Citation Nr: 21024327 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 20-14 266 DATE: April 22, 2021 ORDER From April 21, 2016, a rating of 60 percent for right lower extremity radiculopathy is granted. From April 21, 2016, a rating of 60 percent for left lower extremity radiculopathy is granted. VA has received new and material evidence to reopen a claim of service connection for a right knee disorder, to include arthritis. REMANDED From April 21, 2016, a rating greater than 60 percent for left lower extremity radiculopathy is remanded. From April 21, 2016, a rating greater than 60 percent for right lower extremity radiculopathy is remanded. Entitlement to a rating greater than 0 percent for bilateral hearing loss is remanded. Entitlement to a rating greater than 0 percent for scar, low back, is remanded. From April 21, 2016, entitlement to a rating greater than 40 percent for lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy is remanded. Entitlement to service connection for a rhinitis and sinusitis, claimed as a nasal disorder, is remanded. Entitlement to a rating greater than 10 percent for a left knee strain with degenerative arthritis is remanded. Entitlement to service connection for a right knee disorder, to include arthritis, is remanded. Entitlement to service connection for a right ankle disorder, to include arthritis, is remanded. Entitlement to service connection for a left ankle disorder, to include arthritis, is remanded. Entitlement to service connection for a cervical disorder, to include arthritis, is remanded. Entitlement to service connection for a right foot/toes disorder, to include arthritis, is remanded. Entitlement to service connection for a left foot/toes disorder, to include arthritis, is remanded. Entitlement to service connection for a left wrist disorder, to include arthritis, is remanded. Entitlement to service connection for a right wrist disorder, to include arthritis, is remanded. Entitlement to service connection for a right hand/fingers disorder, to include arthritis, is remanded. Entitlement to service connection for a left hand/fingers disorder, to include arthritis, is remanded. Entitlement to service connection for a left shoulder disorder, to include arthritis, is remanded. Entitlement to service connection for a right shoulder disorder, to include arthritis, is remanded. Entitlement to service connection for a right hip disorder, to include arthritis, is remanded. Entitlement to service connection for a left hip disorder, to include arthritis, is remanded. FINDINGS OF FACT 1. From April 21, 2016, the Veteran has had a level of impairment that is consistent with severe incomplete paralysis of the sciatic nerve of the right lower extremity. 2. From April 21, 2016, the Veteran has had a level of impairment that is consistent with severe incomplete paralysis of the sciatic nerve of the left lower extremity. 3. VA denied the Veteran’s claim for service connection for a right knee disorder in August 2016. The Veteran did not appeal this denial, nor did he submit new and material evidence within one year of the decision. Therefore, the August 2016 rating decision became final. 4. Evidence received since the final August 2016 rating decision is not cumulative or redundant of the evidence of record, does relate to an unestablished fact, and does raise the possibility of substantiating the Veteran’s claim of entitlement to service connection for a right knee disorder. CONCLUSIONS OF LAW 1. From April 21, 2016, the criteria for a 60 percent rating for radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8520. 2. From April 21, 2016, the criteria for a 60 percent rating for peripheral radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8520. 3. The August 2016 rating decision denying the claim for service connection for a right knee disorder is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. 4. New and material evidence has been submitted to allow the reopening of the claim for service connection for a right knee disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1960 to August 1963. The Veteran died in October 2020. The Appellant, the Veteran's widow, has substituted. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2018 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). Neither the Appellant nor her representative has raised any other issues, nor has the record reasonably raised any issues beyond those on the title page above. