Citation Nr: 21028621 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-48 236A DATE: May 11, 2021 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for left ear hearing loss is granted. Entitlement to service connection for a sleep disorder is denied. REMANDED Entitlement to service connection for right ear hearing loss is remanded. Entitlement to service connection for epididymitis is remanded. Entitlement to service connection for erectile dysfunction secondary to epididymitis is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as secondary to epididymitis, erectile dysfunction, and/or hearing loss, is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a left shoulder disability secondary to a left elbow disability is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability secondary to a right foot disability is remanded. Entitlement to service connection for a left ankle disability secondary to a right foot disability is remanded. Entitlement to service connection for a left knee disability secondary to a right foot disability is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise that the Veteran's tinnitus had its onset during service as a result of military noise exposure. 2. The evidence is at least in equipoise that the Veteran's left ear hearing loss had its onset during service as a result of military noise exposure. 3. The Veteran does not have a currently-diagnosed sleep disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a sleep disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1974 to February 1978. These matters are before the Board of Veterans' Appeals (Board) on appeal from December 2014 and July 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Veteran and his spouse testified before the undersigned Veterans Law Judge at a virtual tele-hearing. A transcript of the hearing is of record. The Veteran submitted an untimely VA Form 9 in September 2019. The Board has considered that a substantive appeal is not a jurisdictional requirement, and VA may waive any issue of timeliness in the filing of a substantive appeal, either explicitly or implicitly, where appropriate. Percy v. Shinseki, 23 Vet. App. 37 (2009). In this case, the RO subsequently certified the relevant issues to the Board and the Veteran was granted a Board hearing on the merits of the issues and was led to believe that these issues were on appeal before the Board. Accordingly, the Board will exercise its discretion to waive the untimeliness of the Veteran's substantive appeal and will address the merits of the claims. Duties to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. Neither the Veteran nor his representative have advanced any procedural arguments in relation to VA's duty to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic disorders, to include tinnitus and sensorineural hearing loss, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In such cases, the disease is presumed under the law to have had its onset in service even if there is no evidence of such disease during service. 38 C.F.R. § 3.307(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Gilbert, 1 Vet. App. at 53-56. 1. Entitlement to service connection for tinnitus The Veteran seeks service connection for tinnitus, which he contends was incurred in service due to exposure to excessive military noise. The Veteran asserts that he was exposed to hazardous noise while stationed onboard the USS Fort Snelling where his military occupational specialty (MOS) of machinist's mate required him to work in the ship's forward engine and boiler rooms. Due to his MOS, VA has already conceded the Veteran's noise exposure during service. The Veteran testified at the August 2020 Board hearing that he first began experiencing tinnitus during service and that the symptoms have continued ever since. Initially, the Board notes that tinnitus is a type of disability that may be established on the basis of lay evidence alone. Charles v. Principi, 16 Vet. App. 370 (2002). As such, there is no dispute that the Veteran has a current diagnosis of tinnitus. Therefore, the question remaining before the Board is whether the Veteran's current tinnitus is etiologically related to his in-service noise exposure. Based on a careful review of the subjective and clinical evidence of record, the Board resolves all reasonable doubt in the Veteran's favor and finds that service connection for tinnitus is warranted. The Veteran underwent a VA audiology examination in December 2014. The VA examiner opined that the Veteran's tinnitus is less likely than not caused by or a result of military noise exposure. The examiner noted that, on examination, the Veteran reported an onset of tinnitus about five years ago, which is over 30 years post-military service. The examiner further remarked that the service treatment records do not contain complaints of tinnitus or document significant threshold shifts in hearing during active duty service, and, therefore, there is no physical cause or nexus found for the Veteran's tinnitus. The Board finds this medical opinion to be inadequate because the examiner did not take into consideration pertinent evidence of record, such as the Veteran's lay statements or MOS, with regard to his significant exposure to acoustic trauma during service and as to experiencing an in-service onset of symptoms of tinnitus. As such, the VA opinion, which is the only medical opinion of record, cannot serve as a basis to deny the Veteran's claim for service connection. The Board acknowledges that the record does not contain an adequate medical opinion with regard to the etiology of the Veteran's tinnitus. Nonetheless, the Board finds that there is sufficient evidence in the record to decide the claim. In the absence of an adequate medical opinion to the contrary, the Board accepts the Veteran's lay statement that his tinnitus had its onset during service and that it has continued ever since. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Based on the Veteran's competent and credible statements regarding the in-service onset and continuity of his symptoms of tinnitus, the Board finds that the evidence is at least in equipoise that the Veteran's tinnitus was caused by in-service noise exposure. Accordingly, resolving all reasonable doubt in the Veteran's favor, service connection for tinnitus is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. 2. Entitlement to service connection for left ear hearing loss The Veteran seeks entitlement to service connection for left ear hearing loss, which he contends was incurred in or caused by military noise exposure. As noted above, VA has already conceded that the Veteran was exposed to hazardous noise during service due to his MOS of machinist's mate. The Veteran maintains that his hearing loss began during service and has continued to worsen ever since. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified puretone and speech recognition criteria. Audiometric testing measures puretone threshold hearing levels (in decibels) over a range of frequencies (in hertz). Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In evaluating service connection claims for hearing loss, it is observed that the threshold for normal hearing is from zero to 20 decibels, with higher threshold levels indicating some degree of hearing loss. Hensley, 5 Vet. App. 155. As an initial matter, the Board finds that the Veteran has a currently-diagnosed hearing loss disability in his left ear. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (a claimant must have a current disability in order to be considered for service connection). In this regard, the Veteran underwent a private audiology examination in July 2014, which showed auditory thresholds of greater than 40 decibels at all frequencies from 1000 to 4000 hertz in the left ear. As such, the Veteran has a current hearing loss disability in his left ear as defined by 38 C.F.R. § 3.385. In making this finding, the Board acknowledges that a December 2014 VA audiological examination did not show the Veteran to have a hearing loss disability in the left ear as defined by VA regulation; however, since the Veteran had a current diagnosis at the time that he filed his claim for service connection in August 2014, the disability is eligible for service connection. See McLain v. Nicholson, 21 Vet. App. 319, 321 (2007). Next, the Board finds that the Veteran had an in-service incurrence of left ear hearing loss. At his January 1974 enlistment examination, the Veteran reported a history of frequent ear infections and a reconstructed left ear tympanic membrane. However, audiometric data taken at enlistment did not reveal the Veteran to have a hearing loss disability, nor did the examining physician note the Veteran to have any such hearing impairment. Service treatment records show that the Veteran was treated several times during service for various ear problems, such as infections, fluid in the ear, and cerumen impaction. He revealed during these episodes a history of frequent ear problems as a young child, resulting in four surgical procedures before the age of five, including two skin grafts for repair or replacement of the left ear drum. At his February 1978 separation examination, audiometric testing revealed puretone thresholds in the left ear as follows: 15 dB at 500 hertz; 25 dB at 1000 hertz; 35 dB at 2000 hertz; 40 dB at 3000 hertz; and 50 dB at 4000 hertz. The examining physician noted a diagnosis of high frequency hearing loss in the left ear. Just over one year later, in April 1979, at an enlistment examination for Naval Reserve service, audiometric testing revealed puretone thresholds in the left ear as follows: 40 dB at 500 hertz; 35 dB at 1000 hertz; 30 dB at 2000 hertz; 40 dB at 3000 hertz; and 45 dB at 4000 hertz. The Board notes that a veteran is presumed to be in sound condition when entering military service except for conditions noted on the entrance examination. To rebut this presumption of soundness, VA must establish clear and unmistakable evidence that (1) an injury or disease existed before acceptance and enrollment into service, and (2) that the preexisting condition was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Significantly, only such conditions as are recorded in examination reports are considered to be noted. 38 C.F.R. § 3.304(b). In this case, the Board notes that although there is evidence that the Veteran had significant left ear problems as a child, resulting in a tympanoplasty, he was not noted to have a hearing loss disability of the left ear on enlistment and he was found fit for duty. Therefore, the Veteran is presumed to have been sound upon entrance. Moreover, the Board does not find any other objective medical evidence of record to suggest that the Veteran had preexisting left ear hearing loss upon entry to active duty. As such, the presumption of soundness is not rebutted in this case. Given the above, the Board finds that the Veteran did not have a hearing loss disability, as defined by 38 C.F.R. § 3.385, in his left ear upon entry onto active duty in January 1974. However, his left ear recorded auditory thresholds of 40 dB or above at the frequencies of 3000 and 4000 hertz at his February 1978 separation examination. As such, the Veteran had a hearing loss disability for VA purposes at separation. Notably, he still had this left ear hearing loss disability 14 months after separation, as shown by April 1979 audiometric testing. Therefore, the Board finds that