Citation Nr: 21026252 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 10-42 189 DATE: April 30, 2021 ORDER Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a bilateral eye disorder is denied. Entitlement to service connection for migraine headaches as secondary to service-connected unspecified anxiety disorder and tinnitus is granted. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) by reason of service-connected disabilities is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a heart disorder at any time during or approximate to the pendency of the claim. 2. The Veteran’s hypertension was not shown as chronic in service, did not manifest to a compensable degree within the applicable presumptive period, a continuity of symptomatology is not established and is not otherwise etiologically related to an in-service injury or disease. 3. The bilateral eye disorder, to include diabetic retinopathy and cataracts, was not shown as chronic in service and is not otherwise etiologically related to an in-service injury or disease. 4. Resolving reasonable doubt in the Veteran's favor, the Veteran's migraine headaches are proximately due to his service-connected unspecified anxiety disorder and tinnitus. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a bilateral eye disorder have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.9. 4. The criteria for service connection for migraine headaches as secondary to unspecified anxiety disorder and tinnitus have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to June 1983. These matters come before the Board of Veterans' Appeals (hereinafter Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. By a rating action in March 2016, the RO denied the Veteran's claims of entitlement to service connection for a heart condition and service connection for a left knee disorder. By a rating action in September 2016, the RO confirmed the denial of service connection for a heart condition; the RO also denied the claims of entitlement to service connection for a bilateral eye condition, service connection for headaches and service connection for hypertension. The Veteran perfected a timely appeal to those decisions. In July 2018, the Board remanded the case to the RO for further evidentiary development of the issues on appeal. Specifically, the claims were remanded to obtain outstanding private treatment records and obtain etiology opinions as to the claimed hypertension, left knee disorder and bilateral eye disorder. An August 2019 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain private treatment records. VA examinations were conducted in November 2020. Following the requested development, a supplemental statement of the case (SSOC) was issued in March 2021. The Board therefore finds that there has been substantial compliance with its previous remand. An April 2020 rating decision granted the Veteran's claim for service connection for an unspecified anxiety disorder and assigned an initial rating. As this decision represents a full grant of the benefits sought with respect to this claim for service connection, such issue is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: "(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"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including cardiovascular renal disease, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also 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). Establishing service connection on a secondary basis requires evidence showing (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id. see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a heart disorder The Veteran maintains that he developed a heart disorder as a result of military service. Specific argument in support of this appeal has not been submitted. Based on the evidence of record, the Board concludes that the Veteran does not have a current diagnosis of a heart disease or a heart disorder, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). In this regard, the Board notes that the service treatment records are silent as to any complaints, treatment, or clinical diagnosis for a heart disorder. Post service treatment records, VA as well as private, were negative for any complaints of or treatment for a heart disorder. The Veteran filed his claim for service connection for a heart condition in January 2016. During the pendency of the claim or immediately preceding filing, he was not diagnosed with any heart disorders by a medical professional. Treatment records dated from March 2006 to August 2015 were negative for any complaints of or treatment for a heart disorder. Indeed, a primary care note, dated in December 2015, indicates that the Veteran reported being hospitalized several times for a transient ischaemic attack (TIA) and was given aspirin; however, subsequent a computed tomography (CT) scan and electrocardiogram (EKG) were negative for any heart condition. On examination, clinical evaluation of the cardiovascular system revealed no chest pain or palpation. Lastly, while VA treatment records associated with the claims file in August 2019 indicated that the Veteran reported having suffered a heart attack in 2016, subsequent diagnostic studies were reported to be normal. In a letter dated in May 2019, it was noted that an echocardiogram showed normal heart function. Similar findings were noted during a primary care evaluation in July 2019. The treatment records do not indicate that the Veteran was diagnosed with a current heart disorder. With regard to the claimed heart disorder there is not sufficient evidence to show that the Veteran has had a heart disorder during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board acknowledges the Court’s holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of a heart disorder. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). The Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). To the extent that the Veteran asserts that he has a heart condition, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether there is a currently existing heart condition, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board places less probative value on the Veteran's lay statements wherein he relayed or provided a self-diagnosis. The Board notes that the Veteran has not been afforded a VA examination addressing his claimed heart disorder. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The service and post-service treatment records are otherwise negative for complaints, treatments or diagnoses related to a heart disorder. Further, the evidence does not indicate that his claimed heart disorder may be related to his military service. See McLendon, supra. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide this claim. In conclusion, as the record does not demonstrate that the Veteran currently has a heart condition, service connection is not warranted. As such, the Board must deny this issue on appeal. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, supra. In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the claim, the doctrine is not for application. Therefore, service connection for a heart disorder is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, supra. 2. Entitlement to service connection for hypertension The Veteran essentially contends that he is entitled to service connection for hypertension. The service treatment records are completely silent with respect to any finding of hypertension. Significantly, the enlistment examination in April 1980 noted a blood pressure reading of 98/56. A May 1981 treatment note reported a blood pressure reading of 126/96, but no diagnosis of hypertension. A treatment note, dated in March 1983, recorded a blood pressure reading of 110/72. And, on the occasion of a quadrennial examination during reserves, in November 1985, the Veteran denied any history of high blood pressure; the examination findings reported a blood pressure reading of 120/68. The Board has first considered whether service connection is warranted on a presumptive basis. The record does not show blood pressure readings consistent with hypertension, as defined by regulation, during his active duty service or within one year of his separation from active duty service in June 1983. Indeed, the first clinical evidence of hypertension was made in a VA primary care note in June 2000, more than 17 years after the Veteran's separation from active duty, well after the presumptive period had elapsed. As such, service connection on a presumptive basis is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. With regards to direct service connection, a November 2020 VA examiner opined that the claimed condition was less likely than incurred in or caused by the claimed inservice injury, event, or illness. The examiner explained that, in order to establish a diagnosis of hypertension, the patient must have three recorded blood pressure readings above 140/90 on three different occasions, and this is why one reading of 125/96 is not sufficient to establish a diagnosis of hypertension; otherwise there was no other records of elevated blood pressure during the service or immediately after discharge from the service. The examiner further explained that most common causes for hypertension are family history, age, race, diet, sedentary lifestyle, tobacco use, overweight, but none of those factors are caused by the military service. The examiner noted that the Veteran had multiple visits at the VA documenting that his hypertension is under control including visits in 2018. Consequently, the examiner concluded that it is less likely than not that the current well controlled hypertension is incurred during the military service. The examiner's opinion is probative, because it is based on an accurate medical history and provide an explanation containing clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no contrary opinion of record. The Board has considered the statements of the Veteran asserting that his hypertension is related to service. While the Veteran is competent to provide statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Veteran has not demonstrated medical or scientific expertise. His opinion as to what caused his hypertension, under the facts of this case, is not competent evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For the foregoing reasons, the evidence does not establish that the Veteran had hypertension during active service or to a compensable degree within one year of separation from active service, or that his hypertension is otherwise related to active service. Accordingly, hypertension was not incurred in or aggravated by service, nor may it be presumed to have so been incurred. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, supra. 3. Entitlement to service connection for a bilateral eye disorder The Veteran is seeking service connection for an eye disorder, including cataracts, which he claims developed as a result of his active service. As an initial matter, the Board notes that congenital or developmental defects, such as refractive error of the eyes, are not diseases or injuries within the meaning of applicable legislation and, thus, are not disabilities for which service connection may be granted. 