Citation Nr: 22014115 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 17-04 775 DATE: March 11, 2022 ORDER A rating in excess of 10 percent for lumbar spine degenerative arthritis with lumbosacral strain is denied. REMANDED Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a gastrointestinal/liver disability (to include gastroesophageal reflux disease (GERD)) is remanded. Entitlement to service connection for a psychiatric disability is remanded. FINDING OF FACT For the entire evaluation period, the Veteran's lumbar spine degenerative arthritis with lumbosacral strain is shown to have been manifested by full forward flexion (i.e., 90 degrees) and full combined range of motion (i.e., 240 degrees) with no functional loss due to painful motion, repeated use over time, or flare-ups; and such disability is not shown to have manifested in muscle spasm or guarding, ankylosis, associated neurological manifestations, or intervertebral disc syndrome at any time during the evaluation period. CONCLUSION OF LAW A rating in excess of 10 percent for lumbar spine degenerative arthritis with lumbosacral strain is not warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003 (2020), 5010 (2020 & 2021), DC 5237 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1982 to July 1994 with an earlier period of active duty for training (ACDUTRA) from December 1974 to May 1975. In August 2019, a videoconference hearing was held before the undersigned Veterans Law Judge, and a transcript of the hearing is associated with the record. In May 2020, the Board remanded the current issues for additional development. Thereafter, in an October 2020 rating decision, the Agency of Original Jurisdiction (AOJ) recharacterized the Veteran's service-connected lumbar spine disability (as lumbar spine degenerative arthritis with lumbosacral strain) and increased the rating for such disability from 0 percent to 10 percent, effective May 1, 2012 (i.e., the date VA received the Veteran's current claim for an increased rating for such disability). Because that award did not represent a total grant of benefits sought on appeal for the Veteran's lumbar spine disability, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In February 2021, the Board again remanded the current issues for additional development. Entitlement to a rating in excess of 10 percent for lumbar spine degenerative arthritis with lumbosacral strain. Generally, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate "staged" ratings may be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007). For musculoskeletal disabilities (such as the lumbar spine degenerative arthritis with lumbosacral strain addressed below), in determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran filed the instant claim for an increased rating for his service-connected lumbar spine degenerative arthritis with lumbosacral strain on May 1, 2012. For the entire evaluation period, the Veteran's lumbar spine degenerative arthritis with lumbosacral strain has been rated under DC 5010 (for arthritis due to trauma or post-traumatic arthritis) and under DC 5237 (for lumbosacral strain). Effective February 7, 2021, VA revised the criteria for rating disabilities of the musculoskeletal system and muscle injuries. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (codified at 38 C.F.R. § 4.71a (2021)). Because the current increased rating claim for the Veteran's lumbar spine degenerative arthritis with lumbosacral strain stems from a claim received by VA on May 1, 2012 (as noted above), the Board is required to consider the claim in light of both the former and revised schedular criteria in order to determine whether a higher rating is warranted for that disability. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C. § 5110(g). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. Under the version of DC 5010 in effect prior to February 7, 2021, arthritis due to trauma and substantiated by X-ray findings is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010 (2020). Under the version of DC 5003 in effect prior to February 7, 2021, degenerative arthritis (hypertrophic or osteoarthritis) established by X-ray findings is to be rated on the basis of limitation of motion under the appropriate DC(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate DC(s), a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003 (2020). Under the version of DC 5010 which became effective on February 7, 2021, post-traumatic arthritis is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint; and if there are two or more joints affected, then each rating shall be combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5010 (2021). Under DC 5237 (which was not changed by VA's rating criteria revisions effective as of February 7, 2021), lumbosacral strain is to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine, which provides the following criteria for rating the disability 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. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, for the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, for muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, for vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, for the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, for 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 limited to 30 degrees or less, or, for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, DC 5237. Any associated objective neurologic abnormalities are to be evaluated separately, under an appropriate DC. 38 C.F.R. § 4.71a, DC 5237, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, normal extension is 0 to 30 degrees, normal left and right lateral flexion is 0 to 30 degrees, and normal left and right lateral rotation is 0 to 30 degrees. 