Citation Nr: 21028991 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 13-22 569 DATE: May 12, 2021 ORDER Entitlement to service connection for chest pain, as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for left hand fifth finger disability is denied. REMANDED Entitlement to service connection for a low back disability, to include as secondary to the service-connected PTSD, is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his chest pains are proximately due to or caused by his service-connected PTSD/anxiety attacks. 2. The weight of the competent and probative evidence shows that a left fifth finger disability was not present in service or until many years thereafter and is against finding that the Veteran's left hand fifth finger disability is related to an in-service injury or event. CONCLUSIONS OF LAW 1. The criteria for secondary service connection for chest pains are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 2. The criteria for service connection for a finger disability have not been met. 38 U.S.C. §§ 1101, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to March 1992. He testified before the undersigned Veterans Law Judge during a June 2015 hearing. A transcript of that proceeding is associated with the claims file. As an initial matter, the Veteran had a hearing before Judge Zissimos in January 2019, and in a June 2019 Board decision the claim for an earlier effective date for the grant of service connection for PTSD was denied and the claims for a higher initial evaluation than 50 percent for PTSD; for an earlier effective date for the 2010 and 2015 temporary total evaluations based on treatment for PTSD requiring hospitalization for over 21 days; and for entitlement to TDIU were remanded. Those issues are on a separate appeal stream that was re-certified to the Board in August 2020 and will be addressed at a later time by Judge Zissimos. The procedural history of this particular appeal is a lengthy one, involving multiple remands by the Board. First, in October 2015, the Board remanded the issues on appeal for additional development. However, in June 2018, June 2020, and December 2020 Board decisions, the Board found that the Agency of Original Jurisdiction (AOJ) did not substantially comply with the Board's remand directives, and again remanded the claims for further development. Unfortunately, although the Board sincerely regrets the additional delay occasioned by multiple remands, the Board errs when it fails to ensure substantial compliance with a Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Where the Board fails to ensure substantial compliance, remand is appropriate. Stegall, at 271. Accordingly, due to the reasons discussed in the remand section below, another remand is warranted as to the claim for service connection for a back disability, as the AOJ still did not substantially comply with the remand directives. Stegall, 271. In the most recent post-remand brief dated in March 2021, the Veteran's attorney raised issues with compliance with the remand instructions with respect to the back claim. The Board agrees, and that claim is remanded once more. No arguments were raised concerning the duty to notify, the duty to assist in obtaining documentary evidence, or compliance with the remand instructions with respect to the chest pain or finger disability claims in that brief. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Further, neither the Veteran nor his representative has alleged any deficiency with the conduct of the Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from active service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (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, at 53. 1. Service connection for chest pains As noted above, the Veteran has argued that he is entitled to service connection for chest pains that he has had since service, and as secondary to his service-connected PTSD as he has chest pains whenever he is feeling anxious/angry. In addition to the above elements, service connection may be warranted for disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310. Secondary service connection requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The question before the Board is whether the Veteran's claim for chest pain is at least as likely as not related to an in-service injury, event, or disease, to include as secondary to the Veteran's service-connected PTSD. As the Board is granting the Veteran's claim for service connection on a secondary basis theory of entitlement, direct service connection will not be addressed herein. For any claim for service connection, the Veteran must show a current disability. Per the Veteran's VA medical records, he has been diagnosed with and treated for chest pain. Thus, the Board finds that the Veteran's claim meets the first element of secondary service connection. As to the second element of secondary service connection, the Veteran must show evidence of a service-connected disability. Per the June 2014 Rating Decision, the Veteran's claim for PTSD was service connected by the RO. Thus, as the Veteran is claiming that his condition of chest pain is secondary to PTSD, a disability for which he is service connected, the Board finds that the Veteran's claim meets the second element of secondary service connection. As to the last element of secondary service connection, the Veteran must show medical nexus evidence establishing a connection between the service-connected disability and the claimed condition. Although the multiple remand requests consistently failed to yield an adequate opinion as requested, as noted, the September 2018 examination did consider the Veteran's contentions, but it was