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Notwithstanding this, the Board highlights the following. The AOJ issued a rating decision in June 2019. In that decision, the AOJ granted a) service connection for a psychiatric disorder, b) a total disability based upon individual unemployability (TDIU), and c) Dependents' Educational Assistance (DEA). The AOJ established April 20, 2018 as the effective date of the TDIU and DEA. On December 2, 2019, the Veteran submitted a VA Form 20-0995, "Decision Review Request: Supplemental Claim." In it, he appealed the effective date the AOJ assigned for the TDIU. In a December 20, 2019 rating decision, the AOJ acknowledged the VA Form 20-0995, but it adjudicated a challenge to the effective date of the DEA, not TDIU. The AOJ notified the Veteran of its decision in a December 23, 2019 letter. The Veteran did not appeal this decision prior to his death. Because the Veteran elected AOJ review via the VA Form 20-0995, the Board may not review that issue in this appellate decision under the legacy appeal system. However, the Board notes that the AOJ, despite the December 20, 2019 rating decision, has not adjudicated the issue the Veteran appealed, i.e., entitlement to an effective date earlier than April 20, 2018 for the grant of a TDIU. Therefore, the Board encourages the Appellant to consult her representative about that matter. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where entitlement to compensation has already been established and an increase in the disability is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Issue 1: Entitlement to a rating greater than 10 percent for right lower extremity radiculopathy from April 21, 2016 to April 19, 2018 Issue 2: Entitlement to a rating greater than 20 percent for right lower extremity radiculopathy from April 20, 2018 Issue 3: Entitlement to a rating greater than 10 percent for left lower extremity radiculopathy from April 21, 2016 to April 19, 2018 Issue 4: Entitlement to a rating greater than 20 percent for left lower extremity radiculopathy from April 20, 2018 Bilateral Radiculopathy of the Lower Extremities The Appellant contends that the Veteran was entitled to a higher rating for his bilateral radiculopathy of the lower extremities. The VA's Schedule for Rating Disabilities is used to determine disability ratings once a disability is service connected. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In the Rating Schedule, diagnostic codes (DC) are assigned to specific disabilities. These DCs designate percentage ratings based on the average functional impairment of the Veteran due to a service-connected disability. 38 C.F.R. §§ 3.321, 4.10. Here, the AOJ service connected the Veteran's low back disorder and associated radiculopathy of the lower extremities in a May 2017 rating decision. It rated the radiculopathy as 10 percent disabling from April 21, 2016, the day VA received the Veteran’s service connection claim for the low back disorder. On April 20, 2018, the Veteran filed a new claim for benefits, requesting compensation for a "nose condition" and "arthritis, degenerative." The AOJ construed this statement, as relevant here, to be increased rating claims for the low back disorder and bilateral radiculopathy. The AOJ, based on an August 2018 VA examination, increased the radiculopathy ratings to 20 percent disabling, bilaterally, from April 20, 2018. Notwithstanding this, VA treatment records added February 2, 2018 show a January 2018 MRI for the low back. The Board finds this treatment record is, pursuant to 38 C.F.R. § 3.156(b), new and material evidence as it was received within one year of the May 2017 rating decision. Therefore, the Board finds the May 2017 rating decision did not become final. As such, the period on appeal for the low back disorder and radiculopathy issues begins on April 21, 2016, the effective date of the grant of service connection for the low back disorder. The AOJ rated the Veteran's radiculopathy of both lower extremities under DC 8520, which is a DC applicable to impairment of the sciatic nerve. The minimum 10 percent rating is warranted for incomplete mild paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. The maximum 80 percent rating is warranted for complete paralysis, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. In rating peripheral nerve injuries and their residuals, attention should be given to the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The VA Schedule for Rating Disabilities does not define the words "mild," "moderate," and "severe." Rather than applying a mechanical formula, the Board must evaluate all the evidence so that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of such terminology by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The term "incomplete paralysis," with these and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. In Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018), the Court noted that "DC 8520 does not define 'mild,' 'moderate,' 'moderately severe,' or 'severe,' or generally associate those terms with specific symptoms." One possible source for such definitions would be the dictionary. Webster's II New College Dictionary defines "mild" as "not severe." Id. at 694 (1995). A synonym for "mild" is "slight," and definitions for "slight" includes "small in size, degree, or amount." Id. at 1038. The definitions for "moderate" include "of average or medium quantity, quality, or extent." Id. at 704. Finally, definitions for "severe" include "extremely intense." Id. at 1012. It is also noted that the term "moderately severe" includes impairment that is considered more than "moderate" but not to the extent as to be considered "severe." Merits This case turns on the AOJ's failure to properly apply Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), which held that VA is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Here, medical professionals have diagnosed the Veteran with both diabetic peripheral neuropathy and radiculopathy of the bilateral lower extremities, only the latter of which is service connected. Indeed, an August 2018 VA examination and addendum are dispositive. In August 2018, Dr. S.C., M.D., examined the Veteran's back, to include peripheral nerves. In stating the Veteran's medical history, he noted, as relevant here, that: The Veteran also has type II diabetes with severe bilateral LE diabetic neuropathy requiring Gabapentin 300 mg TID. He still has complete loss of sensation in both feet, both soft touch and vibratory. The combination of the lumbar DDD/DJD with radiculopathy/diabetic peripheral neuropathy/bilateral knee DJD has made it very difficult for the Veteran to walk except for a very few steps at a time. The AOJ sought an addendum opinion, which Dr. S.C., provided: The symptoms in the bilateral lower extremities noted on my examination on 8/10/2018 and on the QTC examination of 4/18/2017 are due to a combination of both diabetic peripheral neuropathy and lumbar spine radiculopathy of the bilateral LEs. The Veteran has type II diabetes and is on Gabapentin for bilateral LE peripheral neuropathy, which is manifested primarily by burning of the feet and bilateral decreased cold and vibratory sensation. The Veteran also has a recent lumbar CT from January 2018 which is consistent with bilateral LE lumbar radiculopathy and is manifested also by bilateral LE numbness and tingling. If ordered, EMGs would serve to only confirm/substantiate these two diagnoses, but would not be able to assist in apportionment at all. Additionally, I cannot tell you how much of the LE symptoms is due to diabetic neuropathy vs lumbar radiculopathy without resorting to mere speculation. Given the foregoing, the Board must attribute the symptoms of the diabetic neuropathy to the Veteran's lumbar radiculopathy. From April 21, 2016 to present, the above evidence reflects that the Veteran's right and left lower extremity radiculopathy has been manifested by pain and marked muscle atrophy. Considering the definitions above, the Board concludes that the Veteran's reported neurological symptoms and the clinical findings of impaired sensation and reflexes have most closely approximated the criteria for 60 percent ratings for paralysis of the sciatic nerve under DC 8520. This finding of severe incomplete paralysis reflects the Board's reasoned opinion that the Veteran's lay and medical reports of pain, complete loss of sensation, and evidence of atrophy are analogous to symptoms that are extremely intense. Issue 5: Whether VA has received new and material evidence to reopen a claim of service connection for a right knee disorder, claimed as arthritis New and Material Evidence – General Under 38 U.S.C. § 7104(b), the Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. King v. Shinseki, 23 Vet. App. 464 (2010); see DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006) (holding that res judicata generally applies to VA decisions). However, the finality of a previously disallowed claim can be overcome by the submission of new and material evidence. See 38 U.S.C. § 5108. New evidence means evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Merits The AOJ denied the Veteran's claim for service connection for a right knee disorder in August 2016. The Veteran did not appeal this denial, nor did he submit new and material evidence within one year of the decision. Therefore, the August 2016 rating decision became final. At the time of the AOJ’s August 2016 denial, the record consisted, as relevant here, of service treatment records and VA treatment records. Subsequently, the AOJ added VA treatment records to the record. It also had the Veteran examined in June 2018, which included an etiological nexus statement. The VA records and June 2018 examination report are new. The AOJ construed them as material because they help substantiate the claim, and they relate to a reason VA previously denied his claim, i.e., nexus. The Board agrees. Reopening of the Veteran's the claim for service connection for a right knee disorder based on the receipt of new and material evidence is therefore warranted. Shade v. Shinseki, 24 Vet. App. 110 (2011) (holding that the phrase "raises a reasonable possibility of substantiating the claim" in applicable regulation as "enabling rather than precluding reopening"). REASONS FOR REMAND Remand is warranted for the remaining issues in this appeal as discussed below. A general matter, however, first merits discussion. First, under 38 C.F.R. § 20.1305, any pertinent evidence that is submitted to the Board, including evidence obtained and added to the file by VA, must be referred to VA for initial review unless this right is waived by the appellant or