Citation Nr: 21021305 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 17-06 584 DATE: April 12, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a prostate condition, claimed as benign prostate hyperplasia (BPH), is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for a bilateral wrist disorder is denied. Entitlement to service connection for tinnitus is granted. REMANDED Entitlement to service connection for a low back disorder, to include myositis and degenerative disc disease of the low back, is remanded. Entitlement to service connection for a bilateral knee disorder, to include a left knee meniscal tear and bilateral knee arthritis, is remanded. Entitlement to service connection for a bilateral shoulder disorder is remanded. Entitlement to service connection for a cervical spine disorder, to include chronic cervical myositis and degenerative disc disease of the cervical spine, is remanded. Entitlement to service connection for a bilateral hip disorder is remanded. Entitlement to service connection for a bilateral ankle disorder is remanded. Entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for hypertensive cardiovascular disease, to include hypertension, is remanded. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of PTSD. 2. The preponderance of the evidence of record is against finding that the Veteran has a prostate condition, to include BPH, that is the result of his military service. 3. The preponderance of the evidence of record is against finding that the Veteran has sleep apnea that is the result of his military service. 4. The preponderance of the evidence of record is against finding that the Veteran has a bilateral wrist disorder that is the result of his military service. 5. Resolving all reasonable doubt in the Veteran’s favor, his tinnitus is the result of acoustic trauma sustained during his military service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a prostate condition, to include BPH, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a bilateral wrist disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1965 to October 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2016 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Board previously remanded the appeal for additional development and consideration. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110,1131; 38 C.F.R. § 3.303 (a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established for a chronic disease as enumerated for VA compensation purposes, to include hypertension and arthritis, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for an enumerated “chronic disease” listed under 38 C.F.R. § 3.309(a) can also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. PTSD The Veteran is seeking entitlement to service connection for PTSD. At the outset, the Board notes the Veteran has not presented any argument advancing this claim. In fact, he failed to respond to a June 2016 VA Memorandum requesting information regarding in-service stressors. However, during his February 2020 VA Initial PTSD Disability Benefits Questionnaire (DBQ), the Veteran identified the following: an incident in which another solider bit off the ear of a man, but the Veteran was in the barracks at that time of the incident; being picked on by a Second Class Petty Officer; and, being called derogatory names, such as “Mexican” and “greaser.” See February 2020 VA PTSD DBQ. Service connection for PTSD, in particular, requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between the current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). The Board has carefully reviewed the evidence but finds that service connection for PTSD is not warranted. In this regard, the Board points out that a key element in establishing service connection is to show that a veteran currently has a diagnosis of the disability for which service connection is sought. See 38 C.F.R. § 3.304. Although the Veteran believes he suffers from PTSD as a result of the statements regarding his stressors he experienced during service, a crucial element of the claim to establish service connection is not demonstrated. In support of his claim, the Veteran submitted a statement from Dr. C.M.Q., dated in September 2015, that lists a diagnosis of PTSD and attributes the claimed disorder to the Veteran’s military service. However, the Board finds this diagnosis and statement inadequate. Specifically, there is no indication that the Veteran has PTSD in accordance with the DSM-5, which is not referenced at all by Dr. C.M.Q. Further, the statement linking this diagnosis to service is conclusory as it does not include any rationale for the finding. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A mere conclusion without an underlying rationale is of no probative value. See Miller v. West, 11 Vet. App. 345 (1998). Therefore, as this opinion contains no rationale, it provides an insufficient basis upon which to decide the Veteran’s claim. Conversely, the February 2020 VA PTSD DBQ and accompanying opinion fail to note a diagnosis of PTSD that conforms with the DSM-5, as is required. 