Citation Nr: 21041099 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 15-28 271 DATE: July 8, 2021 ORDER Entitlement to service connection for a neck disorder is denied. 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 right arm disorder is denied. Entitlement to service connection for a right leg disorder is denied. Entitlement to service connection for a left leg disorder is denied. REMANDED Entitlement to service connection for residuals of a head injury is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for a right hand disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right foot disorder is remanded. Entitlement to service connection for a left foot disorder is remanded. FINDINGS OF FACT 1. The Veteran has cervical spine degenerative disc disease with disc desiccation, C3-4 disc bulge, and C5-6 disc spurring that was incurred years after active duty service and is unrelated to service. 2. The Veteran has lumbar spine degenerative disc disease and stenosis, status-post L4-5 laminotomy, foraminotomy, microdiscectomy, and reduction and re-exploration and revision discectomy, that was incurred years after active duty service and is unrelated to service. 3. The Veteran has right shoulder tendinopathy, tenosynovitis, and labrum tear that were incurred years after active duty service and is unrelated to service. 4. The Veteran has right carpal tunnel that was incurred years after active duty service and is unrelated to service. 5. The Veteran has a right lower extremity radiculopathy that resulted from non-service-related lumbar spine degenerative disc disease and stenosis, status-post L4-5 laminotomy, foraminotomy, microdiscectomy, and reduction and re-exploration and revision discectomy. 6. The Veteran has a left lower extremity radiculopathy that resulted from non-service-related lumbar spine degenerative disc disease and stenosis, status-post L4-5 laminotomy, foraminotomy, microdiscectomy, and reduction and re-exploration and revision discectomy. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for a lumbar spine disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria for service connection for a right shoulder disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 4. The criteria for service connection for a right arm disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 5. The criteria for service connection for a right leg disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 6. The criteria for service connection for a left leg disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from September 1981 through March 1990. This appeal arises from the agency of original jurisdiction's (AOJ's) October 2013 rating decision. The issues on appeal were remanded previously by the Board in August 2018 and in September 2020. The development ordered in those remands are complete and the matter now returns to the Board for review. The most recent Supplemental Statement of the Case concerning the issues on appeal was issued by the AOJ in March 2021. The records show that additional VA treatment records relevant to treatment received by the Veteran from March through May of 2021 were subsequently added to the record. Those records, however, contain information that is merely duplicative of the evidence already assembled. Under the circumstances, the Veteran is not prejudiced by the Board adjudicating the issues herein decided. Service Connection Generally, service connection will be granted if the evidence shows that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires an evidentiary showing of three essential elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection for certain listed chronic diseases, including arthritis and organic diseases of the nervous system such as carpal tunnel and radiculopathies, may also be awarded under 38 C.F.R. § 3.309(a) on a presumptive basis even in the absence of evidence showing the onset of that disability during service, provided that such disability is shown as having been manifest to a compensable degree within one year of separation from active duty. In such instances, the disease at issue is presumed as having been incurred during active service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309(a). An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through an evidentiary showing of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease that was first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). 1. Entitlement to service connection for a neck disorder. The Veteran asserts in his July 2012 claim that he is entitled to service connection for a neck disorder. In a July 2015 statement, he asserts broadly that he has experienced chronicity since service of all of his claimed disorders, to include his claimed neck disorder. As discussed more fully below, the evidence shows that the Veteran has cervical spine degeneration that likely resulted from post-service injuries. Contrary to the vague assertion raised in the Veteran's July 2015 statement, the service treatment records are entirely silent for any neck-related complaints by the Veteran and for objective findings, treatment, or diagnoses related to the Veteran's neck and cervical spine. Repeated medical examinations conducted during service, including the Veteran's January 1990 separation examination, note no neck-related complaints or any objectively observed cervical spine abnormalities. Post-service treatment records obtained from the Social Security Administration show initial findings for decreased cervical spine motion during treatment in September 2007 at Greensboro Spine & Scoliosis Center. An October 2007 cervical spine MRI showed disc desiccation at multiple discs in the Veteran's cervical spine, disc bulge at C3-4 that mildly narrowed the right foramen, and disc spurring and disc desiccation at C5-6. During a November 2007 visit, the Veteran reported that his neck pain began two years before following a 2005 accident (described more fully below). Records for subsequent VA and private treatment show that the Veteran has been followed for ongoing neck pain and decreased cervical spine motion. Nonetheless, those records provide no opinion that even suggests any relationship between the Veteran's cervical spine degeneration and his active duty service. The Veteran's vague assertion that he has had chronic neck problems that date back to service carry grave credibility concerns and are not entitled any weight. As mentioned, the Veteran provided a contradictory medical history during treatment in November 2007, when he self-reported that his neck problems began in 2005. As also mentioned, the service treatment records reflect no in-service complaints by the Veteran for any neck problems. The Veteran's separation examination noted no reported history of neck problems and spine and neurological examinations were normal. Given the Veteran's inconsistent statements and the contrary evidence, the Board assigns little weight to the Veteran's assertions, and instead, assigns greater weight to the other evidence in the record. The evidence shows that the Veteran has cervical spine degeneration that was likely incurred after the Veteran's separation from service. The Veteran is not entitled to service connection for a neck disorder. To that extent, this appeal is denied. 2. Entitlement to service connection for a lumbar spine disorder. The Veteran asserts in his July 2012 claim that he is entitled to service connection for a lumbar spine disorder. He elaborates in his July 2015 substantive appeal that he incurred back injuries during service and experienced chronic symptoms after service which he treated with over-the-counter medication prior to undergoing two back surgeries. The evidence shows that the Veteran has lumbar spine degenerative disc disease and stenosis that was likely incurred after the Veteran's separation from service. Service treatment records show that the Veteran was treated for low back muscle strain injuries from March through April of 1988, August 1988, and in January 1990. Although the Veteran reported recurrent back pain during his January 1990 separation examination, spine and neurological examinations conducted at that time were normal. The post-service treatment records reflect no back-related complaints, findings, diagnoses, or treatment until July 2005 when the Veteran was admitted at Med Central for back complaints after a work-related incident in which a crate fell on top of him. The admission records reflect that the Veteran was reported that he felt a pop in his low back and experienced immediate pain and discomfort. An examination revealed tenderness to palpation over the spine. Straight leg raises revealed numbness and tingling in both of the Veteran's thighs and decreased muscle strength. The Veteran received an initial diagnosis for low back strain; however, an August 2005 MRI showed a mild central posterior annular bulge and annular tear at L4-5 superimposed upon spondylosis resulting in mild central canal narrowing and mild to moderate biforaminal stenosis. The Veteran underwent surgery in February 2006 for left L4-5 laminotomy, foraminotomy, microdiscectomy, and reduction and removal of a central disc herniation. The Veteran experienced no improvement after the 2006 surgery and underwent a second surgery for re-exploration and discectomy revision in April 2007. Private treatment records obtained from the Social Security Administration show that the Veteran was followed post-surgically in 2007 at Greensboro Spine & Scoliosis Center. Those records show that the Veteran continued to report severe low back pain and pain and decreased sensation in his lower extremities. Notably, the records appear to relate the Veteran's ongoing lumbar spine disorder to his work-related accident in 2005. Records for subsequent VA treatment received by the Veteran document ongoing complaints of back pain and radicular symptoms in his lower extremities. The VA treatment records provide no opinions that contradict the conclusion that the Veteran's back disorder resulted from his 2005 work accident. The Veteran was scheduled to undergo a spine examination in September 2013. At that time, he self-reported that he injured his back while on the job in August 2005. He reported ongoing back pain and radicular symptoms since the injury. The Veteran was observed ambulating in a wheelchair and a scooter. A physical examination of the Veteran's spine was aborted given the Veteran's complaints and physical limitations. Still, based on the Veteran's reported history and review of the claims file, the examiner opined that the Veteran's lumbar spine disorder was not caused by the Veteran's in-service injuries. As rationale, he explained that although the Veteran was treated during service for acute lumbar strain, the subsequent service treatment records indicate no sequelae, and moreover, the Veteran's back was normal during his separation examination. The examiner concluded that the Veteran's in-service injuries resolved during service. He noted further that the Veteran was able to work without limitations after service prior to a debilitating on the job injury in 2005. The Veteran was afforded a new spine