representative in writing or on the record during a hearing. Additionally, under 38 U.S.C. § 7105(e)(1), for substantive appeals received on or after February 2, 2013, a waiver of VA review is not required for new pertinent evidence that is submitted by the appellant or representative, and the Board may proceed with adjudication and consideration of the new evidence in the first instance. VA has not interpreted this automatic waiver to apply, as here, to evidence the appellant did not submit. Here, the AOJ transferred the appeal to the Board in May 2020. The AOJ subsequently uploaded over 1,100 pages of VA treatment records to the Veteran's file in June 2020. In July 2020, the Board requested a waiver of AOJ review from the Veteran. The Veteran, approximately two weeks later, declined to waive AOJ review. Therefore, the Board will remand the appeal for AOJ consideration of all evidence, to include the 1,100 pages of VA treatment records to the Veteran’s file in June 2020, received since the April 2020 Statement of the Case. Specific development is ordered below. From April 21, 2016, a rating greater than 60 percent for left lower extremity radiculopathy From April 21, 2016, a rating greater than 60 percent for right lower extremity radiculopathy The Board has bifurcated the appeal of these two issues. This will expedite the AOJ's implementation of the Board's award above for the Appellant. However, because the Board could not, based on the evidence it could consider, award the highest available rating available, it must allow the AOJ to consider the VA treatment records added in June 2020 in the first instance before adjudicating these issues to finality. To be clear, the Board is ordering no additional development for these issues. Entitlement to a rating greater than 0 percent for bilateral hearing loss Entitlement to a rating greater than 0 percent for scar, low back From April 21, 2016, entitlement to a rating greater than 40 percent for lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy The Board is ordering no additional development for these issues. It is remanding them to comply with 38 C.F.R. § 20.1305 and the Veteran's declination of waiver of AOJ review. Entitlement to service connection for rhinitis and sinusitis, claimed as a nasal disorder A VA examiner diagnosed the Veteran with allergic rhinitis and sinusitis in June 2018. This satisfies the first prong of direct service connection for this claim. In September 1962, the Veteran, in a Report of Injury contained in his service treatment records, stated he "fell down the steps coming out of the Non-Commissioned Officers Club at 2100 hours, 2 September 1962, and broke my nose." The "nature and extent of injury" was listed as a "dislocation." This satisfies the second prong of direct service connection for this claim. The appeal turns on the third prong of a direct service connection claim – medical nexus. VA examined the Veteran for this claim in June 2018. The examiner opined that the in-service injury did not cause the Veteran's sinusitis. The examiner opined that "sinusitis is not likely due to broken nose since there is no evidence of deviated septum on sinus CT." Indeed, the examiner found that the Veteran's "known risk factors" of "allergic rhinitis and 25 pack year smoking" history were, absent a deviated septum, the more likely cause of his sinusitis. Notwithstanding this negative nexus for sinusitis, remand is warranted for two reasons. First, the examiner did not opine on the etiology of the Veteran’s rhinitis. Because the AOJ adjudicated the claim to include both rhinitis and sinusitis, the Board will remand for an addendum opinion for the rhinitis. Second, the Veteran submitted an academic study regarding rhinitis and tobacco smoke exposure in October 2018. The examiner did not have the opportunity to consider this study and must do so before the Board can adjudicate the claim. Entitlement to a rating greater than 10 percent for a left knee strain with degenerative arthritis The Veteran submitted a DBQ completed in March 2016 that showed he had flare-ups in his left knee that limited his range of motion. VA examination reports in May 2016, June 2018, and June 2019 violate Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the United States Court of Appeals for Veterans Claims held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. The 2016 examiner stated he could not describe the diminished range of motion because the Veteran was "not seen after a flare up." The 2018 examiner noted "flare-ups" were "not applicable" to the Veteran's left knee when all evidence points to the contrary. The 2019 examiner, trying to comply with Sharp, stated that the examination was conducted during a flare-up and that flare-ups "significantly limit" his "functional ability" but then measured the same range of motion as the initial range of motion reading. These statements are internally inconsistent. Given these various shortcomings, the Board would have ordered a new examination. Because the Veteran has passed, it may only seek clarification