Citation Nr: 21042569 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-15 289 DATE: July 13, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of service connection for asthma is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for sinusitis (to include sinus infections, deviated septum, and polyp growth) is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for avascular necrosis of the right hip is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for avascular necrosis of the left hip is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for cellulitis, bilateral feet is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for bilateral pes planus (also claimed as tendonitis), bilateral feet is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for radiculopathy left shoulder/arm is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for right shoulder torn muscle is granted. REMANDED Entitlement to service connection for asthma is remanded. Entitlement to service connection for sinusitis (to include sinus infections, deviated septum, and polyp growth) is remanded. Entitlement to service connection for avascular necrosis of the right hip is remanded. Entitlement to service connection for avascular necrosis of the left hip is remanded. Entitlement to service connection for cellulitis, bilateral feet is remanded. Entitlement to service connection for bilateral pes planus (also claimed as tendonitis), bilateral feet is remanded. Entitlement to service connection for radiculopathy, left arm/shoulder is remanded. Entitlement to service connection for right shoulder torn muscle is remanded. FINDINGS OF FACT 1. An October 2002 rating decision denied claims of service connection for sinusitis, avascular necrosis of the right hip, and asthma. The Veteran was notified of the decision but did not appeal or submit new and material evidence within the appliable one-year appeal period. 2. Evidence submitted since the October 2002 rating decision was not previously of record and relates to unestablished facts necessary to substantiate the claims of service connection for sinusitis and asthma. 3. A January 2015 rating decision denied reopening the previously denied claims for service connection for avascular necrosis of the right hip, asthma, and sinusitis; and, denied claims of service connection for avascular necrosis of the left hip, cellulitis of the bilateral feet, bilateral pes planus, radiculopathy, left arm/shoulder, and right shoulder torn muscle. The Veteran was notified of the decision but only appealed the denials of service connection for asthma and sinusitis, and did not appeal or submit new and material evidence within the applicable one-year appeal period with respect to the other denied claims. 4. Evidence submitted since the January 2015 rating decision was not previously of record and relates to unestablished facts necessary to substantiate the claims of service connection for avascular necrosis of the right hip, avascular necrosis of the left hip, cellulitis, bilateral feet, pes planus, bilateral feet, radiculopathy, left arm/shoulder, and right shoulder torn muscle. CONCLUSIONS OF LAW 1. The October 2002 is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.20, 19.52, 20.1103. 2. The January 2015 rating decision is final as to the issues of service connection for avascular necrosis of the right hip, avascular necrosis of the left hip, cellulitis, bilateral feet, bilateral pes planus, radiculopathy, left arm/shoulder, and right shoulder torn muscle. 38 U.S.C. § 7105; 38 C.F.R. §§ 19.20, 19.52, 20.1103. 3. As new and material evidence has been received, the previously denied claims for service connection for asthma, sinusitis, avascular necrosis of the right hip, avascular necrosis of the left hip, cellulitis, bilateral feet, bilateral pes planus, radiculopathy, left arm/shoulder, and right shoulder torn muscle are reopened. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Coast Guard from February 1977 to March 1979. This matter is before the Board of Veterans Appeals (the Board) on appeal from a January 2015 and August 2016 Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. The January 2015 rating decision denied reopening of claims for service connection for asthma, avascular necrosis of the right hip, and sinusitis because no new and material evidence has been received. The January 2015 rating decision also denied service connection for pes planus, both feet, avascular necrosis, left hip, radiculopathy left shoulder/arm, right shoulder torn muscle, and cellulitis of both feet. The Veteran's Notice of Disagreement (NOD) was received in January 2016. In his NOD, the Veteran appealed the issues of service connection for asthma and sinusitis. In August 2016, the Veteran filed claims for service connection for avascular necrosis of the right hip, avascular necrosis of the left hip, right shoulder torn muscle, cellulitis of both feet, tendonitis of both feet, radiculopathy of the left shoulder and radiculopathy of the left arm. As a result, the August 2016 rating