examination in May 2019. At that time, the Veteran acknowledged his 2005 work injury but reported that prior to that injury, he experienced the gradual onset of back pain during service in 1984. A physical examination conducted at that time showed decreased and painful thoracolumbar spine motion and localized tenderness during palpation over the spine. A neurological examination revealed findings that were consistent with radiculopathies in the Veteran's lower extremities involving moderate incomplete paralysis of the sciatic nerves and intervertebral disc syndrome (IVDS). A surgical scar was also observed over the low back, measuring 0.3 centimeters by 7.0 centimeters. The examiner diagnosed degenerative arthritis of the spine and IVDS but opined that it is less likely as not that the Veteran's back disorder was incurred during service or that it resulted from an in-service injury or event. The examiner explained that the service treatment records are notable for treatment during service for self-limiting back pain that resolved. The examiner noted further that post-service records show that the Veteran incurred a post-service work-related injury in July 2005, but prior to that injury, was apparently able to work without limitations during the period between his separation from service and the July 2005 work-related injury. Indeed, the examiner noted that a June 2009 evaluation with Dr. S. notes that the Veteran was a full-time worker and was able to run and swim prior to his 2005 injury. Based on the evidence in the record and the Veteran's history, the examiner concluded that the Veteran did not incur a permanent back injury during service and that his current disorder is not related etiologically to his active duty service. In October 2020, VA sought a revised medical opinion which considered the Veteran's assertions that he had chronic back problems after service, prior to his 2005 injury. On review of the claims file, the reviewing clinician noted that the Veteran's in-service complaints were diagnosed as "acute low back pain" and were self-limiting and acute in nature. Moreover, the reviewing clinician stated, although the separation examination notes complaints by the Veteran of recurrent back pain, the physical examination showed a normal spine. The reviewing clinician observed further that the Veteran was able to maintain civilian employment as a warehouse worker, which entailed lifting 30 pounds and up to a maximum 80 pounds regularly and walk distances of 100 feet per hour, as described by the Veteran in his social security disability application. The reviewing clinician observed that the Veteran's chronic problems are shown in the record as beginning from the Veteran's 2005 injury. As such, the reviewing clinician opined that the Veteran's current back disorder is likely related to his post-service injury in 2005. A February 2021 medical opinion essentially concurs with the previous negative opinions. Though acknowledging the Veteran's contention that he had chronic back problems that he treated with over-the-counter medication prior to his 2005 work injury, the reviewing clinician noted the Veteran's medical history and observed that the evidence showed that the Veteran's ruptured disc injuries were incurred in the 2005 accident. In conclusion, the examiner stated, there is insufficient evidence to conclude that the Veteran's in-service back injury contributed significantly to his current lumbar spine disorder. The weight of the evidence shows that the current conditions in the Veteran's lumbar spine were incurred after service in the 2005 work-related accident and did not result from the Veteran's in-service muscle strain injuries. Although the Board is sympathetic to the Veteran's belief that his current back problems are related etiologically to events during his active duty service, the Veteran's assertions in that regard are not entitled significant probative weight. In that regard, the question of whether the Veteran's back problems are related to his active duty service is a medically complex one and the Veteran is not qualified to offer a probative opinion as to that question. In contrast, the negative etiology opinions expressed in the treatment records and by examiner and reviewing clinicians in September 2013, May 2019, October 2020, and February 2021 are based on thorough review of the evidentiary record, history obtained from the Veteran, and objective findings on examination. Indeed, those opinions are consistent with the evidence. For these reasons, the Board assigns far greater probative weight to the negative opinions and other evidence in the record. The Veteran is not entitled to service connection for a lumbar spine disorder. To that extent, this appeal is denied. 3. Entitlement to service connection for a right shoulder disorder. The Veteran asserts also that he is entitled to service connection for a right shoulder disorder. An August 2013 notation in the record states that the Veteran was asserting that his shoulder disorder was secondary to his claimed lumbar spine disorder. He asserts alternatively in a July 2015 substantive appeal that he has had chronic right shoulder problems that date back to his active duty service. By the foregoing analysis denying service connection for a lumbar spine disorder, service connection for the Veteran's claimed right shoulder disorder cannot be granted on the basis that it is secondary to the Veteran's back disorder. The question remains as to whether the Veteran has a right shoulder disorder that was either incurred during active duty service, or, resulted