never considered by the AOJ as specifically requested in the June and December 2020 remands. Regardless of the lack of discussion of this pertinent evidence, the Board notes that the February 2021 SSOC listed the September 2018 examination under evidence; therefore, the Board may proceed. Further, although the February 2021 examiner's opinion again failed to comply with the specific remand directives, there is no prejudice as the decision for service connection for chest pains is wholly favorable to the Veteran. Specifically, in favor of the Veteran's claim is the September 2018 VA examination. The Veteran stated he has chest pain during times of confrontation or when anxious and that he takes multiple medications for anxiety. He stated that these symptoms first began while he was in service, and he was air lifted out thinking he was having a heart attack. He stated his current symptoms include pain to the right chest wall and heavy breathing when anxious, or during times of confrontation or stress. After a physical examination, the examiner opined that the Veteran's current severity of his PTSD "warrants by proximity association of the [chest pains]." The rationale was that this "disorder began subsequent to the service-connected condition and is the direct result of the antecedent condition" and that medical literature supports this conclusion. Specifically, that "symptoms of feeling right sided chest pain and shortness of breath may be related to panic attacks experienced with diagnosis of PTSD." The examiner also noted the diagnosis for left ventricular hypertrophy (LVH) "can also cause the same symptoms of chest pain, shortness of breath, and dizziness" but that the Veteran's records show that he has experienced these symptoms during the January 2018 examination even though the January 2018 echocardiogram did not show results of LVH. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the September 2018 examiner was aware of the Veteran's medical history, provided a fully articulated opinion, and furnished a reasoned analysis for his conclusions. Although the 2018 examiner did not consider the contradicting opinions, the Board regardless attaches some probative value to this opinion. Further, the medical evidence of record corroborates this opinion. For example, the January 2018 VA examination also showed that the Veteran reported that his chest discomfort is like a "muscle pain" located on his chest wall and he reports that this pain is almost constant although gets worse if he anxious or preoccupied. The examiner noted that "the possibility of dysfunction being part and parcel of his current mental health issues cannot be entirely ruled out." The August 2019 VA examination report shows that the Veteran reported he has chest pain and shortness of breath when he "feels angry or stressed." The Board acknowledges the negative VA examiners' opinions, but finds they were already determined to be not probative or are inadequate by the Board in prior decisions. For example, the August 2019 VA examiner opined the chest pains were not related to service because although the Veteran's military medical records do show evidence that the Veteran had chest pain in service, there was a lack of chronicity of care after. This opinion was deemed inadequate by the Board in the June 2020 decision. Then, the August 2020 VA examiner opined that "the medical record clearly documents the Veteran's symptoms of [shortness of breath] and chest pain are directly related to his morbid obesity and not a mental health or cardiac condition." However, there was no probative or adequate opinion as to the question of whether the Veteran's service-connected PTSD caused his obesity; therefore, this opinion is not valid (see remand discussion below). The August 2020 examiner further stated that "the diagnosis of left ventricular hypertrophy is clearly in error LVH is defined as a left ventricular wall thickness greater than 1.2cm. (normal LV wall thickness 0.6-1.2cm). The Veterans echocardiogram shows a left ventricular wall thickness of 1.1cm, the Veteran does not meet the diagnostic criteria for LVH and thus no symptoms can be attributed to such." However, as noted above, the September 2018 examiner clearly stated this is irrelevant as the Veteran's symptoms existed even when the ECG showed he does not have LVH and opined the pains ARE due to his anxiety and PTSD. Further, the Board found this opinion to be inadequate in the December 2020 decision. Finally, the February 2021 VA examiner opined that the Veteran does not have a diagnosed cardiac condition other than hypertensive heart disease but this is not what was asked in the directives; rather, the remand directives specifically requested the examiner to list all current diagnoses of chest pain from August 2009 to present; opine whether chest pain was proximately due to or aggravated by the service-connected PTSD; discuss the January 2018 and September 2018 opinions which noted the possibility that the chest pain was, in fact, due to or the result of his PTSD; and to consolidate the conflicting opinions in the record. Rather, the examiner provided an opinion as to whether the Veteran's hypertension not PTSD caused or aggravated his chest pains. The examiner also relied on the 2020 examiner's opinion regarding the diagnosis of LVH but again, that opinion was deemed inadequate by the December 2020 Board decision and reliance on that opinion is wholly unacceptable as the directives clearly requested the examiner to "review this remand for a discussion as to why the prior opinion was inadequate" this was obviously not done. Therefore, this opinion is also inadequate. That notwithstanding, the 2021 examiner did