decision was issued. The rating decision denied service connection for avascular necrosis of the right hip, avascular necrosis of the left hip, cellulitis, bilateral feet, pes planus, both feet, radiculopathy left shoulder/arm, and torn muscle, right shoulder, because the evidence submitted is not new and material. The Veteran's NOD was received in August 2016. The Statement of the Case with respect to the issues from August 2016 rating decision was issued in February 2017, and the Veteran's VA Form 9, substantive appeal to the Board was received in March 2017. With respect to the issues of service connection for asthma and sinusitis, the Statement of the Case was issued in May 2017, and the Veteran's VA Form 9 was received in July 2017. In April 2021, the Veteran and his attorney appeared before the undersigned Veterans Law Judge (VLJ) for a Board virtual hearing. The transcript is of record. 1. Whether new and material evidence has been received sufficient to reopen the claims of service connection for asthma, sinusitis (to include sinus infections, deviated septum, and polyp growth), avascular necrosis of the right hip, avascular necrosis of the left hip, cellulitis, bilateral feet, bilateral pes planus (also claimed as tendonitis), radiculopathy left shoulder/arm, and right shoulder torn muscle. In January 2002, the Veteran filed his original claims of service connection for asthma, sinusitis, and avascular necrosis of the right hip. The claims were denied in an October 2002 rating decision. The basis for the denial was that the Veteran's disabilities were not incurred in or caused by service. The Veteran was notified of the rating decision in October 2002. The Veteran did not appeal the decision and did not submit new and material evidence within one-year appeal period, and the August 2013 rating decision became final. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. In January 2014, the Veteran filed claims of service connection for avascular narcosis of the right and left hip. In June 2014, the Veteran submitted claims of service connection for cellulitis of both feet, asthma, sinusitis, radiculopathy of the left shoulder/arm, torn right shoulder muscle, and pes planus of both feet. As previously noted, the January 2015 rating decision denied reopening of claims of service connection for asthma, sinusitis, and avascular necrosis of the right hip. The rating decision also denied claims of service connection for pes planus, bilateral feet, avascular necrosis of the left hip, cellulitis, bilateral feet, radiculopathy left shoulder/arm, and right shoulder torn muscle. The Veteran was notified of the rating decision in January 2015. In his January 2016 Notice of Disagreement, the Veteran only appealed the issues of service connection for asthma and sinusitis. Moreover, the Veteran filed claims for service connection for avascular narcosis of the right and left hip, cellulitis, bilateral feet, pes planus, bilateral feet, radiculopathy left shoulder/arm, and right shoulder torn muscle in August 2016, more than one year after the January 2015 rating decision. As the Veteran only appealed the January 2015 rating decision insofar as it denied service connection for asthma and sinusitis, and did not submit his subsequent claims within one year, the January 2015 rating decision became final as to the issues of service connection for avascular narcosis of the right and left hips, cellulitis, bilateral feet, bilateral pes planus, radiculopathy left shoulder/arm, and right shoulder torn muscle. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. After a decision becomes final, a claimant must present new and material evidence to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers. Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable probability of substantiating the claim. 38 C.F.R. § 3.156(a). Newly submitted evidence is generally presumed to be credible for the purposes of reopening a claim. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required as to each previously unproven element of a claim to reopen. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Id. at 117-18. With respect to service connection for asthma and sinusitis, the evidence of record at the time of the October 2002 denial includes the Veteran's service treatment records (STRs) and the Veteran's VA treatment records from July 1997 to June 2002. The evidence after October 2002 includes the Veteran's VA treatment records after June 2002, the Veteran's Social Security Administration records, the Veteran's private treatment records, and the Veteran's April 2021 Board testimony. These records, in particular the Veteran's April 2021 Board testimony, indicate that the Veteran was surgically treated for a deviated septum within two years of discharge, and developed chronic sinusitis and asthma as a result. These records were not in existence at the time of the October 2002 rating decision and relate to an unestablished fact necessary to substantiate these claims. The credibility of this evidence is presumed for the purpose