from an in-service injury or event. The evidence shows that the Veteran has right shoulder tendinopathy, tenosynovitis of the extra-articular portion of the tendon of the long head of the biceps, superior labrum tear, and osteophytes and acromioclavicular degeneration that were likely incurred in a post-service accident at home. Contrary to the Veteran's assertion that he has had chronic right shoulder problems since his active duty service, the service treatment records indicate no in-service complaints by the Veteran of any right shoulder problems or any in-service findings, treatment, or diagnoses related to the Veteran's right shoulder. During the January 1990 enlistment examination, the Veteran expressly denied having any previous history of painful or "trick" shoulders. The post-service treatment records similarly show no complaints, findings, or treatment related to the Veteran's right shoulder prior to VA treatment in May 2013, when the Veteran reported pain in his right shoulder and upper extremity after a fall in his shower two weeks earlier. A physical examination conducted at that time showed tenderness over the acromioclavicular joint and positive cross shoulder and impingement tests. A right shoulder MRI showed mild tendinopathy of the distal supraspinatus tendon, mid tenosynovitis of the extra-articular portion of the tendon of the long head of the biceps, findings consistent with a possible superior labrum tear, and osteophytes and acromioclavicular degeneration. The Board does not assign significant weight to the Veteran's general assertion that he has had chronic right shoulder problems that date back to service. As discussed, such assertions are contradicted by inconsistent statements made by the Veteran during his separation examination. Such assertions are contradicted further by the self-reported right shoulder medical history given by the Veteran during VA treatment in May 2013, in which he attributed his complaints to a fall two weeks earlier and made no mention of any earlier right shoulder symptoms or impairment. Rather, the preponderance of the evidence shows that the Veteran's current right shoulder disorder resulted from his post-service fall at home in 2013. The Veteran is not entitled to service connection for a right shoulder disorder. To that extent, this appeal is denied. 4. Entitlement to service connection for a right arm disorder. The Veteran asserts also that he is entitled to service connection for a right arm disorder. Similar to assertions raised in relation to his claimed right shoulder disorder, an August 2013 notation in the record expresses that the Veteran was asserting that his right arm disorder was secondary to his claimed lumbar spine disorder. He asserts alternatively in a July 2015 substantive appeal that he has had chronic right arm problems that date back to his active duty service. Again, service connection for the Veteran's claimed right arm disorder cannot be granted on the basis that it is secondary to the Veteran's back disorder. The Board remains compelled to consider whether the Veteran has a right arm disorder that was either incurred during active duty service, or, resulted from an in-service injury or event. The evidence shows that the Veteran has been treated since May 2013 for right arm and elbow pain diagnosed as carpal tunnel that was likely incurred in a post-service fall at home. The service treatment records reflect no in-service complaints by the Veteran of any right arm problems. Similarly, the records note no in-service findings, treatment, or diagnoses related to the Veteran's right arm or upper extremity. Although the January 1990 enlistment examination notes complaints by the Veteran of painful or swollen joints, the examination report shows that the Veteran did not expressly describe any symptoms or complaints related to his right arm. Indeed, a physical examination revealed no abnormalities in either of the Veteran's upper extremities. Subject to the above, there is no indication in the post-service treatment records of any complaints, findings, treatment, or diagnoses related to the Veteran's right arm until May 2013, at which time the Veteran sought VA treatment for right upper extremity complaints after he fell in the shower two weeks earlier. A physical examination showed tenderness during palpation over the right elbow. A June 2013 right elbow MRI revealed increased fluid signal within the ulnar nerve in the right cubital tunnel that was deemed consistent with mild inflammation. Records for subsequent VA treatment received by the Veteran show that the Veteran was followed periodically for ongoing right elbow pain diagnosed as carpal tunnel. The foregoing medical chronology and medical history self-reported by the Veteran at initial treatment in May 2013 suggests strongly that the Veteran's right arm and elbow carpal tunnel likely resulted from the Veteran's post-service fall in 2013. Although the Board is mindful of the Veteran's vague assertion that he had chronic right arm problems that date back to his period of active duty, that assertion is not entitled significant weight. As mentioned, those assertions are contradicted by earlier inconsistent statements made by the Veteran during his separation examination, and also, the self-reported history given by the Veteran during his treatment visit in May 2013 in which he reported the onset of symptoms after his fall in the shower. Overall, the preponderance of the evidence shows that the Veteran's right carpal tunnel likely resulted from the Veteran's post-service fall at home in 2013. The Veteran is not entitled to service connection for a right arm disorder. To that extent, this appeal is denied. 