Citation Nr: 21031664 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 12-06 442 DATE: May 24, 2021 ORDER Entitlement to service connection for a lumbar spine disorder is denied. Entitlement to service connection for a right shoulder disorder is denied. Entitlement to service connection for a left shoulder disorder is denied. REMANDED Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. FINDINGS OF FACT 1. The diagnosed degenerative arthritis and osteopenia of the lumbar spine are not etiologically related to the Veteran's period of service, did not manifest in service or within one year of separation from service, and have not been chronic since an in-service onset. 2. The diagnosed acromioclavicular arthritis and bursitis of the right shoulder are not etiologically related to the Veteran's period of service, did not manifest in service or within one year of separation from service, and have not been chronic since an in-service onset. 3. The diagnosed glenohumeral arthritis and osteopenia of the left shoulder are not etiologically related to the Veteran's period of service, did not manifest in service or within one year of separation from service, and have not been chronic since an in-service onset. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative arthritis and osteopenia of the lumbar spine are not met on a direct or presumptive basis. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for acromioclavicular arthritis and bursitis of the right shoulder are not met on a direct or presumptive basis. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for glenohumeral arthritis and osteopenia of the left shoulder are not met on a direct or presumptive basis. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1958 to October 1959. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded by the Board in October 2014, December 2016, September 2017, January 2019, and December 2020. In December 2020 VA obtained an adequate VA addendum opinion regarding the lumbar spine and bilateral shoulders that complies or substantially complies with the prior remand directives. Thus, additional remand for those issues is not required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). VA has also satisfied the duty to notify and assist. The Veteran was given the opportunity to identify relevant private treatment records, and VA obtained federal records on his behalf. In June 2015, VA sent a request to National Personnel Records Center (NPRC) for the Veteran's complete service treatment records (STRs) and personnel records. In July 2015, the NPRC responded that the Veteran's record was affected by a fire at the facility. The NPRC explained that all available personnel documents from the Veteran's reconstructed record were sent to VA in July 2015, but no STRs or dental records were recovered. In this case, the Veteran's STRs were obtained by VA in 1959 prior to the fire at the NPRC as part of his 1959 claim for VA benefits. Those records appear complete, as they contain entrance and separation examinations, as well as records of treatment for various conditions during the Veteran's period of service. To the extent there may be missing personnel records, those records are not relevant to the service-connection claims on appeal as the Veteran's participation in airborne jump school is not in dispute. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See 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). . Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including degenerative arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for a lumbar spine disorder is denied. The Veteran alleges that a lumbar spine disorder is etiologically related to multiple jumps during airborne training, and that he struck his lower back on a tree trunk during one of those parachute jumps. See April 2008 Correspondence; see August 2015 VA examination report. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). April 2012 VA x-rays were significant for minimal degenerative changes of the lumbar spine. An August 2015 VA examiner diagnosed degenerative arthritis of the spine based on x-rays showing osteopenia of the spine and lumbar spondylosis. Thus, there are lumbar spine disorders diagnosed during the appeal period. Second, the Board finds that there was an in-service event. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran participated in airborne school and completed multiple jumps. There is no objective evidence of lumbar spine symptoms in service and the Veteran's testimony of in-service lumbar spine symptoms is inconsistent. In December 2008, the Veteran wrote that his back disorder was a residual or latent effect of his participation in jump school, and that he did not go to sick call for every ache and pain. At an August 2015 VA examination, the Veteran reported that his back pain began in 1959 or 1960 and worsened in approximately 2011. In the March 2016 notice of disagreement, the Veteran wrote that his back discomfort was a residual pain that was resurfacing years after the fact. The Veteran has testified to experiencing back symptoms in service, and alternatively, that residual back pain developed years after military service. The STRs show the Veteran was seen for multiple other complaints during his period of service (such as sore throat, sprained left wrist, vomiting, diarrhea, psychiatric complaints, and upper respiratory infections), but there is no mention of back symptoms. The Veteran denied painful joints, arthritis, or bone or joint deformity on his