Citation Nr: 21024407 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 17-21 961 DATE: April 22, 2021 ORDER Entitlement to service connection for diabetes mellitus, type II, to include as due to environmental hazards, is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for lumbosacral spondylosis with arthritis is remanded. Entitlement to a compensable rating for right lower extremity radiculopathy of the sciatic nerve prior to November 12, 2019, and a rating in excess of 10 percent thereafter is remanded. Entitlement to a compensable rating for left lower extremity radiculopathy of the sciatic nerve prior to November 12, 2019, and a rating in excess of 10 percent thereafter is remanded. Entitlement to service connection for a left knee disability, to include osteoarthritis and a knee strain, is remanded. Entitlement to service connection for a right knee disability, to include osteoarthritis and tendonitis, is remanded. Entitlement to service connection for hypertension/high blood pressure, to include as due to environmental hazards, is remanded. FINDING OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s diabetes mellitus, type II, was manifest during active service or is related to service. CONCLUSION OF LAW 1. The criteria for entitlement to service connection for diabetes mellitus, type II, to include as due to environmental hazards, have not been met. 38 U.S.C. §§ 1101, 1112, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from May 1976 to May 1979 and from May 1982 to April 2000, to include service in Southwest Asia. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded these matters to the RO for further development. As an initial matter, the Board notes that in a June 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for left and right lower extremity radiculopathy of the sciatic nerve and assigned a 10 percent rating for each extremity from November 12, 2019. Because the grant of service connection for left and right lower extremity radiculopathy of the sciatic nerves is essentially part and parcel of the Veteran’s initial lumbar spine increased rating claim, and as it does not commence from the earliest possible effective date stemming from the underlying claim for a higher rating for the service-connected lumbar spine disability (Swain v. McDonald, 27 Vet. App. 219, 224 (2015)), or constitute the highest possible rating for radiculopathy (AB v. Brown, 6 Vet. App. 35 (1993), the Board has recharacterized the issues as identified above. See 38 C.F.R. § 4.71a, DC 5237, Note 1 (evaluate any associated objective neurologic abnormalities...separately). In other words, because the June 2020 rating decision is only a partial grant of the benefit sought, whether higher ratings for bilateral lower extremity sciatic nerve radiculopathy may be awarded throughout the appeal period remains at issue. Additionally, given the evidence of record, the Board has recharacterized and consolidated the claims of service connection for left knee osteoarthritis and a left knee strain as one claim for service connection for a left knee disability, to include osteoarthritis and a knee strain and has also recharacterized and consolidated the claims of service connection for right osteoarthritis and right knee tendonitis as one claim for service connection for a right knee disability, to include osteoarthritis and tendonitis. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (finding that what constitutes a claim is not limited by a lay veteran’s assertion of his or her condition in the application but must be construed based on the reasonable expectations of the non-expert claimant and the evidence developed in processing the claim). Finally, the Board notes that after issuance of the most recent Supplemental Statement of the Case (SSOC) in June 2020, additional VA medical records were added to the claims file, to include a VA posttraumatic stress disorder (PTSD) examination. However, these records are either not relevant to the issues on appeal or duplicative of the medical records already in the Veteran’s claims file. As such, there is no prejudice to the Veteran in proceeding with this appeal. 1. Entitlement to service connection for diabetes mellitus, type II, to include as due to environmental hazards The Veteran contends that his diabetes mellitus, type II, is related to service, to include as due to exposure to environmental hazards/toxins while serving in the Southwest Asia Theater of Operations. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurrent in service. 38 C.F.R. § 3.303(d). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may also be granted for chronic conditions that have manifested continuous symptomology since separation of service. 38 C.F.R. §§ 3.307, 3.309. Additionally, Persian Gulf veterans may be entitled to service connection for a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness in certain circumstances. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf veteran is defined as one who served on active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Persian Gulf War began on August 2, 1990. 