38 C.F.R. § 4.125(a); see again February 2020 VA PTSD DBQ. The Board observes that the available VA treatment records also do not contain a diagnosis of PTSD. In fact, the VA treatment records do not even show that the Veteran has ever been treated for PTSD during this appeal period. Consequently, the Board gives more probative weight to the competent medical evidence that fails to show the Veteran has received treatment for or a diagnosis of this disorder. Therefore, the Board finds the evidence does not show that PTSD has been diagnosed in accordance with 38 C.F.R. § 4.125. Since regulations require medical evidence diagnosing the claimed condition, the Veteran’s self-assessment is not competent 38 C.F.R. § 3.304. In this respect, a clinical professional has the greater skill. The Veteran’s belief that he has PTSD related to service is not credible to establish a lay nexus to service. See Jandreau v. Nicholson, 492 F.3d 1372 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board finds that the Veteran’s claim fails as he has not met the first element of service connection, the requirement of a current diagnosis, for the claimed disorder. As the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for this disorder, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b). As such, the claim must be denied. 2. Benign prostate hyperplasia The Veteran is seeking entitlement to service connection for a prostate condition, to include BPH. At the outset, the Board notes the Veteran has not presented any argument advancing this claim. The Board concludes that, while the Veteran has a diagnosis of BPH, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d); see also February 2020 Male Reproductive Organ Conditions DBQ. Here, the Veteran’s service treatment records are completely silent regarding any complaints, treatment, or a diagnosis pertaining to the prostate, to include BPH. Post-service VA and private treatment records do show his treatment for BPH, to include undergoing a transurethral ablation procedure in August 2014. See August 2015 Statement from Dr. A.Y., urologist. In support of his claim, the Veteran submitted a statement from Dr. C.M.Q., dated in September 2015, that attributes the claimed BPH to the Veteran’s military service. However, the Board finds this opinion inadequate. Specifically, there is no indication that the private physician reviewed the Veteran’s medical records, addressed any objective medical evidence, or provided a rationale for this conclusion. See Nieves-Rodriguez, 22 Vet. App. at 304. A mere conclusion without an underlying rationale is of no probative value. See Miller, 11 Vet. App. 345. Therefore, as this opinion contains no rationale, it provides an insufficient basis upon which to decide the Veteran’s claim. Most recently the Veteran was scheduled for a VA Male Reproductive Organ Conditions DBQ and opinion in February 2020. At that time, the VA examiner determined it was less likely than not the diagnosed BPH was incurred in or caused by the Veteran’s military service. In this respect, the examiner noted that there was no evidence to support a nexus due to the lack of objective evidence of a prostate condition until 2014. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the service connection claim. The February 2020 VA examiner conducted a comprehensive clinical examination and evidentiary review of the file and indicated familiarity with the Veteran’s pertinent medical and lay history. The examiner noted there was no evidence in-service of the claimed disorder and provided a rationale as to the etiology of the Veteran’s diagnosed disorder. For these reasons, the Board finds the February 2020 VA examiner’s opinion highly probative. Moreover, there are no other opinions of record supported by a rationale that support the Veteran’s contentions that his BPH, or any other prostate condition, is the result of his military service. The Board has also considered the Veteran’s generic contention that his BPH is due to service, which is gleaned only from the fact he filed a compensation claim seeking as much. While the Veteran is competent to report when he first noticed any symptomatology associated with a prostate condition, such as urinary frequency or urgency, and provide comment on his in-service experiences, he is not competent to opine regarding the etiology of a diagnosed prostate condition as this requires medical expertise regarding the genitourinary system and diagnostic ability. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. In sum, the Board has found the Veteran does not have a prostate condition, to include BPH, that was incurred in, due to, or aggravated by service. Accordingly, the criteria for service connection are not met and the claim must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 3. Sleep apnea The Veteran is seeking entitlement to service connection for sleep apnea. At the outset, the Board notes the Veteran has not presented any argument advancing this claim. The question for the Board is whether the Veteran currently has sleep apnea that began during service or is at least as likely as not related to an in-service injury, event, or disease. At the outset, the Board notes that there is some conflict as to whether the Veteran has a current diagnosis of sleep apnea. Specifically, a September 2015 statement from Dr. C.M.Q. notes a diagnosis of sleep apnea, but does not include any objective evidence to substantiate the diagnosis. See September 2015 Private Treatment Record. Conversely, the report of a February 2020 VA Sleep Apnea DBQ determined the Veteran did not have a diagnosis of sleep apnea, and the Veteran denied suffering from sleep apnea. See February 2020 VA Sleep Apnea DBQ. Nevertheless, resolving all reasonable doubt in the Veteran’s favor, the Board will find that he does have a current diagnosis and, therefore, the question becomes whether his currently diagnosed sleep apnea is attributable to his military service. The Veteran’s service treatment records are completely silent regarding complaints of, treatment for, or a diagnosis for the claimed disorder. Further, the available VA treatment records do not include any notations that the Veteran has sought treatment for this disorder during the appeals period. In support of his claim, the Veteran submitted a statement from Dr. C.M.Q., dated in September 2015, that attributes the claimed sleep apnea to the Veteran’s military service. However, the Board finds this opinion inadequate. Specifically, there is no indication that the private physician reviewed the Veteran’s medical records, addressed any objective medical evidence, or provided a rationale for this conclusion. See Nieves-Rodriguez, 22 Vet. App. at 304. A mere conclusion without an underlying rationale is of no probative value. See Miller, 11 Vet. App. 345. Therefore, as this opinion contains no rationale, it provides an insufficient basis upon which to decide the Veteran’s claim. Conversely, the February 2020 VA Sleep Apnea DBQ noted there was no evidence of a current diagnosis of sleep apnea. In fact, the examiner specifically noted the Veteran denied ever suffering from sleep apnea during the examination. Consequently, the accompanying VA medical opinion determined it was less likely than not sleep apnea was incurred in or caused by the Veteran’s military service. See February 2020 VA Medical Opinion. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the service connection claim. The February 2020 VA examiner conducted a comprehensive clinical examination and evidentiary review of the file and indicated familiarity with the Veteran’s pertinent medical and lay history. The examiner noted there was no evidence in-service of the claimed disorder and provided a rationale as to the etiology of the Veteran’s diagnosed disorder. For these reasons, the Board finds the February 2020 VA examiner’s opinion highly probative. Moreover, there are no other opinions of record supported by a rationale that support the Veteran’s contentions that the Veteran suffers from sleep apnea that is the result of his military service. Finally, to the extent the Veteran believes he currently suffers from sleep apnea, a fact which he denied in February 2020, he is not competent to provide a nexus opinion in this case. The issue requires specialized medical education pertaining to the respiratory system, as well as the ability to interpret complicated diagnostic medical testing in order to render such an opinion. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence that fails to show the Veteran has received treatment for this disorder or that it is attributable to his military service. The Board finds that the Veteran’s claim fails as he has not met the second or third elements of service connection, the requirement of an in-service incurrence and a nexus, for the claimed disorder. As the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for this disorder, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b). As such, the claim must be denied. 