of whether it is deemed new and material. Overall, this evidence is not redundant or duplicative, and raises a reasonable possibility of substantiating the claims. Therefore, reopening of the claims for service connection for asthma and sinusitis is warranted. To this extent only, the appeal is granted. With respect to the claims of service connection for avascular necrosis of the right and left hips, cellulitis, bilateral feet, bilateral pes planus (also claimed as tendonitis), radiculopathy left shoulder/arm, and right shoulder torn muscle, the evidence of record at the time of the January 2015 rating decision includes the Veteran's STRs, his private treatment records up to July 2014, his statements received prior to January 2015, his Social Security Administration records, the January 2015 VA feet examination report, and his VA treatment records up to January 2015. The evidence after January 2015 includes the Veteran's private treatment records after July 2015, his VA treatment records after January 2015, statements from the Veteran received after January 2015, and the Veteran's April 2021 Board hearing testimony. These records, in particular the Veteran's testimony, indicate the Veteran's belief that his disabilities may have been caused or aggravated by his service-connected disabilities. In particular, the Veteran testified that he believes his hip disabilities are caused by the steroids used to treat his service-connected back disability and his sinus disability for which he seeks service connection. He also testified as to his belief that his shoulder disabilities and his foot disabilities are caused by the altered gait and use of cane which were the result of his service-connected left knee disability, his service-connected back disability, and his hip disabilities for which he seeks service connection. These records were not in existence at the time of the January 2015 rating decision and relate to an unestablished fact necessary to substantiate these claims. The credibility of this evidence is presumed for the purpose of whether it is deemed new and material; and, although it does not appear that the Veteran possess the requisite medical expertise to provide a competent opinion as to causation with respect to the etiology of internal medical processes, he nevertheless raises new theories of entitlement to service connection on a secondary basis. Overall, this evidence is not redundant or duplicative, and raises a reasonable possibility of substantiating the claims. Therefore, reopening of the claims for service connection for avascular necrosis of the right and left hips, cellulitis, bilateral feet, pes planus (also claimed as tendonitis), bilateral feet, left arm/shoulder radiculopathy, and right arm torn muscle is warranted. To this extent only, the appeal is granted. REASONS FOR REMAND 1. Entitlement to service connection for asthma. 2. Entitlement to service connection for sinusitis (to include sinus infections, deviated septum, and polyp growth). During the April 2021 Board hearing, the Veteran testified that he began having breathing problems in service. He testified that he served on USS Azalea and was exposed to asbestos. He also testified that the administrative building where he was sandblasting boat materials also had asbestos within the insulation. The Veteran testified that within two years of discharge, he had surgery for a deviated septum, which he relates to service. He testified that after the surgery, he had multiple sinus infections and polyps build up necessitating further procedures. He contends that his asthma and sinusitis developed after the deviated septum procedure and are related to service, to include exposure to asbestos. The Veteran indicated that he was treated at Durham VA in 1979 and underwent procedures for his disability there. However, the earliest VA treatment records from Durham VA that have been associated with the Veteran's file are from July 1997. A July 2014 records request was submitted, but it is unclear whether all of the Veteran's records were located. As such, as remand is necessary to obtain the outstanding VA treatment records. Moreover, it does not appear that the RO completed any development in an attempt to determine any amount of asbestos exposure, if any. Thus, on remand, the RO should attempt to determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. In this case, the Veteran alleges that he was exposed to asbestos from insulation and other parts of USS Azalea while served on it, and while he was sandblasting boat materials in an administrative building with asbestos insulation. A review of the record does not show which steps the RO made to determine whether or not asbestos exposure occurred. Additionally, no memorandum with a formal finding has been produced. Accordingly, a remand is necessary to undertake the necessary development to determine whether the Veteran was exposed to asbestos in service. Finally, the Veteran has not been afforded a VA examination for his claims. VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. §5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. The Veteran's records contain a diagnosis for sinusitis and allergic asthma. The Veteran contends that these disabilities are related to service, to include potential asbestos exposure. While the Veteran does not possess the medical expertise to provide a nexus opinion in this case, his contentions overcome the low threshold of McClendon. As such, VA examinations with complete nexus opinions are warranted. These matters are remanded for further development and adjudication. 