Citation Nr: 22005778 Decision Date: 02/02/22 Archive Date: 02/02/22 DOCKET NO. 18-12 103 DATE: February 2, 2022 ORDER As the claim is withdrawn, the claim of entitlement to service connection for a jaw condition is dismissed. The petition to reopen the previously denied claim for a left shoulder disability (previously denied as bilateral shoulder condition) is granted. REMANDED Entitlement to a rating in excess of 20 percent prior to June 19, 2019, and in excess of 30 percent therefrom for cervical strain with degenerative arthritis and cervical spondylosis C5-6-7 (cervical spine disability) is remanded. Entitlement to a rating in excess of 20 percent for radiculopathy of the left upper extremity is remanded. Entitlement to a rating in excess of 20 percent for right brachial flexus injury to include radiculopathy of the right upper extremity (dominant arm) is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for bilateral knee disability is remanded. . FINDINGS OF FACT 1. On July 21, 2021, prior to the promulgation of a decision in the appeal, the Veteran notified the Board at her hearing on appeal that she sought to withdraw her claim for entitlement to service connection for a jaw condition. 2. An unappealed December 1988 rating decision denied entitlement to service connection for bilateral shoulder condition; the Veteran withdrew her claim in March 1990; subsequently received evidence includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim for entitlement to service connection for a jaw condition by the appellant (or his authorized representative) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The December 1988 rating decision denying service connection for bilateral shoulder condition is final; and new and material evidence has been received to reopen the claim for service connection for left shoulder disability. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), 20.302, 20.1103. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1980 to July 1983. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The VLJ held the record open for 30 day at the representative's request for the submission of treatment records. See Hearing Transcript at 2 (July 2021). It is noted that VA received additional treatment records, which are now associated with the claim file, from the Veteran's representative. See Medical Treatment Record Government Facility (July 2021). 1. Entitlement to service connection for a jaw condition. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. In the present case, prior to the promulgation of a decision in the appeal, the Veteran (appellant) notified the undersigned VLJ at the July 21, 2021 hearing on appeal that she sought to withdraw her appeal for the claim for entitlement to service connection for a jaw condition. See Hearing Transcript (July 2021). This request was made with full understanding of the consequences and in consultation with her attorney. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); see also Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). Hence, there remain no allegation of error of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal of the matter and it is dismissed. 2. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for left shoulder disability. The Board concludes that the December 1988 rating decision denying the claim for entitlement to service connection for bilateral shoulder condition is final; and that new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5103, 5103A, 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156(a), 20.302, 20.1103. Generally, a claim that has been denied in an unappealed RO or Board decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means 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 can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). A December 1988 rating decision denied service connection for a bilateral shoulder condition because the evidence of record showed no disability of the left shoulder on VA examination (normal range of motion and no tenderness in the left shoulder). The evidence considered by the RO included the Veteran's service treatment records (STRs), an August 1987 VA examination and her application for disability compensation. VA notified the Veteran of this decision in a January 1989 letter and how to appeal. The Veteran timely submitted a notice of disagreement to that decision in February 1989, after which the RO continued to deny her claim in a March 1989 Statement of the Case. In January 1990, she submitted a timely appeal to the Board via a VA Form 9. However, during a March 1990 hearing before a Hearing Officer, the Veteran withdrew her claim for service connection for left shoulder disability. Thus, the December 1988 rating decision became final. 