38 C.F.R. § 4.71a, DC 5237, Note (2). All measured ranges of motion are to be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, DC 5237, Note (4). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar 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. 38 C.F.R. § 4.71a, DC 5237, Note (5). The Veteran has not had intervertebral disc syndrome at any time during the evaluation period. Therefore, the criteria for rating such disability under 38 C.F.R. § 4.71a (DC 5243 and the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes) are not applicable to his lumbar spine degenerative arthritis with lumbosacral strain and will not be discussed. For the entire evaluation period, the Veteran's lumbar spine degenerative arthritis with lumbosacral strain is shown to have been manifested by full forward flexion (i.e., 90 degrees) and full combined range of motion (i.e., 240 degrees) with no functional loss due to painful motion, repeated use over time, or flare-ups; and such disability is not shown to have manifested in muscle spasm or guarding, ankylosis, associated neurological manifestations, or intervertebral disc syndrome at any time during the evaluation period, as shown by the pertinent evidence of record outlined below. At an April 2013 VA back examination, testing revealed that the Veteran's thoracolumbar spine forward flexion measured 90 degrees (with pain beginning at 90 degrees) and that his combined range of motion for his thoracolumbar spine measured 240 degrees (with no objective evidence of painful motion for extension, right or left lateral flexion, or right or left lateral rotation). He was able to perform repetitive-use testing, with no additional limitation in range of motion following such testing, and the VA examiner noted that the Veteran had no functional loss or functional impairment of the thoracolumbar spine. The Veteran did not report that flare-ups impacted the function of his thoracolumbar spine. It was noted that he did have localized tenderness or pain to palpation in the left sacroiliac (SI) joint, but also that he had no guarding or muscle spasm of the thoracolumbar spine. All neurological testing (including muscle strength, reflex, sensory, and straight leg raise testing) was normal, and it was noted that he did not have any radicular pain or any other signs or symptoms due to radiculopathy and that he did not have any other neurologic abnormalities. It was further noted that he had no intervertebral disc syndrome and no vertebral fracture. While contemporaneous pelvis X-rays showed moderate lumbar levoscoliosis, this was noted in conjunction with a congenital leg length difference (due to his right femoral head being approximately four to six millimeters lower than his left femoral head). The VA examiner concluded that the Veteran had a sacro-iliac condition and strain which was secondary to his congenital-developmental short leg and that symptoms of such were not related to any service-connected condition, because diagnostic osteopathic counterstrain techniques resulted in significant improvement of the Veteran's sciatica-like symptoms that he had claimed stemmed from his lumbar strain. Thereafter, April 2017 VA X-rays of the Veteran's lumbar spine showed mild levoscoliosis. However, as noted above, this was a condition previously noted in conjunction with a congenital leg length difference and was not shown at any time to be due to muscle spasm or guarding (to include any that would be severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis). At his August 2019 Board hearing, the Veteran testified that his back affected his gait, but he described this as "sometimes I walk like I'm going to lose my balance" and did not assert that he had an abnormal gait due to muscle spasm or guarding. He also testified that his whole left leg down to his ankle sometimes went numb, and that he got "duck foot" ("[w]here you can't really lift your foot, and you plop it down, and then it comes back [and] goes back to normal"). At a September 2020 VA back examination, testing revealed that the Veteran's thoracolumbar spine forward flexion measured 90 degrees and that his combined range of motion for his thoracolumbar spine measured 240 degrees. While pain was noted on examination with all motions, the VA examiner noted that such pain did not result in or cause functional loss. The Veteran was able to perform repetitive-use testing, with no additional loss of function or range of motion after such testing, and the VA examiner noted that pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability with repeated use over a period of time. The Veteran did not report flare-ups of the thoracolumbar spine. It was noted that there was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine, and also that he had no guarding or muscle spasm of the thoracolumbar spine. All neurological testing (including muscle strength, reflex, sensory, and straight leg raise testing) was normal, and it was noted that he did not have any radicular pain or any other signs or symptoms due to radiculopathy and that he did not have any other neurologic abnormalities. It was further noted that he had no ankylosis, no intervertebral disc syndrome, and no thoracic vertebral fracture with loss of 50 percent or more of height. The VA examiner noted that there was evidence of pain on passive range of motion and on weight-bearing (but not on nonweight-bearing), but that it was less likely than not that the Veteran's pain could limit functional ability with an additional range of motion loss in the lumbar spine during flare-ups or when the joints were used repeatedly over a period of time, based on the objective evidence of record showing no