Citation Nr: 21041307 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 08-27 710 DATE: July 8, 2021 ORDER Service connection for a left shoulder disorder is denied. An initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for residuals of a head injury is remanded. FINDINGS OF FACT 1. A left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest to a compensable degree within one year of separation from active duty, and such is not caused or aggravated by service-connected cervical spine degenerative disc disease (DDD). 2. For the entire appeal period, the Veteran's PTSD is manifested by psychiatric symptomatology resulting in occupational and social impairment in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1977 to April 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2007 and January 2009 by a Department of Veterans Affairs (VA) Regional Office. In June 2009, the Veteran testified at a hearing before a Decision Review Officer (DRO) and, in July 2011, one of the undersigned Veterans Law Judges. In November 2011 and July 2017, the case was remanded for additional development. In November 2018, the Veteran testified at another Board hearing before a different one of the undersigned Veterans Law Judges. A transcript of each hearing is associated with the record. In April 2021, the Veteran was informed of his right to a third hearing with a different Veterans Law Judge who would participate with the other two Veterans Law Judges in deciding his appeal. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). However, he waived his right to a third hearing later the same month. The Board notes that, in March 2019, the Veteran's claims for service connection for hypertension, gastrointestinal disorder (GERD), a sleep disorder, and chronic headaches were remanded for additional development and will be the subject of a separate Board decision adjudicated by the Veterans Law Judge who conducted the November 2018 hearing on such matters. Furthermore, since the issuance of the February 2020 supplemental statement of the case, additional evidence has been associated with the record. However, the Veteran, through his representative, waived Agency of Original Jurisdiction (AOJ) consideration of such evidence in May 2020, and the subsequently received evidence is irrelevant and/or contains findings that are duplicative to those previously considered by the AOJ. Thus, the Board finds there is no prejudice to the Veteran in proceeding with the adjudication of his claims at the present time. 38 C.F.R. § 20.1305(c). 1. Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected cervical DDD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran asserts that he sustained two separate injuries to his left shoulder while on active duty. The first injury is reported to have occurred in May 1979 when he fell off a tank and allegedly landed on, as relevant, his left shoulder. The second injury is reported to have occurred in January 1980 when he was attacked by five or six men while outside a nightclub in Germany. Alternatively, the Veteran alleges that his left shoulder disorder is secondary to (38 C.F.R. § 3.310) his service-connected cervical spine disability. The service treatment records (STRs) reflect that in May 1979 the Veteran "fell off track" and sustained a slight sprain to his right wrist. Also, a January 1980 STR reflects that he was seen for a laceration to his head, which he testified was due to the assault in Germany, and is currently service-connected for PTSD as a result of such event. While such STRs do not detail treatment for the Veteran's left shoulder in May 1979 or January 1980, he has offered sworn testimony that he also injured his left shoulder as a result of such events, which has been accepted. Nonetheless, the remainder of his STRs are likewise negative for any complaints, findings, treatment, or diagnosis referable to a left shoulder disorder. Furthermore, in November 2007, after reviewing the record, recording the Veteran's reported history of sustaining a left shoulder injury during a fall in 1979 and an assault in 1980, and conducting a physical examination with diagnostic testing, a VA examiner opined that the currently diagnosed age-related degenerative changes of both shoulders was not caused by an injury in service. In support of such opinion, the examiner noted that there was no documentation of any such injury in the STRs, and that the currently diagnosed degenerative changes were age-related. Additionally, in August 2018, another VA examiner reviewed the record, interviewed the Veteran, and conducted a physical examination and opined that the left shoulder disorder, diagnosed as degenerative changes of the left shoulder, was less likely than not incurred in or caused by his military service. In offering such opinion, the VA examiner noted the Veteran's reported in-service injuries due to a fall and assault, but still opined there was no nexus establishing causality between current complaints and military service. The rationale for this opinion included that there was no residual or chronic disability shown by the STRs or the post-service treatment records, as the STRs were negative for such injury, he has had no surgery on the left shoulder, and X-rays did not show any fracture, dislocation, or soft tissue abnormality. The VA examiner in August 2018 also opined that the Veteran's left shoulder disorder was less likely than not caused or aggravated by his service-connected cervical spine disability. The rationale included that there was no medical nexus establishing causality between his acromioclavicular (AC) joint (shoulder) arthritis and cervical spine DDD; rather, degenerative arthritis was a part of the normal aging process. The Board affords great probative weight to the November 2007 and August 2018 VA