Citation Nr: 22011735 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 15-22 994 DATE: March 1, 2022 ORDER Entitlement to service connection for a bilateral eye disability is denied. REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for low back disability is remanded. Entitlement to service connection for an upper back disability is remanded. FINDING OF FACT The weight of the evidence is against finding that a bilateral eye disorder began during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for a bilateral eye disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1973 to August 1975. In June 2018, the Veteran testified at a video conference hearing (hearing) before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board denied the claims in November 2018. The Veteran appealed the November 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to the September 2019 order granting a Joint Motion for Partial Remand (JMPR), the Court vacated the Board's decision and remanded the Veteran's service connection claims to the Board for action consistent with the terms of the JMPR. See September 2019 JMPR. The parties agreed in the JMPR that the Board did not satisfy its duty to assist when it relied on inadequate VA medical opinions from January 2013 in denying the claims. This matter was previously remanded by the Board of Veterans' Appeals (Board) in April 2020, May 2021, and November 2021 for additional development. It now returns for further appellate review. 1. Bilateral Eye Disability The Veteran contends that his current eye disabilities were the result of dirt particles and liquids dropping in his eye while he was underneath trucks while working as an infantry diesel mechanic. See Hearing Transcript. The Veteran also states that he worked without any eye protection. Id. Legal Criteria Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Relevant Facts and Analysis The June 2021 VA examiner confirmed the Veteran's bilateral eye disabilities were bilateral nuclear sclerotic cataracts, bilateral dry eye, and bullous retinoschisis left eye. See June 2021 VA Eye Conditions DBQ. As such, the first element of service connection, a current disability has been met. Regarding the second element of service connection, an in-service injury or occurrence, the Board notes that the Veteran's STR's are silent for complaint or treatment for any eye problems. However, the Veteran has provided competent and credible lay statements that dirt and liquids dropped into his eyes while working as as an infantry diesel mechanic. See Hearing Transcript. He also asserted that "[l]ots of dust and metal particles fell in my eyes which has created my eye problems." See June 2012 VA Form 21-4138, Statement in Support of Claim. As such, the second element of service connection, has been established. Thus, the issue is whether there is a nexus established that connects the Veteran's current bilateral eye disabilities and the in-service occurrence of dirt and liquids dropping into his eyes while working as an infantry diesel mechanic. To answer this question, the Board has obtained several VA medical opinions. Unfortunately, the evidence fails to demonstrate a nexus between the Veteran's current disabilities and his in-service experience of having dirt and liquids drop into his eyes. First, a January 2021 VA examiner clarified that the Veteran's dry eyes were noted in 2015, which is 40 years after service, in opining that "it is less likely than not that the Vets dry eyes is related to service." See January 2021 VA Addendum Medical Opinion. Next, the June 2021 VA examiner opined that the Veteran's bilateral eye disabilities were less likely than related to service because, these conditions were not diagnosed in service and were more likely age related. See June 2021 VA Medical Opinion DBQ. Regarding, the Veteran's right eye Myokymia, the examiner opined that it was less likely than not caused by the Veteran's service-connected disabilities because he had nonpathological Myokymia and that it "is not associated with any service-connected disease." Id. However, the examiner did not address whether the Veteran's right eye Myokymia was aggravated (any incremental increase) by his service-connected disabilities. Accordingly, the Board most recently remanded the bilateral eye disability claim in November 2021 to address whether the Veteran's migraine headaches caused fatigue or sleep disturbance which led to Myokymia, or whether the Veteran's right eye Myokymia was caused or aggravated by any of his service-connected disabilities including migraine headaches and/or insomnia. Pursuant to the November 2021 Board remand, the VA obtained another medical opinion in February 2022. See February 2022 VA Medical Opinion DBQ. The examiner provided a negative nexus opinion for nuclear sclerotic cataracts finding that it was caused by aging, and that there was no evidence of cataracts during active service. He also opines that bullous retinoschisis is not related to active service but is caused by aging. He further states that "[i]t is highly unlikely that particulates could penetrate only the eye to cause" nuclear sclerotic cataracts and bullous retinoschisis to occur. Id. The examiner also explains that "[i]n order for the particulates to cause any of these problem[s], they would have to damage the ocular structures. They eyelids do not show damage. It is also impossible for the particulates to penetrate the globe to cause cataracts and retinoschisis." Id. The examiner also noted that the Veteran's dry eyes were age-related and due to the Veteran's diagnosed blepharitis. The Board finds that the February 2022 VA medical opinion is entitled to great probative weight because the examiner provided a well-reasoned rationale for his opinions. The Board notes that the February 2022 VA examiner performed the July 2021 VA examination, and based his opinions on examination of the Veteran, the opinion considered an accurate history, was definitive and was supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Regarding, the Veteran's right eye myokymia, the February 2022 examiner stated that it is unclear whether the Veteran's myokymia was caused by his insomnia. See February 2022 VA Medical Opinion DBQ. He was unable to provide an opinion whether the Veteran's insomnia aggravated his myokymia. The examiner also stated that there were no signs of myokymia present at this most recent ophthalmic examination. The Board notes that myokymia is generally defined as