through a medical opinion based on the available clinical evidence. Entitlement to service connection for right knee disorder, to include arthritis The AOJ denied the Veteran's first service connection claim on a direct theory of entitlement. The AOJ continued to pursue this theory when it reopened his claim, as discussed above. However, the Veteran, in documents submitted through his congressman in October 2018 and July 2019, alleged a secondary theory of entitlement, i.e., that his right knee disorder is secondary to his back and left knee disabilities. Remand is necessary for an addendum opinion to explore this contention. Entitlement to service connection for right ankle disorder, to include arthritis Entitlement to service connection for left ankle disorder, to include arthritis Entitlement to service connection for cervical disorder, to include arthritis Entitlement to service connection for right foot/toes disorder, to include arthritis Entitlement to service connection for left foot/toes disorder, to include arthritis Entitlement to service connection for left wrist disorder, to include arthritis Entitlement to service connection for right wrist disorder, to include arthritis Entitlement to service connection for right hand/fingers disorder, to include arthritis Entitlement to service connection for left hand/fingers disorder, to include arthritis Entitlement to service connection for left shoulder disorder, to include arthritis Entitlement to service connection for right shoulder disorder, to include arthritis Entitlement to service connection for right hip disorder, to include arthritis Entitlement to service connection for left hip disorder, to include arthritis Under McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), a VA medical examination must be provided when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83 The Veteran, in medical articles submitted through his congressman in October 2018 and July 2019, alleged a secondary theory of entitlement for each of the 13 claimed disabilities above, i.e., that each of the 13 disabilities is secondary to his back and/or left knee disabilities. Given the orthopedic nature of these possibly related claims and the medical articles on lumbar radiculopathy and arthritis cited above, the Board finds he had satisfied McLendon prior to his passing. Because the Board may not order an examination, it will order a medical opinion based on the available clinical evidence. Therefore, remand is necessary for an opinion to explore the Veteran’s contention. The matters are REMANDED for the following action: 1. Obtain updated VA and non-VA treatment records. 2. Obtain an addendum medical opinion from the June 2018 rhinitis and sinusitis VA examiner, or another similarly qualified medical professional if the June 2018 VA examiner is unavailable. The examiner must answer the following questions: a) Is it as least as likely as not (50 percent or greater probability) that the Veteran’s claimed rhinitis began during, or was otherwise caused by, service? Why or why not? In answering this question, the clinician must expressly address the academic study entitled “Allergic Sensitization, Rhinitis, and Tobacco Smoke Exposure in US Adults” that the Veteran submitted in October 2018. b) Does the academic study the Veteran submitted in October 2018 change your negative nexus opinion on the etiology of the Veteran's sinusitis? Why or why not? 2. Obtain a medical opinion based upon the available clinical evidence to determine the nature and severity of the Veteran's left knee disorder. In so doing, expressly ask the medical professional, to the degree possible, to estimate the reduction in the Veteran's range of motion due to flare-ups from March 7, 2016 (the date of service connection for his left knee disorder) to his passing in October 2020. To comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017), the examiner is asked to describe whether pain, weakness, fatigue, or incoordination significantly limited the Veteran's functional ability during flares or repetitive use, and if so, the examiner must estimate what the Veteran's range of motion during flares or repetitive use was. If an opinion cannot be provided without resort to speculation, the medical professional should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. A rationale should be provided for each medical opinion presented. 