Citation Nr: 22012007 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 15-43 040 DATE: March 2, 2022 ORDER The application to reopen a previously denied claim for service connection for a heart condition, to include as due to exposure to in-service herbicide agents, is granted. Entitlement to a rating in excess of 10 percent for the service-connected chronic lumbosacral strain disability is denied. REMANDED Entitlement to service connection for a heart condition, to include as due to exposure to in-service herbicide agents, is remanded. Entitlement to service connection for a bilateral shoulder condition, to include as secondary to the service-connected chronic lumbosacral strain, is remanded. Entitlement to service connection for cervical spine degenerative arthritis-severe osteoarthritis (cervical spine disability), to include as secondary to the service-connected chronic lumbosacral strain, is remanded. FINDINGS OF FACT 1. An unappealed July 1983 notification that denied service connection for a heart condition is final. 2. The evidence received since the July 1983 notification that denied service connection for a heart condition is new and material, in that, it is not cumulative or redundant of the evidence of record at the time of the July 1983 notification and raises a reasonable possibility of substantiating the claim. 3. For the entire appellate period, the Veteran's back disability was manifested by forward flexion greater than 60 degrees and a combined range of motion greater than 120 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, ankylosis, incapacitating episodes due to intervertebral disc syndrome (IVDS), or other neurologic abnormalities. CONCLUSIONS OF LAW 1. The July 1983 decision that denied service connection for a heart condition is final. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.160(d), 3.156, 20.200, 20.302, 20.1103. 2. New and material evidence has been received sufficient to reopen a previously denied claim for service connection for a heart condition. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.160(d), 3.156, 20.200, 20.302, 20.1103. 3. For the entire appeal period, the criteria for a rating in excess of 10 percent for the Veteran's service-connected back disability were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242-5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1967 to July 1970. He died in July 2018; his surviving spouse is the substituted claimant (Appellant). These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2011, February 2013, and August 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. The record reflects that, in January 2021, the Appellant requested a Board of Veterans' Appeals (Board) virtual hearing. However, the record also reflects that she did not report for such hearing. There is also no indication that she requested to have that hearing rescheduled. As such, the hearing request is considered withdrawn. New and Material EvidenceA Heart Condition The Veteran was denied service connection for a heart condition in a July 1983 notification letter. He did not appeal that decision, and it became final on the date it was issued. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100 (a). The Board notes that a prior rating decision issued in January 1971 also denied entitlement to service connection for a heart condition. A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). Evidence is new if it has not been previously submitted to agency decision makers. Id. Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative with, or redundant of, evidence already of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). In Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010), the U.S. Court of Appeals for Veterans Claims (Court) clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. Here, the evidence received since the last final denial includes a February 2011 VA examination report for heart conditions, a May 2011 private medical opinion, and additional VA treatment records. Assuming the credibility of this new evidence, as the Board must for this purpose, the Board finds that new and material evidence has been received sufficient to reopen this previously denied claim. This evidence was not previously before agency decision makers in 1983, and raises a reasonable possibility of substantiating the claim. 38 U.S.C. § 5108; Fortuck, 17 Vet. App. at 179-80; Justus, 3 Vet. App. 510. The claim for service connection for a heart condition is considered reopened. To this extent only, the claim is granted. Increased RatingChronic Lumbosacral Strain Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran's claim for an increased rating was received in February 2012. His back disability was evaluated as noncompensable from October 1, 1970 to February 27, 2012, and at 10 percent disabling from February 28, 2012 until his death on July 15, 2018, under DC 5242-5237. The Board notes that hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the Veteran's back disability is rated as analogous to degenerative arthritis of the spine (DC 5242) and lumbosacral strain (DC 5237). 38 C.F.R. § 4.71a, DCs 5237, 5242. The Veteran alleged his back disability was more severe than what was reflected by the assigned 10 percent rating. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38 C.F.R. § 4.71a). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3-2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, VA has made clear that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5242 do not apply to the rating schedule itself but added instruction to classify disabilities associated with all non-IVDS disabilities under DC 5242. As such, DC 5242 now reflects "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either [DC] 5003 or 5010)." Here, the changes do not apply to the Veteran as he died in July 2018; thus, evaluation of his disability under the pre- and post-February 7, 2021 regulations is not required. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he ever had IVDS, to include incapacitating episodes. Thus, the IVDS Rating Formula would not allow for higher ratings for the Veteran's back disability at any point during the appellate periods. Private treatment records obtained in February 2012 reflect complaints of back pain. However, there are no range of motion measurements that fall within the criteria for a rating in excess of 10 percent. At a March 2012 VA examination, the Veteran reported having constant back pain with increased activity. He also reported flare-ups of the thoracolumbar spine, described as increased pain with lifting and bending, but stated that the flare-ups were relieved with resting. On examination, range of motion measurements revealed forward flexion to 80 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 25 degrees; each with evidence of painful motion. The Veteran was able to perform repetitive-use testing, with no additional limitation in range of motion. Functional loss or functional impairment resulted in less movement than normal. There was localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine, described as the thoracic and lumbar muscles being tender to palpation. The Veteran did not have guarding, muscle spasm, atrophy, ankylosis, or IVDS. There were no other neurologic abnormalities. Arthritis was documented. The examiner indicated that the Veteran's back disability did not impact the Veteran's ability to work. At an October 2015 VA examination, the Veteran reported having more tightness and pain in his back. He also reported having flare-ups of the thoracolumbar spine, described as suddenly worsened pain for no apparent reason. The Veteran did not report having any functional loss or functional impairment of the thoracolumbar spine. On examination, range of motion measurements revealed forward flexion to 90 degrees, extension to 20 degrees, and 30 degrees each for right and left lateral flexion, and for right and left lateral rotation. Pain was noted on examination, but it did not result in functional loss. Extension and right lateral flexion were noted to exhibit pain. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine, described as tenderness over the lumbar area and sacroiliac joint. The Veteran was able to perform repetitive-use testing with at least three repetitions, with no additional loss of function or range of motion. He was not examined immediately after repetitive use over time or during a flare-up. The examiner noted that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. Pain, fatigue, and lack of endurance did not significantly limit functional ability with repeated use over a period of time. However, pain was noted to significantly limit functional ability with flare-ups. The examiner further indicated that there was no change in range of motion. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Localized tenderness did not result in abnormal gait or abnormal spinal contour. Muscle strength testing results were all normal. Reflex and sensory examination results were also normal. Ankylosis and IVDS were not present, and there were no other neurologic abnormalities. The examiner indicated that x-rays revealed arthritis. He noted that the thoracolumbar spine condition impacted the Veteran's ability to work, as the Veteran had trouble walking for 15 minutes, standing for 30 minutes, sitting for 30 minutes, lifting over 15 pounds at a time, bending repeatedly, and crawling or squatting. At an October 2016 VA examination, the Veteran reported having increased back pain, daily, which was worse when he stood for 10 minutes or longer, and when he bent or twisted his back until he changed position. He denied having flare-ups of the thoracolumbar spine. He reported having functional loss or functional impairment of the thoracolumbar spine, described as daily low back pain. On examination, range of motion measurements revealed forward flexion to 80 degrees, and 20 degrees each for extension, right and left lateral flexion, and right and left lateral rotation. Range of motion did not contribute to functional loss. Pain was noted on examination, but it did not result in functional loss. Right and left lateral rotation were noted to exhibit pain. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with at least three repetitions, with no additional loss of function or range of motion. He was not examined immediately after repetitive use over time. The examiner noted that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, fatigue, and lack of endurance did not significantly limit functional ability with repeated use over a period of time. As the Veteran denied having flare-ups, he was not examined during flares. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing results were all normal. Reflex and sensory examination results were also normal. Ankylosis and IVDS were not present, and there were no other neurologic abnormalities. The examiner indicated that x-rays revealed arthritis. He noted that the thoracolumbar spine condition impacted the Veteran's ability to work, as the Veteran had trouble standing for 10 minutes or longer, bending, and twisting, due to pain. The Veteran reported that his lifting was limited by his heart condition. The examiner remarked that the Veteran's back condition did not restrict the Veteran from sedentary occupations. Based on the evidence of record, the Board finds that a disability rating in excess of 10 percent is not warranted for the Veteran's back disability at any time during the appellate period. As previously stated, to warrant a 20 percent disability rating under the General Rating Formula, forward flexion of the thoracolumbar spine must be limited to at least 60 degrees; the combined range of motion must be limited to at least 120 degrees; or muscle spasms or guarding must be severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. However, review of the evidence does not reveal symptomatology consistent with a 20 percent rating. Specifically, range of motion testing conducted during the VA examinations revealed forward flexion, at most, to 80 degrees, even with pain, and a combined range of motion that was greater than 120 degrees. Although the October 2015 VA examination reflected additional functional loss due to pain during flare-ups, the additional functional loss did not reflect forward flexion to at least 60 degrees or combined range of motion to at least 120 degrees. Thus, range of motion measurements did not more nearly approximate those required for a rating in excess of 10 percent under the General Rating Formula. Additionally, the evidence does not indicate that the Veteran had muscle spasms or guarding severe enough to result in abnormal gait or abnormal spinal contour at any point during the appellate period. None of the VA examination reports show that the Veteran had guarding or muscle spasm of the thoracolumbar spine. As such, a rating in excess of 10 percent for the Veteran's back disability is not warranted at any point during the appellate period. The Board has also considered whether separate ratings for associated objective neurologic abnormalities are warranted at any time throughout the appeal period, pursuant to Note (1) of the General Rating Formula. The Veteran did not contend, and the evidence does not show, that there were neurologic abnormalities associated with the Veteran's back disability, to warrant separate ratings. In reaching the foregoing determination, the Board acknowledges the Veteran's sincerely held belief that his back disability was more severe than that which was reflected by his assigned rating, and notes he was competent to describe his symptoms and their effects on his daily life. See Jandreau, supra; Layno, supra; Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, he was not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds instead that the medical evidence, in which professionals with medical expertise examined the Veteran, completed necessary testing, considered his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria, is more persuasive than his own reports regarding the severity of such conditions. The Board has also considered whether additional staged ratings under Hart, supra, were appropriate for the Veteran's service-connected back disability; however, the Board finds that his symptomatology had been stable throughout the appellate period. Accordingly, the Board finds that a rating in excess of 10 percent was not warranted for the Veteran's back disability; the claim is therefore denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, neither the Appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND A Heart Condition Ischemic heart disease may be presumed to have been incurred during active military service as a result of exposure to herbicide agents if the disease is manifest to a degree of 10 percent at any time after which the Veteran was exposed to herbicide agents during active service. 38 C.F.R. §§ 3.307 (a)(6)(ii), 3.309(e). Although the Veteran claimed to have had ischemic heart disease, the evidence shows otherwise. See, for instance, February 2011 VA Examination Report. While there was a diagnosis of congestive heart failure, the examiner indicated that the Veteran did not have ischemic heart disease. Id. Nonetheless, the Veteran was entitled to seek service connection on a direct basis due to herbicide agent exposure. Combee v. Brown, 5 Vet. App. 248 (1993). The Veteran claimed to have been exposed to herbicide agents during his tour in Korea. The Department of Defense (DOD) has confirmed to VA that herbicide agents were used along the Demilitarized Zone (DMZ) in Korea from April 1968 to July 1969. Fields of fire between the front-line defensive positions and the south barrier fence were defoliated. The