38 C.F.R. § 3.2(i). The Southwest Asia Theater of Operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, and the Red Sea. 38 C.F.R. § 3.317(e)(2). As the Veteran served on active duty in the Southwest Asia Theater of Operations during the Persian Gulf War, he is considered a Persian Gulf Veteran under the applicable regulations. Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. Under the applicable provisions, an undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As an initial matter, the Board finds that the Veteran has a diagnosis of diabetes mellitus, type II, for VA compensation purposes. See March 2015 VA examination. Therefore, the remaining questions are whether the Veteran experienced an in-service injury, event, or disease and whether there is a nexus or link between the Veteran’s current disability and any in-service injury, event, or disease. Turning to the evidence of record, the Veteran’s active duty service treatment records (STRs) are silent as to any complaints, treatment, or diagnoses related to diabetes mellitus. Throughout his service, the Veteran underwent several medical examinations, which reflect a normal endocrine system upon clinical evaluation. See e.g. February 1977 Report of Medical Examination; July 1978 Report of Medical Examination; August 1992 Report of Medical Examination. In his March 2000 Retirement Report of Medical History, the Veteran reported that his father had diabetes as well as his grandmothers on both sides of his family. He further reported that he was often tired and nods off after lunch and thought this may be related to a blood sugar problem. His associated March 2000 Retirement Report of Medical Examination reflects that his endocrine system was normal upon clinical evaluation. His urine sugar and albumin were also negative while his fasting blood sugar was 99 milligrams per deciliter (mg/dl). The post-service medical records reflect that the Veteran was first diagnosed with diabetes mellitus in February 2008 based on a fasting blood glucose level above 126 mg/dl. Specifically, a February 2008 private treatment record reflects that the Veteran was diagnosed with non-insulin-dependent diabetes mellitus that was new in onset. In support of his claim that his disability is related to service in the Persian Gulf, the Veteran submitted notification letters from the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness, and Military Deployments, dated July 1997 and December 2000. The letters explained that if the Veteran was with his unit between March 10, 1991, and March 13, 1991, he may have been exposed to a very low level of sarin and cyclosarin, which are chemical/nerve agents. The July 1997 notification letter specifically noted that although little was known about the long-term effects from a brief, low level exposure to nerve agents, current medical evidence indicated that long-term health problems were unlikely. The December 2000 follow up notification letter informed the Veteran that the possible exposure was considered to be generally smaller than those modeled in 1997 and that based on current medical evidence and ongoing research, there was no indication that any long-term health effects would be expected from the brief, low-level exposure to chemical agents that may have occurred as due to the referenced incident. See September 2016 and March 2019 correspondences. The record also contains several VA opinions regarding the nature and origin of the Veteran’s condition. The Veteran was first afforded a VA Gulf War examination with an associated diabetes mellitus examination in March 2015. The March 2015 examiner found that the Veteran’s claimed conditions, including diabetes, constituted diseases with a clear and specific etiology and diagnosis. The examiner also found that it was less likely than not that the Veteran’s disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner noted the length of time between the Veteran’s service in Southwest Asia and his onset of diabetes in 2008 and explained that diabetes or other endocrine/metabolic disorders have not been associated with service in Southwest Asia. In support of her conclusion, the examiner cited to medical research addressing the health effects of serving in the Gulf War. The November 2018 Board decision found that the March 2015 VA opinion was inadequate because the VA examiner did not provide an opinion as to whether the Veteran’s disability was related to any other aspect of his military service outside of service in Southwest Asia. However, the Board assigns some probative weight to this opinion in so far as the opinion addresses whether the Veteran’s diabetes mellitus, type II, is related to environmental hazards while serving in Southwest Asia. Thereafter, the Veteran underwent another VA examination in November 2019. The November 2019 VA examiner opined that the Veteran’s condition was less likely than not related to service, to include as due to environmental hazards in Southwest Asia on a non-presumptive basis. The examiner explained that although the Veteran reported at the time of his March 2000 retirement examination that he was often tired and nodded off after lunch, which may be a blood sugar problem, laboratory testing for diabetes was normal. The examiner explained that, at that time, his fasting blood glucose was 