examiners' opinions as such considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary. In this regard, while the Veteran's representative reported at the November 2018 hearing that Dr. D.M. offered a favorable opinion in November 2013, a review of such report reflects that he only offered opinions addressing the etiology of the Veteran's lumbar spine, cervical spine, and right shoulder disorders, and there was no mention of a left shoulder disorder. Moreover, the Board acknowledges that the Veteran believes that his current left shoulder disorder is related to his military service and/or his service-connected cervical spine disability. However, while lay persons are competent to provide opinions on some medical issues, under the specific facts of this case that include no chronic in-service symptoms and no continuous symptoms for years after service, the etiology of a left shoulder disorder falls outside the realm of common knowledge of a lay person to make a nexus between the current diagnosed degenerative changes and any in-service injury. Specifically, such matter involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, the diagnosis of arthritis requires the administration and interpretation of musculoskeletal testing, and the etiology of such requires knowledge of the musculoskeletal system, to include the impact trauma and/or a cervical spine disability has on the shoulder joint. Accordingly, the Veteran's opinion as to the etiology of his left shoulder disorder is not competent evidence and, consequently, is afforded no probative weight. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (holding that ACL injury is too "medically complex" for lay diagnosis); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or DJD to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury). Furthermore, the evidence of record fails to demonstrate that symptoms of left shoulder arthritis were chronic in service, or were continuous after service, including to a compensable degree within one year of service separation, in order to meet the criteria for presumptive service connection as a "chronic" disease. While in-service injuries have been acknowledged, the other evidence, including STRs, show no complaints, findings, or diagnosis referable to a left shoulder disorder. Additionally, a November 2007 X-ray conducted almost thirty years after service separation only showed "some" degenerative changes of the AC joint, which the VA examiners assessed to be age-related and part of the normal aging process. Finally, as noted in November 2007, the Veteran reported that his left shoulder did not start affecting him until after separation from service. Consequently, presumptive service connection for the chronic disease of arthritis of the left shoulder is not warranted. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Based on the foregoing, the Board finds that the Veteran's left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, symptoms of arthritis were not chronic in service or continuous after service, arthritis did not manifest to a compensable degree within one year of separation from active duty, and the currently diagnosed arthritis is not caused or aggravated by service-connected cervical spine disability. Consequently, service connection for a left shoulder disorder must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 2. Initial rating for PTSD. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran's service-connected PTSD is evaluated (rated) as 70 percent disabling since May 11, 2007, the date of service connection, pursuant to DC 9411, which provides that such disability is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. In this regard, a 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation, although the actual rating is based on the degrees of occupational and social impairment. VazquezClaudio v. Shinseki, 713 F.3d 112, 11617 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran's appeal was certified to the Board in April 2011 and, as such, the DSM-IV applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. As the DSM-IV governs the Veteran's claim, such scores would be relevant to the evaluation of his PTSD; however, because of the Court's emphatic pronouncement in Golden v. Shulkin, 29 Vet. App. 221 (2018), that GAF scores are methodologically flawed and are particularly unreliable, in this decision, the Board will place no reliance on GAF scores for rating this Veteran's PTSD. Turning to the evidence of record, the Veteran was afforded a VA examination in November 2007, at which time he reported that he previously lived with two girlfriends, but did not get along very well with them and currently lived alone. However, he had custody of his two children. He also stated that he was not social and was afraid to go to public places, but reported that he occasionally played cards with friends and was brought to his appointment by a friend. The Veteran further indicated that he was doing painting work off and on, but did not have a job. The examiner noted that the psychiatric symptoms included insomnia, nightmares, bad dreams, anxiety, loneliness, suspiciousness towards others, not wanting to go to public places, and passive suicidal ideation. Mental status examination was normal with the exception of an anxious affect and thought content was preoccupied with paranoia about other people. The examiner concluded that the Veteran had mild symptoms of PTSD. In March 2009, the Veteran reported difficulty sleeping and insomnia. An April 2009 psychosocial assessment and employability evaluation assessed that the Veteran's symptoms of difficulty concentrating, flashbacks/intrusive thoughts, sleep disturbance and insomnia, waves of memory loss, overwhelming feelings of sorrow, withdrawal, and bouts of depression caused severe