5. Entitlement to service connection for a right and left leg disorders. The Veteran asserts in his July 2012 claim that he is entitled to service connection for unspecified disorders in his right and left leg. Again, he asserts generally in his July 2015 substantive appeal that he has had chronic problems in his legs since service. As discussed above in the Board's analysis concerning the Veteran's claimed lumbar spine disorder, the evidence shows that the Veteran incurred lumbar spine disc injuries, central canal narrowing and stenosis, and associated radicular symptoms in the Veteran's lower extremities in a July 2005 post-service occupational accident. A neurological examination conducted as part of the Veteran's May 2019 spine examination confirmed various objective findings that were determined as being consistent with IVDS and radiculopathies in the Veteran's lower extremities and involving moderate incomplete paralysis of the sciatic nerves. A review of the evidence in the claims file reveals no other complaints, findings, or diagnoses that are related specifically to the Veteran's right or left leg. The Board assigns no weight to the Veteran's assertion that he has had chronic problems in his legs that date back to his period of active duty service. Contrary to those assertions, the service treatment records document no in-service complaints, findings, diagnoses, or treatment related to the Veteran's legs. Indeed, repeated physical examinations conducted as part of the Veteran's May 1981 enlistment examination, August 1989 medical examination, and January 1990 separation examination revealed no abnormalities in either of the Veteran's lower extremities. Although the Veteran reported having a history of painful or swollen joints and a "trick" or locked knee, he did not apparently report any problems related to either of his legs specifically. To that extent, the Veteran's current assertion that he has had chronic problems in his legs since service seems to be inconsistent with the history reported by the Veteran during his separation examination. For these reasons, the Board finds that the Veteran's assertions concerning chronicity of symptoms in his legs lack credibility. Overall, the evidence shows that the Veteran has radiculopathies in his right and left lower extremities that resulted from his non-service-related lumbar spine disorder. As such, service connection cannot be granted for the Veteran's radiculopathies on either a direct basis under 38 C.F.R. § 3.303 or on a secondary basis under 38 C.F.R. § 3.310. Service connection for the Veteran's radiculopathies also cannot be awarded on a presumptive basis pursuant to 38 C.F.R. § 3.309(a) because the evidence shows the initial onset of the Veteran's radicular symptoms in 2005, many years after the Veteran was separated from service. The Veteran is not entitled to service connection for right and left leg disorders. To that extent, this appeal is denied. REASONS FOR REMAND 1. Medical opinion for head injury. The Veteran asserts in his July 2012 claim that he is entitled to service connection for residuals of head injuries incurred during service. In a July 2015 statement, he asserted broadly that he has experienced chronicity since service of all of his claimed disorders, to include claimed residuals associated with an in-service head injury. The service treatment records show that the Veteran was evaluated and treated during service in January 1990 for an eight centimeter laceration over the his right occipital area that was incurred after the Veteran fell and struck his head on a washing machine and the floor. The record shows that the Veteran denied losing consciousness and denied vision changes. Indeed, no specific physical, cognitive, or neurological symptoms were reported by the Veteran at that time. A physical examination revealed only the laceration on the Veteran's scalp. A neurological examination was grossly normal and included normal findings of the Veteran's cranial nerves. No cognitive impairment was noted, and the Veteran demonstrated good coordination. Skull x-rays showed no evidence of any fracture. Still, the Veteran reported during his separation examination, conducted five days after the in-service head injury, such symptoms as headaches; dizziness and fainting spells; eye trouble; and, a head injury. Per the Board's August 2018 remand, the Veteran was afforded a head injury examination in May 2019. During the examination, the Veteran reported that he had been having chronic migraines. Notably, he also reported that he sometimes "sees stars" in his visual field. On examination, the examiner noted no abnormalities or impairment in any of the areas of the Veteran's memory, attention, concentration, executive function, judgment, social interaction, orientation, motor function, visual spatial orientation, communication, consciousness, or neurobehavioral effects. Also, no physical residual symptoms or scars associated with head trauma were observed. The examiner opined overall that the Veteran did not have current head injury residuals; however, did not consider or address the significance of the Veteran's subjectively reported headaches or vision changes. The Board remanded the issue again in September 2020. In doing so, the Board directed that VA obtain an etiology opinion for the Veteran's reported headaches. Notably, the Board made no mention in its remand of the Veteran's reported visual changes, namely that he "sees stars," and did not