99, which is not consistent with a blood sugar problem (neither diabetes nor hypoglycemia) and that his urinalysis was also negative for sugar and albumin/protein. The examiner further explained that the Veteran was diagnosed with diabetes mellitus in February 2008, approximately eight years after his discharge from service, when he was over 50 years old, and after he had gained over 50 pounds since service. The examiner noted that the Veteran also reported a strong family history of diabetes. As such, the VA examiner concluded that the Veteran’s diabetes mellitus, type II, is most likely due to his advancing age and weight gain in the setting of a genetic predisposition to diabetes. In support of her conclusion, the examiner also cited to online medical research concerning risk factors associated with diabetes mellitus, type II. The examiner further noted that although the Veteran reported he received notification in 1997 about possible exposure to nerve agents while serving in Iraq, the notification showed that current medical evidence indicated that long term health effects were unlikely. Finally, she concluded that the Veteran’s diabetes was not part of a chronic disability pattern associated with Southwest Asia environmental hazards defined as "undiagnosed illnesses" or "diagnosed medically unexplained chronic multi-symptom illnesses.” In light of the above evidence, the Board finds that the preponderance of the evidence is against finding that the Veteran’s claimed condition was manifest during service, or was shown to have developed as a result of an in-service injury, event, or disease. Specifically, the probative medical evidence of record does not indicate that his current diabetes mellitus, type II, is related to his time in active service. The Board finds that the November 2019 VA opinion of record constitutes highly probative evidence of the medical nexus question as this opinion was based upon a review of the Veteran’s documented medical history, assertions, and other examinations of records, and based upon rationale with clear conclusions and supporting evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the November 2019 opinion sets forth, with detailed rationale, that the Veteran’s diabetes mellitus, type II, was not caused by service, to include any presumed exposure to hazardous environmental toxins while serving in the Persian Gulf. The examiner also explained, with rationale supported by medical literature, that the Veteran’s diabetes mellitus, type II, is more likely related to age, weight-gain, and genetic predisposition. The Board notes that there is no contrary probative opinion of record. Moreover, the March 2015 Gulf War examiner specifically found that the Veteran’s diabetes mellitus, type II, was not related to exposure to environmental hazards while serving in Southwest Asia and the examiner also cited generally to online research to support this contention. As such, the Board also assigns this opinion some probative weight as to the issue of whether the Veteran’s disability is related to exposure to environmental hazards. Therefore, while the Board concedes exposure to environmental hazards while serving in Southwest Asia, the probative medical opinions of record do not show that the Veteran’s diabetes mellitus, type II, is related to such exposure or otherwise related to his active duty service. Further, the medical evidence of record does not show any complaints or symptoms related to the Veteran’s diabetes mellitus, type II, until several years after his active duty service. The Board notes that this delay, while not conclusive, weighs against the establishment of service connection. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board’s denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board acknowledges that the Veteran is competent to report the symptoms that he experienced. However, he is not competent to provide an opinion as to the nature and cause of his disability or to opine that the symptoms that he experienced, as well as any in-service exposure, are related to specific diagnoses. These issues are medically complex, as they require specialized medical education and interpretation of medical test results. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As the Veteran is not shown to have appropriate training and expertise, he is not competent to render a persuasive opinion as to such matters. See id. Moreover, the Board finds that the November 2019 opinion, which is supported by rationale, as well as the contemporaneous medical records to be of more probative weight than the general assertions of the Veteran. Accordingly, when weighing the medical and lay evidence of record, including the contemporaneous medical records that do not reflect a diagnosis or symptoms of diabetes mellitus, type II, until years after active service and the probative opinions of record, the preponderance of the evidence shows that the Veteran’s current disability is not related to service, or any in-service injury, event, or disease, including presumed exposure to environmental hazards while serving in Southwest Asia and/or exposure to any nerve agents. In this regard, the Board finds probative the December 2000 