October 1959 report of medical history at separation. No back issue was identified on the October 1959 separation examination. Available medical evidence also does not show chronic back symptoms since an in-service onset. The Veteran filed a claim for service-connection for psychiatric and dental conditions in November 1959 but did not mention any back issue. A January 1960 general VA examination found no abnormality of the spine and the Veteran reported he was in good health. The examiner noted the Veteran had a normal gait and good posture/carriage. At an October 2011 VA new patient appointment, the Veteran reported pain in the knee and shoulder, which he attributed to jump school, but he did not describe any back pain. Available VA records show the Veteran first mentioned chronic low back pain in April 2012, when he reported he had been pulling up carpets and had exacerbated his chronic low back pain. The Veteran asserts he was treated for a back condition prior to then, but that all those records had been destroyed or were otherwise unavailable. See March 2012 Correspondence. The Veteran did submit limited private treatment records, including a June 1998 private record that includes the Veteran's past medical history. That past medical history documents multiple conditions (such as hypertension, gout, and arthritis of the knees), but does not mention a history of a back condition or complaints. In light of the Veteran's inconsistent statements regarding the onset of his back symptoms and the lack of any supporting objective evidence of low back pain in-service or shortly after separation, the Board does not find the lay testimony of in-service back symptoms and chronic symptoms since service to be credible. To summarize, the only conceded in-service event is the Veteran's participation in jump school. Third, the Board finds that the evidence of record does not support a finding that a low back disorder is related to active service, to include the conceded in-service participation in jump school. The Veteran underwent a VA back examination in August 2015 and an opinion was obtained in January 2016. The examiner opined that the diagnosed degenerative arthritis of the spine was not etiologically related to the Veteran's period of service. In support of that opinion, the examiner opined there was no evidence of back problems in service. In December 2016, the Board remanded the matter for an addendum opinion that addressed the Veteran's participation in jump school and his assertion that his current back symptoms were a delayed response to the strain from jump school. An addendum opinion was obtained in January 2017. That examiner again opined that the Veteran's claimed back condition was unrelated to his period of service, to include strenuous physical activity during jump school. The examiner again cited to the lack of back symptoms noted in the STRs and on the 1960 VA examination report. Rather, the examiner said age could be a possible etiology because the risk of osteoarthritis increased with age. In September 2017, the Board remanded for an addendum opinion based on a finding that the examiner failed to consider the Veteran's report on continuity of back symptoms since an in-service onset, and did not provide a rationale for the finding that the current back symptoms were not a delayed response of the in-service strenuous physical activity. The Veteran then failed to report to a November 2017 VA examination and contacted VA to explain that he did not wish to attend another VA examination. See December 2017 Report of General Information. The Board remanded the matter again in January 2019 to obtain an addendum opinion without a new examination. The examiner was requested to clarify why the Veteran's chronic back pain noted in 2012 and current arthritis was more likely due to age and less likely due to participation in jump school. VA obtained another addendum opinion in September 2019. In December 2020, the Board remanded the matter again based on a finding that there was not substantial compliance with the January 2019 remand directives. Specifically, the Board found that the September 2019 VA examiner did not sufficiently address the lay testimony of back pain since service and treatment for a back condition prior to 2011. Most recently, VA obtained an addendum opinion in December 2020. The examiner opined that the lumbar spine arthritis was not etiologically related to the Veteran's period of service and more likely related to aging. In support of that conclusion, the examiner noted that the first radiographic evidence pertaining to a back condition was obtained when the Veteran was in his 70s and only showed mild degenerative changes of the lumbar spine. The examiner cited to the lack of treatment for a back condition in service despite treatment for other complaints. The examiner highlighted the fact that the 1959 separation examination and 1960 VA examination were silent for any back condition and noted the Veteran did not report any back problem when he first presented to VA in 2011. The examiner also noted the Veteran's civilian career was in construction, which he retired from in his 60s. The examiner cited to a comparative medical study of the prevalence of degenerative changes in parachutists versus non-parachutists that found the degenerative changes were similar in both groups. The examiner explained that the study suggested that military parachuting itself did not accelerate the development of disc degeneration. Other studies showed that parachuting