Citation Nr: 21030267 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 17-19 948 DATE: May 18, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), to include as secondary to service-connected disabilities, is granted. REMANDED Entitlement to service connection for a right hip disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a left hip disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a right foot disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a left foot disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected right shoulder, bilateral upper extremity carpal tunnel syndrome, and back disabilities is remanded. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected bilateral upper extremity carpal tunnel syndrome back disabilities is remanded. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea and restless leg syndrome, to include as secondary to service-connected major depressive disorder is remanded. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected major depressive disorder, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected major depressive disorder, service-connected disabilities, and/or medications to treat service-connected disabilities is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected major depressive disorder, service-connected disabilities, and/or medications to treat service-connected disabilities is remanded. Entitlement to an effective date prior to May 11, 2017, for the award of service connection for right lower extremity radiculopathy of the femoral nerve is remanded. Entitlement to an effective date prior to May 11, 2017, for the award of service connection for left lower extremity radiculopathy of the femoral nerve is remanded. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is remanded. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy of the sciatic nerve is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy of the sciatic nerve is remanded. FINDINGS OF FACT 1. The Veteran's PTSD is related to his fear of hostile military or terrorist activity. 2. The Veteran's MDD is proximately due to his service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, diagnosed as PTSD and MDD, to include secondary to service-connected disabilities are met. 38 U.S.C. §§ 1110, 1131, 1154; 38 C.F.R. §§ 3.304(f)(3), 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1983 to March 1986 and June 1989 to November 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2016, April 2017, and September 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board has recharacterized the claim for an acquired psychiatric disorder as reflected on the title page to ensure consideration of all diagnoses of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The appeal was remanded for further development in December 2018. Initial Matters As an initial matter, the Board notes that the Veteran's representative has submitted statements consisting of pages of boilerplate language that is not in any way specific to the Veteran's appeal, including a general assertion that he preserves for appeal "all legal errors, errors in fact-finding, failure to follow VA Adjudication Manual M21-1, failure to discharge the duty to assist, failure to apply the doctrine of reasonable doubt, and other due process errors." See, e.g., April 2017, February 2020, and May 2020 VA Form 9. Such vague, unspecific assertions of general due process errors do not amount to a specific procedural argument in this case and thus need not be addressed. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (the Board's obligation to read filings in a liberal manner does not require the Board or the Veterans Court to search the record and address procedural arguments when the claimant fails to raise them before the Board). Moreover, in his substantive appeals, the Veteran's attorney incorrectly indicated that VA must advise him of "the existence of negative evidence and how to counter this evidence." Notably, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has specifically found that the duty to notify "may be generic in the sense that it need not identify evidence specific to the individual claimant's case (though it necessarily must be tailored to the specific nature of the Veteran's claim)." See Wilson v. Mansfield, 506 F.3d 1055 (Fed. Cir. 2007) at 1062. The Court has further stated since 38 U.S.C. § 5103(a) "deals only with information and evidence gathering prior to the initial adjudication of a claim...it would be senseless to construe that statute as imposing upon the Secretary a legal obligation to rule on the probative value of information and evidence presented in connection with a claim prior to rendering a decision on the merits itself." See Locklear v. Nicholson, 20 Vet. App. 410, 416 (2006). In sum, the Veteran's attorney has indicated no valid duty to notify inadequacy in this case. Service Connection 1. Entitlement to service connection for an acquired psychiatric disorder, diagnosed as PTSD and MDD, to include as secondary to service-connected disabilities, is granted. The Veteran asserts his psychiatric disorder is due to traumatic events in service, including witnessing a U.S. Special Forces soldier being killed in Honduras by an insurgent at the School of the Americas in March 1984 while the Veteran was