Citation Nr: 21029496 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 18-06 046A DATE: May 13, 2021 ORDER New and material evidence having been received, the previously denied claim of entitlement to service connection for bilateral hammertoes fourth and fifth toes with callosities is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for strain, right knee is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for strain lateral collateral ligaments, left knee is reopened. REMANDED The claim of entitlement to service connection for bilateral hammertoes fourth and fifth toes with callosities is remanded. The claim of entitlement to service connection for a bilateral knee disorder is remanded. The claim of entitlement to service connection for hallux valgus, right great toe is remanded. The claim of entitlement to service connection for hallux valgus, left great toe is remanded. The claim of entitlement to service connection for intractable plantar keratosis (IPK) is remanded. The claim of entitlement to service connection for unequal length, right leg is remanded. The claim of entitlement to service connection for hypertension is remanded. The claim of entitlement to service connection for hemorrhoids is remanded. The claim of entitlement to service connection for dry eye syndrome, bilateral is remanded. The claim of entitlement to service connection for a left clavicle/shoulder disorder is remanded. The claim of entitlement to service connection for hepatitis C is remanded. FINDINGS OF FACT 1. Final June 1978 and June 2005 rating decisions denied service connection for hammertoes fourth and fifth toes with bilateral callosities, based on findings that the Veteran's hammertoes was congenital and there was no nexus between the claimed disability and the Veteran's military service. 2. Evidence added to the record since the June 2005 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for hammertoes fourth and fifth toes with callosities, bilateral. 3. A final January 1984 rating decision denied service connection for bilateral knee disorders based on findings that the Veteran's in-service knee complaints were acute and transitory. 4. Evidence added to the record since the January 1984 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claims of entitlement to service connection for bilateral knee disorders. CONCLUSIONS OF LAW 1. The June 1978 and June 2005 rating decisions that denied service connection for hammertoes fourth and fifth toes with callosities, bilateral are final. 38 U.S.C. § 7104 (b); 38 C.F.R. § 20.1100. 2. New and material evidence has been received to reopen the previously denied claim of entitlement to service connection for hammertoes fourth and fifth toes with callosities, bilateral. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The January 1984 rating decision that denied service connection for a bilateral knee disorders is final. 38 U.S.C. § 7104 (b); 38 C.F.R. § 20.1100. 4. New and material evidence has been received to reopen the previously denied claims of entitlement to service connection for bilateral knee disorders. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1977 to May 1978. These matters come before the Board of Veterans' Appeals (Board) from a November 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. With regard to the bilateral knee issues, the Board notes that these issues were adjudicated by the RO on the merits in the November 2014 rating decision and, with regard to the hammertoes issue, the Board notes that this issue was adjudicated by the RO on the merits in a September 2017 statement of the case. However, under the legacy appeals system, as service connection has previously been denied for these issues, the Board must initially consider whether new and material evidence has been submitted to reopen these claims as the Board has a jurisdictional responsibility to determine whether a claim previously denied by the RO is properly reopened. See Jackson v. Principi, 265 F.2d 1366 (Fed. Cir. 2001) (citing 28 U.S.C. §§ 5108, 7105(c)). The Veteran testified before the undersigned Veterans Law Judge at a Central Office Board hearing in December 2020. A transcript of this proceeding has been associated with the claims file. Notably, the Veteran has also perfected an appeal regarding six other issues under the Appeals Modernization Act (AMA) system. This appeal is separately docketed and currently awaiting the scheduling of a hearing. Legal Criteria Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Generally, in the legacy appeals system, a claim which has been denied in an unappealed decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 1. New and material evidence having been received, the previously denied claim of entitlement to service connection for bilateral hammertoes fourth and fifth toes with callosities is reopened. The Veteran submitted an initial claim for service connection for hammertoes in May 1978. In connection with the claim, the RO reviewed the Veteran's service treatment records (STRs) which include a May 1977 enlistment examination showing congenital deformity and callosities of the 5th toes and a May 1978 separation examination showing hammertoe deformity of the 4th and 5th toes. In a June 1978 rating decision, the RO denied service connection for hammertoes, 4th and 5th toes, bilaterally, finding that the Veteran's hammertoes pre-existed his military service and were not aggravated beyond their normal course by his military service. The Veteran did not appeal the denial. The Veteran attempted to reopen the previously denied claim in September 1995 but, by correspondence dated in