letter from the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness, and Military Deployments, indicating that based on current medical evidence and ongoing research, there was no indication that any long-term health effects would be expected from the brief, low-level exposure to chemical agents that may have occurred. See September 2016 and March 2019 correspondences. Finally, as noted above, the record does not reflect that the Veteran’s current diabetes mellitus, type II, manifested during the Veteran’s active duty service, or within one year after his separation from service. As such, presumptive service connection for this disability, on the basis of a chronic disease, is not warranted. Additionally, as the Veteran’s diabetes mellitus, type II, is a diagnosed condition, which the November 2019 VA examiner found to be more likely than not age and weight related, the Gulf War presumptions are not for application in this case. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (defining qualifying chronic disease for purposes of Gulf War presumptions and stating when they are applicable). Therefore, the record does not show that the Veteran’s diabetes mellitus, type II, is related to service. As the weight of the evidence is against the claim, entitlement to service connection for diabetes mellitus, type II, is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for lumbosacral spondylosis with arthritis and entitlement to compensable ratings for left and right lower extremity radiculopathy of the sciatic nerves prior to November 12, 2019, and ratings in excess of 10 percent thereafter Unfortunately, the Board finds that additional development is necessary prior to final adjudication of these claims. Most recently, in a November 2018 decision, the Board remanded the Veteran’s increased rating claim for his lumbar spine disability to obtain a VA examination that tested for pain in active motion, passive motion, weight-bearing, and non-weightbearing and that included adequate information concerning functional loss during flare-ups and after repeated use over time. As such, the Veteran underwent another VA examination in November 2019. However, while the November 2019 VA examiner provided initial range of motion measurements, the examiner did not record the range of motion measurements for where pain began despite finding that pain was noted on examination and caused functional loss. Additionally, the examiner did not provide passive range of motion measurements or measurements with weight bearing despite also finding that there was pain with these tests. The Board reiterates that in Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) concluded that 38 C.F.R. § 4.59 requires VA examinations, whenever possible, to include joint testing for pain on both active and passive range of motion, as well as with weightbearing and non-weightbearing, and that if an examiner is unable to conduct the required testing or concludes that such is unnecessary, he or she should clearly explain why that it so. Here, the November 2019 VA examiner did not provide an explanation for her failure to provide the required range of motion measurements. Additionally, the November 2019 VA examination includes contradictory findings concerning the Veteran’s functional loss after repeated use over time. In this regard, the November 2019 VA examiner found that pain, weakness, fatigability, or incoordination does not significantly limit functional ability with repeated use over a period of time despite also finding that the Veteran’s pain limited his standing to no more than five to ten minutes at a time. The examiner further noted, without any explanation, that she had no basis to offer additional losses of function or motion when it comes to repetitive use or during a flare-up. As the VA examiner’s findings regarding functional loss appear contradictory and she did not provide an explanation for the bases of her conclusions, the Board finds that the November 2019 VA examination report also does not include the detailed findings concerning functional impairment contemplated in Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, a remand is warranted for a VA examination that complies with the provisions under Correia and Sharp as well as the prior Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Finally, as the findings from the VA examination on remand could impact the Veteran’s radiculopathy increased rating claims, the issues are inextricably intertwined. Moreover, given that the Veteran’s left and right lower extremity radiculopathy of the sciatic nerves have been found to be associated with the Veteran’s lumbar spine disability, and as his lumbar spine increased rating claim begins from May 31, 2013, the Board finds that a retrospective opinion concerning the severity of the Veteran’s left and right radiculopathy is warranted on remand in order to adequately assess the severity of these disabilities throughout the appeal period. 