was associated with some spinal changes, the most common finding being a compression fracture or premature disc degeneration. The examiner explained that the latter study did not implicate parachuting as a cause of non-premature disc degeneration, spondylolysis, or spondylolisthesis; and that the evidence did not show any compression, wedge, or impact injury. The examiner explained the Veteran's mild disc space narrowing and arthrosis was of a degree that was very consistent with age and typically present in most persons in the Veteran's age group. Although more advanced disc disease was associated with spinal injury from parachuting, the mild degree of the Veteran's arthritis was consistent with age without any other contribution. The examiner also explained that osteopenia was consistent with aging because men reached peak bone mass in their 20s, bone mass declined with age, and 47 percent of men over age 50 had osteopenia. Thus, the finding of osteopenia on imaging when the Veteran was at least 70 years old was not an unexpected finding and aging was the only contributor. The 2020 examiner's opinion substantially complies with the Board's prior remand directives. The 2020 examination report indicates the examiner reviewed the August 2015 VA back examination, and the August 2015 examination report notes the Veteran's testimony of chronic back symptoms since an in-service onset. The examiner fully discussed the objective medical evidence and explained how that evidence does not support a finding that back symptoms manifested in service or were chronic since service. The 2020 examiner based their opinion on a thorough review of the objective evidence as well as the lay testimony included in the August 2015 examination report. To the extent the examiner did not specifically address the lay testimony in the rationale section of the back opinion, that testimony is not credible, and the objective medical evidence is more probative. For these reasons, there has been substantial compliance with the prior remand directives. The 2020 medical opinion is adequate and afforded significant probative weight. The 2020 examiner thoroughly reviewed the STRs and relevant medical evidence and summarized that evidence in a factual manner. The examiner also provided a fully articulated rationale as to why the lumbar spine degenerative arthritis and osteopenia were more likely related to aging and not related to his in-service parachute jumps. Overall, the December 2020 VA opinion substantially complies with the prior remand directives, is adequate, and weighs heavily against the claim. There is no medical opinion to the contrary. Although the Veteran asserts his current back condition is etiologically related to service, as a lay person he has not demonstrated the medical expertise necessary to provide a medical opinion on a complex medical question. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (noting that a lay witness is competent to report to factual matters of which he or she has first-hand knowledge). As a result, his lay opinion is not competent or entitled to probative weight. In sum, the preponderance of the evidence shows the claimed lumbar spine disorder is not etiologically related to service on a direct basis. The preponderance of the evidence is also against a finding that arthritis manifested in service or within one year of separation. Accordingly, service connection is denied on a direct and presumptive basis. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a right shoulder disorder 3. Entitlement to service connection for a left shoulder disorder The Veteran also alleges that bilateral shoulder disorders are also etiologically related to his participation in jump school. See April 2008 Correspondence. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). October 2011 x-rays of the right shoulder are significant for mild acromioclavicular joint degenerative changes. July 2012 VA treatment notes record a diagnosis of right shoulder bursitis. August 2015 x-rays of the left shoulder show osteopenia and degenerative changes. The December 2020 VA examiner confirmed current diagnoses of right subacromial/subdeltoid bursitis and right acromioclavicular joint osteoarthritis, and left shoulder glenohumeral joint osteoarthritis and osteopenia. Thus, there are disabilities of the right and left shoulders present during the appeal period. Second, there is an in-service event. The Veteran's participation in jump school is conceded and he relates his current shoulder conditions to that participation. To this extent, there is an in-service event. The preponderance of the evidence does not show shoulder symptoms began in service or within one year of separation, and shoulder symptoms have not been chronically present since service. Again, the Veteran's testimony regarding his shoulder symptoms is conflicting in the same fashion it was for his lumbar spine claim. In October 2008 correspondence the Veteran wrote that his claimed shoulder conditions surfaced slowly over the years as residual or latent effects of the strain his body experienced in jump school, and that he did not go to sick call for every ache and pain in service. In March 2012, the Veteran wrote that his private medical records from prior to 2011 were unavailable, but that he had received treatment for his shoulders prior to then. When the Veteran first presented to VA for treatment in October 2011, he reported right shoulder pain "for years," but did not report any left shoulder pain. He attributed