October 1995, was informed that he needed to submit new and material evidence to reopen the previously denied claim. The Veteran again attempted to reopen the previously denied claim in February 2005 and, by rating decision dated in June 2005, the RO found that the Veteran had failed to submit new and material evidence to reopen the previously denied claim. The Veteran did not appeal this denial either. The Veteran submitted the current claim for service connection for hammertoes in March 2014. In connection with this claim, the Veteran testified at a Board hearing in December 2020. Significantly, the Veteran testified that his pre-existing hammertoes were aggravated by his military service due to wearing military issued boots and participating in significant marching/running exercises. The Veteran also testified that he had experienced continued pain in his feet since his discharge from service. The Board finds that the evidence received since the June 2005 rating decision is new and material. Specifically, the Veteran's allegation of increased bilateral foot pain during his military service due to wearing military issued boots and participating in significant marching/running exercises during the December 2020 Board hearing relates to an unestablished fact necessary to substantiate the claim. The prior denial in June 2005 was based, in part, upon a finding that there was no evidence of aggravation of a pre-existing disability. The new evidence includes allegations of increased foot pain during the Veteran's military service. Therefore, the Board finds that the evidence added to the record since the June 2005 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for hammertoes. Consequently, the Board finds that new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for hammertoes. The underlying merits of the issue will be discussed in the Remand section below. 2. New and material evidence having been received, the previously denied claims of entitlement to service connection for bilateral knee disabilities are reopened. The Veteran submitted an initial claim for service connection for a left knee disability in October 1983. In connection with the claim, the RO reviewed the Veteran's STRs which show complaints of bilateral knee pain in September 1977 but also show normal lower extremities in a May 1978 separation examination and no "'trick' or locked knee" upon report of medical history in May 1978. In a January 1984 rating decision, the RO denied service connection for bilateral knee disabilities based on findings that the Veteran's in-service knee complaints were acute and transitory. The Veteran did not appeal the denial. The Veteran submitted the current claim for service connection for bilateral knee disorders in March 2014. In connection with this claim, the Veteran testified at a Board hearing in December 2020. Significantly, the Veteran testified as to his belief that his bilateral knee disabilities are related to his military service, to include his participation in significant marching/running exercises but also secondary to his foot problems. The Veteran also testified that he had experienced continued pain in his knees since his discharge from service. The Board finds that the evidence received since the January 1984 rating decision is new and material. Specifically, the Veteran's allegation of participation in significant marching/running exercises but also experiencing a bilateral knee disorder secondary to his foot problems during the December 2020 Board hearing relates to an unestablished fact necessary to substantiate the claim. The prior denial in January 1984 was based, in part, upon a finding that the Veteran's in-service knee complaints were acute and transitory. The new evidence includes allegations of in-service bilateral knee trauma and post-service knee complaints secondary to the Veteran's foot problems. Therefore, the Board finds that the evidence added to the record since the January 1984 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for bilateral knee disorders. Consequently, the Board finds that new and material evidence has been received to reopen the previously denied claims of entitlement to service connection for bilateral knee disorders. The underlying merits of the issue will be discussed in the Remand section below. REASONS FOR REMAND 1. The claims of entitlement to service connection for bilateral hammertoes fourth and fifth toes with callosities, bilateral hallux valgus, and IPK are remanded. The Veteran contends that service connection is warranted for disabilities of the feet, specifically bilateral hammertoes fourth and fifth toes with callosities, bilateral hallux valgus, and IPK. As above, the Veteran's May 1977 enlistment examination shows a congenital deformity and callosities of the 5th toes and his May 1978 separation examination showing hammertoe deformity of the 4th and 5th toes. Also, during the December 2020 Board hearing, the Veteran testified that his pre-existing hammertoes were aggravated by his military service due to wearing military issued boots and participating in significant marching/running exercises, and that he had experienced continued pain in his feet since his discharge from service. The Veteran also testified that he experienced other disabilities of the feet, specifically hallux valgus and IPK, which are either due to wearing military issued boots while participating in significant marching/running exercises in service and/or secondary to his hammertoes. STRs show some complaints regarding the feet. Specifically, in May 1977 and May 1978 reports of medical history, the Veteran specifically