eye-twitching. See https://www.mayoclinic.org/symptoms/eye-twitching/basics/definition/sym-20050838 (accessed February 18, 2022). Notably, the July 2021 VA examiner explained that there are two types of myokymia including "eyelid myokymia [] associated with twitching of the eyelid and is a benign condition.... [And] a pathological version which affects the vertical muscle which are caused by pathology but there is no evidence for there being any service connection for this entity." See July 2021 VA Medical Opinion DBQ. The examiner also stated that the Veteran has "myokymia that is not associated with pathology." Id. As such, even if the evidence is unclear that his service-connected insomnia caused his myokymia, the Board finds that myokymia is not a disability for VA purposes because the Veteran did not have any associated pathology with myokymia. See July 2021 VA Medical Opinion DBQ. The February 2022 VA examiner further stated that there were no signs of myokymia at the most recent VA examination in July 2021. See February 2022 VA Medical Opinion DBQ. In so finding, the Board finds the Veteran is perfectly competent to describe eye twitching, as he has reported symptoms throughout the record. However, the fact remains that there is no medical evidence to suggest such condition is more than a benign mechanical disturbance or that it produces any impairment of earning capacity, as contemplated by the Court's definition of "disability" in this context. See Palczewski v. Nicholson, 21 Vet. App. 174, 178 (2007). Notably, the Veteran's competence to identify the observable symptom at issue is not transferable to the realm of diagnosis that is to say, the opinion of the VA examiner in this case is far more probative evidence than the Veteran's own observations when determining whether his eye twitching constitutes a disability. Consequently, the Board has no choice to deny the claim for myokymia because there is no evidence of a current disability, the benefit-of-the-doubt rule does not apply, and the appeal in this matter must be denied. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018)( finding term "disability" as used in 38 U.S.C. §... cause of said disability," and holding that "pain alone can serve as a functional impairment and therefore qualify as a disability." ) The Board observes that Saunders was in the context of the musculoskeletal system. Nonetheless, Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis). Here, there is no evidence that the Veteran experienced pain or functional impairment of earning capacity as a result of myokymia, and the Veteran did not demonstrate pathology of myokymia. Consideration has been given to the Veteran's contentions that his current bilateral eye disabilities are related to his service. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making definitive clinical diagnoses and causation findings based on medical knowledge of ophthalmology. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran is certainly competent to report that he had in-service exposure to excessive sunlight and that he has current eye complaints, he is not competent to link those complaints to a particular diagnosis or etiology. His assertions are therefore not competent evidence of a medical nexus. Thus, based on the foregoing, the competent medical opinions from July 2021 and February 2022 outweigh the Veteran's lay statements that his current bilateral eye disabilities are related to service. Accordingly, the Board finds that the claim of entitlement to service connection for a bilateral eye disability must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the weight of the evidence is not in approximation, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND The Board regrets further delay but finds a remand is necessary in order to comply with the November 2021 Board remand. Specifically, the November 2021 Board remand requested the Regional Office (RO) to obtain VA examinations and/or medical opinions to determine the etiology of the Veteran's claimed conditions. See November 2021 Board Remand. It appears that the Regional Office attempted to obtain the requested examinations and medical opinions. See VA Examination Scheduling Request dated February 3, 2022. However, in a subsequent examination request form, the VA representative indicated that clarification was necessary, and that processing of the request was suspended. See VA Examination Request Clarification Response dated February 8, 2022. The Board notes that the VA obtained a VA medical opinion for the Veteran's bilateral eye disability claim. However, the requested VA examinations and medical opinions for the Veteran's other claims were not obtained. The RO transferred the claims file back to the Board for review. Given that the requested VA examinations and medical opinions have not been completed, the Board finds that the RO has not substantially complied with the November 2021 Board remand. Given such, the Board will once again remand the claims to ensure compliance with September 2019 JMPR and the November 2021 Board Remand. A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Neck Disability and Upper Back Disability Regrettably, the Board finds another remand is necessary for the Veteran's claimed cervical spine and upper back disabilities in order to ensure compliance with the November 2021 Board remand which directed the RO to comply with the May 2021 Board remand and to obtain an adequate medical opinion, that complies with the September 2019 JMPR. The Board remanded the claim in May 2021 to obtain an addendum medical opinion as to the Veteran's neck and upper back disability, to address the Veteran's lay statements. See May 2021 Board Remand. Consequently, the June 2021 VA examiner found that the Veteran did not have a current diagnosed cervical spine or upper back disability. See June 2021 VA Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (DBQ). The examiner provided the following remarks: Unable to access neck because veteran was belligerent and argumentative and refused to have neck assessed stating that "he has neuropathy and doesn't want to do all that standing and bending and stuff and fall and bust up his shoulder. And I don't know why they have to do that stuff anyways. That doesn't make sense." Also veteran was very insulting and disrespectful to provider including demeaning the provider's education. Also when asked about his occupational history to assess for any other possible causes for the veteran's claimed