3. Obtain a medical opinion based on the available clinical evidence to determine the nature and etiology of the Veteran's claimed a) right ankle disorder, to include arthritis; b) left ankle disorder, to include arthritis, c) cervical disorder, to include arthritis; d) right foot/toes disorder, to include arthritis; e) left foot/toes disorder, to include arthritis; f) left wrist disorder, to include arthritis, g) right wrist disorder, to include arthritis; h) right hand/fingers disorder, to include arthritis; i) left hand/fingers disorder, to include arthritis; j) left shoulder disorder, to include arthritis; k) right shoulder disorder, to include arthritis; l) right hip disorder, to include arthritis; m) left hip disorder, to include arthritis; n) right knee disorder, to include arthritis. The claims file and a copy of this Remand should be made available to and reviewed by the medical professional who reviews these issues. The medical professional must answer the following questions: c) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right ankle disorder, to include arthritis? Why or why not? d) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right ankle disorder, to include arthritis? Why or why not? e) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left ankle disorder, to include arthritis? Why or why not? f) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left ankle disorder, to include arthritis? Why or why not? g) Is it at least as likely as not that the Veteran's left knee strain with degenerative arthritis CAUSED his claimed left ankle disorder, to include arthritis? Why or why not? h) Is it as least as likely as not (50 percent probability) that the Veteran's left knee strain with degenerative arthritis AGGRAVATED his claimed left ankle disorder, to include arthritis? Why or why not? i) Is it as least as likely as not (50 percent probability) that the Veteran’s claimed cervical disorder, to include arthritis, began during, or was otherwise caused by, service? Why or why not? j) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right foot/toes disorder, to include arthritis? Why or why not? k) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right foot/toes disorder, to include arthritis? Why or why not? l) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left foot/toes disorder, to include arthritis? Why or why not? m) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left foot/toes disorder, to include arthritis? Why or why not? n) Is it at least as likely as not that the Veteran's left knee strain with degenerative arthritis CAUSED his claimed left foot/toes disorder, to include arthritis? Why or why not? o) Is it as least as likely as not (50 percent probability) that the Veteran's left knee strain with degenerative arthritis AGGRAVATED his claimed left foot/toes disorder, to include arthritis? Why or why not? p) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left wrist disorder, to include arthritis? Why or why not? q) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left wrist disorder, to include arthritis? Why or why not? r) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right wrist disorder, to include arthritis? Why or why not? s) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right wrist disorder, to include arthritis? Why or why not? t) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right hand/fingers disorder, to include arthritis? Why or why not? u) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right hand/fingers disorder, to include arthritis? Why or why not? v) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left hand/fingers disorder, to include arthritis? Why or why not? w) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left hand/fingers disorder, to include arthritis? Why or why not? x) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left shoulder disorder, to include arthritis? Why or why not? y) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left shoulder disorder, to include arthritis? Why or why not? z) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right shoulder disorder, to include arthritis? Why or why not? aa) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right shoulder disorder, to include arthritis? Why or why not? (bb) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right hip disorder, to include arthritis? Why or why not? (cc) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right hip disorder, to include arthritis? Why or why not? (dd) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed left hip disorder, to include arthritis? Why or why not? (ee) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed left hip disorder, to include arthritis? Why or why not? (ff) Is it at least as likely as not that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy CAUSED his claimed right knee disorder, to include arthritis? Why or why not? (gg) Is it as least as likely as not (50 percent probability) that the Veteran's lumbar strain with degenerative disc disease (DDD), degenerative joint disease (DJD) and spinal stenosis status-post lumbar discectomy AGGRAVATED his claimed right knee disorder, to include arthritis? Why or why not? (hh) Is it at least as likely as not that the Veteran's left knee strain with degenerative arthritis CAUSED his claimed right knee disorder, to include arthritis? Why or why not? (ii) Is it as least as likely as not (50 percent probability) that the Veteran's left knee strain with degenerative arthritis AGGRAVATED his claimed right knee disorder, to include arthritis? Why or why not? Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Sopko, 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.