reported a history of "foot trouble." Also, the Veteran was treated for foot pain in April 1978, found to be due to a corn on the little toe, athlete's foot, and his 4th/5th toe deformities. Post-service treatment records show continued complaints regarding the feet as early as February 2005. Specifically, a February 2005 VA treatment records shows that the Veteran had severe pain in the outer lateral areas of both feet with a history of hammertoes, 4th and 5th toes and surgery on both feet in 1989/90. The impression was chronic bilateral foot pain, rule out degenerative joint disease, and hammertoes. A March 2005 VA treatment record shows corns but no hallux valgus. A February 2013 VA treatment record shows IPK/keratosis. A May 2015 private treatment record shows diagnoses of flat foot, plantar fascial fibromatosis, calcaneal spur, and metatarsalgia. The law provides that Veterans shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Thus, there is a rebuttable presumption of soundness unless a condition is noted at entry. To rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran has not yet been afforded a VA examination for the purpose of determining whether a current foot disorder may be related to his military service. The medical documentation of foot problems in service along with the Veteran's allegation of strain of his feet due to wearing military issued boots while participating in significant marching/running exercises is sufficient to trigger the duty on the part of VA to provide an examination as to these claims. Therefore, the Veteran should be afforded a VA examination so as to determine whether he currently has a disorder of either foot and, if so, the nature and etiology of such disorder(s). 2. The claims of entitlement to service connection for a bilateral knee disorder and unequal length of the right leg are remanded. The Veteran contends that service connection is warranted for a bilateral knee disorder as well as unequal length, right leg. As above, the Veteran's STRs show complaints of bilateral knee pain in September 1977 but also showed normal lower extremities in a May 1978 separation examination and no "'trick' or locked knee" upon report of medical history in May 1978. Also, during the December 2020 Board hearing, the Veteran testified as to his belief that his bilateral knee disabilities are related to his military service, to include his participation in significant marching/running exercises but also secondary to altered gait due to his foot problems, and that he had experienced continued pain in his knees since his discharge from service. With regard to the unequal leg length issue, the Veteran also testified as to his belief that the unequal length of the right leg is secondary to altered gait caused by a bilateral foot disability. Post-service treatment records show complaints regarding the left knee as early as August 2002 and complaints regarding both knees as early as March 2005. These records also show a history of a pre-service left knee injury while the Veteran was playing football in high school. Specifically, a June 1997 VA treatment record shows a history of a knee injury playing high school football and, during the December 2020 Board hearing, the Veteran clarified that this injury was specific to the left knee. An August 2002 VA treatment record shows complaints of left knee tenderness with, otherwise, normal physical examination. A March 2005 VA treatment record shows complaints of bilateral knee pain and also shows a limb length discrepancy, the left being greater than the right. The Veteran has not yet been afforded a VA examination for the purpose of determining whether a current knee/leg disorder may be related to his military service. The medical documentation of knee problems in service along with the Veteran's allegation of strain on his knees due to wearing military issued boots and participating in significant marching/running exercises, as well as a bilateral knee/right leg disorder secondary to a foot disorder, are sufficient to trigger the duty on the part of VA to provide an examination as to these claims. Therefore, the Veteran should be afforded a VA examination so as to determine whether he currently has a disorder of either knee/right leg and, if so, the nature and etiology of such disorder(s). 3. The claims of entitlement to service connection for hypertension, hemorrhoids, and dry eye syndrome are remanded. The Veteran contends that service connection for hypertension, hemorrhoids, and dry eye syndrome is warranted. Specifically, during the December 2020 Board hearing, the Veteran testified as to his belief that such disabilities are due to medications used to treat his bilateral foot/knee disorders. Also, specific to the Veteran's claimed hypertension, he testified that his hypertension was secondary to an inability to exercise due to his bilateral foot/knee disorders. A review of the record shows a diagnosis of hypertension as early as September 2010, a diagnosis of hemorrhoids as early as May 3013, and a diagnosis of dry eye syndrome as early as April 2013. Also, VA treatment records show that the Veteran has been prescribed Ketorolac Tromethamine (a pain medication in the form of eye drops). Given the requested development above, the Veteran's claims for service connection for hypertension, hemorrhoids, and dry eye syndrome are inextricably intertwined with the issues of entitlement to service connection for bilateral foot/knee disorders, which have been remanded for additional development. Therefore, a final decision on the issues of entitlement to service connection for hypertension, hemorrhoids, and dry eye syndrome cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). 