the Veteran incurred a left ear hearing loss disability during active service. The Board notes that a VA medical opinion was obtained from the VA audiologist who performed the December 2014 VA audiology examination. The VA examiner provided a negative etiology opinion for the left ear, stating that there was no significant threshold shift in hearing between the Veteran's January 1974 enlistment examination and the present examination (December 2014). The examiner did not address the diagnosis of hearing loss in the left ear noted on the Veteran's separation examination. As such, the medical opinion is inadequate and has not been considered in the Board's decision herein. The Veteran is not prejudiced by VA's failure to obtain an adequate medical opinion on his behalf, as the Board's decision on the Veteran's claim is fully favorable. After thorough consideration of the foregoing evidence of record, the Board concludes that service connection for left ear hearing loss is warranted. As noted above, the evidence establishes that the Veteran was exposed to hazardous noise during service in the Navy where he served on a ship as a machinist's mate, and that he incurred a left ear hearing loss disability during service. Moreover, the Veteran has testified that he has experienced decreased hearing acuity in his left ear continuously since discharge from service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that a veteran's statement is competent evidence as to events that are capable of lay observation). Finally, he has been diagnosed with a left ear hearing loss disability for VA purposes during the pendency of the appeal. The sum of these factors is enough to find that the evidence is at least in equipoise that the Veteran's current left ear hearing loss disability had its onset during active duty service and is etiologically related to military noise exposure. As the criteria for service connection have been met, the Veteran's claim with regard to left ear hearing loss is granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. 3. Entitlement to service connection for a sleep disorder The Veteran seeks service connection for a sleep disorder, which he generally contends is related to his active duty service. At the August 2020 Board hearing, the Veteran testified that he has trouble sleeping due to his tinnitus and pain from his various musculoskeletal disabilities, but stated that he has never been diagnosed with a sleep disorder. The Veteran's service treatment records have been associated with the claims file. They include his January 1974 enlistment examination and February 1978 separation examination, on which the Veteran denied a history of frequent trouble sleeping. The records are silent for complaint, treatment, or diagnosis of any sleep problems during service. Notably, there are no post-service private or VA treatment records in the Veteran's claims file. The Veteran has not provided any medical evidence to show that he has sought medical treatment for sleep problems or has been diagnosed with a sleep disorder at any time. The existence of a current disability is the cornerstone of a claim for VA disability compensation; consequently, failure to establish a current disability results in the denial of a claim. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; see Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Specifically, a claimant must have a disability in order to be considered for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the medical evidence of record does not reflect a current diagnosis of any sleep disorder, and the Veteran does not contend that any such diagnosis has been rendered at any time during the pendency of this appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board acknowledges that the Veteran testified at his hearing that he experiences sleeping problems, including waking frequently in the night, due to pain and ringing in his ears. However, the Board finds it significant that the Veteran has never sought medical treatment for his sleeping problems and has never been officially diagnosed with a sleep disorder. While the Veteran is competent to report symptoms of disability, he does not have the specialized medical training to render a diagnosis of a sleep disorder. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, the Veteran has not provided any other competent or credible evidence of the existence of a current sleep disorder. As such, the Board finds that the weight of the probative evidence is against a finding that the Veteran has a current diagnosis for a sleep disorder. Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110. In the absence of proof of current disability there can be no valid claim for service connection. See Brammer, 3 Vet. App. at 225. Thus, in the absence of competent evidence showing a current diagnosis of a sleep disorder, it is unnecessary to address the remaining elements of the claim for service connection. See id. Accordingly, the Board finds that a preponderance of the evidence weighs against the Veteran's claim for service connection for a sleep disorder. Because the evidence fails to establish that the Veteran has a current diagnosis of a sleep disorder, the claim does not satisfy the criteria for service connection. Therefore, the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Unfortunately, the issues remaining on appeal must be remanded for further development. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the claims so that the Veteran is afforded every possible consideration. 