attached to the 7th Special Forces Group; other soldiers being killed; suicides by civilians; exposure to IED and direct fire attacks; and having to flee and fearing for his life on numerous occasions. He maintains that symptoms of his psychiatric disorder, including nightmares and intrusive memories began during service and have continued since that time. See December 2015 VA Form 21-0781, December 2015 VA treatment record, June 2016 Third Party Correspondence and VA Form 21-4138, and June 2018 VA examination report. Alternatively, he maintains his psychiatric disorder is due to his service-connected disabilities. See May 2016 VA Form 21-526b and June 2020 and July 2020 Third Party Correspondences. Service connection generally may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection requirements for PTSD are more specific than general service connection requirements. Establishing service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) a link, established by medical evidence, between a Veteran's current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f), 4.125(a); Cohen v. Brown, 10 Vet. App. 128, 139 (1997); 80 Fed. Reg. 53, 14308 (March 19, 2015). As is the case here, if a stressor claimed by the Veteran is related to his fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). The Board notes that "fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection generally requires (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512. The Veteran has current diagnoses of PTSD and MDD. See June 2018 VA examination report. Thus, element one for both psychiatric disorders on a direct and secondary basis is met. As to element two for PTSD, a link between the Veteran's current symptoms and his in-service stressor, the Board notes that a request to the U.S. Army and Joint Services Records Research Center (JSRRC) and/or National Archives and Records Administration (NARA) records has not been initiated, as the Veteran has not provided adequate information regarding the stressful event surrounding his witnessing a U.S. Special Forces officer being killed in Honduras and his service personnel and medical records do not corroborate the event. See January 2016 Deferred Rating. However, the June 2018 VA examiner, a VA-contracted psychologist, outlined various other stressors and related the Veteran's PTSD specifically to a fear of hostile military or terrorist activity. See June 2018 VA examination report. Furthermore, the Veteran has competently, consistently and credibly related the other pertinent stressors, in detail, including taking multiple trips to remote locations throughout Central and South America and being involved in multiple hostile engagements with combatants while targeting drug activities and hearing of casualties of the soldiers he trained; witnessing other soldiers being killed; witnessing suicides by civilians; exposure to IED and direct fire attacks; and having to flee and fearing for his life on numerous occasions. See December 2015 VA Form 21-0781, December 2015 VA treatment record, June 2016 Third Party Correspondence and VA Form 21-4138, and June 2018 VA examination report. Additionally, his military personnel records confirm his military occupational specialty (MOS) as a weapons sergeant, infantryman, special operations sergeant, and special forces and confirm his service in Honduras. As such, the Board finds that the claimed stressors are consistent with the places, types, and circumstances of the Veteran's service and is adequate to support a diagnosis of PTSD based on fear of hostile military or terrorist activity, and the second element is established for PTSD. As to medical nexus regarding PTSD, the Veteran presented for a VA examination in June 2018. The examiner indicated his above-named stressors met the criteria for a diagnosis of PTSD, that his stressors were related to a fear of hostile military or terrorist activity as noted above, and that his stressors contributed to his PTSD. The Board finds the examiner's opinion to be probative. Therefore, the Board finds the Veteran's symptoms are related to the claimed stressors and in the absence of clear and convincing evidence to the contrary, which is not demonstrated here, his lay statements sufficiently support the occurrence of his claimed in-stressors. Thus, the third element is established for PTSD. As such, element three for direct service connection is established, and service connection for PTSD is warranted. As to major depressive disorder, the evidence of record is favorable as to secondary service connection. Thus, no other theory of entitlement will be discussed. Regarding element two of secondary service connection, the Veteran is service-connected for multiple disabilities, including bilateral carpal tunnel syndrome, lumbosacral strain with degenerative disc disease and intervertebral disc disease (IVDS), radiculopathy of the lower extremities, right knee internal derangement with limitation of extension/flexion, tinnitus, hearing loss and right shoulder osteoarthritis and cyst disabilities. Thus, elements one and two for secondary service connection are met. The crux of the secondary service connection claim therefore rests on element three, whether there is a relationship, or nexus, between major depressive disorder and his service-connected