the pain on the right side to being taught to roll on his right side after landing a jump. At a May 2014 VA appointment, the Veteran reported his right shoulder pain had been chronic since his airborne training. At the August 2015 VA examination, the Veteran reported pain in both shoulders that began in 1969 or 1960 and worsened in 2011. In April 2016, the Veteran wrote that his current shoulder complaints were latent effects of in-service jump school. He stated that when he was young his body could deal with physical activity, but it had taken a toll as he aged and caused residual pain. The Veteran's testimony of chronic shoulder symptoms since an in-service onset is inconsistent with his other testimony that his shoulder pain is a latent or residual effect of strain during jump school. The objective medical evidence also does not support the Veteran's claim of chronic right or left shoulder symptoms since service. Although the Veteran was seen for multiple complaints in service, the STRs do not contain any mention of shoulder problems. At separation, the Veteran specifically denied painful or trick shoulder and examination of the upper extremities was normal. See October 1959 report of medical history; see October 1959 separation examination. The Veteran also did not mention any shoulder complaints when he filed his 1959 claim for benefits. At the January 1960 VA examination, the Veteran reported he was in good general health, he did not report any shoulder problems, and on examination the musculoskeletal system was normal. A June 1998 private records includes the Veteran's past medical history of other conditions but is silent for any shoulder condition. Overall, the objective medical evidence does not support the Veteran's assertion of chronic shoulder symptoms since an in-service onset. Because the Veteran's testimony is inconsistent and unsupported by the objective medical record, the Board does not find the testimony credible. As a result, the preponderance of the evidence does not show shoulder symptoms in service, within one year of separation from service, or chronic symptoms since an in-service onset. Third, the preponderance of the evidence is against a finding that the currently diagnosed shoulder conditions are etiologically related to the Veteran's period of service. The Veteran underwent a VA shoulder examination in August 2015 and an opinion was obtained in January 2016. The examiner opined that the claimed shoulder conditions were not etiologically related to the Veteran's period of service, citing to the lack of evidence of shoulder problems in service. In December 2016, the Board remanded the matter for an addendum opinion that addressed the Veteran's participation in jump school and his assertion that his current back symptoms were a delayed response to the strain from jump school. An addendum opinion was obtained in January 2017 and provided the same opinion for the shoulders as for the back, which is detailed above. The September 2017 Board remand found the 2017 shoulder opinions inadequate for the same reason the back opinion was inadequate. After the Veteran failed to report to a November 2017 examination, the Board remanded the matter again in January 2019 to obtain an addendum without an examination. VA obtained another addendum opinion in September 2019, but the December 2020 Board remand found the September 2019 VA examiner did not sufficiently address the lay testimony of shoulder pain since service and treatment for the shoulders prior to 2011. Most recently, VA obtained an addendum opinion in December 2020. The examiner reviewed the STRs and noted the Veteran was seen on several occasions for other conditions but was never seen for any shoulder complaints. Further, no shoulder condition was noted on separation or on VA examination the following year. The first documentation of complaints was in 2011, when the Veteran reported chronic right shoulder pain but did not mention any left shoulder pain. Rather, the first objective evidence of left shoulder symptoms was not until 2015. Regarding the left shoulder, the examiner opined that the glenohumeral osteoarthritis and osteopenia were not etiologically related to the Veteran's period of service, to include his participation in jump school. The examiner noted that the Veteran had told his VA medical provider in 2011 that he rolled on his right side when he landed, which was against a finding of any injury to the left shoulder. Further, the Veteran's mild degenerative changes of the left shoulder were not noted until 2015 and were consistent with aging as opposed to any in-service injury or strain. The examiner reviewed medical literature and explained that the predominant risk factors for glenohumeral arthritis included age and physical work like construction, and that osteoarthritis was prevalent in persons age 70 and older. If the osteoarthritis were posttraumatic, then it would have been expected to be more advanced than the mild arthritis currently present in the left shoulder. Further, there was no objective evidence of any left shoulder injury. The examiner again explained how osteopenia was an age-related finding that was unrelated to any alleged prior trauma or injury. The examiner explained that despite the lay testimony of shoulder symptoms in service and chronically thereafter, there was no objective evidence to support the lay testimony. Rather, the glenohumeral arthritis and osteopenia were more likely related to age and the Veteran's construction career. The examiner also