4. Bilateral wrist disorder The Veteran is seeking entitlement to service connection for a bilateral wrist disorder. At the outset, the Board notes the Veteran has not presented any argument advancing this claim. The question for the Board is whether the Veteran currently has a bilateral wrist disorder that began during service or is at least as likely as not related to an in-service injury, event, or disease. At the outset, the Board notes that there is some conflict as to whether the Veteran has a bilateral wrist disorder. Specifically, a September 2015 statement from Dr. C.M.Q. notes a diagnosis of degenerative joint disease of the wrists, but does not include radiograph evidence to substantiate the diagnosis. See September 2015 Private Treatment Record. Conversely, the report of a February 2020 VA Wrist Conditions DBQ determined the Veteran did not have a bilateral wrist disorder, and the Veteran denied suffering from a bilateral wrist disorder. See February 2020 VA Wrist Conditions DBQ. Nevertheless, resolving all reasonable doubt in the Veteran’s favor, the Board will find that he does have a current diagnosis and, therefore, the question becomes whether his currently diagnosed bilateral wrist disorder is attributable to his military service. However, as the record does not include radiographic evidence of arthritis, despite Dr. C.M.Q.’s conclusory statement to the contrary, entitlement to presumptive service connection is not warranted. See February 2020 VA Wrist Conditions DBQ. Moreover, continuity of symptomatology is not for application as he does not currently have a chronic disability, i.e. a diagnosis of arthritis substantiated by x-rays. See 38 C.F.R. § 3.303; Walker, 708 F.3d at 1335-36, 1340; see also February 2020 VA Wrist Conditions DBQ. The Veteran’s service treatment records are completely silent regarding complaints of, treatment for, or a diagnosis for the claimed disorder. Further, the available VA treatment records do not include any notations that the Veteran has sought treatment for this disorder during the appeals period. In support of his claim, the Veteran submitted a statement from Dr. C.M.Q., dated in September 2015, that attributes the claimed bilateral wrist disorder to the Veteran’s military service. However, the Board finds this opinion inadequate. Specifically, there is no indication that the private physician reviewed the Veteran’s medical records, addressed any objective medical evidence, or provided a rationale for this conclusion. See Nieves-Rodriguez, 22 Vet. App. at 304. A mere conclusion without an underlying rationale is of no probative value. See Miller, 11 Vet. App. 345. Therefore, as this opinion contains no rationale, it provides an insufficient basis upon which to decide the Veteran’s claim. The only remaining opinion of record is the February 2020 VA Wrist Conditions DBQ and accompany VA Medical Opinion which, as noted above, determined there was no evidence of a bilateral wrist disorder. See again February 2020 VA Wrist Conditions DBQ. Moreover, the accompany VA medical opinion concluded that it was less likely than not the claimed disorder was incurred in or caused by the Veteran’s military service. As rationale, the examiner noted the Veteran’s denial of having a bilateral wrist disorder at the time of the examination. Further, the examiner stated that after a review of the records, there was no evidence to support a finding of a current or chronic bilateral wrist disorder. See February 2020 VA Medical Opinion. Based on the foregoing, the Board concludes that the preponderance of the evidence is against the service connection claim. The February 2020 VA examiner conducted a comprehensive clinical examination and evidentiary review of the file and indicated familiarity with the Veteran’s pertinent medical and lay history. The examiner noted there was no evidence in-service of the claimed disorder and provided a rationale as to the etiology of the Veteran’s diagnosed disorder. For these reasons, the Board finds the February 2020 VA examiner’s opinion highly probative. Moreover, there are no other opinions of record that support the Veteran’s contentions that he has a bilateral wrist disorder that is the result of his military service. Further, to the extent the Veteran believes he currently suffers from a wrist disorder that is due to his military service, even though he has denied the existence of a current bilateral wrist disorder in the February 2020 VA Wrist Conditions DBQ, he is not competent to provide a nexus opinion in this case. The issue requires specialized medical education pertaining to the musculoskeletal system, as well as the ability to interpret complicated diagnostic medical testing in order to render a diagnosis and opinion. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence that fails to show this disorder is due to his military service. The Board finds that the Veteran’s claim fails as he has not met the second or third elements of service connection, the requirement of an in-service incurrence and a nexus, for the claimed disorder. As the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for this disorder, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b). As such, the claim must be denied. 