disabilities. Here, the evidence of record substantiates the relationship. Specifically, the October 2020 VA examiner opined that the Veteran's major depressive disorder was at least likely as not proximately due to his service-connected disabilities. In support of his opinion, the examiner stated that medical research suggests a correlation between chronic pain and depression and that about half of all people who have chronic pain also have depression. He explained that individuals with chronic pain may experience a general decline in physical activities, a sense of loss for previously held abilities, and a loss of interest in these activities and in turn, the person may have an increased irritability, sense of hopelessness, and difficulties coping with normal stress of daily life. He highlighted the fact that chronic pain lasts much longer than would be expected from the original problem or injury and that with chronic pain, one may feel constantly tense and stressed. To this end, the examiner stated that over time, the stress can result in different emotional problems associated with depression as well, conditions like the Veteran's service-connected disabilities prevent them from engaging in activities that they once enjoyed, potentially leading to further depressive symptoms. Thus, the examiner concluded that the Veteran's major depressive disorder was more likely than not caused by his service-connected disabilities. The Board finds that this opinion tends to substantiate the relationship between the Veteran's service-connected disabilities and his major depressive disorder as the examiner took the Veteran's lay statements and medical evidence into consideration and provided adequate reasoning for his conclusion. Moreover, there is no opinion to the contrary. Thus, the nexus element of secondary service connection is also met. Accordingly, service connection for an acquired psychiatric disorder, diagnosed as PTSD and MDD, to include as secondary to service-connected disabilities is warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(3), 3.310; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). REASONS FOR REMAND 2. Entitlement to service connection for a right hip disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 3. Entitlement to service connection for a left hip disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 4. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 5. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 6. Entitlement to service connection for a right foot disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 7. Entitlement to service connection for a left foot disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 8. Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee, bilateral lower extremity radiculopathy, and back disabilities is remanded. 9. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected right shoulder, bilateral upper extremity carpal tunnel syndrome, and back disabilities is remanded. 10. Entitlement to service connection for a left shoulder disability, to include as secondary to service-connected bilateral upper extremity carpal tunnel syndrome back and disabilities is remanded. The Veteran seeks direct and/or secondary service connection for his bilateral hip, bilateral ankle, bilateral foot, left knee, cervical spine, and left shoulder disabilities. See May 2016 VA Form 21-526b. The evidence of record suggests his musculoskeletal disabilities may be related to the cumulative impact of numerous parachutes jumps and the Board concedes these in-service injuries due to his receipt of a parachute badge. See DD 214 Form. The Veteran was afforded VA examinations in October 2016 and July 2018. However, none of the examiners' opinions adequately address direct and secondary service connection or discuss the concession of in-service injuries due to numerous parachutes jumps for all the issues outlined above. Thus, on remand addendum opinions are necessary to adequately address all theories of entitlement. 11. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea and restless leg syndrome, to include as secondary to service-connected major depressive disorder is remanded. The Veteran asserts his sleep apnea is due to service and/or his now service-connected major depressive disorder. See May 2016 VA Form 21-526b. Specifically, he asserts that his major depressive disorder and other service-connected disabilities caused or aggravated his obesity, which caused his sleep apnea. See July 2020 Third Party Correspondence. The Veteran was afforded a VA examination in July 2018. However, the examiner's opinion is insufficient as he did not discuss the Veteran's obesity as an intermediate step for secondary service connection. Additionally, no direct opinion on the issue is of record. Thus, an addendum opinion is warranted to adequately address the issue. 12. Entitlement to service connection for fibromyalgia, to include as secondary to service-connected major depressive disorder, is remanded. The Veteran asserts his fibromyalgia is due to service and/or his now service-connected major depressive disorder. See May 2016 VA Form 21-526b. The Veteran was afforded a VA examination in July 2018. The examiner opined negatively on secondary service connection however, the aggravation opinion is unclear as to whether depression can aggravate fibromyalgia. Moreover, no direct opinion on the issue is of record. Thus, an addendum opinion is warranted to adequately address the issue. 13. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected major depressive disorder, service-connected disabilities, and/or medications to treat service-connected disabilities is remanded. 14. Entitlement to service connection for GERD, to include as secondary to service-connected major depressive disorder, service-connected disabilities, and/or medications to treat service-connected disabilities is remanded. The Veteran maintains that his erectile dysfunction and GERD are due to service and/or his now service-connected major depressive disorder, other service-connected disabilities, and/or the medications used to treat his service-connected disabilities. He asserts that his service-connected conditions may have caused or aggravated his obesity which caused his erectile dysfunction and/or GERD disabilities. See July 2020 Third Party Correspondence. The Veteran was afforded VA examinations in July 2018. However, the examiners did not discuss obesity as an intermediate step for secondary service connection, did not provide direct service connection opinions, and did not address the aggravation prong of secondary service connection for GERD. Thus, on remand addendum opinions are warranted to adequately address all theories of entitlement. 15. Entitlement to an effective date prior to May 11, 2017, for the award of service connection for right lower extremity radiculopathy of the femoral nerve is remanded. 16. Entitlement to an effective date prior to May 11, 2017, for the award of service connection for left lower extremity radiculopathy of the femoral nerve is remanded. 17. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is remanded. 18. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy of the sciatic nerve is remanded. 19. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy of the sciatic nerve is remanded. The Veteran was afforded a VA back examination in August 2017. However, the examinations are insufficient in light of recent decisions in Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Correia, the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, and in weight-bearing and nonweight-bearing. Additionally, in Sharp, the Court affirmed that in order for an examination to comply with 38 C.F.R. § 4.40, the examiner must express an opinion regarding functional impairment and the examiner's determination in that regard should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. Further, the Court in Sharp notes that an examiner may not decline to provide an opinion on the basis of speculation unless the examiner has "considered all procurable and assembled data" and offered a basis for this conclusion, and it must be apparent that the inability to provide an opinion without speculation reflects "the limitation of knowledge in the medical community at large," as opposed to a limitation of the individual examiner (lack of expertise, insufficient information, or unprocured testing). Id. Thus, on remand a current VA examination that complies with Correia and also adequately address functional loss is warranted. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Any outstanding VA treatment records should be secured, and the Board will defer action on the earlier effective date claims as a result. Additionally, the Veteran's earlier effective date claims for bilateral lower extremity radiculopathy of the femoral nerve is inextricably intertwined with his increased rating claim for his back, given the Veteran's attorney's arguments. See September 2018 Notice of Disagreement (NOD). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records. 3. Then, obtain an addendum opinion from an examiner other than the October 2016 and July 2018 VA examiners that addresses the etiology of the Veteran's bilateral hip, bilateral ankle, bilateral foot, left knee, cervical spine, and left shoulder disabilities. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine on whether: (a) Is it at least as likely as not (50 percent or greater probability) that diagnosed (i) bilateral hip strain (ii) bilateral ankle strain (iii) bilateral foot strain (iv) bilateral heel spurs (v) left knee joint osteoarthritis (vi) degenerative arthritis of the cervical spine (vii) IVDS (viii) cervical radiculopathy (ix) left shoulder acromioclavicular joint osteoarthritis and (x) left shoulder strain (see October 2016 and July 2018 VA examination reports): (1) had their onset during service; (2) in the case of arthritis and radiculopathy manifested to a compensable degree within one year of separation of service for arthritis diagnoses, or (3) are otherwise related to service, including as result of the cumulative impact of conceded parachute jumps. In addressing this question, please address the Veteran's documented complaints of joint pain in his knees and ankles and endorsement of foot trouble, swollen or painful joints, and arthritis on his Report of Medical History. See April 1995 STR. Please do rely on unremarkable service treatment (STRs) as the sole basis of a negative opinion, or it will be returned as inadequate. (b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's (i) bilateral hip strain (ii) bilateral ankle strain (iii) bilateral foot strain (iv) bilateral heel spurs and (v) left knee joint osteoarthritis: (1) are proximately due to service-connected right knee, bilateral lower extremity radiculopathy, and/or back disabilities; (2) have been aggravated (worsened) by service-connected right knee, bilateral lower extremity radiculopathy, and/or back disabilities? (c) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's (i) degenerative arthritis of the cervical spine (ii) IVDS (iii) cervical radiculopathy (iv): (1) are proximately due to service-connected right shoulder, bilateral upper extremity carpal tunnel syndrome, and/or back disabilities; or (2) have been aggravated (worsened) by service-connected right shoulder, bilateral upper extremity carpal tunnel syndrome, and/or back disabilities? (d) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's (i) left shoulder acromioclavicular joint osteoarthritis and (ii) left shoulder strain: (1) are proximately due to service-connected back disability; or (2) has been aggravated (worsened) by service-connected bilateral upper extremity carpal tunnel syndrome and/or back disabilities? (e) If and only if any bilateral hip, bilateral ankle, bilateral foot, left knee, cervical spine, and/or left shoulder disabilities are service-connected above, then please opine on whether it is it at least as likely as not (a 50 percent or greater probability) that any remaining disabilities that are not service-connected above are: (1) proximately due to or; (2) aggravated (worsened) by such service-connected disabilities. The examiner is advised that inquiries (b)-(e) require separate opinions for proximate causation and aggravation and a comprehensive rationale must be furnished for all opinions expressed. The examiner is also advised that the primary disability (service-connected) need not be service-connected or even diagnosed at the time the secondary disability is incurred and reliance on this fact will render the opinion inadequate. 4. Then, obtain an addendum opinion from an examiner other than the July 2018 VA examiner that addresses the etiology of the Veteran's sleep disorders. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. The examiner is requested to provide an opinion as to the following questions: (a) (1) Is it at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities (major depressive disorder, bilateral carpal tunnel syndrome, lumbosacral strain with degenerative disc disease and IVDS, radiculopathy of the lower extremities, right knee internal derangement with limitation of extension/flexion, tinnitus, hearing loss, and right shoulder osteoarthritis and cyst disabilities) caused him to become obese/gain weight? (2) If so, is it at least as likely as not that obesity/weight gain was a "substantial factor" in causing obstructive sleep apnea (OSA) and/or restless leg syndrome (RLS)? (3) If so, is it at least as likely as not that OSA and/or RLS would not have occurred but for the obesity/weight gain caused by the service-connected disabilities? In arriving at the opinion on OSA and RLS and weight gain/obesity, inform the examiner that all lay evidence must be considered. Inform the examiner further that, under applicable legislation and VA requirements, obesity is not a disease or disability, but it may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis. To determine whether any weight gain or obesity is an "intermediate step" between either any or all of the Veteran's service-connected disabilities and OSA or RLS, the examiner should fully answer the above questions. (b) If the answer to questions (a)(1), (2) or (3) is no, is it at least as likely as not (50 percent or greater) that the Veteran's OSA and/or RLS had their onset in or are otherwise related to service? (c) If the answer to questions (a)(1), (2) or (3) and (b) is no, then is it at least as likely as not (50 percent or greater) that the Veteran's OSA and/or RLS are either (1) proximately due to or (2) aggravated (worsened) by any service-connected disability, to include his now service-connected major depressive disorder? In addressing inquiry (c), the examiner should acknowledge and comment on medical literature submitted by the Veteran in July 2020 that addresses a relationship between psychiatric disorders and OSA. The examiner is also advised that inquiry (c) requires separate opinions for proximate causation and aggravation and a comprehensive rationale must be furnished for all opinions expressed. The examiner is also advised that the primary disability (service-connected) need not be service-connected or even diagnosed at the time the secondary disability is incurred and reliance on this fact will render the opinion inadequate. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. Then, obtain an addendum opinion from an examiner other than the July 2018 VA examiner that addresses the etiology of the Veteran's fibromyalgia. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. (a) Following a review of the claims file, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that diagnosed fibromyalgia (see July 2018 VA examination report) had its onset in service or is otherwise related to service. Please address the Veteran's documented complaints of joint pain in his knees and ankles and endorsement of swollen or painful joints on his Report of Medical History. See April 1995 STR. (b) If not, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's fibromyalgia is (i) proximately due to service-connected major depressive disorder or (ii) has been aggravated (worsened) by service-connected major depressive disorder? (c) If and only if fibromyalgia is service-connected above, then please opine on whether it is it at least as likely as not (a 50 percent or greater probability) that the Veteran's left shoulder disability is (i) proximately due to his fibromyalgia or (ii) has been aggravated (worsened) by his fibromyalgia? The examiner is advised that inquiries (b)-(c) require separate opinions for proximate causation and aggravation and a comprehensive rationale must be furnished for all opinions expressed. The examiner is also advised that the primary disability (service-connected) need not be service-connected or even diagnosed at the time the secondary disability is incurred and reliance on this fact will render the opinion inadequate. 6. Then, obtain an addendum opinion from an examiner other than the July 2018 VA examiner that addresses the etiology of the Veteran's erectile dysfunction and GERD disabilities. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. The examiner is requested to provide an opinion as to the following questions: (a) (1) Is it at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities (major depressive disorder, bilateral carpal tunnel syndrome, lumbosacral strain with degenerative disc disease and IVDS, radiculopathy of the lower extremities, right knee internal derangement with limitation of extension/flexion, tinnitus, hearing loss, and right shoulder osteoarthritis and cyst disabilities.) caused him to become obese/gain weight? (2) If so, is it at least as likely as not that obesity/weight gain was a "substantial factor" in causing erectile dysfunction and/or GERD? (3) If so, is it at least as likely as not that erectile dysfunction and/or GERD would not have occurred but for the obesity/weight gain caused by the service-connected disabilities? In arriving at the opinion on erectile dysfunction and GERD and weight gain/obesity, inform the examiner that all lay evidence must be considered. Inform the examiner further that, under applicable legislation and VA requirements, obesity is not a disease or disability, but it may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis. To determine whether any weight gain or obesity is an "intermediate step" between either any or all of the Veteran's service-connected disabilities and erectile dysfunction or GERD, the examiner should fully answer the above questions. (b) If the answer to questions (a)(1), (2) or (3) is no, is it at least as likely as not (50 percent or greater) that the Veteran's erectile dysfunction and/or GERD had its onset in or is otherwise related to service? (c) If the answer to questions (a)(1), (2) or (3) and (b) is no, then is it at least as likely as not (50 percent or greater) that the Veteran's erectile dysfunction and GERD (1) proximately due to or (2) aggravated (worsened) by any service-connected disability, to include his now service-connected major depressive disorder and any medications used to treat any service-connected disability? In addressing inquiry (c), the examiner should acknowledge and comment on medical literature submitted by the Veteran in July 2020 that addresses a relationship between psychiatric disorders and erectile dysfunction and GERD. The examiner is also advised that inquiry (c) requires separate opinions for proximate causation and aggravation and a comprehensive rationale must be furnished for all opinions expressed. The examiner is also advised that the primary disability (service-connected) need not be service-connected or even diagnosed at the time the secondary disability is incurred and reliance on this fact will render the opinion inadequate. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 7. Then schedule the Veteran for a VA examination to determine the current nature and severity of his back disability. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. The examiner is asked to address the following: (a) Please provide an opinion as to the full range of motion of the Veteran's back and left knee in (1) active motion, (2) passive motion, (3) in weight-bearing (4) in nonweight-bearing, and (5), if applicable, with range of motion of the opposite undamaged joint. Please specify range of motion measurements in all areas outlined above. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). (b) Considering the Veteran's reported history, please also provide an opinion describing functional impairment of the Veteran's back and left knee disabilities, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If unable to provide such an opinion without resorting to speculation, please provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician's Guide to estimate, "per [the] veteran", what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. A full and complete rationale must be provided for all opinions expressed. If unable to opine without speculation, please provide a rationale for this conclusion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Asante, Ruby 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.