38 C.F.R. § 3.303(c); see also 38 C.F.R. § 4.9; Beno v. Principi, 3 Vet. App. 439 (1992). The Board concludes that, while the Veteran has a current diagnosis of cataracts, dry-eye syndrome, pinguecula, diabetic retinopathy, and evidence shows that he was treated for abrasion in the left eye and laceration over the right eye in service, the preponderance of the evidence weighs against finding that the Veteran's currently diagnosed eye conditions began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records show that the Veteran was seen in May 1981 after suffering a laceration over the right eye. In May 1982, the Veteran was seen for complaints of burning of the eyes. In June 1982, he was again seen for burning and irritation of the eyes; he was diagnosed with mild follicles. In an optometry clinic note, dated in October 1982, it was reported that prescription was given for near only. In March 1983, the Veteran was seen for evaluation after being hit on the head with a hanger and suffering an abrasion over the right eye; he was diagnosed with healing abrasion and was doing well. Post-service VA treatment records document eye disabilities decades after the Veteran's separation from service. Moreover, following a June 2016 VA examination, the examiner opined that the claimed eye condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner stated that the Veteran does not have a bilateral eye condition that incurred in or was caused by any treatment during service. The examiner noted that the current diagnoses of non-proliferative diabetic retinopathy, dry eye and pinguecula were not present in service; he further noted that the conditions for which the Veteran was treated while in service resolved without sequelae. On the occasion of a more recent VA examination in January 2021, the examiner noted the diagnoses of bilateral cataracts and bilateral diabetic retinopathy. It was noted that the Veteran developed diabetes in 2005; and, as time passes, he has changes in his retina that required laser treatment of the retina, and he has some decreases in vision due to the diabetes and a cataract. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness. The examiner stated that there was no reason for the Veteran’s development of diabetes, and it was not due to anything that happened in service. He stated that the cataracts are due to his age. A March 2021 addendum opinion indicates that the Veteran does not have an ocular diagnosis that are at least as likely as not caused or otherwise related to the Veteran's service, that his diabetic retinopathy is due to his diabetes mellitus and that glaucoma suspect is idiopathic or hereditary and that the presbyopia/hyperopia are developmental errors of refraction. The examiner noted that the conditions are not due to the records and complaints of a knot on the right upper eye lid and/or bilateral eye burning or other abnormal bilateral eye symptoms noted between 1981 to 1983 in the service treatment records. Considering this evidence, the Board finds that, regardless of whether or not the symptoms related to eye injuries in service had resolved prior to Veteran’s discharge from active duty, the Board finds that the most probative evidence is against finding a nexus between the in-service complaints or incidents and the current diagnoses of diabetic retinopathy and cataracts. As noted above, the examiner opined that the cataracts are related to the Veteran’s age and clearly the retinopathy is related to his diagnosis of diabetes, which is not service connected. To the extent that the Veteran asserts that he has eye disability that is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the current diagnoses because he does not have the requisite medical knowledge or training, and because this matter is beyond the ability of a lay person to observe. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1377. Therefore, the Veteran is not considered competent (meaning medically qualified) to address the etiology of his claimed eye disorder. As the preponderance of the evidence is against the claim of entitlement to service connection for an eye disability, including retinopathy and cataracts, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 4. Entitlement to service connection for migraine headaches The Veteran maintains that he developed headaches as a result of his military service. Alternatively, it is argued that the Veteran’s migraine headaches developed secondary to his psychiatric disorder and tinnitus. There is no dispute as to the existence of a current headache disability. Indeed, submitted in support of the Veteran's claim was a VA examination report dated in December 2017, which reflects a diagnosis of tension headaches. The Veteran also has been service connected for tinnitus and was most recently service-connected for unspecified anxiety disorder. Thus, the first two elements of secondary service connection have been established. See Allen, 7 Vet. App. at 446; 38 C.F.R. § 3.310. In assessing the Veteran's secondary service connection claim, the sole question remaining for consideration is whether the medical evidence demonstrates a causal relationship between the service-connected unspecified anxiety disorder and the Veteran's tension headaches. Turning to the medical evidence at hand, the Board notes that the Veteran obtained a private opinion for this issue. In a medical statement, dated in December 2017, Dr. H.S. noted that the Veteran reported that his headaches are brought on by stress, back and neck pain, ringing in his ears, and sinus problems. The physician also noted that a psychological evaluation in November 2017 reflects a diagnosis of depressive disorder with symptoms of anxiety, depressed