4. The claim of entitlement to service connection for a left clavicle/shoulder disorder is remanded. The Veteran contends that service connection is warranted for residuals of a left clavicle fracture/left shoulder disorder. Specifically, during the December 2020 Board hearing, the Veteran testified that he fractured his left clavicle prior to his military service but that this fracture had completely healed and that in-service carrying of backpacks aggravated his left clavicle/shoulder. STRs are negative for complaints regarding the left clavicle/shoulder. Significantly, the Veteran's May 1978 separation examination shows normal lower extremities and in a May 1978 report of medical history, the Veteran specifically denied "painful or 'trick' shoulder or elbow." Post-service treatment records show complaints regarding the left shoulder as early as April 2013. Specifically, an April 2013 VA treatment record shows an impression of shoulder arthralgia. These records also show a history of a pre-service left clavicle injury while the Veteran was playing football in high school. Specifically, an August 2002 VA treatment record shows a history of a left clavicle fracture in high school. In connection with this claim, the Veteran was afforded a VA shoulder examination in October 2014. Significantly, the examiner found that the Veteran did not currently have, nor had he ever had a left shoulder/clavicle disorder. Unfortunately, the Board finds that the October 2014 VA shoulder examiners finding is based on factual inaccuracy as a review of the record shows that the Veteran does have a history of a left shoulder/clavicle disorder. As such, on remand, the Veteran should be afforded a new VA examination that considers all of the Veteran's prior diagnoses of the left clavicle/shoulder (i.e., pre-service fracture of the left clavicle as well as the April 2013 impression of shoulder arthralgia) and a determination should be made as to whether there is "clear and unmistakable evidence" that a left clavicle/shoulder disorder pre-existed his military service and, if so, whether the pre-existing left clavicle/shoulder disorder was aggravated by the Veteran's military service. 5. The claim of entitlement to service connection for hepatitis C is remanded. The Veteran contends that service connection is warranted for hepatitis C. Specifically, during the December 2020 Board hearing, he testified as to his belief that he contracted hepatitis C through jet gun inoculation during his military service. The Veteran also testified that, while he had a history of drug abuse, he had never used intravenous drugs. The Veteran's STRs are negative for hepatitis C and post-service treatment records show a history of hepatitis C as early as February 2012. Significantly, a June 1997 VA treatment record shows no history of a diagnosis of hepatitis and an April 2004 VA treatment record shows that the Veteran had no risk factors for hepatitis C. While a February 2012 VA treatment record suggests that the Veteran's hepatitis is likely related to illicit drug use and VA treatment records also confirm a history of alcohol, cocaine, cannabis, and nicotine abuse, records are negative for a history of intravenous drug use. The Veteran submitted an initial claim for service connection for hepatitis C in March 2014. In connection with this claim, he was afforded a VA hepatitis examination in October 2014. Significantly, the VA examiner noted a diagnosis of hepatitis C, with an onset of 2013 (although noting that the hepatitis C likely began in early 2000) and opined that it was less likely as not (less than 50/50 probability) that the Veteran's hepatitis C was related to his military service. As rationale for this opinion, the examiner noted that the Veteran's STRs show a visit for chancroid in 1978, which would be considered a sexually transmitted disease (STD). However, STD transmission of hepatitis C is considered too slight of an increased risk which would not be considered a 75 percent relation. Also, records from an infectious disease specialist show a history of cocaine dependence and only list illicit drug use as a risk factor. Therefore, the examiner could not state that the Veteran's diagnosis of chancroid while in service is related with a greater than 50 percent probability to his present diagnosis of hepatitis C. Unfortunately, the Board finds that the October 2014 VA medical opinion is inadequate as the examiner, incorrectly, assumed that the Veteran had a history of intravenous drug abuse when, according to the Veteran and the medical records, there is no such history. Furthermore, the October 2014 VA opinion does not consider the Veteran's allegation that he contracted hepatitis C through jet gun inoculation during his military service. As such, on remand an addendum medical opinion should be obtained. Also, with regard to all of the remanded issues, the Veteran should be provided with an opportunity to identify any VA or non-VA healthcare provider who has treated him for his claimed bilateral foot/knee disorders, unequal leg length, hypertension, hemorrhoids, dry syndrome, left clavicle/shoulder disability, and/or hepatitis C since his discharge from military service. Specifically, as above, it appears that the Veteran underwent surgery on his feet in 1989/90, however, such records have not been obtained. Also, there are likely outstanding VA treatment records as the Veteran has consistently sought treatment at VA since June 1997, but the most recent VA medical records in the claims file are dated in April 2019. Therefore, all outstanding VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Afford the Veteran an opportunity to identify any healthcare provider who has treated him for his claimed bilateral foot/knee disorders, unequal leg length, hypertension, hemorrhoids, dry syndrome, left clavicle/shoulder disability, and/or hepatitis C since his discharge from military service, to include any records pertaining to 1989/90 surgery on the Veteran's feet. After obtaining any necessary authorization from the Veteran, obtain all identified records, to include updated VA treatment records dated from April 2019 to the present. 