flare-ups and no decreased range of motion in degrees during repetitive use. See Correia v. McDonald, 28 Vet. App. 158 (2016); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Pursuant to the Board's February 2021 remand, VA asked the Veteran in an April 2021 letter to provide authorization for VA to obtain all pertinent private treatment records, including from his private primary care provider. However, the Veteran did not provide the requested authorization. The Board notes that the duty to assist is not a one-way street and that VA fulfilled its obligation to assist the Veteran by way of its April 2021 letter. See Wood v. Derwinski, 1 Vet. App. 190 (1991). As described above, the pertinent evidence during the evaluation period shows that the Veteran's thoracolumbar spine forward flexion and combined range of motion have not been limited, and no functional loss has been shown (to include due to painful motion, repeated use over time, or flare-ups). 38 C.F.R. §§ 4.10, 4.40, 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995). In addition, his thoracolumbar spine disability is not shown to have manifested in muscle spasm or guarding, ankylosis, associated neurological manifestations, or intervertebral disc syndrome at any time during the evaluation period. As noted above, his diagnosis of levoscoliosis has been noted in conjunction with a congenital leg length difference and has not been shown at any time to be due to muscle spasm or guarding, and his August 2019 hearing testimony regarding altered gait was not alleged to be due to muscle spasm or guarding. In addition, as noted at his April 2013 VA back examination, his left lower extremity sciatica symptoms were found to be due to his congenital-developmental short leg and not related to his thoracolumbar spine condition; and despite his August 2019 hearing testimony regarding numbness in his left leg and having "duck foot," all neurological testing throughout the evaluation period has yielded normal results. Therefore, his lumbar spine degenerative arthritis with lumbosacral strain is not entitled to a rating in excess of 10 percent under DC 5237, including any separate ratings for neurological impairment. Accordingly, for the entire evaluation period, the Board finds that the weight of the evidence is persuasively against a rating in excess of 10 percent at any time for the Veteran's lumbar spine degenerative arthritis with lumbosacral strain. As such, the benefit of the doubt doctrine is inapplicable, and the claim is denied. See 38 C.F.R. § 4.71a, DC 5003 (2020), 5010 (2020 & 2021), 5237 (2021); see also Francisco, 7 Vet. App. at 55, 58; see also Hart, 21 Vet. App. at 505. REASONS FOR REMAND 1. Entitlement to service connection for a left ankle disability. The Board's February 2021 remand directed the AOJ to obtain an ankle examination of the Veteran with imaging studies and for the examiner to provide an opinion as to whether any current left ankle disability (to include pain alone which results in functional impairment of earning capacity) was at least as likely as not incurred in or related to the Veteran's military service. At a June 2021 VA ankle examination, it was noted that the Veteran did not have a current left ankle diagnosis and that his left ankle symptoms did not impact his ability to perform any type of occupational task. However, the June 2021 examiner noted that the Veteran had pain that caused functional impairment during flare ups, including a decrease in plantar flexion to 40 degrees. Additionally, it does not appear that the examiner considered the Veteran's testimony at the August 2019 hearing that his ankle gives out and that he has weak ankles. In October 2021, a VA physician opined that the Veteran's claimed left ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness; however, this opinion was based on the finding of no current left ankle diagnosis at the June 2021 VA ankle examination and did not consider the functional impairment noted above. Additionally, X-rays of the Veteran's left ankle in September 2021 revealed a prominent left ventral calcaneal spur. The Veteran is already service connected for a left heel bone spur; however, an opinion has not been provided as to whether the Veteran's functional impairment of the left ankle is caused or aggravated by the service-connected left heel bone spur. On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinion must be obtained. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not substantially complied with, the Board errs as a matter of law when it fails to ensure substantial compliance). 2. Entitlement to service connection for a right ankle disability. The Board's February 2021 remand directed the AOJ to obtain an ankle examination of the Veteran with imaging studies and for the examiner to provide an opinion as to whether any current right ankle disability (to include pain alone which results in functional impairment of earning capacity) was at least as likely as not incurred in or related to the Veteran's military service. At a June 2021 VA ankle examination, it was noted that the Veteran did not have a current right ankle diagnosis and that his right ankle symptoms did not impact his ability to perform any type of occupational task. However, the June 2021 examiner noted that the Veteran experienced moderate flare ups in the right ankle once a week and that pain caused functional impairment during flare ups, including a decrease in plantar flexion to 40 degrees. Additionally, it does not appear that the examiner considered the Veteran's testimony at the August 2019 hearing that his ankle gives out and that he has weak ankles. Thereafter, X-rays of the Veteran's right ankle in September 2021 revealed a right ventral calcaneal spur. In October 2021, a VA physician opined that the Veteran's claimed right ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness; however, this opinion was based on the finding of no current right ankle diagnosis at the June 2021 VA ankle examination and did not consider whether functional impairment of the right ankle from pain and weakness is related to his service or is caused or aggravated by the service-connected left heel bone spur (to include a September 1983 STR noting right heel tenderness in conjunction with left heel pain and bone spur). On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinion must be obtained. See Stegall, 11 Vet. App. at 268, 271. 