA Nurse Practitioner who reviewed the Veteran’s claims file and opined that the Veteran’s current lumbar spine condition was more likely than not (greater than a 50% probability) caused by, related to a continuation of, or a progression of his in-service lumbar spine condition. The Nurse Practitioner noted that lumbar spine x-ray in March 1984 showed a possible slight disc space narrowing at L4-5 and a small spur off the anterior aspect of L4. The Nurse Practitioner stated the such findings were indicative of lumbar DDD and lumbar spondylosis/arthritis during active duty; that both were progressive degenerative conditions that would not spontaneously resolve; that on two x-rays and two independent radiological readings that there was evidence for DDD in the form of narrowing between the L4-5 level on two x-rays and two independent radiological readings; and that there was evidence of arthritis at the L4 level in the form of the “spur.” The Veteran underwent VA examination in June 2014 at which time he diagnosed the Veteran as having DDD of the lumbar spine with spondylosis. The examiner noted that the Veteran was treated for lumbar strain in the service in 1972 and 1984 with no treatment for a back problem and that after 1984, and on exit examination, he had no complaints of back pain and examination was normal. The examiner noted that the Veteran was diagnosed as having DDD of the lumbar spine with spondylosis in 2001. The examiner opined that based on the history, it was less likely than not that his back condition was related to service and that it was not aggravated by service. The Veteran underwent VA examination in November 2020 at which time the examiner diagnosed the Veteran as having degenerative arthritis of the spine. The examiner opined that the Veteran’s lumbar spine disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that during service, the Veteran’s low back pain with radiculopathy was acute only. The examiner stated that there was no evidence of chronicity of care and that symptoms were subjective only. The examiner noted that a review of the Veteran’s service treatment records were positive for two acute cases of lower back pain, one in 1982 and another in 1984, and that the record was silent for complaints of or treatment of lower back pain to include a periodic health assessment on October 11, 1988, and his exit examination on February 23, 1994. The examiner noted that a review of the Veteran’s post- service treatment records was positive for complaints of lower back pain dating back decades. The examiner opined that the Veteran’s DDD was less likely than not incurred in or because of his time in service. Upon review of the record, the Board finds that the Veteran’s DDD and arthritis had their onset in service. As noted above, the January 2014 medical opinion the VA Nurse Practitioner that there was x-ray evidence during service of both DDD in the form of narrowing between the L4-5 level and arthritis at the L4 level in the form of the “spur.” In addition, the October 1994 VA examination report included x-ray findings of a small nonmarginal osteophyte formation noted at the mid-lumbar spine (minimal spondylosis). The January 2014 opinion by the Nurse Practitioner specifically noted that both were progressive degenerative conditions that would not spontaneously resolve. The Board finds that the Nurse Practitioner’s opinion provided a much more thorough rationale than the VA examiner’s opinions in June 2014 and November 2020. Thus, upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current lumbar spine DDD and spondylosis/arthritis had its onset in service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for lumbar spine DDD and spondylosis/arthritis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for left lower extremity radiculopathy The Veteran contends that he has left lower extremity radiculopathy secondary to his service-connected lumbar spine disability. In his January 2014 Statement in Support of Claim, the Veteran stated, “I have complained of numbness and tingling and pain radiating down my left leg since the military. I have been diagnosed with Sciatica. My EMG nerve study showed that it was a Left S1 nerve condition causing this symptom. I continue to have this leg pain.” Current VA medical records have a few diagnoses of radiculitis and radiculopathy. MRI of the lumbar spine in March 2015 showed multilevel relatively mild degenerative changes with findings most prominent from L3-S1. A review of the neurological system indicated L5-S1 left. The June 2014 VA examiner found that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy; however, the November 2020 VA examiner found that the Veteran had mild radiculopathy with involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve). Thus, upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran has a left lower extremity lumbar radiculopathy. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for lumbar spine DDD and spondylosis/arthritis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board notes that the Veteran is already separately service-connected for diabetic peripheral neuropathy of the left lower extremities and that a 10 percent rating has been assigned for mild incomplete paralysis of the sciatic nerve. Thus, assigning separate ratings for radiculopathy would constitute pyramiding, which is to be avoided. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). As such, the Veteran’s left lower extremity radiculopathy will be combined with the left lower extremity peripheral neuropathy (sciatic nerve). 