3. Entitlement to service connection for avascular necrosis of the right hip. 4. Entitlement to service connection for avascular necrosis of the left hip. During the April 2021 Board hearing, the Veteran testified that he believes that his avascular necrosis of the bilateral hips is related to the steroids that he took for his sinus problems and his back disability. Specifically, the Veteran testified that following his deviated septum surgery, he was prescribed inhalant steroids for his sinus infections. He also testified that he was treated with steroids for his back pain. He indicated that he used inhalant steroids long term but not prednisone long term. Overall, he indicated that he was treated with methylprednisolone, prednisone, and cortisones. In support of his contention, the Veteran submitted an article indicating that avascular necrosis is a side effect of cortisone. The Veteran also submitted several letters from treating physicians indicating that his avascular necrosis is secondary to steroid use. These include an October 1999 letter from Dr. J.U, an April 2001 letter from Dr. C.N., a February 2002 letter from Dr. D.H., and an April 2009 letter from Dr. J.K. The article does not pertain to the Veteran's particular etiology. Thus, while it is well-established that, generally, avascular necrosis can be attributed to excessive and extended use of steroids, it can also be attributable to other causes such as alcohol abuse. In essence, the letters do not provide a basis for a nexus because the record remains unclear as to the amount and frequency of steroid use, and the article does not indicate that the Veteran's particular steroid treatment was the proximate cause of his avascular necrosis. The October 1999, April 2001, February 2002, and April 2009 letters are not afforded probative value because they are based on the Veteran's own self reporting. With respect to the October 1999 letter, the medical opinion is inconclusive, self-contradictory, and not supported by the record. Specifically, the October 1999 letter from Dr. J.U. indicates that the Veteran's avascular necrosis is related to the Veteran's August 1996 work injury, "whether he was injured at the time or whether it is secondary to the steroids that he took for the back therapy." First, this opinion is not conclusive, as it is unclear whether the Veteran's right hip was injured in his August 1996 work injury or whether it is caused by the steroids that he took for his back pain. Next, under history, Dr. J.U. indicates that the Veteran had hip and pack pain since hurting his back at work in August 1996, that he was treated with steroids in November 1996 for pneumonia and pleurisy, and that he was treated with IV steroids for an allergic reaction. This medical history does not support Dr. J.U.'s conclusion. In other words, Dr. J.U. concluded that the Veteran's avascular necrosis is related to steroids used to treat his back injury, but only lists steroid treatment for pneumonia, pleurisy, and allergies. Moreover, these contentions have been contradicted by the record. There are no records of the Veteran receiving IV steroids for an allergic reaction, the Veteran himself testified that the only long-term steroid treatment he was on was inhalants, not IV. Moreover, the Veteran's private treatment records indicate that he had his work-related back injury in 1996 and did not experience hip pain until 1999. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion is only as good and credible as the history on which it was based, and if based on an inaccurate factual premise it has no probative value.); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal). With respect to the remaining private medical opinions, they are not afforded probative value because they are based solely on the Veteran's self-reported history, which is not clear. However, the Veteran has not been afforded a VA examination for his claims. A must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. §5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. The Veteran's records contain a diagnosis for avascular necrosis of the right and left hip. The Veteran contends that these disabilities are related to service, to include steroids that he used to treat his sinus infections and/or his back pain. While the Veteran does not possess the medical expertise to provide a nexus opinion in this case, his contentions overcome the low threshold of McClendon. As such, a VA examination with a complete nexus opinion is warranted. These matters are remanded for further development and adjudication. 