social, personal, and social impairment. The Veteran reported that he was not currently working and, while he reported severe trust issues, difficulty with relationships, and a lack of close friends, he was currently raising his two young children. In July 2010, the Veteran underwent another VA examination. At such time, he reported that he stayed to himself, but did not have any problems talking to people, and that it was hard for him to get close as far as developing a relationship, but was happy with his children and that he was fine if he never got married. The Veteran further reported that he basically stayed with his family as most of his friends in New York faded away and he did not really have friends now. The Veteran stated that he liked to take his children to the movies, roller skating, and fishing, and his children are what kept him going. While the Veteran reported that he previously worked odd jobs, he reported the he was not currently employed. Mental status examination in July 2010 was normal with the exception of psychomotor activity, which was described as restless, fatigued, and tense; anxious mood; short attention span; rambling and circumstantiality in thought process; preoccupation with one or two topics, ruminations, and paranoid ideation; sleep disturbance; isolative and emotionally withdrawn; compulsive checking; and mildly impaired memory. The examiner assessed that the Veteran's PTSD resulted in occupational and social impairment in most areas, but not total occupational and social impairment. At the July 2011 Board hearing, the Veteran alleged an increase in PTSD symptomatology in that his mind wandered and he was hypervigilant. For this reason, another VA examination was held in December 2015. At such time, the Veteran reported that, while he avoided his neighbors and was not working, he got along with family, had fishing friends, and was currently living in a house with his two children. Reported symptoms included suspiciousness, difficulty in establishing and maintaining effective work and social relationships, and inability to establish and maintain effective relationships. Mental status examination was normal. The VA examiner assessed that the Veteran's PTSD resulted in occupational and social impairment in most areas, but not total occupational and social impairment, noting that the Veteran took care of his children, went shopping with them, helped them with homework, went fishing with friends for fun, and got along with his siblings. The examiner in December 2015 was unable to reconcile the April 2009 report with the November 2007 and July 2010 VA examinations without resorting to mere speculation. In this regard, the VA examiner noted that the findings were too divergent from the October 2008 traumatic brain injury (TBI) examination results as such examiner used objective assessment measures, which the other examinations did not (the Veteran was the sole source of information). The VA examiner in December 2015 also noted that the July 2010 examination incorporated results from a self-report instrument and determined that it was not relevant for him to obviate collegial conclusions; thus, the VA examiner assessed that the conclusions of the November 2007 VA examination, October 2008 TBI assessment, and the December 2015 VA examination were more proximately convergent. In February 2016, the Veteran reported mild anxiety, severe depression, and sleep problems, and at the November 2018 Board hearing, he testified to experiencing nightmares. In November 2019, the Veteran had a stroke and presented with acute onset of aphasia along with confusion; thus, his attention and concentration were diminished, and memory testing showed impaired short-term and long-term memory. Nonetheless, the Veteran reported he had excellent social support from extended friends and family, including his mother, siblings, and several nieces and nephews. Upon discharge home, there was noted an appropriate mood and affect with good insight and judgment. Upon review of all the evidence of record, lay and medical, the Board finds that, for the entire rating appeal period, the nature, frequency, severity, and duration of the Veteran's PTSD symptomatology, to include as reported in the foregoing evidence and reflected upon examination, has not more nearly approximated total occupational and social impairment. For this reason, an initial rating in excess of 70 percent for such disability is not warranted for any period. Throughout the appeal period, while the Veteran has been unemployed (and is in receipt of a total disability rating based on individual unemployability) and has reported social isolation and avoidance of people, he has been able to maintain long-term relationships with his family, including his two children whom he raised on his own. Additionally, he reported that he has had friends throughout the appeal period as he reported that he played card with friends and a friend took him to the November 2007 VA examination. During the July 2010 VA examination, the Veteran reported that he liked to take his children to the movies, roller skating, and fishing and, at the December 2015 VA examination, he indicated that he got along with family and had fishing friends, and reported excellent social support from family and friends in November 2019. While an April 2009 psychological evaluation suggests a severe degree of impairment associated with the Veteran's PTSD, that examiner noted the Veteran was raising his children and, in reaching her conclusions, she did not have the benefit of the remainder of the evidence of record demonstrating that the Veteran maintained relationships with his family and friends. Consequently, the April 2009 evaluation is based on an incomplete record of symptoms and impairment, so is afforded less probative weight than the VA