3. Entitlement to service connection for right knee MCL laxity The Veteran contends that he has right knee MCL laxity that is secondary to service-connected right knee disability. In his January 2014 Statement in Support of Claim, the Veteran stated, “My medical records have documented repetitively on examinations that my MCL has laxity and thus instability. This has caused me to fall on numerous occasions, … causing other injuries.” The Board notes that in April 2001, the Veteran complained of his right knee being weak, having pain and instability; assessment included chronic neck and shoulder pain. In May 2001, the Veteran was seen for complaints that his right knee gives out on him and he falls. In September 2001, the Veteran underwent diagnostic arthroscopy and intraarticular debridement of the right shoulder as well as arthroscopy and arthroscopic partial medial meniscectomy. The question for the Board is whether the Veteran has a current diagnosis of right knee MCL laxity during the appeal period that is related to service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of right knee MCL laxity and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran underwent VA examinations in June 2014, September 2016, and November 2020. Joint stability tests of the right knee at each examination were normal. In addition, at the September 2015 and November 2020 VA examination, the examiner noted that there was no history of recurrent subluxation or lateral instability. The Board recognizes that when considering whether lay evidence is competent the Board must determine on a case-by-case basis whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Board finds the Veteran is competent to describe many symptoms of his left knee disability, such as perceived laxity. Id. at 1376 (lay witness capable of diagnosing dislocated shoulder). In Jandreau, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” The issue of whether the Veteran’s perceived symptom of knee instability is competent and sufficient to establish that he has actual instability of the knee sufficient to warrant a separate disability rating under Diagnostic Code 5257 is analogous to the situation described in Jandreau. In this case, the Veteran has described his perception of knee instability; however, medical professionals have tested his right knee for instability during the pendency of his appeal, which testing involved four different tests, and no instability was found. Because the Veteran’s perceived symptom of right knee instability has not been demonstrated or confirmed on clinical testing by an independent medical professional, his lay statement is insufficient to establish the presence of anterior, posterior, medial, or lateral instability sufficient to warrant separate disability rating for right knee MCL laxity. To the extent that the Veteran has reported falling due to pain and/or weakness of the right knee, his lack of stability in the context of standing and/or walking does not equate to physiological instability of the anatomical components of the knee. In English v. Wilkie, 30 Vet. App. 347 (2018), the United States Court of Appeals for Veterans Claims held that the Board cannot find objective medical evidence categorically more probative than lay evidence without explaining why that is the case. To be clear, the Board finds the objective medical evidence more probative than the Veteran’s reports of perceived right knee laxity. The four tests, performed on three separate occasions which did not reveal any instability, supports the conclusion that the Veteran’s perceived knee instability is not due to anterior, posterior, medial, or lateral knee joint laxity. In the absence of competent medical evidence that diagnosis of right knee MCL laxity exists and that such was caused by or aggravated by the Veteran’s military service, the criteria for establishing service connection for right knee MCL laxity have not been established. 38 C.F.R. § 3.303. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application. 4. Entitlement to service connection for right quadriceps atrophy The Veteran contends that he has right quadriceps atrophy that is secondary to service-connected right knee disability. In his January 2014 Statement in Support of Claim, the Veteran stated, “I began to ‘favor’ the right knee and compensate for the persistent pain and symptoms by transferring my weight to the left leg. Thus my right quadriceps muscle withered away with atrophy and became smaller than my left thigh.” The question for the Board is whether the Veteran has a current diagnosis of right quadriceps atrophy that is related to service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of right quadriceps atrophy and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran underwent VA examination in June 2014 at which time the examiner noted a diagnosis of right quadriceps atrophy; however, muscle strength testing was normal. In a July 2014 Addendum, the VA examiner who conducted the June 2014 VA examination stated that there was no evidence of right quadriceps atrophy. The Veteran underwent VA examination in September 2016 at which time muscle strength testing was slightly diminished; however, there was no muscle atrophy. The Veteran underwent VA examination in November 2020at which time muscle strength testing was normal, and there was no muscle atrophy. The November 2020 VA examiner noted that he could find no indication of right thigh atrophy on physical examination and that the Veteran had contralateral strength equal to the right. Thus, the medical evidence in the file since the Veteran filed his claim for service connection are absent a diagnosis of right quadriceps atrophy. In the absence of competent medical evidence that a right quadriceps disability exists and that such was caused by or aggravated by the Veteran’s military service, the criteria for establishing service connection for right quadriceps atrophy have not been established. 