5. Tinnitus The Veteran contends that he suffers from tinnitus as a result of his military service. For the reasons discussed below, the Board finds service connection is warranted. The Veteran has received a diagnosis of tinnitus. See February 2020 Hearing Loss and Tinnitus DBQ. Thus, the first element of service connection has been met. The Veteran’s service treatment records fail to show in-service treatment for or a diagnosis of tinnitus during service. However, the Veteran’s military occupational specialty was an Aircraft Ground Support Equipment Technician, which has a high probability for hazardous noise exposure. See DD Form 214. Therefore, the Board finds that the Veteran sustained acoustic trauma during service on account of his hazardous noise exposure. Thus, the second element of service connection has been met. Regarding the etiology of the diagnosed tinnitus, the VA medical opinion accompanying the February 2020 VA Hearing Loss and Tinnitus DBQ noted that the Veteran’s military occupational specialty was an Aircraft Ground Support Equipment Technician, which has a high probability for hazardous noise exposure. The examiner noted that tinnitus is a known symptom of noise exposure and it is common for tinnitus to go unreported until it persists into a more persistent condition. Therefore, the examiner concluded that the claimed condition was at least as likely as not incurred in or caused by the Veteran’s military service. Thus, the third element of service connection has been met. Based on the favorable findings of the February 2020 VA examiner, the Board finds in the Veteran’s favor. Entitlement to service connection for tinnitus is warranted. REASONS FOR REMAND 1. Hypertension The Veteran is seeking entitlement to service connection for hypertension. In compliance with the February 2019 Board remand directives, the Veteran was provided a VA examination and an etiological opinion was requested. The February 2020 VA examiner opined that it was less likely than not the diagnosed hypertension is due to the Veteran’s military service. As rationale, the examiner found no objective evidence of a hypertension diagnosis or treatment rendered during service. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). A remand for an addendum opinion is therefore required. 2. Lumbar spine disorder The Veteran is seeking entitlement to service connection for a lumbar spine disorder. Specifically, he states he hurt his back on multiple occasions while in the military, to include during the same injury in which he injured his shoulders. See February 2020 VA Shoulder Conditions DBQ. He went to sick call and was giving muscle relaxants and did physical therapy sessions. Moreover, the Veteran reports he continued to have back pain throughout the course of the years. See February 2020 VA Back Conditions DBQ. The record currently reflects diagnoses of degenerative disc disease with chronic lumbar myositis, and degenerative arthritis of the lumbar spine. See June 2016 VA Back Conditions DBQ; see also February 2020 VA Back Conditions DBQ. In February 2019, the Board remanded this claim for a new examination and opinion. The February 2020 VA examiner noted the occurrence of in-service treatment for the lumbar spine but concluded it was less likely than not that the lumbar spine disorder is due to the Veteran’s military service. As rationale, the examiner indicated that the condition was acute only, and the claims file lacks evidence for continuity or chronicity of care. However, it does not appear that the examiner considered the Veteran’s lay statements when rendering this opinion, specifically as it pertains to considering continuity/chronicity of symptomology, not just care. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). A remand for an addendum opinion is therefore required. 3. Cervical spine The Veteran is seeking entitlement to service connection for a cervical spine disorder. The record reflects current diagnoses of degenerative disc disease, degenerative arthritis, and spondylolisthesis of the cervical spine. See February 2020 VA Cervical Spine Conditions DBQ and October 2019 Private Treatment Record from Dr. L.D. In February 2019, the Board remanded this claim for a new examination and opinion. The February 2020 VA examiner concluded it was less likely than not that the cervical spine disorder is due to the Veteran’s military service. As rationale, the examiner found no objective evidence of a cervical spine diagnosis or treatment rendered during service. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate as the examiner relied solely on the absence of in-service treatment/diagnosis. See Buchanan, 451 F.3d at 1337. A remand for an addendum opinion is therefore required. 