cite to medical literature as to causes for chest pain, to include panic attacks and that "periods of intense fear accompanied by chest pain, a rapid heartbeat, rapid breathing, profuse sweating, shortness of breath, nausea, dizziness and a fear of dying" are panic attacks. This citation further corroborates the September 2018 examiner's positive opinion that the Veteran's chest pains are proximately due to his PTSD symptoms, which includes anxiety and panic attacks. Further, the Veteran has consistently reported chest pains since service and that his chest pains are secondary to his PTSD and anxiety. Specifically, his service medical records show that in April 1990, he had chest pain with radiation to his arm and shortness of breath, but the diagnosis workup ruled out myocardial infarction. Post-service, in September 2001, he reported chest tightness and pain. In October 2001, he was diagnosed with LVH and abnormalities were noted, to include aortic sclerosis and mildly dilated aortic root. In November 2005, he reported acute chest pain, but testing ruled out pathology, and he was diagnosed with atypical chest pain. In September 2007, he reported chest pain that is sharp in nature and the assessment was costochondritis. In the November 2010 VA examination, he reported chest pains for the last several years that lasts for several minutes up to several days. During the 2015 Board testimony, he provided sworn testimony that he had chest pains in service and had to be hospitalized after he had an anxiety attack, and the records showed his heart was fine. He testified that his pains occur when he has anxiety or has a confrontation with someone, and it feels like he is having a heart attack. He stated his doctors have told him that he needs to relax more and that his stress causes him to over-react. As such, although there are multiple negative VA medical opinions that find it less likely than not that the Veteran's chest pain is etiologically related to service or to his service-connected PTSD, those medical opinions of record have not adequately considered the Veteran's competent and credible reports, nor did they consider the September 2018 examiner's opinion or the conflicting evidence as clearly requested multiple times by the Board in prior remand decisions. Thus, while the Board finds the September 2018 opinion is not perfect, its probative value far outweighs the other VA opinions, and the Board does not wish to remand for potential negative development. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (cautioning against multiple remands for the sole purpose of developing negative evidence against a claim). Therefore, the Board must resolve all reasonable doubt in favor of the Veteran, and service connection for chest pain as secondary to the service-connected PTSD is warranted. See 38 C.F.R. §§ 3.102, 3.303(a). 2. Service connection for left hand fifth finger disability The Veteran asserts that he injured his left hand fifth finger while in service, and that he has a current disability as a result of that injury. As an initial matter, as to post-remand compliance and the multiple remands, the Board notes that the most recent 2021 post-Remand record shows that the Veteran was provided a VA examination in February 2021 with an addendum opinion. Moreover, the Board finds that the post-remand etiology opinion provided by the 2021 VA examiner and the September 2018 examiner (which was not considered by the RO as noted in prior Remands) are adequate to adjudicate the claim and substantially complies with the Remands. Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the veteran's position). The Board has reached the above conclusion because after a review of the record on appeal and an examination of the Veteran, the September 2018 and February 2021 examiners provided opinions as to the etiology of the claimant's finger disability, and those opinions were supported by evidence found in the record, including the fact that service treatment records are negative for treatment for the fifth finger disability. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). In this regard, the Court in Hensley v. Brown, 5 Vet. App. 155, 160 (1993) held that a disability need not manifest during service if evidence otherwise establishes a current disability is causally related to service to establish service connection. However, the Court in Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) held that "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators..." Moreover, in Bloom v. West, 12 Vet. App. 185, 187 (1999) the Court held that the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Therefore, because the above VA examiners, when opining that the Veteran's current finger disability was not due to his military service, weighed the totality of the medical evidence found in the claims file, including the fact that service treatment records are negative for the claimed disorder, the Board finds the etiology opinions are adequate. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases). In other words, because the negative service treatment record was not the sole basis for the opinions, the Board finds them adequate to adjudicate the claim. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim). The Board will next address that while the Veteran's service treatment records show an injury to the left-hand index finger, the Veteran contended during the Board hearing that it was actually his fifth finger, not the index finger, that was injured. In this regard, a review of the record on appeal reveals that all available service treatment records were obtained by the RO and they are negative for a left hand fifth finger injury or treatment but ONLY indicate the index finger. As noted in the prior Remands, the Veteran argues that it was not his index finger, but his fifth finger, that was injured in service. The Remands recognized his contentions on this point, but those were not binding determinations finding that he injured the fifth finger during service (only that he alleged such). By its very nature, a Board remand is not a final adjudication of a claim and because the Board is not bound by the statements found in Remands, current adjudication of the appeal is based on all the evidence of record. The service treatment records are negative for complaints, diagnoses, or treatment for a fifth finger disability. As such, the remaining question is whether the Veteran's claim for an alleged left hand fifth finger disability is at least as likely as not related to an in-service injury, event, or disease. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. For any claim for service connection, the Veteran must show a current disability. Per the Veteran's VA medical records, the evidence is in equipoise that he has a current disability. For example, multiple VA examiners have opined that he does not have a current disability. However, the 2019 VA examiner diagnosed him with a chronic left hand fifth finger sprain following the 2018 X-ray findings that he has an osseous prominence on the finger. Thus, the Board finds in the Veteran's favor that he has a current disability. However, there is no medical opinion indicating that the Veteran's current left hand fifth finger disability is related to service. First, the service medical records do not document any injury, complaints, or symptoms nor show the Veteran being diagnosed with a fifth finger left hand disability. Again, as noted above, the records clearly indicate that in October 1986, he reported left-hand index finger pain after he unknowingly injured it during softball practice. It was specifically noted that it was his first finger on the left hand, and X-rays were negative. In May 1989, he reported to sick call again after injuring his right thumb during softball and was diagnosed with a hand sprain, but he did not mention any left-hand fingers being injured or painful. Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not sustain a disease or injury while on active duty that caused his alleged left hand fifth finger disability. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). The detailed records in service provide particularly negative evidence against the claim, clearly indicating treatment for problems other than the issue before the Board, including consistent complaints of and treatment for other fingers. Since the Veteran did seek treatment for other finger symptoms during service, it is reasonable to assume that he would have also sought treatment for the fifth finger, had he injured it. Additionally, the Board finds that the record does not show the Veteran had a continued problem with a left hand fifth finger disability in and since service. In fact, as noted above, the service treatment records are negative for a history, complaints, diagnoses, or treatment for a left hand fifth finger disability providing highly probative evidence against the claim. Likewise, and more important than the above, the post-service record is negative for complaints, diagnoses, or treatment for a left hand fifth finger disability until May 2010 when he filed the claim almost two decades after service. Private medical records submitted from 2001 to 2008 or from his Family Practice between 2008 and 2009 do not indicate or show any complaints of or treatment for any type of finger or hand pain. His VA medical records beginning June 2009 to April 2010 were also negative for any complaints of or treatment for his fingers. Rather, it was not until 2010 that he first reported left hand little finger pain, but denied any recent injury to the finger. Therefore, prior to filing this claim, there is no evidence showing any history of continuity of symptoms. Furthermore, the Board finds that the most probative evidence of record shows that the Veteran's post-service left hand fifth finger disability is not due to his military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d). Specifically, at the 2010 VA examination, the Veteran argued that he injured his fifth finger of the left hand, not the index as noted in the service records. He stated it is constantly tender and cannot be bent. The examiner noted there was no prior reports of finger pain or treatment in the Veteran's medical records. All range of motion testing was normal except for the left hand fifth finger "that the Veteran for some reason cannot bend" as the examiner noted that he kept the finger in extension only. However, the examiner stated there is no edema, bony deformity, or erythema. The examiner noted the October 2010 X-ray findings that he had mild deformity of the distal interphalangeal joint space of the fifth digit, but the examiner noted that there is "no subjective complaints or objective residual of claimed injury of the first finger on the left hand" and that the fifth finger disability is not related to service as there is no history of injury or complaints while in service as to that particular finger. In a July 2011 orthopedic consultation, the Veteran reported a painful bump on the left little finger, and stated that he sustained a fracture of the finger while in service. He stated about six months prior, he noticed a mass on his left little finger that has slowly increased in size and become more tender. The doctor noted that X-rays of the left hand are within normal limits and opined that the Veteran had a painful synovial cyst on his