38 C.F.R. § 3.303. Although the Veteran believes that he has a current diagnosis of right quadriceps atrophy, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application. 5. Entitlement to a TDIU The Veteran filed his application for a TDIU in June 2014 and noted that the date he last worked full time was June 27, 2007. The Veteran’s TDIU claim was filed during the pendency of a claim for an increased evaluation that stemmed from a VA examination scheduled by the AOJ to evaluate a service-connected disability on October 7, 2013. As such, the appeal period of the Veteran’s TDIU is appeal linked to his claims and appeals for increased evaluations downstream from this examination. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Accordingly, the appeal period for consideration with regard to this appealed issue is from October 7, 2012, to the present – which includes the one year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). A TDIU will be granted where the schedular rating is less than 100 percent if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. See 38U.S.C. §1155; 38C.F.R. §§3.340, 3.341, 4.16, 4.18 and 4.19. A TDIU may be assigned where the Veteran is rated at 60 percent or more for a single service-connected disability, or rated at 70 percent for two or more service-connected disabilities and at least one disability is rated at least at 40 percent, and when the disabled person is unable to secure or follow a substantially gainful occupation as a result of the service-connected disability or disabilities. 38C.F.R. §§3.340, 3.341, 4.16(a). For purposes of calculating the percentage requirements of one 60 percent disability, or one 40 percent disability, disabilities resulting from common etiology or a single accident will be considered one disability. A high combined rating is a recognition that physical and mental impairment makes it difficult to obtain and maintain employment. See VanHoose v. Brown, 4 Vet. App. 361, 363 (1993). At the time of this decision, the Veteran’s combined ratings for compensation was 90 percent. In addition, service connection has been established for diabetes mellitus type II, right lower extremity peripheral neuropathy, and left lower extremity peripheral neuropathy; each rated as 20 percent disabling. As such, as these disabilities result from a common etiology, the Veteran meets the threshold requirements for a TDIU. The VA Nurse Practitioner who provided the opinion regarding the Veteran’s lumbar spine disability also opined that the Veteran would be considered permanently and totally disabled related to his current service-connected disabilities. She stated that there was sufficient evidence, well-documented in the medical records, to consider that his service-connected disabilities, which are chronically progressive and unstable, would render him incapable of substantially gainful employment and vocational opportunities. In her opinion, the Nurse Practitioner addressed the Veteran’s level of education and lack of training as well as the instability and worsening of medical conditions. The Nurse Practitioner also went through functional deficits for each of the Veteran’s service-connected disabilities. The Nurse Practitioner noted, Due to multiple restrictions and limitations, as well as medical instability with his service-connected disability conditions, he would have a difficult time finding a job description that would meet his physical capabilities, at any work level. He would most likely be deemed a liability for any potential employer, due to his service-connected conditions and their resultant effects, both physical and psychologically due to pain. Of record is a March 2021 letter from Dr. V.K. Cooper which states, [The Veteran] is under my care in the neurology clinic. It is my medical opinion that the p[a]t[ient] has service connected type 2 diabetes resulting in lower and upper extremity neuropathies that would preclude him from being gainfully employed, be it sedentary work or otherwise. He also suffers from cervical radiculopathy. It is my opinion that he is totally and permanently disabled. The Board notes that the Veteran has undergone numerous VA examinations for his various disabilities. Each examiner has determined the functional impact of the disability or disabilities being evaluated. The February 2014 VA examiner found that pain from the Veteran’s cervical spine condition impacted his ability to work; however, no elaboration or rationale was provided. The June 2014 VA examiner noted that the Veteran’s shoulder disability prohibited lifting or overhead work, that the Veteran’s lumbar spine disability prohibited lifting, bending, and digging; and that the Veteran’s right knee disability limited walking and standing. The November 2020 VA examiner noted that that the Veteran was a retired city park foreman. He also noted that the Veteran reported that the constant driving from facilities would be impossible due to lower back pain from transitioning