38 U.S.C. § 7105(b), (c); 38 C.F.R. §§ 3.160(d), 20.201, 20.302, 20.1103. Thereafter, in January 2014, VA received the Veteran's claim to reopen the previously denied claim of entitlement to service connection claim for left shoulder disability. Evidence associated with the claims file since the prior final disallowance includes evidence that is not cumulative or redundant and relates to an unestablished fact necessary to reopen the claim. Specifically, there are several VA examinations as well as a July 2021 private medical assessment reflecting that the Veteran has a current diagnosis of left shoulder disability. This evidence was not previously considered by decision-makers and tends to support the claim, because the recent evidentiary submissions show a current disorder of the left shoulder. Therefore, the Board finds that new and material evidence has been received. Accordingly, the petition to reopen the claim is granted. REASONS FOR REMAND 3. Entitlement to a rating in excess of 20 percent prior to June 19, 2019, and in excess of 30 percent therefrom for cervical spine disability. 4. Entitlement to a rating in excess of 20 percent for radiculopathy of the left upper extremity. 5. Entitlement to a rating in excess of 20 percent for right brachial flexus injury to include radiculopathy of the right upper extremity dominant arm. 6. Entitlement to service connection for a left shoulder disability. 7. Entitlement to service connection for bilateral knee disability. Issues 3-7: To ensure that VA has met its duty to assist, the Board finds that remand is necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). First, the Veteran's record does not contain any service personnel records (SPRs) and there is no indication that these records were requested. Therefore, remand is necessary to obtain complete SPRs for the Veteran's period of service from July 1980 to July 1983. Second, a review of the Veteran's VA treatment records discloses that multiple medical records had been scanned into the VA medical records system and note Vista-Imaging-scanned documents. However, the VA treatment records in the claims file do not include those scanned (Vist-A Imaging) documents. Given the above, remand is necessary to associate copies of these treatment records with the claims file. See 38 C.F.R. § 3.159(c)(2); Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). Third, as there are scanned non-VA medical record indicated in the Veteran's VA treatment records, the Veteran should be afforded an opportunity to authorize release to any relevant private treatment records to VA. 38 C.F.R. § 3.159(c). The Veteran is reminded that VA's duty to assist in the development of a claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran should cooperate and assist as requested in the development of the appeal. Issues 3 5: The Veteran, and her representative, contends that a higher evaluation is warranted for her service-connected disabilities. The Board finds that remand is necessary. First, the Board observes that the Veteran testified to a worsening of symptoms since her last VA examination. See Hearing Transcript at 6-8 (July 2021). Indeed, she stated that her service-connected disabilities had worsened since her last VA examination in July 2019. Id. While the mere passage of time is not grounds for a new examination, a new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Here, the Veteran testified to an increased severity of symptoms associated with her disabilities since his last VA examinations. See generally Hearing Transcript (July 2021) (detailing and exemplifying an increase in severity and frequency of symptoms associated with service-connected disabilities). Given the competent evidence of worsened symptoms since the last VA examination, a remand is necessary to adequately evaluate the current severity of the Veteran's service-connected disabilities. Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity). Next, the record reflects that the Veteran underwent a VA examination for her cervical spine disability, radiculopathy of the left upper extremity and right brachial flexus injury in July 2019. However, an addendum is necessary to comply with the Court's ruling in Correia v. McDonald, 28 Vet. App. 158 (2016). Although report noted pain with weight bearingthe report does not include range of motion findings on both active and passive and with and without weight bearing (i.e. four sets of findings). See C&P Exam (July 2019). Thus, retrospective findings are needed. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Chotta v. Peake, 22 Vet. App. 80, 85-86 (2008) (discussing situations when it may be necessary to obtain a "retrospective" medical opinion to determine the date of onset or severity of a condition in years past); Vigil v. Peake, 22 Vet. App. 63 (2008) (holding that the duty to assist may include development of medical evidence through a retrospective medical evaluation where there is a lack of medical evidence for the time period being rated). Issue 6: The Veteran contends that her left shoulder disability is secondary to her service-connected right shoulder disability. Specifically, via her representative, she asserts that her physicians have told her that, because she is right-handed and her right shoulder is so significantly limited, she has to compensate with her left shoulder. See Hearing Transcript (July 2021). She stated that she had no injuries to or pain in the left shoulder during service, and that she first noticed left shoulder pain in around 1993-1994, and has experienced symptoms and received treatment since. Id. At her September 2017 VA examination, the Veteran expressed her belief that she injured her left shoulder in a motor vehicle accident in service in 1981, because her left shoulder hurt on and off since. See C&P Exam (September 2017). To ensure that VA has met its duty to assist, remand is necessary. 