1. Entitlement to service connection for right ear hearing loss is remanded. The Veteran seeks entitlement to service connection for right ear hearing loss, which he contends was incurred in service due to military noise exposure. The Veteran last underwent a VA audiological examination in December 2014; however, he was not shown to have a right ear hearing loss disability under the provisions of 38 C.F.R. § 3.385 at that time. At the August 2020 Board hearing, the Veteran testified that his hearing acuity has worsened since it was last evaluated on VA examination in December 2014. Given the Veteran's competent testimony and the significant length of time since his last audiometric testing, the Board finds that remand is warranted to afford the Veteran a VA audiological examination to determine if he has a current right ear hearing loss disability and, if so, whether such disability is etiologically related to service. 2. Entitlement to service connection for epididymitis is remanded. 3. Entitlement to service connection for erectile dysfunction secondary to epididymitis is remanded. The Veteran seeks service connection for epididymitis, which he contends was incurred in or caused by military service. Service treatment records confirm that the Veteran was treated on at least three occasions for episodes of epididymitis during service. The Veteran testified at his August 2020 Board hearing that he has only sought treatment for epididymitis one time since service, sometime in the early 1990s, and was treated with antibiotics and told there was nothing else that could be done except to rest. The Veteran underwent a VA examination in June 2019. The Veteran reported that he has a knot in his left testicle which is painful on palpation and that he has flare-ups without medical intervention two to three times per year. However, physical examination of the Veteran's testes or epididymis were not performed at the Veteran's request. The VA examiner provided a negative etiology opinion for the epididymitis diagnosed during service, noting that the Veteran's current complaints are a new and separate condition not related to service. No further rationale for this finding was provided. The Board finds the June 2019 VA examination and medical opinion to be inadequate. First, the examination report does not clarify whether the Veteran has a current diagnosis of epididymitis. Moreover, the examiner did not provide any explanation for her finding that the Veteran's "current complaints are a new and separate condition" or provide a diagnosis for any such new condition. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for the purposes of the determination being made. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because the record does not contain a VA examination or medical opinion sufficient to fairly adjudicate the Veteran's claim, the Board finds that remand is necessary. On remand, the Veteran must be afforded a VA examination to determine if he has a current diagnosis of epididymitis, or any other condition of the reproductive system, to include erectile dysfunction, that is related to the episodes of epididymitis during military service. The Veteran's claim for service connection for erectile dysfunction is inextricably intertwined with his claim for epididymitis, as the Veteran contends that he has erectile dysfunction that is caused or aggravated by his epididymitis. As such, they must be adjudicated together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 4. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, to include as secondary to epididymitis, erectile dysfunction, and/or hearing loss, is remanded. Initially, the Board notes that the Veteran filed service connection claims for PTSD, depression, anxiety, mood disorder, and anger issues. As discussed with the Veteran at the August 2020 Board hearing, the Board has recharacterized his claim to an acquired psychiatric disorder, which encompasses all potential psychiatric diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Veteran contends that symptoms of his acquired psychiatric disorder began in service after he was involved in a traumatic automobile accident. Alternatively, the Veteran contends that his acquired psychiatric disorder may be secondary to epididymitis, erectile dysfunction, and/or hearing loss, as these conditions and their effects cause him to feel depressed. To date, the Veteran has not been afforded a VA examination with respect to his claim for service connection for an acquired psychiatric disorder. Therefore, the Board finds that remand is necessary to afford the Veteran a VA examination and medical opinion before it can render an informed decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). Moreover, at the August 2020 Board hearing, the Veteran testified that he currently receives mental health treatment from a private counselor. However, the Board notes that the Veteran has not submitted these records nor authorized VA to obtain them on his behalf. On remand, these private treatment records should be obtained. 5. Entitlement to service connection for a left elbow disability is remanded. 6. Entitlement to service connection for a left shoulder disability secondary to a left elbow disability is remanded. 7. Entitlement to service connection for a right foot disability is remanded. 