4. Bilateral shoulder disorder The Veteran is seeking entitlement to service connection for a bilateral shoulder disorder. The Veteran reported that during service he was trying to lift a metal locker with another guy, who let go and he hurt his shoulders, mostly his right side and his back. He went to sick call and was giving a muscle relaxant. The Veteran reported that continued to have shoulder pain throughout the course of the year, to include cortisone shots and pain medications. See February 2020 VA Shoulder Conditions DBQ. In compliance with the February 2019 Board remand directives, the Veteran was provided a VA examination and opinion regarding his bilateral shoulder disorders. The February 2020 VA examiner noted the presence of bilateral shoulder pain, which resulted in an inability to lift anything heavy. The examiner noted a diagnosis of right shoulder strain, but a normal left shoulder. X-rays were not conducted in order to confirm a diagnosis of arthritis, as was noted in a private September 2015 treatment record from Dr. C.M.Q. See February 2020 VA Shoulder Conditions DBQ. Regarding the etiology of the right shoulder strain, the examiner opined that it was less likely than not the diagnosed right shoulder strain is due to the Veteran’s military service. As rationale, the examiner found no objective evidence of a shoulder diagnosis or treatment rendered during service. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate as the examiner relied solely on the absence of in-service treatment/diagnosis. See Buchanan, 451 F.3d at 1337. Moreover, the examiner failed to consider and discuss the Veteran’s reported injury during service, his statements as to chronic symptomology since service, and whether the pain associated with the left shoulder resulted in functional limitations such that it constitutes a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Further, the Board finds the failure of the VA examiner to order x-rays to confirm or rule out a diagnosis of arthritis renders the examination inadequate as a complete picture of the current disabilities was not obtained. See Barr, 21 Vet. App. at 311-12. A remand for an examination and opinion is therefore required. 5. Bilateral hip disorder The Veteran is seeking entitlement to service connection for a bilateral hip disorder. In compliance with the February 2019 Board remand directives, the Veteran was provided a VA examination and opinion regarding his bilateral hip strains. X-rays were not conducted in order to confirm a diagnosis of arthritis, as was noted in a private September 2015 treatment record from Dr. C.M.Q. See February 2020 VA Hip and Thigh Conditions DBQ. Regarding the etiology of the bilateral hip strains, the examiner opined that it was less likely than not due to the Veteran’s military service. As rationale, the examiner found no objective evidence of right or left hip diagnoses or treatment rendered during service. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate as the examiner relied solely on the absence of in-service treatment/diagnosis. See Buchanan, 451 F.3d at 1337. Further, the Board finds the failure of the VA examiner to order x-rays to confirm or rule out a diagnosis of arthritis renders the examination inadequate as a complete picture of the current disabilities was not obtained. See Barr, 21 Vet. App. at 311-12. A remand for an examination and opinion is therefore required. 6. Bilateral knee disorder The Veteran is seeking entitlement to service connection for bilateral knee disorders. Specifically, he states he suffered from a left knee disorder since service and, thereafter, developed a right knee disorder. See February 2020 VA Knee and Lower Leg Conditions DBQ. The record reflects the Veteran has current diagnoses of a left knee meniscal tear and bilateral knee arthritis. See June 2016 VA Knee and Lower Leg Conditions DBQ and February 2020 VA Knee and Lower Leg Conditions DBQ. In February 2019, the Board remanded this claim for a new examination and opinion. The February 2020 VA examiner noted the occurrence of in-service treatment for the knee but concluded it was less likely than not that the bilateral knee disorders are due to the Veteran’s military service. As rationale, the examiner indicated that the in-service condition was acute only, and the claims file lacks evidence for continuity or chronicity of care. However, it does not appear that the examiner considered the Veteran’s lay statements when rendering this opinion, specifically as it pertains to considering continuity/chronicity of symptomology, not just care. See Barr, 21 Vet. App. at 311-12. A remand for an addendum opinion is therefore required. 