opined that the right shoulder acromioclavicular arthritis was not etiologically related to the Veteran's period of service, to include participation in jump school. The examiner incorporated by reference the same medical history provided in the left shoulder opinion, including the lay testimony of chronic symptoms since an in-service onset. Despite the lay testimony, the examiner explained there was no objective evidence of an old injury or advanced degenerative changes of the right shoulder. The radiographic findings of mild osteoarthritis of the acromioclavicular joint at age 72 were no more advanced than would be expected of someone in the Veteran's age group. If the Veteran had right shoulder trauma in service, then the expected finding would be more advance disease, which the Veteran did not have. The examiner again highlighted that the Veteran worked in construction for most of his life, and persons with that occupation had a much greater risk of developing osteoarthritis. Regarding the right shoulder bursitis, the examiner opined bursitis was also not due to the Veteran's period of service. The examiner explained that bursitis was not an uncommon finding in persons who had acromioclavicular arthritis and was most often associated with repetitive overuse consistent with the Veteran's occupational history. Thus, the bursitis was more than likely related to the acromioclavicular joint arthritis and the Veteran's occupational history, and not related to his period of service. The December 2020 VA opinions regarding the left and right shoulder are adequate and complied with the prior remand directives. The 2020 examiner specifically noted consideration of the lay testimony of shoulder symptoms in service and the allegations of shoulder symptoms from 1960 through 2011 in compliance with the Board's prior remand directives. The examiner's rationale also adequately explained why the current left and right shoulder disorders were not etiologically related to the conceded participation in jump school. The examiner's rationale was thorough, based on an accurate reporting of the facts, and adequately considered the lay assertions. The opinions comply with the remand directives, are adequate, and weigh heavily against the claim. There is no medical opinion to the contrary. To the extent the Veteran has asserted that the claimed shoulder conditions are etiologically related to his period of service, as a lay person he is not competent to offer a medical opinion that requires medical knowledge of the musculoskeletal system. Thus, his opinion is not competent or entitled to probative weight. In sum, the preponderance of the evidence is against a finding that the claimed left and right shoulder disorders manifested in service, existed chronically since service, or are otherwise related to the Veteran's period of service. The criteria for service connection on a direct and presumptive basis are not met and the claims are denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a right knee disorder is remanded. 2. Entitlement to service connection for a left knee disorder is remanded. Unfortunately, remand is again required for adequate addendum opinions on the etiology of the claimed right and left knee disorders. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA most recently obtained a medical opinion in December 2020 on the etiology of the claimed left and right knee disorders. The examiner addressed knee imaging studies in 2015 and based their negative opinions on a finding that the degenerative changes of the knees were more likely related to aging and the Veteran's career in construction. The examiner overlooked a June 1998 private treatment record documenting a past medical history of arthritis in the knees that significantly predates the 2015 imaging studies. As a result, the opinion is not based on a full and accurate reporting of the facts and is not adequate. Therefore, another addendum is required. On remand, VA should undertake appropriate efforts to obtain outstanding and relevant treatment records. Although the Veteran has been provided with opportunities to submit outstanding private treatment records previously, VA medical records indicate he continues to receive private treatment. On remand, the Veteran should be given another opportunity to submit any relevant and outstanding private treatment records. The Veteran also appears to receive regular medical care through VA. On remand VA should obtain VA treatment records from 2020 onward. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed knee disorders from a VA examiner, preferably the examiner who provided the 2020 opinion. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (Continued on the next page) (a.) For each diagnosed right and left knee disorder, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the disorder had onset in, or is otherwise related to, active service. (b.) The examiner is requested to review the December 2020 examination report and evidence contained therein, the lay testimony of chronic knee symptoms since an in-service onset, the lay testimony that the knee symptoms are due to jump school, and a June 1998 private record documenting a past medical history of arthritis of the knees (located on page 38/41 of the document titled "Medical Treatment Record Government Facility" that was associated with the claims file on October 26, 2017). CHRSTOPHER J. O'DONNELL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Smith, 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.