8. Entitlement to service connection for a left foot disability; a left ankle disability; and a left knee disability, secondary to a right foot disability, are remanded. The Veteran seeks direct service connection for a left elbow disability and a right foot disability, which he contends were incurred in or caused by military service. The Veteran has also claimed secondary service connection for other musculoskeletal conditions of the left shoulder, left foot, left ankle, and left knee, which he asserts are caused or aggravated by his left elbow or right foot disabilities. At the August 2020 Board hearing, the Veteran asserted that he suffered a significant injury to his left elbow during service for which he was placed on profile or light duty. He stated he wore a sling for three to four weeks. Service treatment records show that in February 1977, the Veteran reported pain and swelling in his left elbow after falling down a ladder. An x-ray was within normal limits. The Veteran was told to wrap his elbow in an ace bandage. The records do not indicate that the injury required any follow-up treatment, nor do they reflect that the Veteran was placed on profile or light duty. At the hearing, the Veteran also testified that he broke five bones in his right foot during service. His representative referenced a February 10, 1976 service treatment record which stated that the Veteran was treated for a broken foot at Portsmouth Naval Hospital and placed in a cast for six to eight weeks. However, the Board notes that this record is not in the Veteran's claims file. In light of the above, the Board finds that there may be outstanding service treatment records that have not yet been obtained. As such, remand is required to obtain any outstanding service treatment records, to include any Naval Reserve records, to ensure that there is a complete record upon which to decide the Veteran's claims. On remand, the RO must undertake appropriate action pursuant to 38 C.F.R. § 3.159 to identify and obtain these records. Moreover, the Veteran was afforded VA examinations of his left elbow and right foot in December 2019. The VA examiner rendered a diagnosis of left elbow pain based on the Veteran's subjective reports. With regard to the right foot claim, the examiner noted that the Veteran reported no problems with his right foot, but that he had broken his left foot during service. The VA examiner diagnosed left foot pain based on the Veteran's subjective reports. For both the left elbow and left foot, the VA examiner opined that his current complaints are a new and separate condition from the injuries sustained during service. No further rationale was provided for the examiner's conclusions. As such, the Board finds the opinions to be inadequate. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for the purposes of the determination being made. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Because the record does not contain VA examinations or medical opinions sufficient to fairly adjudicate the Veteran's claims, the Board finds that remand is necessary. On remand, the Veteran must be afforded VA examinations and medical opinions that adequately address the nature and etiology of his claimed left elbow and right foot disabilities. Moreover, the hearing, the Veteran testified that he receives private medical treatment for his claimed musculoskeletal disabilities. However, the Board notes that the Veteran has not submitted these records nor authorized VA to obtain them on his behalf. On remand, these private treatment records should be obtained. Finally, the Veteran's secondary service connection claims for the left shoulder, left foot, left ankle, and left knee are inextricably intertwined with his service connection claims for the left elbow and right foot. As such, they must be adjudicated together and the secondary claims must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the matters are REMANDED for the following actions: 1. Contact the Veteran and request that he provide information as to any outstanding private treatment records relevant to his claims on appeal. After obtaining the necessary authorization from the Veteran, the RO must make reasonable efforts to obtain any identified records. For private treatment records, at least two (2) attempts must be made to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Undertake appropriate efforts to request and associate with the claims file any outstanding service treatment records, to include records from Naval Reserve service. If the RO cannot locate the aforementioned records, it must specifically document the attempts that were made to locate them and explain in writing why further attempts to locate or obtain these government records would be futile. The RO should then: (a) notify the Veteran of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The Veteran must then be given an opportunity to respond. 3. Then, schedule the Veteran for VA examinations, with VA physicians of appropriate expertise, to determine the nature and etiology of his claimed disabilities: (i) right ear hearing loss; (ii) epididymitis and erectile dysfunction; (iii) an acquired psychiatric disorder; (iv) left shoulder and left elbow; and (v) right foot, left foot, left ankle, and left knee. The respective examiner must review the Veteran's entire claims file, to include a copy of this REMAND, and that review must be noted in the examination report. A complete history of symptoms must be elicited from the Veteran and recorded in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. Thereafter, the respective examiner is asked to provide fully-articulated medical opinions adequately addressing the following: Right Ear Hearing Loss (a) If audiometric testing reveals the Veteran to have a right ear hearing loss disability pursuant to 38 C.F.R. § 3.385, is it at least as likely as not (50 percent or greater probability) that the Veteran's right ear hearing loss had its onset during active duty service, within one year of separation, or is otherwise related to any in-service disease, event, or injury? The examiner is reminded that the lack of documented hearing loss during service cannot serve as the sole basis for a negative finding. The Veteran's lay contentions, to include his hearing testimony as to the onset and continuity of symptoms of his hearing loss, must be considered and weighed in making the determination as to whether a nexus exists between the claimed hearing loss and military service. Epididymitis and Erectile Dysfunction (a) Set forth all currently-diagnosed male reproductive conditions, to include epididymitis and/or erectile dysfunction. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed reproductive condition, to include epididymitis, was incurred in or caused by an in-service injury, illness, or event? In providing the above opinion, the examiner must address the Veteran's service treatment records which show that he was treated for reoccurring epididymitis in October 1975 (for which he was hospitalized for 12 days), May 1976, and November 1976. If, and only if, the examiner finds that the Veteran's epididymitis is related to military service, then he or she should provide responses to questions (c) and (d). (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction is caused by epididymitis? (d) Is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction is aggravated (increased in severity beyond its natural progression) by epididymitis? Acquired Psychiatric Disorder (a) Set forth all currently-diagnosed acquired psychiatric disorders. (b) If a diagnosis of PTSD is warranted, is it at least as likely as not (50 percent probability or greater) that the Veteran's PTSD is related to his claimed in-service stressor(s), or otherwise related to any other in-service event? (c) Is it at least as likely as not (50 percent probability or greater) that any other currently-diagnosed psychiatric disorder was incurred in or caused by the Veteran's active duty service? (d) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed psychiatric disorder was caused by the Veteran's epididymitis, erectile dysfunction, and/or hearing loss? (e) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed psychiatric disorder was aggravated (increased in severity beyond its natural progression) by the Veteran's epididymitis, erectile dysfunction, and/or hearing loss? The examiner is advised that the Veteran is competent to report his psychiatric symptoms and history and such reports must be acknowledged and considered in formulating any opinion. Note that the lack of documented treatment in service, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the claimed psychiatric disorder and military service. Musculoskeletal Disabilities Left Elbow, Left Shoulder, Right Foot, Left Foot, Left Ankle, and Left Knee (a) Set forth all currently-diagnosed conditions of the left elbow, left shoulder, right foot, left foot, left ankle, and left knee. If necessary to confirm diagnoses, the examiner should conduct the appropriate diagnostic testing, to include imaging. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left elbow disability was incurred in or caused by an in-service injury, illness, or event? In providing the above opinion, the examiner must address the February 1977 service treatment record showing the Veteran injured his left elbow when he fell off a ladder. If, and only if, the examiner finds that the Veteran's left elbow disability is related to military service, then he or she should provide responses to questions (c) and (d). (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder disability is caused by his left elbow disability? (d) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder disability is aggravated (increased in severity beyond its natural progression) by his left elbow disability? (e) Is it at least as likely as not (50 percent or greater probability) that the Veteran's right foot disability was incurred in or caused by an in-service injury, illness, or event? If, and only if, the examiner finds that the Veteran's right foot disability is related to military service, then he or she should provide responses to questions (f) and (g). (f) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left foot, left ankle, and/or left knee disabilities are caused by his right foot disability, to include due to altered gait or overcompensation? (g) Is it at least as likely as not (50 percent or greater probability) that the Veteran's left foot, left ankle, and/or left knee disabilities are aggravated (increased in severity beyond its natural progression) by his right foot disability, to include due to altered gait or overcompensation? ------------------------------------------------------------------ Each respective examiner is reminded that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. It is imperative that the examiner's report reconcile the evidence of record, to include the Veteran's lay statements and hearing testimony, service treatment records, post-service medical records, prior VA examinations and private medical opinions, and any other pertinent lay evidence of record. The examiner is advised that the Veteran is competent to report his medical history, including when his symptoms began, and such reports must be acknowledged and considered in formulating any opinion. The Veteran's lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. It should be noted that a lack of documented treatment during service for the given disability, while probative, cannot serve as the sole basis for a negative finding. (Continued on next page) The examiner must provide a complete rationale for any opinion expressed, citing to the examiner's clinical experience, medical expertise, and established medical principles, as necessary. If the examiner is unable to provide an opinion without resorting to speculation, he or she should fully explain why that is so and what, if any, additional evidence would be necessary before an opinion could be rendered. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.