2. After obtaining any outstanding records, to the extent possible, schedule the Veteran for a VA foot examination by an appropriate medical professional to identify the current nature and etiology of his claimed bilateral foot disorder(s). Based on the examination and review of the record, the examiner should identify all current foot disorders found to be present during the appeal period beginning March 2014 and provide opinions as to: (a) whether there is clear and unmistakable evidence that the Veteran's hammertoes existed prior to service. (b) If the examiner determines that hammertoes did clearly and unmistakably exist prior to service, the examiner must address whether there is clear and unmistakable (undebatable, obvious, or manifest) evidence that the disability was not aggravated by such service. Note: Aggravation in this context means that the disability was permanently worsened beyond the natural progression of the disease; temporary or intermittent flare-ups of a preexisting injury during service are insufficient to constitute aggravation in service, unless the underlying condition itself, as contrasted with mere symptoms, has worsened. (c) whether it is at least as likely not (50 percent probability or greater) that a disorder of either foot (to include bilateral hammertoes fourth and fifth toes with callosities, bilateral hallux valgus, and IPK) is caused by or is otherwise related to the Veteran's active duty service, to include wearing military-issued boots while participating in marching/running training exercises. (d) whether it is at least as likely not (50 percent probability or greater) that a disorder of either foot is caused by or aggravated by a service-connected disability. In doing so, the examiner should address the following: (i) the Veteran's May 1977 enlistment examination showing a congenital deformity and callosities of the 5th toes and his May 1978 separation examination showing hammertoe deformity of the 4th and 5th toes (see VBMS, document labeled STR, receipt date 11/27/13, pages 1-4; VBMS, document labeled STR - Medical, receipt date 8/6/2014, pages 6 and 8); (ii) May 1977 and May 1978 reports of medical history wherein the Veteran specifically reported a history of "foot trouble" and STRs showing that Veteran was treated for foot pain in April 1978, found to be due to a corn on the little toe, athlete's foot, and his 4th/5th toe deformities (see VBMS, document labeled STR, receipt date 11/27/13, pages 5, 7, 15, and 23); (iii) post-service treatment, specifically, a February 2005 VA treatment records showing that the Veteran had severe pain in the outer lateral areas of both feet with a history of hammertoes, 4th and 5th toes and surgery on both feet in 1989/90 with an impression chronic bilateral foot pain, rule out degenerative joint disease, and hammertoes: a March 2005 VA treatment record showing corns but no hallux valgus: a February 2013 VA treatment record showing IPK/keratosis: and May 2015 private treatment record showing diagnoses of flat foot, plantar fascial fibromatosis, calcaneal spur, and metatarsalgia (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, page 9; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, pages 156-57; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, page 176; VBMS, document labeled Medical Treatment Record Non-Government Facility, receipt date 6/8/15, pages 1-2); and iv) the Veteran's December 2020 testimony that his pre-existing hammertoes were aggravated by his military service due to wearing military issued boots and participating in significant marching/running exercises as well as his testimony that he experienced other disabilities of the feet, specifically hallux valgus and IPK, which are either due to wearing military issued boots while participating in significant marching/running exercises in service and/or secondary to his hammertoes and that he has experienced continued foot pain since his discharge from service (see VBMS, document labeled Hearing Transcript, receipt date 12/2/20, pages 3 -8). 3. After obtaining any outstanding records, to the extent possible, schedule the Veteran for a VA knee/leg examination by an appropriate medical professional to identify the current nature and etiology of his claimed knee/leg disorder(s). Based on the examination and review of the record, the examiner should identify all current knee/leg disorders found to be present during the appeal period beginning March 2014 and provide opinions as to: (a) whether it is at least as likely not (50 percent probability or greater) that a disorder of either knee/leg is caused by or is otherwise related to the Veteran's active duty service, to include wearing military-issued boots while participating in marching/running training exercises. (b) whether it is at least as likely not (50 percent probability or greater) that a disorder of either knee/leg is (i) caused by or (ii) aggravated by a service-connected disability. Note that aggravation in this context