7. Bilateral ankle disorder The Veteran is seeking entitlement to service connection for a bilateral ankle disorder. The Veteran reported suffering from swollen and painful ankles, to the extent he could hardly walk. Moreover, it appears he is also contending his ankle disorder is due to or aggravated by the medications he requires for his hypertension. See February 2020 VA Ankle Conditions DBQ. In compliance with the February 2019 Board remand directives, the Veteran was provided a VA examination and opinion regarding his claimed bilateral ankle disorders. The February 2020 VA examiner noted the presence of bilateral ankle pain, which the Veteran states impairs his ability to walk. The examiner noted normal ankles, bilaterally, on examination. X-rays were not conducted in order to confirm a diagnosis of arthritis, as was noted in a private September 2015 treatment record from Dr. C.M.Q. See February 2020 VA Ankle Conditions DBQ. Regarding the etiology of the claimed bilateral ankle disorder, the examiner opined that it was less likely than not due to the Veteran’s military service. As rationale, the examiner found no objective evidence of ankle disorders and, therefore, a nexus was not established. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate as the examiner failed to consider and discuss the Veteran’s statements as to chronic symptomology, and whether the pain associated with the bilateral ankle disorders resulted in functional limitations such that it constitutes a disability. See Saunders, 886 F.3d at 1361. Further, the Board finds the failure of the VA examiner to order x-rays to confirm or rule out a diagnosis of arthritis renders the examination inadequate as a complete picture of the current disabilities was not obtained. See Barr, 21 Vet. App. at 311-12. A remand for an examination and opinion is therefore required. 8. Bilateral foot disorder The Veteran is seeking entitlement to service connection for a bilateral foot disorder. In compliance with the February 2019 Board remand directives, the Veteran was provided a VA examination and opinion regarding his bilateral foot disorder. The February 2020 VA Foot Conditions DBQ noted a diagnosis of bilateral plantar fasciitis. X-rays were not conducted in order to confirm a diagnosis of arthritis, as was noted in a private September 2015 treatment record from Dr. C.M.Q. See February 2020 VA Foot Conditions DBQ. Regarding the etiology of the bilateral foot disorder, the examiner opined that it was less likely than not due to the Veteran’s military service. As rationale, the examiner found no objective evidence of bilateral foot disorders diagnoses or treatment rendered during service. See February 2020 VA Medical Opinion. The Board finds this opinion to be inadequate as the examiner relied solely on the absence of in-service treatment/diagnosis. See Buchanan, 451 F.3d at 1337. Further, the Board finds the failure of the VA examiner to order x-rays to confirm or rule out a diagnosis of arthritis renders the examination inadequate as a complete picture of the current disabilities was not obtained. See Barr, 21 Vet. App. at 311-12. A remand for an examination and opinion is therefore required. 9. Acquired psychiatric disorder, other than PTSD The Veteran is seeking entitlement to service connection for an acquired psychiatric disorder, other than PTSD, that he believes is due to his military service. Specifically, the Veteran states he experienced an incident in which another solider bit off the ear of a man, but the Veteran was in the barracks at that time of the incident; being picked on by a Second Class Petty Officer; and, being called derogatory names, such as “Mexican” and “greaser.” See February 2020 VA Initial PTSD DBQ. The record reflects he has been diagnosed with unspecified anxiety disorder with other depressive symptoms. See February 2020 VA Initial PTSD DBQ. Regarding whether the Veteran’s diagnosed disorder is due to his military service, the VA examiner concluded it was less likely than not incurred in or caused by his military service due to the lack of in-service records indicating psychiatric treatment. The Board finds this examination to be inadequate as the examiner relied solely on the absence of in-service treatment/diagnosis. See Buchanan, 451 F.3d at 1337. Moreover, there is simply no indication the examiner considered the Veteran’s statements as to his claimed in-service occurrences. A remand for an addendum opinion is required. 10. Bilateral hearing loss The Veteran is seeking entitlement to service connection for bilateral hearing loss that he claims is due to his military service and, specifically, to conceded noise exposure during service as a result of his military occupational specifically as an Aircraft Ground Support Equipment Technician. Here, the record reflects the Veteran has been diagnosed with bilateral hearing loss. See May 2016 VA Hearing Loss and Tinnitus DBQ. As was noted in the prior February 2019 Board remand, the May 2016 VA examiner’s opinion was inadequate as the rationale for a negative opinion was due to the fact that hearing was normal at discharge. However, the Board finds the February 2020 VA examiner’s opinion to also be inadequate as the examiner was unable to determine the presence and/or severity of hearing loss due to inconsistent responses and, therefore, an opinion was not offered. Thus, there remains no adequate opinion of record to which the Board may rely upon in adjudicating this claim. A remand for an addendum opinion is required. The matters are REMANDED for the following action: 1. The AOJ must schedule the Veteran for the following examinations and respond to the questions accordingly: (a.) Bilateral Shoulder Disorder: 1. The examiner must provide x-rays regarding the claimed disorder to confirm or rule out a diagnosis of arthritis. Any and all diagnosed right and/or left shoulder disorders must be identified. 