left little finger and wanted to have it removed. Thereafter, in the June 2015 Board hearing, the Veteran testified that he broke his fingers while playing flag football while in service, and he re-broke his left pinky finger again during Desert Storm while digging latrines. He stated the service records indicating he injured his left index finger is in error. He was afforded another VA examination in January 2018, where it was opined that he does not have a current diagnosis. The examiner noted that his claimed condition was residuals of a fifth finger fracture but that "there is insufficient evidence to warrant or confirm a diagnosis of an acute or chronic residual of fracture at this time. No medical opinion can be rendered as no condition is diagnosed." Further, the examiner noted that the Veteran's service records not only document a different finger, but also that the reported fracture was confirmed as not a fracture. Additionally, the Veteran reported that while deployed a "tent came down" and hit his left fifth finger, and since they were deployed and had limited medical, he only got a splint, but his finger healed wrong. A September 2018 VA examination report noted that the Veteran stated injuring the left fifth finger while playing flag football during service and that he jammed the finger and had to wear a splint. He then stated that he injured the same finger again while in Desert Storm and had to wear a splint a second time. The examiner noted the Veteran has a chronic deformity of the left fifth finger, but the 2018 X-ray findings found that he had "a chronic deformity projecting over the distal interphalangeal joint as there is evidence of elongation of off and dorsal aspect of the proximal end of the distal phalanx." However, the examiner noted that there is NO evidence of acute radiographic abnormality. The examiner further opined that "the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness" as there is no objective evidence for when the left fifth finger injury occurred. While the Veteran reports a fracture to his left fifth finger playing football, the service records indicated a left index finger after softball. Further, the Veteran argued that he fractured his finger twice in service; but the examiner stated that the Veteran's X-rays note a deformity but "does not show evidence of a previous fracture." This examination report, X-ray findings, and opinion are especially important because, as noted above, the September 2018 examination findings were not considered in prior SSOCs or Board decisions. Thereafter, the August 2019 VA examination provided the diagnosis of chronic left fifth digit sprain, but the VA examiner opined that "there are no further complaints within the STRs and there is no evidence of chronicity of care following military service." Following the June 2020 Board remand, an August 2020 examiner opined that the medical records do not show evidence of the diagnosis, treatment or symptoms suggestive of a left fifth digit injury while on active duty or within one year of separation; and also noted again that the 1986 injury was to the Veteran's index finger. Further, X-rays were negative for fractures. The examiner opined that "while the Veteran now claims it was the left 5th digit injured in service, there is no documentary evidence to support this claim" and that the current findings show the Veteran "essentially...has a bump on his left fifth finger...[which] is most likely developmental." Following the December 2020 remand, the February 2021 examiner opined that there is no chronic diagnosis for the left fifth finger. The examiner further notes that the Veteran did not report any finger or hand issues during his Social Security assessment in 2014. As such, the examiner opined that the condition was less likely than not due to service because while there was evidence of a finger injury during service, it was the first digit not the fifth digit. The VA examiners' opinions are more probative than the Veteran's statements. These more contemporaneous medical records are far more credible than the statements he makes now, since it is reasonable to expect one would report chronic hand/finger pain and being unable to bend their finger to their medical providers. Although he states he has had left fifth finger pain ever since service, the fact is the Veteran himself failed to report having finger or hand pain for several decades after service but rather not until he filed his claim for service connection in 2010. Furthermore, although his service records show treatment and x-ray reports for another finger, there is no corroboration of a fifth finger injury. Considering the records contain the x-ray report for other finger injury, it is inconceivable that somehow a single record concerning the fifth finger would somehow be missing. Therefore, the absence of any x-ray corroboration of the alleged fracture of the fifth finger weighs against the Veteran's claim, since the records clearly contain documentation as to other finger treatment/x-rays. Regardless, the medical evidence as noted by the September 2018 examiner indicates that current x-rays show no evidence of a prior fracture of the left fifth finger. Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent or credible evidence sufficient to establish service connection for his left fifth finger disability. As such, the Board finds that the most probative evidence of record shows that the Veteran's post-service finger disability is not due to his military service. The Board has reached this conclusion because it finds that the September 2018 and February 2021 opinions that the finger disability was not due to his military service the most probative evidence of record because the opinions were provided after a review of the record on appeal, an examination of the Veteran, are supported by citation to relevant evidence found in the claims file, and/or are not contradicted by any other medical evidence of record. Owens, 7 Vet. App. 429, 433. While the Board recognizes the Veteran's assertions that his left fifth finger is related to service and is competent to testify as to events that occurred in military service, the Veteran is not competent to conclude that any condition he was diagnosed with over two decades after service is connected to his service. Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case, musculoskeletal issues, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the Board finds that the claim of service connection for a left fifth finger disability is denied. In reaching this conclusion, the Board considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claim, the Board finds that this doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-56. REASONS FOR REMAND As noted above, most recently in December 2020, the Board remanded the matter for service connection for a back disability for an addendum medical opinion. The AOJ obtained medical opinions in February 2021. Regrettably, the Board finds that the record does not reflect substantial compliance with the Board's remand directives, and that a new VA examination and medical opinion are required. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA provides a medical opinion, it must be adequate). Specifically, the opinions obtained in February 2021 again failed to comply with the remand directives. First, the June 2020 and December 2020 remand directives requested that the examiner "specifically address whether the Veteran's service-connected psychiatric symptoms, such as overeating when feeling depressed, led to his current obesity, which then led to his current low back condition." The examiner was also asked to consider specifically identified medical evidence, which was not done, and that an opinion based on a mental health condition not causing physical changes to the spine IS NOT adequate, and "the examiner must consider that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis." Further, the examiner was given clear instructions to "note his or her review of the complete claims file and should review this remand for a discussion as to why the prior opinion was inadequate." Regardless of these clear instructions, the February 2021 examiner provided another similar opinion as to that of the 2020 examiner, stating that "PTSD does not affect the lumbar spine nor does it cause obesity which is the recognized potential cause of the low back pain...[and] back pain fluctuates based upon weight and activity level. NO evidence to suggest aggravation of the PTSD and depressive disorder." She also provided an opinion based on the Veteran's hypertension which has no bearing on this case. However, the examiner does not in any way discuss whether the Veteran's obesity was the intermediate step between the service-connected PTSD and the back condition, or whether the Veteran's back condition was aggravated beyond its natural progression due to PTSD by way of his obesity, but rather, that the Veteran's "obesity is a choice and is due to consuming more calories than expenditure despite the Veteran's notation that overeating is due to the mental health disorder...[and] there are many individuals that suffer from PTSD and are not obese." She also cited to the previous VA examiner's opinions, despite the December 2020 Board remand clearly stating that opinion was inadequate, and that she must note her review of the remand as to why that opinion was not adequate. This clearly was not done. Additionally, as noted by the Veteran's attorney in a March 2021 statement, the 2021 examiner did "not offer any support for her statement" as to obesity being a choice. The attorney cited to evidence and argued that "the medical records do not support the February 2021 examiner's opinion that the Veteran could just weigh less if he chose to do so." The Board agrees and finds the opinion of obesity being "a choice" is inapplicable. Further, the 2021 examiner's supporting rationale that other individuals with PTSD are not obese has no correlation to this particular Veteran and his medical history. Again, while obesity in of itself is not a disability eligible for service connection (Marcelino v. Shulkin, 29 Vet. App. 155 (2018)), obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310 (a). As the Veteran is service-connected for PTSD and contends his PTSD caused his overeating and weight gain, obesity could be an "intermediate step" between his service-connected PTSD and his back condition. Unfortunately, although the Board regrets the delay occasioned by multiple remands, another remand is warranted. The Board sincerely appreciates the Veteran's patience and apologizes for the further delay as VA works to fulfill its statutory obligation to assist him in obtaining information necessary to substantiate his claims for benefits. Further, given the multiple remands in this case and the Veteran's arguments, the Board finds that it would be prudent to direct that the updated examination be conducted by a physician rather than a nurse practitioner or physician assistant. The matter is REMANDED for the following action: 1. Request a medical opinion concerning the Veteran's obesity from a physician. The examiner must note his or her review of the complete claims file and should review this remand for a discussion as to why the prior opinion was inadequate. Then, the examiner should opine as to the following, with full supporting