condition, veteran was very vague, not forthcoming and very uncooperative in providing occupational history during the 46 year period out of the Navy until present 2021. See June 2021 VA Neck (Cervical Spine) Conditions DBQ. In a separate medical opinion, the June 2021 VA examiner provided a negative nexus opinion and noted that he was "unable to assess neck, knees, shoulders, feet, and back because the Veteran was belligerent and argumentative and refused to have neck, knees, shoulders, feet, and back assessed...." See June 2021 VA Medical Opinion DBQ. He further stated that "[b]y refusing assessment it is impossible to ascertain if veteran had an actual current condition or if he was malingering." Id. Accordingly, the examiner opined his claimed conditions were less likely than not related to his active service. Id. Upon review, the Board finds that a new addendum medical opinion for the Veteran's cervical spine and upper back disability is necessary as the June 2021 medical opinion does not comply with the May 2021 Board remand because the examiner was unable to provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998)( A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders.) Notably, the June 2021 VA medical opinion is inadequate for adjudication purposes because the examiner found that the Veteran did not have a diagnosed neck or upper back disability based on the Veteran's lack of cooperation. However, the claims file confirms the Veteran was diagnosed with cervical spine degenerative disc disease (DDD). See January 2013 Neck (Cervical Spine) DBQ. See also November 2011 VA X-ray Report (confirming mild DDD of the thoracic spine). As such, the June 2021 VA examiner's conclusion that the Veteran does not have a diagnosed neck or upper back disability is inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.) Thus, the Board finds a remand is warranted to obtain an addendum medical opinion for the Veteran's claimed neck and upper back disabilities that addresses the Veteran's lay statements and is supported by adequate rationale. However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 2. Bilateral Knee Disability The Board also finds that the Veteran's left and right (bilateral) knee claims must be remanded for the same reasons as stated above. Notably, the claim was remanded in November 2021 to obtain a medical opinion. However, the claim was returned to the Board without providing the requested medical opinion pursuant to the November 2021 Board remand. Notably, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral knee disability due to the Veteran's lack of cooperation. See June 2021 VA Knee and Lower Leg Conditions DBQ. However, the claims file indicates that the Veteran has right knee osteoarthritis (see February 2016 VA Primary Care Follow Up, in CAPRI received November 2017) and the September 2020 VA medical opinion confirms the Veteran was diagnosed with left knee strain (see September 2020 VA Medical Opinion DBQ.) As such, the June 2021 VA examiner's conclusion that the Veteran does not have a diagnosed bilateral knee disability is inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.) Additionally, the June 2021 VA examiner provided a negative nexus opinion and noted that he was "unable to assess neck, knees, shoulders, feet, and back because the Veteran was belligerent and argumentative and refused to have neck, knees, shoulders, feet, and back assessed...." See June 2021 VA Medical Opinion DBQ. He further stated that "[b]y refusing assessment it is impossible to ascertain if veteran had an actual current condition or if he was malingering." Id. Accordingly, the examiner opined his claimed conditions were less likely than not related to his active service. Id. As the examiner provided a negative nexus opinion for the Veteran's bilateral knee disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 3. Bilateral Foot Disability The Board also finds that the Veteran's left and right (bilateral) knee claims must be remanded for the same reasons as stated above. Notably, the claim was remanded in November 2021 to obtain a medical opinion. However, the claim was returned to the Board without providing the requested medical opinion pursuant to the November 2021 Board remand. Notably, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral foot disability due to the Veteran's lack of cooperation. See June 2021 VA Foot Conditions DBQ. However, the September 2020 VA examination indicated the Veteran has bilateral foot degenerative arthritis. See September 2020 VA Foot Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's bilateral foot disabilities based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's bilateral foot disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 4. Bilateral Shoulder Disability The Board also finds that the Veteran's left and right (bilateral) shoulder claims must be remanded for the same reasons as stated above. Notably, the claim was remanded in November 2021 to obtain a VA medical opinion. However, the claim was returned to the Board without providing the requested medical opinion pursuant to the November 2021 Board remand. Particularly, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral shoulder disability due to the Veteran's lack of cooperation. See June 2021 VA Shoulder Conditions DBQ. However, the September 2020 VA examination confirmed that the Veteran has right shoulder acromioclavicular joint osteoarthritis and a left shoulder strain. See September 2020 VA Shoulder Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's bilateral shoulder disabilities based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's bilateral shoulder disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 5. Low Back Disability The Board also finds that the Veteran's low back disability claim must be remanded for the same reasons as stated above. Notably, the claim was remanded in November 2021 to obtain a VA medical opinion. However, the claim was returned to the Board without providing the requested medical opinion pursuant to the November 2021 Board remand. Specifically, the June 2021 VA examiner found that the Veteran did not have a diagnosed low back disability due to the Veteran's lack of cooperation. See June 2021 VA Back (Thoracolumbar Spine) Conditions DBQ. However, the September 2020 VA examination confirmed that the Veteran has lumbar spine degenerative arthritis. See September 2020 VA Back Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's low back