2. Then, provide an opinion as to whether it is at least as likely as not any identified right and/or left shoulder disorder is related to the Veteran’s military service. (b.) Bilateral Hip Disorder: 1. The examiner must provide x-rays regarding the claimed disorder to confirm or rule out a diagnosis of arthritis. Any and all diagnosed right and/or left hip disorders must be identified. 2. Then, provide an opinion as to whether it is at least as likely as not any identified right and/or left hip disorder is related to the Veteran’s military service. (c.) Bilateral Ankle Disorder: 1. The examiner must provide x-rays regarding the claimed disorder to confirm or rule out a diagnosis of arthritis. Any and all diagnosed right and/or left ankle disorders must be identified. 2. Then, provide an opinion as to whether it is at least as likely as not any identified right and/or left ankle disorder is related to the Veteran’s military service. 3. If, and only if, service connection for hypertension is established, the examiner shoulder also provide an opinion as to whether it at least as likely as not that the Veteran's ankle disorders, claimed as swelling, are related to, or underwent any incremental increase (aggravation) in disability, regardless of its permanence, due to: a. Hypertension, yes or no? b. Medications taken for his hypertension, yes or no? (d.) Bilateral Foot Disorder: 1. The examiner must provide x-rays regarding the claimed disorder to confirm or rule out a diagnosis of arthritis. Any and all diagnosed right and/or left feet disorder, to include plantar fasciitis, must be identified. 2. Then, provide an opinion as to whether it is at least as likely as not any identified right and/or left foot disorder is related to the Veteran’s military service. The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. A complete rationale for all opinions offered must be provided. 2. The AOJ must obtain an addendum opinion from the February 2020 VA examiner regarding the following claims. An in-person examination is not necessary unless the examiner determines that examinations must be conducted to address the questions below. The examiner is asked to specifically address the following: (a.) Hypertension: whether it is at least as likely as not the diagnosed hypertension is related to the Veteran’s military service, to include whether it was diagnosed within one year of separation? (b.) Lumbar Spine Disorder: whether it is at least as likely as not any diagnosed lumbar spine disorder is related to the Veteran’s military service, to include whether arthritis was diagnosed within one year of separation? (c.) Cervical Spine Disorder: whether it is at least as likely as not any diagnosed cervical spine disorder is related to the Veteran’s military service, to include whether arthritis was diagnosed within one year of separation? (d.) Bilateral Knee Disorder 1. whether it is at least as likely as not any diagnosed right and/or left knee disorder is related to the Veteran’s military service, to include whether arthritis was diagnosed within one year of separation? 2. If service connection is established for the left knee, then the examiner must provide an opinion as to whether it at least as likely as not that the Veteran's right knee disorder is related to his left knee or underwent any incremental increase (aggravation) in disability, regardless of its permanence, due to the left knee, yes or no? (e.) Psychiatric Disorder, other than PTSD: whether it is at least as likely as not any diagnosed psychiatric disorder other than PTSD is related to the Veteran’s military service. The examiner must comment on the Veteran’s statements regarding his in-service incidents. (f.) Bilateral Hearing Loss: whether it is at least as likely as not the Veteran’s diagnosed bilateral hearing loss is related to his military service. In providing the opinion, the examiner is reminded that a diagnosis of bilateral hearing loss has been confirmed. Moreover, the Veteran’s military occupational specialty has been associated with a high risk of noise exposure and, therefore, acoustic trauma has been conceded. The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. A complete rationale for all opinions offered must be provided. 3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE, CORRECTIVE ACTION MUST BE IMPLEMENTED. 4. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berry, 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.