5. Entitlement to service connection for pes planus (also claimed as tendonitis), bilateral feet. 6. Entitlement to service connection cellulitis both feet. The Veteran contends that his pes planus (claimed as episodes of tendonitis) and his cellulitis began during basic training and were due to ill-fitting footwear. During the April 2021 Board hearing, the Veteran testified that his feet disabilities are a result of/or aggravated by his service-connected knee disability, his hip disability, and the altered gait from his service-connected back disability. Specifically, the Veteran indicated that as a result of his hip surgery, his legs are different lengths, which aggravates his feet. The Veteran indicated that his disability is worse as a result of his service-connected disabilities. In January 2015, the Veteran was afforded a VA examination for feet. The examination did not address whether the Veteran had a current diagnosis of cellulitis; whether he had a diagnosis of cellulitis at any time during the period on appeal; or, whether he has current residuals of cellulitis. With respect to pes planus, the VA examiner indicated that pes planus preexisted service as it was noted on the March 1977 entrance examination. The VA examiner concluded that pes planus clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service event, injury, or illness. The VA examiner indicated that there was no aggravation because the Veteran currently has mild bilateral pes planus, which is the natural progression of the disease. However, the VA examiner did not address the Veteran's contentions that his pes planus is related to or aggravated by his hip disabilities or his service-connected disabilities. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213, 216 (1992). Accordingly, the matters are remanded for an additional VA examination to address the nature and etiology of the Veteran's pes planus (also claimed as tendonitis) and his cellulitis, including the issues of whether the disabilities pre-existed service, and/or were a result of or aggravated by his service-connected disabilities. 7. Entitlement to service connection for radiculopathy left shoulder/arm. 8. Entitlement to service connection for right shoulder torn muscle. During the April 2021 Board hearing, the Veteran testified that he believes his left shoulder/arm radiculopathy and his right shoulder muscle tear are a result of/or aggravated by his service-connected knee disability, his hip disability, and the altered gait from his service-connected back disability. Specifically, the Veteran indicated that he used a cane as a result of his back disability, left knee disability, and hip disabilities. As a result, he asserts that his altered gait caused a neck disc herniation, which in turn caused his shoulder disabilities. However, the Veteran has not been afforded a VA examination for his claims. A must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. §5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. The Veteran's records contain a diagnosis for left shoulder/arm radiculopathy and right shoulder muscle tear. The Veteran contends that these disabilities are related to his service-connected disabilities and his hip disabilities for which he claims service-connection. While the Veteran does not possess the medical expertise to provide a nexus opinion in this case, his contentions overcome the low threshold of McClendon. As such, a VA examination with a complete nexus opinion is warranted. These matters are remanded for further development and adjudication. These matters are REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records, including all records from the Durham, North Carolina VAMC since approximately 1979, if available. 2. Conduct any necessary development to determine the likelihood of in-service asbestos exposure. Prepare a memorandum for the record with a formal finding on the steps taken to make such a determination. 3. After the abovementioned development, schedule the Veteran for VA examinations with appropriate clinicians to determine the nature and etiology of the Veteran's sinusitis and asthma. The VA examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand. The VA examiner is requested to provide an opinion as to: (a.) Whether it is at least as likely as not (that is, a 50 percent probability or higher), that the Veteran's asthma had its onset during service, or is otherwise causally related to service. (b.) Whether it is at least as likely as not (that is, a 50 percent probability or higher, that the Veteran's sinusitis had its onset during service, or is otherwise causally related to service. (c.) In providing these opinions, the VA examiner is requested to address the Veteran's contention that shortly after discharge, he was surgically treated for a deviated septum, which in turn caused him to develop sinusitis and/or asthma. (d.) In the event that asbestos exposure is conceded or found, whether it is at least as likely as not that the Veteran's asthma and/or sinusitis are etiologically related to, assuming arguendo for the purpose of this opinion only, in-service asbestos exposure. (e.) The VA examiner is requested to provide a full rationale for all conclusions reached. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his right and left hip avascular necrosis. The VA examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand. The VA examiner is requested to provide an opinion as to: (a.) Whether it is at least as likely as not (that is, a 50 percent probability or higher) that the Veteran's avascular necrosis of the right and left hip had their onset in service, or are otherwise causally related to service, to include the steroids used to treat any of the Veteran's service-connected disabilities. (b.) In providing this opinion, the VA examiner is requested to address the Veteran's contention that his avascular necrosis was caused by the history of his steroid treatments, indicating which particular disabilities were treated with steroids, as well as a history of the duration and doses of the steroid use. (c.) The VA examiner is requested to provide full rationale for all conclusions reached. 5. Schedule the Veteran for VA examination(s) to determine the nature and etiology of his pes planus (also claimed as tendonitis) and cellulitis of bilateral feet. The VA examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand. The VA examiner is requested to provide an opinion as to: (a.) Whether it is at least as likely as not (a 50 percent probability or higher) that the Veteran's pre-existing pes planus (also claimed as tendonitis) underwent an increase in disability during service, beyond its natural progression during service. (b.) Whether it is at least as likely as not (a 50 percent probability or higher), that the Veteran's pes planus (also claimed as tendonitis) is aggravated by any the Veteran's service-connected disabilities. The opinion must explicitly address both causation and aggravation to be deemed adequate. The VA examiner is advised that in this context, aggravation means the service-connected disability caused an increase in the severity of an existing nonservice connected disability. If aggravation is found, the medical specialist must attempt to establish the baseline level of severity of pes planus prior to aggravation by the service-connected disability. In providing this opinion, the VA examiner is requested to address the Veteran's contentions that his service-connected back and left knee disabilities caused an altered gait, causing and/or aggravating his foot disability. (c.) Whether it is at least as likely as not (a 50 percent probability or higher), that the Veteran's pes planus (also claimed as tendonitis) is caused by or aggravated by the Veteran's hip disabilities. In providing this opinion, the VA examiner is requested to address the Veteran's contentions that his hip replacement resulted in a 34 inch leg discrepancy, causing and/or aggravating his foot disability. (d.) Whether the Veteran has a current diagnosis of cellulitis or had a diagnosis of cellulitis at any point during the period on appeal. If so, whether the Veteran's cellulitis had its onset in service, or is otherwise causally related to service, to include any service-connected disabilities. (e.) The VA examiner is requested to provide a full rationale for all conclusions reached. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's left shoulder/arm radiculopathy and right shoulder muscle tear. The VA examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand. The VA examiner is requested to provide an opinion as to: (a.) Whether it is at least as likely as not (a 50 percent probability or higher) that the Veteran's left shoulder/arm radiculopathy and right shoulder muscle tear had their onset in service, or are otherwise causally related to an in-service injury or disease? (b.) Whether it is at least as likely as not (a 50 percent probability or higher), that the Veteran's left shoulder/arm radiculopathy and right shoulder muscle tear are caused or aggravated by any of the Veteran's service-connected disabilities. The opinion must explicitly address both causation and aggravation to be deemed adequate. The VA examiner is advised that in this context, aggravation means the service-connected disability caused an increase in the severity of an existing nonservice connected disability. If aggravation is found, the medical specialist must attempt to establish the baseline level of severity of the left and/or right shoulder disabilities prior to aggravation by the service-connected disability. In providing this opinion, the VA examiner is requested to address the Veteran's contentions that his service-connected back and left knee disabilities caused the Veteran to have to use a cane, altering his gait, causing a neck disc herniation, which in turn caused and/or aggravated his shoulder disabilities. (c.) The VA examiner is requested to provide a full rationale for all conclusions reached. In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.