request that the reviewing clinician address whether the Veteran's visual changes are attributable to his active duty service. Subject to the above, the Board notes that repeated eye examinations conducted during VA treatment administered during the appeal period revealed ongoing complaints of similar visual field changes. In March 2016, the Veteran described seeing spots and bubbles in his visual field. During an October 2017 eye examination, he reported that he had been seeing flashes of light in his eyes over the past year. During a February 2020 eye examination, he stated that he was seeing bright yellow rings whenever he closed his eyes. In addition to these reported symptoms, the VA treatment records document ongoing diagnoses for refractive error, cataracts, glaucoma, and vitreous floaters. Pursuant to the September 2020 remand, the AOJ obtained a February 2021 medical opinion in which the reviewing clinician addressed the etiology of the Veteran's headaches. No opinion was given, however, as to whether the vision changes described by the Veteran and noted during eye examinations are residuals associated with the Veteran's head injury and/or are related etiologically to the Veteran's in-service head injury. Such an opinion should be obtained at this time. 2. Pre-enlistment mental health treatment records and mental health examination. The Veteran asserts in his July 2012 claim that he is entitled to service connection for an acquired psychiatric disorder. He asserts broadly in a July 2015 statement that he has experienced chronicity of all of his claimed disorders since service, to include his claimed psychiatric disorder. The service treatment records, to include the Veteran's May 1981 enlistment examination, note no subjective mental health complaints from the Veteran and note no objective mental health findings or diagnoses. Under the circumstances, the Veteran must be presumed as having been of sound mental health when he enlisted into service. That presumption may be overcome only by evidence showing that the Veteran had mental health problems that clearly and unmistakably pre-existed his enlistment into service, and if that is shown, that the pre-existing mental health problems were clearly and unmistakably not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b); Smith v. Shinseki, 24 Vet. App. 40 (2010). Social Security records and VA treatment records show that the Veteran has remained under regular treatment for depression and anxiety since 2007. Notably, more recent VA treatment records dated April 2019 reflect that the Veteran was reporting a history of childhood abuse and trauma. Based apparently on the reported history and the Veteran's presentation during the April 2019 treatment visit, attending mental health staff diagnosed posttraumatic stress disorder (PTSD) and depression. In conjunction with the same, a September 2009 mental health evaluation conducted for the Social Security Administration by Dr. S.O.T. states that the Veteran was reporting a history of recurrent depression and anxiety that dates back to his childhood. He also reported a history of self-mutilation and suicidal ideation that included suicide attempts in the 1970s. Indeed, the Veteran reported that he was raised in orphanages and foster homes since infancy and that he took prescribed psychotropic medications during that time. The Veteran suggests by his reported pre-enlistment history that he underwent extensive mental health evaluation and treatment prior to his enlistment into service in September 1981. VA should contact the Veteran to inquire whether he has specific information as to the whereabouts of records relating to that pre-enlistment treatment. If the Veteran can provide that information, VA should then undertake efforts to obtain those records. Thereafter, VA should schedule the Veteran to undergo a mental health examination to determine the nature of any current mental health disorders; to determine whether the Veteran's mental health disorders clearly and unmistakable pre-existed his enlistment in September 1981; and, if so, whether those pre-existing disorders clearly and unmistakably were not aggravated by the Veteran's active duty service. 3. Right hand examination (foreign body in finger). The Veteran claims also that he is entitled to service connection for an unspecified right hand disorder. As mentioned, he asserts broadly in a July 2015 statement that he has experienced chronicity of all of his claimed disorders since service. As discussed above in the Board's analysis relating to the Veteran's right shoulder and arm, the Veteran sought VA treatment in May 2013 for reported injuries sustained in a fall in his shower two weeks earlier. A physical examination conducted at that time showed that the Veteran was unable to form a fist and that his right hand was tender to palpation. Notably, right hand x-rays showed the presence of "foreign bodies" in the Veteran's right fourth finger. No opinion was given as to the etiology of the foreign bodies in the Veteran's finger and no history was obtained from the Veteran beyond his recent fall. It is unclear from the record whether the symptoms noted during the May 2013 treatment visit are attributable to the foreign bodies in the Veteran's finger, and if so, when the injuries in the Veteran's finger occurred. As such, the Veteran should be afforded an examination of his right hand and fingers to determine the nature of any disorders, and, whether any disorders are related etiologically to the Veteran's active duty service. 