from position to position and that the physical demands of working in multiple locations, driving, and exiting/entering vehicles caused increased bilateral knee pain. The VA examiner who conducted a VA examination in January 2021 found that the Veteran was unable to complete work related tasks requiring keen sense of balance such as ambulating on uneven terrain or climbing ladders due to decreased sensation in the bilateral feet due to neuropathy. Resolving any reasonable doubt in the Veteran’s favor, the Board finds that the evidence demonstrates that the combined effects of the Veteran’s service-connected disabilities since October 7, 2012, rendered him unable to secure or maintain substantially gainful employment consistent with his educational and work history. Thus, the Board finds that a TDIU is warranted throughout the entirety of the appeal period for consideration. REASONS FOR REMAND 1. Entitlement to service connection for BPH In June 2019, the Board remanded this issue for additional development; specifically, the Board directed that the examiner determine the nature and etiology of the Veteran’s BPH and provide rationale including citing to the record to include the January 1989 IVP and cystoscopy. The November 2020 VA examiner noted that the Veteran’s prostate was normal; and the examiner did not discuss the January 1989 IVP and cystoscopy. The Board notes that the Veteran was diagnosed as having BPH in March 1989 after examination which showed an enlarged prostate. In May 1989, the Veteran was given a provisional diagnosis of BPH; but impression after examination and tests were hematuria. VA treatment records indicate normal prostate examinations in September 2002 and June 2006; in October 2007, prostate examination was abnormal and showed 1-2+ enlarged prostate. In March 2005, the Veteran was prescribed Terazosin for prostate; and in January 2008, Finasteride was prescribed to help shrink prostate over time. Private treatment records include a diagnosis of prostatism in August 2004 and BPH in August 2005. On VA examination in June 2014, the Veteran’s prostate was moderately enlarged, smooth, with no nodules. In this case, even assuming any diagnosis during the appeal period has resolved, service connection could be warranted for any diagnosis that existed during the appeal period. If the Veteran does not currently have BPH, the examiner must address all previous diagnoses during the appeal period and explain whether the diagnosis was in error or has resolved. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (because the Veteran had the diagnosis during the appeal period, the VA examiner needed to address that diagnosis and whether it was accurate or in error). Therefore, the Board finds the November 2020 VA examination report inadequate as it did not address the prior BPH diagnosis, and an addendum VA opinion should be obtained to resolve diagnosis during the appeal period and request that the examiner provide an etiological opinion. 2. Entitlement to service connection for a right shoulder disability, to include as due to service-connected disability In June 2019, the Board remanded this issue for additional development; specifically, the Board directed that the Veteran be scheduled for a VA examination to determine the nature and etiology of shoulder disorders. The Board directed that the examiner provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that a right shoulder disorder was related to an in-service injury, event, or disease during service, to include the documented treatment for right shoulder symptoms, including strain of the right trapezius in April 1973, chronic shoulder pain secondary to disc removal in his neck in October 1988, and pain noted in both shoulders in December 1988, or otherwise related to service. The Board also directed that an opinion be provided as to whether it was at least as likely as not that a right shoulder disorder was proximately due to service-connected disability or aggravated beyond its natural progression by service-connected disability, to include the right knee. The November 2020 VA examiner noted that a review of the Veteran’s service treatment records was silent for complaints of or treatment for right shoulder pain. The January 2021 VA examiner that during service, the right shoulder condition was acute only, that there was no evidence of chronicity of care, and that the symptoms were subjective only. The examiner noted that the Veteran mentioned right shoulder pain in 1988 but that the available medical records did not show treatment or a diagnosis for a right shoulder condition while on active duty. The examiner also noted that the right shoulder condition and residuals right knee injury, po arthroscopic surgery with limitation of flexion and chronic pain (prev limitation of flexion of the right knee) were not medically related and that a review of medical literature failed to demonstrate a causal relationship. The examiner noted that the Veteran had been diagnosed with a right shoulder rotator cuff tear in 2001, that the operative note dated 09/11/2001 noted “chondromalacia of the glenohumeral joint of the right shoulder and residual type I superior labrum anterior and posterior lesion of the right shoulder. The examiner noted that rotator cuff tears were caused by injury to the shoulder, progressive degeneration of the tendon tissue, or repetitive overhear reaching or heavy lifting and that certain risk factors such as age, construction type jobs, and family