mood, and chronic sleep impairment. The physician also noted that research has shown that patients with mental health disorders are more likely to develop headaches because pain and mood are regulated by the same part of the brain. The physician stated that, based on his interview with the Veteran, review of the claims file and the above cited medical literature, it was his opinion that the Veteran’s headaches are more likely than not caused by and permanently aggravated by his tinnitus, depressive disorder, back and neck pain and sinus problems. The physician stated that it would be impossible to determine how much of each factor contributes to the headache more than the other. The Board finds this opinion to be probative. The physician reviewed the evidence of record, accounted for the lay statements and provided a medical opinion based on an adequate rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no contrary opinion of record as to secondary service connection nor is there sufficient basis for the Board to reject these supportive opinions and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). The Board notes that although an October 2020 VA examiner provided an negative etiology opinion, such opinion addressed direct service connection only. The Board finds that the evidence is at least in equipoise regarding service connection for headaches and will resolve reasonable doubt in favor of the Veteran. Thus, all the elements necessary for establishing service connection on a secondary basis are met and service connection for headaches as secondary to service-connected unspecified anxiety disorder is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REMANDED ISSUES 5. Service connection for a left knee disorder is remanded. The Veteran essentially contends that his currently diagnosed left knee disorder is related to his active military service. The Veteran indicates that he suffered an injury to his left knee when someone jumped on his knee during basic training and he states that the knee has gotten worse over the years. Following the July 2018 Board remand, a VA opinion was obtained in October 2020. The examiner opined that it was less likely than not that the Veteran's current left knee arthritis was incurred during service as there was evidence in the record of a knee injury during service and that the Veteran's degenerative arthritis is caused by aging of the joint and is not related to military service. The examiner also checked the box which indicated that the claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness. This opinion is therefore internally inconsistent. Moreover, service treatment records reflect complaints of left knee problems in August 1980 and indicated that there was mild suprapatellar crepitus. This opinion appears to be based upon an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993). On remand, an addendum etiology opinion should be obtained. 6. Entitlement to a TDIU Awards of TDIU are governed, in part, by 38 C.F.R. § 4.16. Under subsection (a) of that regulation, total disability ratings for compensation can be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, the disability must be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See also 38 C.F.R. §§ 3.340, 3.341. The Veteran has a current combined rating of 60 percent and hence does not meet the schedular requirements for a TDIU. Although the Veteran does not currently meet the schedular standards for eligibility for a TDIU under 38 C.F.R. § 4.16(a), 38 C.F.R. § 4.16(b) provides that such veterans are nevertheless entitled to such consideration on an extraschedular basis where appropriate. While the Board has granted the Veteran's claim for service connection for migraine headaches herein, the grant of service connection has not yet been implemented by the RO, and as such, a disability rating has yet to be assigned for this disorder. In light of the fact that the Veteran's migraine headaches has not yet been assigned a specific disability rating, the Veteran's current schedular rating could change following additional development of this claim. As such, the Board finds that the Veteran's claim for entitlement to a TDIU is dependent upon implementation of the grant of service connection for migraine headaches. When a determination on one issue could have a significant impact on the outcome of another issue, the issues are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180 (1991). These matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for an appropriate VA examination to assist in determining the etiology of his current left knee disorder. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran's current left knee disorder is caused or otherwise related to the Veteran's active duty service from June 1980 to June 1983? In rendering an opinion, the examiner should discuss the significance of an August 1980 service treatment record showing treatment for left knee problems, including an X-ray. See VBMS entry with document type, "Medical Treatment Record-Government Facility," receipt date 03/02/2016, at page 1. The examiner must provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 3. After implementing the Board's decision, the RO should readjudicate the TDIU claim in light of the additional record and should consider the November 2017 opinion from Dr. H.H.G.. If the Veteran does not meet the schedular criteria, refer the issue of entitlement to TDIU to the Director of Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 4.16 (b). KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Suzie S. Gaston, 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.