size of the treated area was a strip of land 151 miles long and up to 350 yards wide from the fence to north of the civilian control line. According to DOD, there was no indication that herbicides were sprayed in the DMZ itself. Herbicides were applied through hand spraying and by hand distribution of pelletized herbicides. Although restrictions were put in place to limit potential for spray drift, run-off, and damage to food crops, records indicate that the effects of spraying were sometimes observed as far as 200 meters down wind. Effective February 24, 2011, VA amended its adjudication regulations to extend a presumption of herbicide agent exposure to certain veterans who served in Korea. Specifically, VA added a new paragraph (iv) to 38 C.F.R. § 3.307 (a)(6) that reads as follows: A veteran who, during active military, naval, or air service, served between April 1, 1968 and August 31, 1971, in a unit that, as determined by DOD, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a)(6)(iv); see also 38 C.F.R. § 3.814 (c)(2) (The dates for service in or near the Korean DMZ have since been changed to September 1, 1967 to August 31, 1971.) More recent legislation added section 1116B to 38 U.S.C. providing for a presumption of herbicide agent exposure for certain veterans who served in Korea. Specifically, the presumption of exposure will apply to a veteran "who, during active military, naval, or air service, served in or near the Korean [DMZ], during the period beginning on September 1, 1967, and ending on August 31, 1971." 38 U.S.C. § 1116B. This change seemingly relaxed the standard to areas in or near the Korean DMZ, rather than requiring a veteran to be in a unit identified by DOD as having operated in or near the Korean DMZ. In this case, the Veteran served from August 1967 to July 1970. His service personnel records show he served in Korea at some point in 1969, noting that he arrived at "Kimpo AB Korea by air on June 19, 1969." A DD Form 214 shows that he was part of the "2nd Battalion (HAWK) 71st Artillery Eighth Army." VA conceded that he was in Korea during the qualifying time period, but concluded that he was not exposed to herbicides because he was not attached to one of the units named by DOD to have been in or near the Korean DMZ, in an area in which herbicides are known to have been applied. See September 2015 Memorandum of Formal Finding. As the Veteran consistently maintained that he was exposed to herbicide agents while serving in Korea, the pertinent question in this case, given the recent amendment to the statute governing exposure, is whether the Veteran served in or near the Korean DMZ during the period between September 1, 1967 and August 31, 1971. In September 2015, VA provided a memorandum of formal finding regarding the Veteran's potential herbicide exposure in Korea. It outlines the steps taken to verify whether the Veteran was exposed to herbicide agents in or near the Korean DMZ. It was indicated that the Veteran's personnel records and service treatment records were reviewed and that there is no evidence of DMZ service while the Veteran served in Korea. However, the memorandum notes that the Veteran was sent a development letter in July 2015, requesting additional information regarding DMZ service and that the Veteran had not provided the additional information. The Board notes that, since that memorandum was issued, the Veteran provided additional information regarding his service in or near the Korean DMZ. For instance, in April 2017, he submitted photographs that he claimed were taken while he was in Korea. He stated that he was at "Ui Jung Bu, South Korea" with the "2nd BN 71st ARTY, from 1969 to 1970." In June 2018, the Veteran's surviving spouse also submitted a lengthy statement, which provides additional details about the Veteran's service in Korea. She explained that the Veteran was located just a few feet away from the Korean DMZ and that he was exposed to herbicide agents while he worked as a HAWK missile continuous radar repairman. As such, the Board finds that additional development is necessary regarding whether the Veteran served along the DMZ in Korea. On remand, VA should verify whether the Veteran's duties were among those identified as having served in Korea in or around the DMZ during the applicable time period. Should it be confirmed that the Veteran operated in an area in or near the Korean DMZ in which herbicides were applied, any additional development deemed necessary for adjudication purposes, such as obtaining a VA medical opinion, should be done. Bilateral Shoulder and Cervical Spine Disabilities A remand is necessary to obtain another VA medical opinion regarding the etiology of the Veteran's bilateral shoulder disability. The opinion that was last provided, in October 2016, is inadequate. Notably, the examiner primarily relied on a lack of showing of symptoms and diagnosis in the Veteran's service treatment records to conclude that the Veteran's disability was not related to service. There is no consideration of the Veteran's reports regarding the continuity of his symptoms. The October 2016 VA examiner also did not provide an opinion regarding whether the Veteran's bilateral shoulder condition was secondary to his service-connected back