4. Knee examination. The Veteran also claims service connection for unspecified disorders in his right and left knee. Again, he asserts broadly in a July 2015 statement that he has experienced chronicity of all of his claimed disorders since service. The Veteran's service treatment records do not indicate any specific treatment during service for the Veteran's knees. Still, the January 1990 separation examination report notes that the Veteran was reporting a history of "trick" or locked knees. Post-service VA treatment records show that the Veteran began reporting right knee pain in June 2012, although he did state during a July 2012 follow-up visit that he had been having right knee pain for years. X-rays and MRI studies showed osteophytic spurring in the right patella and medial compartment chondromalacia and bursitis. The Veteran has been followed in VA treatment since that time for ongoing medial right knee pain. The records reflect no opinions concerning the etiology of the Veteran's right knee disorder. Relative to the Veteran's left knee, VA treatment records show that the Veteran began reporting left knee pain in March 2013. Although the March 2013 record states that the Veteran's left knee pain was thought to be attributable to an altered gait caused by the Veteran's chronic low back and right knee pain, the attending medical staff gave no explanation or rationale for that opinion. Given the Veteran's general assertions and in the absence of any medical opinion, the record remains unclear as to whether the disorders in the Veteran's knees are related etiologically to his active duty service. As such, the Veteran should also be afforded an examination of his knees to determine the nature of any current disorders, and, whether the Veteran's knee disorders are related etiologically to his active duty service. 5. Foot examination. The Veteran claims entitlement to service connection for unspecified disorders in his feet. Notably, service connection is already in effect for the Veteran for a residual scar on his right foot that resulted from an in-service burn injury. The question on appeal is whether the Veteran has any other disorders in his feet that are related etiologically to his active duty service. The Veteran's service treatment records document the grease burn injury; however, reflect no other subjective complaints, objective findings, treatment, or diagnoses related to the Veteran's feet. Notably, the Veteran reported during the January 1990 separation examination that he did have a history of swollen or painful joints. Nonetheless, he does not report any history of problems in his feet specifically. The post-service VA treatment records reflect that the Veteran began reporting pain and swelling in his feet in late 2011. Subsequent evaluation and workup led to diagnoses for right foot calcaneal stress fracture and Achilles tendon tear and bilateral Achilles tendonitis. Records for subsequent VA treatment through the present show that the Veteran has been followed for ongoing bilateral foot pain treated with Achilles tendon inserts, an orthopedic boot on the Veteran's right foot, and an orthopedic shoe on the Veteran's left foot. Given the Veteran's general assertions and in the absence of any medical opinions, the record remains unclear as to whether the disorders in the Veteran's feet are related etiologically to his active duty service. As such, the Veteran should also be afforded an examination of his feet to determine the nature of any current disorders, and, whether the Veteran's foot disorders are related etiologically to his active duty service. The matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his head injury, acquired psychiatric disorder, right hand, knees, and feet. Records for VA treatment received by the Veteran since May 2012 and any relevant private treatment identified by the Veteran and not already of record should be obtained. If the records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 2. Request the Veteran to provide specific information as to the dates, names for any treatment provides, and locations for any mental health treatment received by him prior to his enlistment into service. If the Veteran can provide such information, obtain the identified records. If the records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 3. After the development ordered in Paragraph 1 is completed, obtain a medical opinion as to whether it is at least as likely as not that the Veteran's vision changes, to include refractive error, cataracts, glaucoma, vitreous floaters, and the subjectively reported visual field changes reported during VA treatment in March 2016, October 2017, and February 2020 resulted from the Veteran's active duty service, to include the Veteran's head trauma in January 1990. The claims file should be made available to the reviewing clinician and the reviewing clinician should review the claims file in forming the requested opinions. The reviewing clinician should provide a detailed rationale that explains fully all of the reasons for the given opinions. If the reviewing clinician determines that a physical examination of the Veteran is required in order to answer the above questions, such should be accomplished. 