38 C.F.R. § 3.159(c). By way of background, the Veteran's enlistment physical in January 1980 shows normal findings. See STR-Medical (January 2014). While part of the examination is not well visible, the notes section does not include any reports of abnormalities. Id. In October 1981, the Veteran was involved in a motor vehicle accident, resulting in a right shoulder injury, for which she was followed in physical therapy for five weeks. Such was also noted at the time of separation, including on separation physical in July 1983. Id. No left shoulder abnormalities were noted at separation physical or reported by the Veteran at the time of separation. Id. While the Veteran has undergone numerous VA examinations, none have provided adequate findings. First, none of the examinations provide clear etiology of the Veteran's now diagnosed left shoulder disability, including left shoulder arthritis, and whether it at least as likely as not began during active service or manifested within one year after discharge from service. To that extent, the July 2014 VA examination shows a diagnosis of shoulder arthritis and the September 2017 VA examination provides diagnoses of left shoulder rotator cuff tendonitis, glenohumeral joint osteoarthritis and acromioclavicular join osteoarthritis. See C&P Exam (July 2014 and September 2017). Yet another VA examination was obtained in October 2019, which provides diagnoses of left shoulder impingement syndrome, glenohumeral joint osteoarthritis and acromioclavicular join osteoarthritis. See C&P Exam (October 2019). However, while the Veteran has expressed her belief that she began to experience left shoulder pain in service and has since, none of the examinations addressed her reports, even though they noted her reports. The Board notes that the Veteran is competent to report signs and symptoms of her disability. See Barr, 21 Vet. App. at 311. Second, the medical opinions are inadequate as the essential rationale for the opinions is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Specifically, the July 2014 VA examination opines that the Veteran's left shoulder condition is less likely than not proximately due to or the result of the Veteran's service connected condition without providing any clear basis for it. See C&P Exam (July 2014). Upon the requested clarification, another VA medical opinion (VAMO) was obtained in May 2015 to provide a rationale for secondary opinion, and reasons that "the medical literature and after examination there is no rational medical connection of left shoulder agrivated [sic] by right brachial plexopathy." See C&P Exam (May 2015). A September 2017 VA examination concludes that the Veteran's left shoulder disability "is less likely than not proximately due to or the result of the Veteran's service connected condition," and not "aggravated beyond its natural progression by" the right shoulder, because "there is no medical evidence to support contralateral shoulder causes injury. She uses right arm more than left and has better function of the right than the left." Id. In this instance, the opinions are inadequate because they do not provide the Board a reasoned rationale supporting the conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("a medical opinion... must support its conclusion with analysis that the Board can consider and weigh against contrary opinions"). With regard to the requested opinion on whether the Veteran's service-connected right shoulder disability caused or aggravated the Veteran's left shoulder disability, the VA examiners' responses were inadequate, because VAMOs contain conclusions that are not fully supported and/or explained. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). The opinions lack an essential rationale although they conclude that that left shoulder disability is "not proximately due to or the result of the Veteran's service connected condition." Monzingo, 26 Vet. App. at 106 (An adequate medical examination report or opinion must also "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion."). Also, the VAMOs did not provide separate rationales to support the causation and aggravation elements of the secondary service connection. See Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018) (an examiner must provide a rationale that deals with causation and aggravation as independent concepts). Lastly, with regard to whether the Veteran's left shoulder disability is secondary to her service-connected right shoulder disability, the examiners refer to "medical literature;" however, the opinions did not reference specific medical literature and did not explain how the general medical research applied to the Veteran's particular circumstances. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (in cases involving herbicide exposure and cancer, examiner's rationale may not be based solely on general medical articles); Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (although general medical research may be considered, it cannot be the sole basis for examiner's conclusion). The Board is cognizant of the private medical opinion submitted by the Veteran in support of her appeal. In a July 2021 opinion, Dr. S. Barber, MD, provided that the Veteran's left shoulder disability is at least as likely as not secondary to her right shoulder disability. This opinion was based on the Veteran's claim that her right shoulder caused her to overuse her left upper extremity as well as summary of studies, as well as claimed review the Veteran's "medical charts." The Board finds the private medical opinion is inadequate to decide the claim. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). An adequate medical opinion must be "accurate and fully descriptive," 38 C.F.R. § 4.1, and based on an accurate factual premise and consideration of a veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). In sum, an adequate medical examination report or opinion must "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." Monzingo, supra. Here, the private medical opinion is inadequate because there is little to no rationale for the conclusion. In this case, the opinion reflects consideration of various pieces of medical and lay evidence, but it does not include a reasoned medical explanation connecting the two. Nieves-Rodriguez, 22 Vet. App. at 301. For instance, the opinion provides that "with the degree of damage to the right shoulder that her left shoulder was being utilized to compensate for left shoulder disease." See Medical Treatment Record - Government Facility (July 2021). Dr. Barber attributed the Veteran's left shoulder disability to right shoulder disability after "extrapolat[ing]" from the risk factors, including the Veteran's relatively young age and her "only risk factors" being "an acute injury and repetitive use injury." Id. However, this opinion makes no attempt to explain why the right shoulder disability, which medical records show to be less severe than the left shoulder disability caused or aggravated the left shoulder disability. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (doctor's generic statement that chest trauma can be linked to restrictive lung disease insufficient to satisfy medical evidence of nexus requirement). In other words, the clinician listed some supporting evidence and made a conclusion, but he did not provide a reasoned medical explanation connecting the supporting evidence to the conclusion. Thus, the Board finds the July 2021 opinion is inadequate because it is not definitive and supported by detailed rationale when weighed against the other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Given the above, the medical opinions are inadequate, and remand is necessary for a new medical opinion to address the etiology of the Veteran's left shoulder disability. See Barr, supra. Issue 7: The Veteran contends that her bilateral knee disability began as knee problems in service and has persisted since. She stated that, as a parachute courier, she made a lot of jumps that resulted in knee pain, for which she sought treatment near Rammstein Air Force Base in approximately 1981. See Hearing Transcript (July 2021). The veteran's attorney also argued, and the Veteran has submitted a private medical opinion supporting that argument, that her service-connected lumbar spine disability resulted in more sedentary lifestyle that caused the Veteran's obesity, which also contributes to her bilateral knee disability. See Hearing Transcript at 19 (July 2021). While the Veteran has undergone a VA examination in this case, such is inadequate. The Board finds that a remand is necessary to afford the Veteran another VA examination. The Veteran's STRs show normal findings prior to enlistment in January 1980. See STR-Medical (January 2014). In August 1980, a sore left knee was noted without history of injury, and was assessed as left chondromalacia patella. Id. In February 1983, the Veteran reported right knee pain. Id. A March 1983 STR shows bilateral knee pain lasting for two to three weeks, diagnosed as mild patellofemoral syndrome (PFS). An April 1983 and a July 1983 separation physical shows normal findings of the lower extremities. Id. VA medical opinion, dated in October 2015, reflects a diagnosis of degenerative arthritis of both knees and conclusion that "[t]he probability is that her knee conditions relate much more to genetics and obesity than to mild patellofemoral symptom of service days." See C&P Exam (October 2015). The rationale was that the Veteran "was seen in service for PFS twice and who has developed tricompartmental arthritis secondary to meniscal problems for which she has had above mentioned procedures ;all done in past 5 years." Id. The VA medical opinion is inadequate because the essential rationale for the opinion is not discernable. Monzingo, supra. For example, the opinion attributes the Veteran's bilateral knee disability to genetics and obesity; however, the opinion does not reveal a reasoned rationale or medical explanation supporting the reached conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("a medical opinion... must support its conclusion with analysis that the Board can consider and weigh against contrary opinions"). Indeed, at most, the Board is able to ascertain the opinions' medical findings and conclusions, however, the essential rationale connecting the medical findings to the conclusions is not discernable and the Board is not competent to substitute its own medical rationale for that of the opinion. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Second, the VAMO makes no mention of the Veteran's reported symptoms during and since service, including those documented in her STRs, and relies on the absence of "procedures" until the preceding five years. The opinion here is predicated on the absence of objective data or information without any consideration of the Veteran's reports of continued symptoms during and since service. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) ("the VA examiner's failure to consider [the Veteran's] testimony when formulating her opinion renders that opinion inadequate."). The Board notes the Veteran is competent to attest to observable symptomatology and, if rejected or found unpersuasive in view of other facts, this must be explained. Here, the October 2015 VA examination does not reflect any consideration of the lay statements to specifically include her continued assertions of bilateral knee symptoms during and since service. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible). The Veteran's reports of symptoms of knee pain while in service are also supported by the available STRs. The opinion, however, does not reveal a rationale or explanation discounting the Veteran's history. Similarly, the VAMO does not address the Veteran's theory that her military occupational specialty as a parachute courier, which required multiple jumps, resulted in knee pain and her current disability. A clinician is required to fully explain why he or she disagrees with the Veteran's theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). Given the above, the Board may not rely upon the VA medical opinion in its present form and, therefore, finds the medical evidence is inadequate for adjudicative purposes. Where VA provides an examination or obtains an opinion, it must be adequate. Barr, supra. Next, the Board acknowledges the private medical opinions, received by VA in February 2018 and July 2021, in support of the claim. The February 2018 private medical opinion concluded that the Veteran sustained parachuting related injuries to her knees and: ...developed chronic degeneration and has been suffering from her symptoms over the years since her service ended. I believe that the current state of her knees can be linked to the combination of stressors, imbalances and abnormal biomechanics stemming from knee injury to her chronic back pain, antalgic gait disturbance and elevated BMI. I do not believe that the arthritis in her knees can be blamed solely on genetics and obesity. See Medical Treatment Record - Non-Government Facility (February 2018). The July 2021 PMO provided multiple causes for the Veteran's bilateral knee disability, stating that (1) "knee disease is very commonplace in Vet after basic training," (2) lumbar spine injuries led to sedentary lifestyle that led to obesity, which cause osteoarthritis of the knees, (3) knee disease is very commonplace in Vet after basic training, and (4) that bilateral knee osteoarthritis is "at least as likely a not due to multiple service-connected factors including enlistment high impact activities, obesity and gait which was also due to enlistment activities." See Medical Treatment Record - Government Facility (July 2021). The Board finds the private medical opinions inadequate to decide the claim. A medical opinion is adequate where it is based upon consideration of a veteran's prior medical history, describes the disability in sufficient detail, and fully informs the Board of the medical expert's judgment on a medical question and the essential rationale for that opinion. Webb v. Wilkie, 32 Vet. App. 309, 314 (2020). Importantly, and relevant here, if an opinion is based on an inaccurate factual premise, it should be discounted entirely. Monzingo, 26 Vet. App. at 107. The opinions, in this case, do not describe the disabilities in sufficient detail to the extent that it informs the Board of the medical expert's judgment on the medical questions. Indeed, the opinions simply provide multiple avenues of how the Veteran's bilateral knee disability is related to service without adequate supporting rationale or explanation connecting the Veteran's service to her current disabilities. Notably, the private medical opinions provide differing etiologies as well as internally conflicting findings. Lastly, the opinions do not reveal consideration of the service separation examination report, in which, the Veteran was evaluated as, essentially, having a clinically normal musculoskeletal and skeletal system, without mention as to having a defect to the knees. See STR-Medical (January 2014). Although an opinion need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo, 26 Vet. App. at 105, it must be clear that the clinician providing the opinion was "informed of sufficient facts upon which to base an opinion relevant to the problem at hand." Nieves-Rodriguez, 22 Vet. App. at 303. In remanding this matter, 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. The matters are REMANDED for the following action: 1. Obtain the Veteran's complete service personnel records for her period of service from July 1980 to July 1983. If such records do not exist or are unavailable, such should be noted in the claims file. 2. Obtain the Veteran's VA treatment records for the period from December 2019 to the present. Associate copies of all treatment records that have been scanned into the Vist-A Imaging system with the Veteran's claims folder. 3. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for her claimed disorders, to include for signs/symptoms/treatment involving the left shoulder and knees since service discharge to include from Dr. Fretter. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 4. Thereafter, schedule the Veteran for a VA examination by an appropriate clinician to determine the current severity of her service-connected (1) cervical spine disability, (2) left upper extremity radiculopathy, and (3) right brachial flexus injury to include radiculopathy of the right upper extremity. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. As to the below, if it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Current Findings (a.) Test the Veteran's active motion, and passive motion, with weight-bearing and without weight-bearing. Note: The examiner should determine the effective range of motion (ROM) for the disability and present the results of ROM tests in a written report which complies with 38 C.F.R. § 4.59 by recording separate sets of the ROM test results for both active and passive motion, and in weightbearing and non-weightbearing. The examiner's report should describe objective evidence of painful motion, if any, during each test. IT IS NOT SUFFICIENT MERELY TO INDICATE WHETHER OR NOT PAIN WAS PRESENT DURING ONE OF THE REQUIRED ROM TESTS. If any of these findings are not possible, please provide an explanation. (b.) Attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. Note: If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced ROM during flares or repetitive use. Retrospective Findings Following a review of the record, the clinician should provide retrospective findings for the below identified past examination. If it is not possible to provide a specific measurement without speculation, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). (c.) Provide an addendum retrospective opinion for the Veteran's service-connected cervical spine disability to supplement the July 2019 VA Examination Report that estimates the amount in degrees of ROM lost due to pain in both weightbearing and non-weight bearing positions, and on both active and passive motion based on the evidence of record and the Veteran's statements. 5. Schedule the Veteran for an examination(s) by an appropriate clinician(s) to determine the nature and etiology of any (1) left shoulder disability, (2) right knee disability, and (3) left knee disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician(s). Based on examination and review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with any of the above disabilities. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). Note (1): A negative medical opinion may not be predicated solely on the absence of in-service documented complaints, findings, or treatment. Note (2):The opinion should provide a complete rationale for any history rejected or discounted (e.g. reports of symptoms do not align with how the currently diagnosed disability is known to develop, explain; the reports are generally inconsistent with medical knowledge or implausible, explain). The clinician must opine on: Direct Service Connection (a.) Whether any left shoulder disability at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease, including in-service motor vehicle accident in 1981, in which, right shoulder injury was documented, or (b.) Whether any knee disability, right and/or left, at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address (1) the Veteran's theory that her disability stems from in-service parachute jumps and (2) the private medical opinions, received by VA in February 2018 and July 2021. Explain. Secondary Service Connection (c.) Whether any left shoulder disability at least as likely as not is (1) proximately due to service-connected right shoulder disability, or (2) aggravated beyond its natural progression by service-connected right shoulder disability. Consider and expressly address (1) the Veteran's theory that she compensated for her right shoulder disability by overusing her left shoulder, and (2) the private medical opinion, received by VA in July 2021. Explain. Indirect Secondary Service Connection for Knees Obesity as an "Intermediate Step" - (d.) Is it at least as likely as not that service-connected disability singly or jointly (1) caused or (2) aggravated the Veteran's obesity? Provide a rationale that deals with causation and aggravation as independent concepts. Explain. Consider and expressly address the Veteran's theories that (1) her service-connected back disability led to a sedentary lifestyle causing weight gain that let do her knee problems. (e.) If so, was the resulting obesity a substantial factor in causing the Veteran's right and/or left knee disability? Explain. (f.) If yes, but for the Veteran's obesity, would the Veteran have developed right and/or left knee disability? Explain. 6. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 7. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. M. Pesin 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.