disability, as alternatively claimed by the Veteran. As such, a remand is required to obtain another medical opinion. The most recent opinion for the Veteran's cervical spine disability was also obtained in October 2016. Similar to the opinion provided for his bilateral shoulder disability, the opinion given for his cervical spine disability is also inadequate, as it primarily relied on a lack of showing of symptoms and diagnosis in the Veteran's service treatment records to conclude that his disability was not related to service. The examiner's opinion regarding secondary service connection is also inadequate. The examiner merely stated that he did not "identify a mechanism for the Veteran's current neck condition to be related to his back with currently available information." The examiner did not explain what information was necessary, or missing, for him to give a more adequate rationale. As such, it is also necessary to remand this issue for another VA medical opinion. The Board notes that in January 2014, the Veteran submitted medical opinions from two private clinicians, dated in September 2013 and October 2013, respectively. However, the Board finds that these opinions are inconclusive, with the examiners stating either that it is "impossible to state" whether an in-service injury caused the Veteran's disabilities (September 17, 2013 letter), or that "it is extremely difficulty to associate a single event or injury and prove that it caused" the current disabilities (October 2013 letter). As such, these opinions cannot be used to determine the Veteran's claims. Accordingly, the matters are REMANDED for the following action: 1. Verify whether the Veteran was in a unit that operated in an area in or near the Korean DMZ in which herbicides were applied. In addition to the Veteran's personnel records that indicate service in Korea during the applicable time period, review and verify additional information submitted by the Veteran in April 2017 (photographs claiming service in Ui Jung Bu, South Korea), and by his spouse in June 2018 (description of duties performed near the Korean DMZ). All efforts to obtain these records, and the responses received, must be documented in the claims file, and must continue until it is reasonably certain that the records do not exist or that further efforts to obtain such verification would be futile. 2. After the foregoing, should it be confirmed that the Veteran operated in an area in or near the Korean DMZ in which herbicides were applied, any additional development deemed necessary for adjudication purposes, such as obtaining a VA medical opinion, should be done. 3. Forward the Veteran's claims file to an appropriate VA clinician to obtain medical opinions regarding the etiologies of the Veteran's bilateral shoulder and cervical spine disabilities. The examiner is requested to review all pertinent records associated with the claims file, including any available service treatment records, post-service medical records, and the Veteran's assertions. After reviewing the claims file, the examiner is asked to: a. Opine whether the Veteran's bilateral shoulder condition at least as likely as not (a 50 percent or greater probability) had its clinical onset during service or is due to an event or incident of the Veteran's period of service. b. Opine whether the Veteran's bilateral shoulder condition was at least as likely as not (a 50 percent or greater probability) proximately due to (or the result of), or aggravated (made worse) by, the service-connected chronic lumbosacral strain disability. c. Opine whether the Veteran's cervical spine degenerative arthritis-severe osteoarthritis disability at least as likely as not (a 50 percent or greater probability) had its clinical onset during service or is due to an event or incident of the Veteran's period of service. d. Opine whether the Veteran's cervical spine degenerative arthritis-severe osteoarthritis disability was at least as likely as not (a 50 percent or greater probability) proximately due to (or the result of), or aggravated (made worse) by, the service-connected chronic lumbosacral strain disability. In answering questions 3a. to 3d. above, the examiner is asked to consider and address medical opinions dated in September 2013 and October 2013, from two private clinicians. The examiner is advised that the term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition beyond its natural progression versus a temporary flare-up of symptoms. The examiner is reminded that a lack of evidence cannot be corroborating to conclude that there is no relationship between the Veteran's disability and his military service. The examiner is advised that the Veteran was competent to report his symptoms and history pertaining to his bilateral shoulder and cervical spine disabilities, and that such reports must be acknowledged and considered in formulating any opinion. A clear explanation for all opinions should be provided with a discussion of the facts and medical principles involved. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence, or information would be useful in rendering an opinion. A. J. Spector Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Trowers, Associate 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.