means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. In doing so, the examiner should address the following: (i) May 1977 and May 1978 reports of medical history wherein the Veteran specifically denied "'trick' or locked knee," a May 1978 separation examination showing normal lower extremities, and STRs showing that Veteran was treated for complaints of bilateral knee pain in September 1977 (see VBMS, document labeled STR, receipt date 11/27/13, pages 1, 5, 7, 14, 17, and 22); (ii) post-service treatment, specifically, a June 1997 VA treatment record showing a history of a knee injury playing high school football: an August 2002 VA treatment record showing a history of a left knee running injury along with complaints of left knee tenderness with, otherwise, normal physical examination: and a March 2005 VA treatment record showing complaints of bilateral knee pain and also showing a limb length discrepancy, the left being greater than the right. (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, pages 4, 29, and 323/05; VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, pages 153 and 156); and iii) the Veteran's December 2020 testimony that his bilateral knee/leg disabilities are related to his military service, to include as due to participating in significant marching/running exercises but also secondary to altered gait due to his foot problems, and that he has experienced continued pain in his knees/legs since his discharge from military service (see VBMS, document labeled Hearing Transcript, receipt date 12/2/20, pages 10-15). 4. After obtaining any outstanding records, to the extent possible, schedule the Veteran for a VA shoulder examination by an appropriate medical professional to identify the current nature and etiology of his claimed left clavicle/shoulder disorder. Based on the examination and review of the record, the examiner should identify all current left clavicle/shoulder disorders found to be present during the appeal period beginning March 2014 and provide opinions as to: (a) whether there is clear and unmistakable evidence that the Veteran's left clavicle/shoulder disorder existed prior to service. (b) If the examiner determines that a left clavicle/shoulder disorder did clearly and unmistakably exist prior to service, the examiner must address whether there is clear and unmistakable (undebatable, obvious, or manifest) evidence that the disability was not aggravated by such service. (c) whether it is at least as likely not (50 percent probability or greater) that a left clavicle disorder (to include the pre-service fracture of the left clavicle as well as the April 2013 impression of shoulder arthralgia) is caused by or is otherwise related to the Veteran's active duty service, to include heavy lifting while participating in marching/running training exercises. In doing so, the examiner should address the following: (i) May 1977 and May 1978 reports of medical history wherein the Veteran specifically denied "painful or 'trick' shoulder and a May 1978 separation examination showing normal upper extremities (see VBMS, document labeled STR, receipt date 11/27/13, pages 1, 5, and 7); (ii) post-service treatment, specifically, an August 2002 VA treatment record showing a history of a pre-service left clavicle injury while the Veteran was playing football in high school and an April 2013 VA treatment record showing an impression of shoulder arthralgia (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, page 29; VBMS, document labeled CAPRI, receipt date 4/8/14, page 122); and iii) the Veteran's December 2020 testimony that he fractured his left clavicle prior to his military service but that this fracture had completely healed and that in-service carrying of backpacks aggravated his left clavicle/shoulder (see VBMS, document labeled Hearing Transcript, receipt date 12/2/20, pages 13 and 17). 5. After obtaining any outstanding records, to the extent possible, return the claims file to the October 2014 VA hepatitis examiner for an addendum opinion on hepatitis C. If the examiner who drafted the October 2014 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should confirm the Veteran's diagnosis of hepatitis C. Thereafter, the examiner should provide an opinion as to whether it is at least as likely as not that such disease is etiologically related to the Veteran's active military service, to include as a result of either jet gun inoculation during his military service and/or in-service sexual activity. In doing so, the examiner should address the following: (i) the Veteran's STRs showing treatment for an STD in April 1978 (see VBMS, document labeled STR, receipt date 11/27/13, page 12); (ii) post-service treatment, specifically, a June 1997 VA treatment record showing no history of a diagnosis of hepatitis: an April 2004 VA treatment record showing that the Veteran had no risk factors for hepatitis C: and a February 2012 VA treatment record suggesting that the Veteran's hepatitis is likely related to illicit drug use compared to VA treatment records also confirm a history of alcohol, cocaine, cannabis, and nicotine abuse, records are negative for a history of intravenous drug use. (see VBMS, document labeled Medical Treatment Record Government Facility, receipt date 11/27/13, pages 30, 111, and 201); and iii) the Veteran's December 2020 testimony as to his belief that he contracted hepatitis C through jet gun inoculation during his military service and that, while he had a history of drug abuse, he had never used intravenous drugs (see VBMS, document labeled Hearing Transcript, receipt date 12/2/20, page 26). Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.