rationales: Is it at least as likely as not that the service-connected PTSD with depression and anxiety caused the Veteran to become obese? An opinion based on options and activities the Veteran could do or could have done for his weight gain/obesity is moot. Rather, please specifically address the Veteran's contentions his service-connected PTSD caused him to overeat, which led to his weight gain and his current obesity. An opinion mimicking the 2021 examiner's opinion that the Veteran "could just weigh less if he chose to do so" is unequivocally erroneous and will be deemed inadequate. The examiner must consider: the July 2019 VA examiner's opinion as well as the August 2019 VA examiner's opinion on PTSD (specifically "Research evidence suggests that exposure to traumatic events and PTSD are associated with a range of physical health conditions including: Cardiovascular and pulmonary risk factors including obesity"); Veteran's reports to VA mental health providers that service-connected psychiatric symptoms such as depressed mood prompt him to overeat, e.g., July 2009 VA mental health note and psychiatric evaluation (noting Veteran reported he overeats when depressed, and that he had gained over 150 pounds since he left service fifteen years ago); December 2015 VA mental health note (depression psychometric test results note various affirmative responses, including appetite issues and overeating "[n]early every day"); and Medical records between April 2004 and August 2005 show the Veteran gained 50 pounds with a note that the Veteran has had a history of morbid obesity and he has attempted to reduce weight and he was put on nutritional counseling and exercise programs but he continued to gain weight and it was noted that he was experiencing episodes of depression. Rationale must be provided for the opinions proffered. If the examiner determines that a requested opinion is not possible without resort to mere speculation, then the examiner must explain why. 2. The opinion requested above on obesity must be obtained prior to requesting the following opinion. If and only if the opinion obtained on the Veteran's obesity indicates it is at least as likely as not that the service-connected PTSD caused the Veteran to become obese, then proceed with instruction #3; if the obesity opinion is negative, then there is no need to solicit any further opinion on the relationship between PTSD and the back condition. 3. Request an addendum medical opinion from a physician for the Veteran's back condition. The examiner must note his or her review of the complete claims file and should review this remand for a discussion as to why the prior opinion was inadequate. THIS MUST BE DONE PRIOR TO PROFERRING AN OPINION. Then, the examiner should opine as to the following, with full supporting rationales: (a.) If and only if the opinion obtained on the Veteran's obesity indicates it is at least as likely as not that the service-connected PTSD caused the Veteran to become obese, then please opine as to whether that obesity was at least as likely as not a substantial factor in causing the back disability? (b.) If and only if the examiner concludes obesity related to the Veteran's service-connected PTSD was a substantial factor in causing the back disability, then please also opine as to whether it is at least as likely as not that the back disability would NOT have occurred BUT FOR the obesity? Specifically, the examiner MUST discuss and consider: medical evidence relating Veteran's current low back condition to his obesity, e.g., January 2018 VA examiner's opinion stating that the effect of his morbid obesity on the reported symptomatology cannot be entirely ruled out; the September 2018 VA examiner's opinion that Current reputable Medical Literature states... intrinsic disc loading (body weight compared with size of the disc) were the predominant predictors of degenerative disc disease; an August 2016 VA primary care note (finding Veteran's complaints of low back pain "100% related to his obesity"); the May 2012 VA medical record showing he had back pain with recent weight gain and feels that has caused his back to hurt more; the February 2008 VA note that the Veteran's back pain "is mostly due to his weight" and he is depressed about his weight; the April 2004 VA note that his back pain improved when he lost some weight but since he has gained some of his weight back it has worsened; the January 1992 service medical record showing that he reported back pain, and that it has been an ongoing problem and states the more he gains weight [sic] the more pain increases; the 2020 opinion that "the medical record clearly shows the Veteran's back condition is due to morbid obesity"; and the 2021 opinion which included the statement that "the Veteran's back pain fluctuates based upon weight and activity level." It is not enough to state that a mental health condition cannot cause physical changes to the spine. The examiner must consider that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis in the rationale. If any findings requested above are not possible without resort to mere speculation, then please explain why. If the VA examiner finds that he or she cannot provide the requested findings without another VA examination, then the RO must schedule one. Any opinion offered must reflect consideration of the Veteran's entire medical history. In rendering such opinion, the examiner should consider, and discuss, the Veteran's subjective complaints as well as the medical records and examinations reports on file to include the evidence discussed in this remand. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, 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.