2. Entitlement to service connection for a left knee disability, to include osteoarthritis and a knee strain, and entitlement to service connection for a right knee disability, to include osteoarthritis and tendonitis Unfortunately, the Board cannot make a fully informed decision the Veteran’s claim because the last VA opinion of record, in November 2019, did not adequately address the secondary service connection issue of aggravation. In this regard, although the November 2019 VA examiner provided negative nexus opinions for direct service connection and the issue of whether the Veteran’s service-connected plantar fasciitis caused the Veteran’s left and right knee disabilities with comprehensive rationale, the examiner did not provide adequate rationale for her finding that the Veteran’s knee disabilities were not aggravated by his service-connected plantar fasciitis. Specifically, the examiner did not provide separate findings and rationales with respect to the independent questions of causation and aggravation and, instead, appeared to focus her rationale on the issue of causation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are independent concepts and should have separate findings and rationales). Although the November 2019 VA examiner noted that the medical literature does not support plantar fasciitis as a significant contributor to osteoarthritis of the knee and cited to a 2013 study on plantar fasciopathy that demonstrated a generally symmetrical gait pattern between the symptomatic and asymptomatic limbs, the examiner did not explain how this study, or the medical literature, shows that in the Veteran’s specific case, his knee disabilities were not aggravated by his service-connected plantar fasciitis. As such, the Board finds that a remand is warranted for an addendum opinion as to the issue of aggravation that contains complete rationale. Additionally, an August 2015 medical record reflects an assessment that the Veteran’s bilateral knee pain is likely related to just normal wear and tear as well as his gait being somewhat turned off from his back pain. As such, on remand, the VA examiner should also provide an opinion as to whether the Veteran’s left and right knee disabilities are caused or aggravated by his service-connected lumbosacral spondylosis with arthritis. 3. Entitlement to service connection for hypertension/high blood pressure, to include as due to environmental hazards Unfortunately, the Board also finds that another remand is warranted because the last VA opinion of record, in November 2019, is inadequate. In this regard, the November 2019 VA examiner found that the Veteran’s hypertension was not related to his active duty service after finding that the Veteran was diagnosed with hypertension in February 2009. However, review of the medical evidence of record reflects that the Veteran was assessed with hypertension prior to this date. Specifically, a May 2007 private treatment record reflects that the Veteran was assessed with hypertension while a December 2008 private treatment record also reflects that the Veteran was diagnosed with hypertension. Further, an April 2005 private treatment record reflects an elevated blood pressure reading of 140/88 mmHg and a treatment plan for the Veteran to check his blood pressures at work. The November 2019 VA examiner did not consider or address this evidence. As such, the November 2019 VA examiner’s finding as to the onset of the Veteran’s disability appears inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (noting that a medical opinion based on an inaccurate factual premise has no probative value). Additionally, the examiner based her negative nexus opinion in part on the premise that although the Veteran had elevated blood pressure readings within a year after his discharge from service, such readings did not amount to a diagnosis of hypertension for VA disability rating purposes. However, the VA examiner did not address whether these elevated blood pressure readings reflect an onset of symptoms, later diagnosed as hypertension. In other words, although the VA examiner found that the Veteran’s elevated blood pressure readings did not meet the criteria for a diagnosis of hypertension, the VA examiner did not attempt to explain whether the Veteran’s diagnosed hypertension could be related to the elevated blood pressure readings. Therefore, for the above reasons, the Board finds that a remand is warranted for an addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated May 2020. 2. Provide the Veteran with another opportunity to identify and/or submit any outstanding private treatment records related to his claims. After securing the necessary releases, attempt to obtain and associate those identified records with the claims file. 3. Then, schedule the Veteran for a VA examination to assess the severity of his service-connected lumbosacral spondylosis with arthritis, to include his associated left and right lower extremity radiculopathy of the sciatic nerves. The claims file, including a copy of this Remand, must be made available to, and be reviewed by the examiner. All indicated testing should be accomplished and all symptomatology associated with the disabilities should be identified. The examiner should respond to the following: (a) The examiner MUST TEST the Veteran’s range of motion on active and passive motion, on weight-bearing and non-weight-bearing, if possible, and record the range of motion measurements. (b) If there is evidence of pain on motion, the examiner must indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination results in any loss of range of motion. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (c) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use due to the Veteran’s lumbar spine disability. The examiner should state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups, if any, he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his lumbar spine and after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion ESTIMATING any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. (d) If it is not feasible to determine the extent to which the Veteran experiences additional functional loss on repeated use over time or during flare-ups without resorting to speculation, the examiner must provide an explanation for why that is so. The examiner is further advised that the inability to provide an opinion without resorting to speculation must be based on the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner.   (e) The examiner is also asked to provide a RETROSPECTIVE OPINION concerning the Veteran’s left and right lower extremity radiculopathy associated with the Veteran’s lumbar spine disability. Specifically, the VA examiner should DISCUSS the severity of the Veteran’s left and right lower extremity radiculopathy since May 31, 2013, to include whether such manifested as mild, moderate, moderately severe, or severe incomplete paralysis, or complete paralysis of the sciatic nerves. In providing the above opinion, the VA examiner should consider all pertinent evidence of record, including: (1) the May 2013 private treatment record reflecting the Veteran had a couple of episodes of radiating pain a couple of times a week; and (3) the August 2016 private treatment record indicating the Veteran’s problems included radicular pain. A rationale should be provided for all opinions expressed. 4. Obtain an addendum opinion from an appropriate medical professional to determine whether the Veteran’s claimed left and right knee disability is aggravated by his service-connected plantar fasciitis. The claims file, including a copy of this Remand, must be made available to, and be reviewed by the examiner. The examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right and left knee disability is aggravated by his service-connected bilateral plantar fasciitis. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right and left knee disability is (1) caused by or (2) aggravated by his service-connected lumbosacral spondylosis with arthritis. The examiner should provide an opinion for BOTH causation and aggravation. If aggravation is found, the examiner should quantify the degree of aggravation, if possible, and state whether there was a medically ascertainable increase in disability regardless of permanence. In providing the above opinion, the examiner must ADDRESS the Veteran’s contention that his service-connected plantar fasciitis caused an alteration of his gait, which impact his knee problems. See March 2015 VA knee examination. In this regard, a September 2012 private treatment record reflects the Veteran had been treated with foot orthoses for plantar fasciitis that severely impacted his ability to walk with comfort and work. An August 2015 medical record also reflects an assessment that his knee pain is likely related to just normal wear and tear as well as his gait being somewhat turned off from his back pain. A complete rationale should be given for each opinion expressed with a fully reasoned explanation. In this regard, a discussion of the facts and medical principles involved would be of considerable assistance to the Board, to include citations to any medical literature, if appropriate. 5. Obtain an addendum medical opinion to address the Veteran’s claim for service connection for hypertension. The claims file, to include a copy of this Remand, should be made available to and be thoroughly reviewed by the examiner. The examiner should respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension had its onset in service or is otherwise related to service, to include from presumed environmental hazard exposure while servicing in Southwest Asia? In providing the above opinion, the examiner must address the Veteran’s elevated blood pressure readings within a year of his separation from service and explain whether such could be related to the Veteran’s later diagnosed hypertension and/or represent early manifestations of his hypertension. In providing the above opinion, the examiner should also consider the (1) April 2005 private treatment record reflecting an elevated blood pressure reading of 140/88 mmHg and a treatment plan to check his blood pressures at work and (2) May 2007 private treatment record reflecting that the Veteran was assessed with hypertension.   The examiner should comment on all questions above and set forth a complete rationale for all opinions. The rationale for a negative opinion must not be based solely on the lack of a relevant in-service diagnosis. A detailed discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Purcell, Associate 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.