4. After the development ordered in Paragraphs 1 and 2 are completed, schedule the Veteran for a mental health examination to determine the nature and etiology of any current mental health disorders. The claims file should be made available to the examiner and the examiner should review the claims file in conjunction with the examination. The examiner should conduct all necessary tests and studies and identify all mental health disorders. For each diagnosed disorder, the examiner should provide an explanation as to how the diagnosis fits the diagnostic criteria. For each diagnosed disorder, the examiner should provide an opinion as to whether the disorder clearly and unmistakably (i.e., undebatably) pre-existed the Veteran's enlistment into service in September 1981. If so, the examiner should also provide an opinion as to whether the disorder clearly and unmistakably was not aggravated by the Veteran's active duty service. If the examiner determines that the Veteran clearly and unmistakably did not have a mental health disorder that pre-existed his enlistment into service, or that the disorder was not clearly and unmistakably not aggravated by service, then the examiner should also provide an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that: a) the disorder was incurred during the Veteran's active duty service; b) the disorder resulted from an injury, illness, or event that occurred during the Veteran's active duty service; c) the disorder resulted from a service-connected disability; and/or d) the disorder was aggravated by a service-connected disability. The examiner should provide a detailed rationale that explains fully all of the reasons for the given opinions. As part of the given rationale, the examiner should address and consider the Veteran's assertion that he has had chronic mental health symptoms since service and explain what significance, if any, the examiner assigns to those assertions in forming his or her opinions. 5. After the development ordered in Paragraph 1 is completed, schedule the Veteran for a right hand examination to determine the nature and etiology of any foreign bodies in the Veteran's right hand and fingers and/or other current disorders. The claims file should be made available to the examiner and the examiner should review the claims file in conjunction with the examination. The examiner should conduct all necessary tests and studies and identify all disorders. For each disorder identified, the examiner should provide opinions as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that: a) the disorder was incurred during the Veteran's active duty service; b) the disorder resulted from an injury, illness, or event that occurred during the Veteran's active duty service; c) the disorder resulted from a service-connected disability; and/or d) the disorder was aggravated by a service-connected disability. The examiner should provide a detailed rationale that explains fully all of the reasons for the given opinions. As part of the given rationale, the examiner should address and consider the Veteran's assertion that he has had chronic right hand symptoms since service and explain what significance, if any, the examiner assigns to those assertions in forming his or her opinions. 6. After the development ordered in Paragraph 1 is completed, schedule the Veteran for a bilateral knee examination to determine the nature and etiology of any current disorders. The claims file should be made available to the examiner and the examiner should review the claims file in conjunction with the examination. The examiner should conduct all necessary tests and studies and identify all disorders. For each disorder identified, the examiner should provide opinions as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that: a) the disorder was incurred during the Veteran's active duty service; b) the disorder resulted from an injury, illness, or event that occurred during the Veteran's active duty service; c) the disorder resulted from a service-connected disability; and/or d) the disorder was aggravated by a service-connected disability. The examiner should provide a detailed rationale that explains fully all of the reasons for the given opinions. As part of the given rationale, the examiner should address and consider the Veteran's assertion that he has had chronic knee symptoms since service and explain what significance, if any, the examiner assigns to those assertions in forming his or her opinions. 7. After the development ordered in Paragraph 1 is completed, schedule the Veteran for a bilateral foot examination to determine the nature and etiology of any current disorders other than the Veteran's service-connected right foot burn scar. The claims file should be made available to the examiner and the examiner should review the claims file in conjunction with the examination. The examiner should conduct all necessary tests and studies and identify all disorders other than the Veteran's right foot burn scar. For each diagnosed disorder, the examiner should provide opinions as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that: a) the disorder was incurred during the Veteran's active duty service; b) the disorder resulted from an injury, illness, or event that occurred during the Veteran's active duty service; c) the disorder resulted from a service-connected disability; and/or d) the disorder was aggravated by a service-connected disability. The examiner should provide a detailed rationale that explains fully all of the reasons for the given opinions. As part of the given rationale, the examiner should address and consider the Veteran's assertion that he has had chronic symptoms in his feet since service and explain what significance, if any, the examiner assigns to those assertions in forming his or her opinions. 8. After completion of the above development, the issues remaining on appeal should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Lee 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.