history can increase the chances of sustaining a rotator cuff tear. The examiner noted that chondromalacia referred to the degeneration of the cartilage cushion in the shoulder joint, that it could be inherited or due to traumatic events, such as falls or overuse of the shoulder with throwing or weightlifting. The examiner noted that the available scientific and medical evidence did not support the conclusion that the Veteran’s right shoulder condition was due to or the result of residuals right knee injury, post-operative arthroscopic surgery with limitation of flexion and chronic pain. The Board emphasizes that in his statement received in January 2014, the Veteran noted that his right shoulder rotator cuff tear was a result of a fall after his right knee gave out. The Veteran stated that it was surgically repaired at the same time as his right knee surgery. In April 2001, the Veteran complained of his right knee being weak, having pain and instability; assessment included chronic neck and shoulder pain. In May 2001, the Veteran was seen for complaints that his right knee gives out on him and he falls. In September 2001, the Veteran underwent diagnostic arthroscopy and intraarticular debridement of the right shoulder as well as arthroscopy and arthroscopic partial medial meniscectomy. At the June 2014 VA examination, the Veteran reported that he fell and tore his right rotator cuff in 2001 and had had two surgeries on the right shoulder. The record indicates that the Veteran’s right shoulder and right knee surgeries were performed at Baxter Regional Medical Center by Dr. Thomas Knox of Regional Orthopaedic Health Care. Although VA has records of the actual surgeries as well as one treatment record in April 2005, it does not appear that VA has requested any of Dr. Knox’s records prior to the Veteran’s shoulder surgery. A remand is required to allow VA to obtain authorization and request these records. 3. Entitlement to service connection for a cervical spine muscle disability is remanded. 4. Entitlement to service connection for a chronic pain syndrome disability is remanded. In June 2019, the Board remanded this issue for additional development; specifically, the Board directed that the Veteran be scheduled for a VA examination to determine the nature and etiology of a disorder involving the neck muscles or chronic neck pain (other than DDD of the cervical spine post fusion). Specifically, the Board directed that the examiner determine whether the Veteran had any current disorder involving the neck muscles or a chronic pain disorder in the neck (other than DDD of the cervical spine post fusion), which could include pain alone that rose to the level of functional impairment and that if a diagnosis or functional impairment was not shown, to explained why this is so. The November 2020 VA examiner noted, No chronic diagnosis is made for cervical muscle condition. Objective exam is normal. Symptoms are subjective only. … Full evaluation of the veteran’s neck was not documented as the neck DBQ was not provided for this exam. Veteran did not report any muscle injuries to his neck. Veteran has significant neck pathology but I found no evidence of a separate of the DDD. Without full evaluation it is my medical opinion the veterans claimed cervical muscle condition does not rise to the level of functional impairment in line with Saunders. The Board finds that the November 2020 examiner’s opinion is inadequate as it was not based on “a full evaluation.” As such, an addendum VA opinion should be obtained to resolve diagnosis during the appeal period and request that the examiner provide an etiological opinion after the examiner has been provided access to the Veteran’s VA cervical spine examinations. The matters are REMANDED for the following action: 1. Obtain a VA opinion from the November 2020 VA examiner, if possible, or an appropriate substitute, to determine the etiology of the Veteran’s BPH. Following a review of the pertinent evidence including the January 1989 IVP and cystoscopy and diagnosis of BPH as well as May 1989 provisional diagnosis of BPH and impression after examination and tests of hematuria. The examiner must clarify whether the Veteran currently has BPH. If a current diagnosis is not established, the examiner must address all previous diagnoses of BPH during the appeal period and explain whether that diagnosis was in error or has resolved. For a current diagnosis or diagnosis during the appeal period of BPH that was not in error, the examiner is asked to provide an opinion as to whether BPH began during active service or was caused or aggravated by his active duty service. 2. Ask the Veteran to complete a VA Form 21-4142 for all records from Dr. Knox regarding treatment for a right shoulder disability and a right knee disability. Make two requests for the authorized records from Dr. Knox unless it is clear after the first request that a second request would be futile. 3. Obtain a VA opinion from the November 2020 VA examiner, if possible, or an appropriate substitute, to determine whether the Veteran has any current disorder involving the neck muscles or a chronic pain disorder in the neck (other than DDD of the cervical spine post fusion), which could include pain alone that rose to the level of functional impairment and that if a diagnosis or functional impairment was not shown, to explained why this is so. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Olson, Patricia 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.