examinations conducted throughout the appeal period, which are based on thorough histories and evidence of record that are consistent with the other evidence of record. For these reasons, the Board finds that the totality of the evidence reflects that, while the Veteran's social relations have been limited, such are not entirely absent, so do not result in total social impairment for any period. The November 2007, July 2010, and December 2015 VA examiners, who have the appropriate expertise in evaluating psychiatric disabilities and considered the Veteran's subjective reports in combination with objective evaluations, found that the Veteran's PTSD resulted in no more than occupational and social impairment in most areas, which, again, is commensurate with the currently assigned 70 percent rating. Consequently, based on the foregoing, the Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by psychiatric symptomatology resulting in occupational and social impairment in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. For these reasons, an initial rating in excess of 70 percent for PTSD is not warranted for any period. 38 C.F.R. §§ 4.3, 4.7. Furthermore, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, in regard to the rating appeal adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). REASONS FOR REMAND 3. Entitlement to service connection for residuals of a head injury. As noted in the Board's prior remands, the Veteran's report of incurring head injuries coincident with his May 1979 fall from a tank and January 1980 assault has been accepted, and the remaining inquiry is whether he currently has any residuals of such in-service injuries. In this regard, the Veteran has alleged experiencing headaches, dizziness, anxiety, tinging in the upper extremities, seizures, and a cognitive disorder; however, he is currently service-connected for PTSD and radiculopathy of the bilateral upper extremities, and has a separate claim for service connection for headaches pending. With respect to the remainder of such reported symptoms, the Board noted in the November 2011 remand that there was conflicting evidence as to whether the Veteran actually had current residuals of in-service head injuries. Specifically, a November 2007 VA examination and October 2008 assessment revealed no residuals of TBI based on a CT scan of the head, which showed no acute abnormalities; neurological testing; and an October 2008 MRI of the brain. An August 2009 assessment from a neuropsychologist reflects a conclusion that the Veteran has residuals of a head injury as a result of service, to include cognitive disorder, not otherwise specified, TBI, and post-concussional syndrome, which were based on the same October 2008 MRI of the brain. In light of such conflicting findings, the Board remanded the claim for a VA examination with clarifying opinion. As noted in the July 2017 remand, a February 2016 VA examination revealed no residuals attributable to a TBI and, in October 2016, the VA examiner further opinioned that there was insufficient evidence to support a TBI diagnosis, the Veteran's alleged seizures were unlikely related to head trauma, and the remainder of the symptoms were most likely related to PTSD. While the VA examiner addressed the October 2008 MRI report, he did not address the January 1980 STR showing treatment for a laceration on the Veteran's head, the November 2007 VA examination report, and the August 2009 neuropsychological evaluation report as directed in the November 2011 remand. For these reasons, the Board again remanded the case to obtain an addendum opinion addressing such relevant evidence. Stegall v. West, 11 Vet. App. 268, 271 (1998). Thereafter, an addendum opinion was obtained in September 2018, at which time the VA examiner opined that, upon a review of the record, the history of the Veteran's symptoms and neuropsychological testing results would suggest that the predominance of his symptoms are related to his PTSD, depression, and anxiety as opposed to an in-service head injury. The VA examiner opined that the Veteran's headaches, anxiety, and depression were related to PTSD and history of depression, rather than such in-service head injury; however, as the VA examiner did not address the October 2008 MRI report, November 2007 VA examination, or the August 2009 neuropsychological evaluation as directed in the July 2017 remand, the Board finds that another remand is necessary for an addendum opinion that addresses such relevant evidence. The issue of service connection for residuals of a head injury is REMANDED for the following action: Request from an appropriate VA examiner an opinion addressing whether the Veteran has any residuals of an in-service head injury. Following a review of the record, the VA examiner should offer the follow opinion: Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran now has residuals of a head injury as a result of a January 1980 assault during service? If so, please describe the nature and severity of such current residuals. In offering such opinion, the examiner should discuss any reports of symptoms since service, the STRs showing treatment for a laceration on his head in January 1980, the November 2007 VA examination report, the October 2008 MRI report, and the August 2009 neuro-psychological evaluation report. (Continued on the next page) The examiner is further advised that the basis for a negative opinion must not be based solely on the lack of evidence of residuals of a head injury in the Veteran's STRs or a lack of medical records demonstrating a continuity of care after service. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals J. PARKER Veterans Law Judge Board of Veterans' Appeals S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Clark, 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.