disability based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's low back disability based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 6. However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. VA Treatment Records The Board notes the claims file reflects that the Veteran has been receiving treatment from the Houston VA Medical Center (VAMC), and that records dated through July 2021 are associated with the file; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). The matters are REMANDED for the following action: 1. Obtain the Veteran's comprehensive VA treatment records for the period from July 2021 to the present, to include from VA medical centers, clinics, counseling centers, hospitals, and outpatient treatment centers. See 38 C.F.R. § 3.159(c)(3) (2020). The Board observes that the Veteran has been treated at Houston VAMC. Neck, Upper Back, Bilateral Knees, Bilateral Shoulders, Bilateral Feet, and Low Back Disabilities 2. Obtain an addendum opinion from an examiner OTHER THAN THE JUNE 2021 VA examiner with appropriate experience to render an etiology opinion for the Veteran's neck, upper back, bilateral knees, bilateral shoulders, bilateral feet, and low back disabilities. 3. A VA examination is not required. However, if the examiner determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination(s). Any clinically indicated testing and/or consultations should be performed. 4. If an in-person examination is required, the Veteran must be provided written notice of the time and place of the examination. A copy of the notice letter sent to the Veteran informing him of the time, place, and location of the examination must be associated with the Veteran's electronic claims file. 5. The letter should also inform the Veteran of the consequence of any failure to report for the examination without good cause. See 38 C.F.R. § 3.655. 6. The examiner must review the claims folder including this remand and acknowledge such review in the report. Based on review of the January 2013 and September 2020 VA examination reports and medical opinions, the examiner is requested to address the following. 7. Identify the Veteran's current neck, upper back, and lower back disabilities. 8. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 9. Assuming that the standard is at least as likely as not, is it possible that the Veteran's current neck, upper back, and lower back disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? 10. Are the Veteran's assertions that his current neck, upper back, and lower back disabilities was incurred as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), consistent with medical knowledge or implausible? 11. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), align with how the Veteran's current neck, upper back, and lower back disabilities are known to develop? 12. Whether it is medically feasible that his current neck, upper back, and lower back disabilities was caused by his in-service injury as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral Shoulder Disabilities 13. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral shoulder conditions(s). Upon review of the evidence, the VA examiner is asked to address the following: 14. Identify the Veteran's current bilateral shoulder disabilities. 15. Opine whether the Veteran's currently diagnosed bilateral shoulder disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 16. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 17. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral shoulder disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? 18. Are the Veteran's assertions that his bilateral shoulder disabilities was incurred as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), consistent with medical knowledge or implausible? 19. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), align with how the Veteran's current bilateral shoulder disabilities are known to develop? 20. Whether it is medically feasible that his bilateral shoulder disabilities was caused by his in-service injury as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral foot disabilities 21. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral foot disabilities. Upon review of the evidence, the VA examiner is asked to address the following: 22. Identify the Veteran's currently diagnosed bilateral foot disabilities. 23. Opine whether the Veteran's currently diagnosed bilateral foot disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 24. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 25. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral foot disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic while standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? 26. Are the Veteran's assertions that his bilateral foot disabilities were incurred as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), consistent with medical knowledge or implausible? 27. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), align with how the Veteran's current bilateral foot disabilities are known to develop? 28. Whether it is medically feasible that his bilateral foot disabilities were caused by his in-service injury as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral knee disabilities 29. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral knee disabilities. Upon review of the evidence, the VA examiner is asked to address the following: 30. Identify the Veteran's currently diagnosed bilateral knee disabilities. 31. Opine whether the Veteran's currently diagnosed bilateral knee disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 32. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 33. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral knee disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic while standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? 34. Are the Veteran's assertions that his bilateral knee disabilities were incurred as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), consistent with medical knowledge or implausible? 35. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), align with how the Veteran's current bilateral knee disabilities are known to develop? 36. Whether it is medically feasible that his bilateral knee disabilities were caused by his in-service injury as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. 37. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. (Continued on the next page) YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.