3. Entitlement to service connection for a left elbow disability. The Board's February 2021 remand directed the AOJ to obtain an elbow examination of the Veteran with imaging studies and for the examiner to provide an opinion as to whether any current left elbow disability (to include pain alone which results in functional impairment of earning capacity) was at least as likely as not incurred in or related to the Veteran's military service, was caused or aggravated (i.e., any increase in severity beyond its natural progression) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain, or was caused or aggravated (i.e., any increase in severity beyond its natural progression) by his service-connected cervical spine degenerative changes/arthritis. At a June 2021 VA elbow examination, the Veteran was diagnosed with left elbow lateral epicondylitis. With supportive rationale, the June 2021 VA examiner opined that the Veteran's currently diagnosed left elbow lateral epicondylitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness (as outlined in a June 2021 addendum) and that his currently diagnosed left elbow lateral epicondylitis was less likely than not proximately due to or the result of his service-connected lumbar spine disability or his service-connected cervical spine disability (as outlined in a June 2021 addendum). However, the June 2021 VA examiner did not provide adequate rationale for opining that the Veteran's currently diagnosed left elbow lateral epicondylitis was not at least as likely as not aggravated beyond its natural progression by his service-connected lumbar spine disability or his service-connected cervical spine disability, because such rationale addressed only the lack of aggravation shown in service rather than the question of aggravation by the aforementioned service-connected disabilities (as outlined in a June 2021 addendum). Thereafter, X-rays of the Veteran's left elbow in September 2021 revealed osteoarthritic changes (i.e., degenerative joint disease) with osteophyte involving the left humeral ulnar joint. In October 2021, a VA physician opined that the Veteran's currently diagnosed left elbow degenerative joint disease was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, and provided supportive rationale for this opinion. However, no secondary service connection opinions were provided for the left elbow degenerative joint disease diagnosis. On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinions must be obtained. See Stegall, 11 Vet. App. at 268, 271. 4. Entitlement to service connection for a right elbow disability. The Board's February 2021 remand directed the AOJ to obtain an elbow examination of the Veteran with imaging studies and for the examiner to provide an opinion as to whether any current right elbow disability (to include pain alone which results in functional impairment of earning capacity) was at least as likely as not incurred in or related to the Veteran's military service, was caused or aggravated (i.e., any increase in severity beyond its natural progression) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain, or was caused or aggravated (i.e., any increase in severity beyond its natural progression) by his service-connected cervical spine degenerative changes/arthritis. At a June 2021 VA elbow examination, the Veteran was diagnosed with right elbow lateral epicondylitis. With supportive rationale, the June 2021 VA examiner opined that the Veteran's currently diagnosed right elbow lateral epicondylitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness (as outlined in a June 2021 addendum) and that his currently diagnosed right elbow lateral epicondylitis was less likely than not proximately due to or the result of his service-connected lumbar spine disability or his service-connected cervical spine disability (as outlined in a June 2021 addendum). However, the June 2021 VA examiner did not provide adequate rationale for opining that the Veteran's currently diagnosed right elbow lateral epicondylitis was not at least as likely as not aggravated beyond its natural progression by his service-connected lumbar spine disability or his service-connected cervical spine disability, because such rationale addressed only the lack of aggravation shown in service rather than the question of aggravation by the aforementioned service-connected disabilities (as outlined in a June 2021 addendum). Thereafter, X-rays of the Veteran's right elbow in September 2021 revealed a small olecranon spur. In October 2021, a VA physician opined that the Veteran's currently diagnosed right elbow olecranon spur was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, and provided supportive rationale for this opinion. However, no secondary service connection opinions were provided for the right elbow olecranon spur diagnosis. On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinions must be obtained. See Stegall, 11 Vet. App. at 268, 271. 5. Entitlement to service connection for a right knee disability. The Board's February 2021 remand directed the AOJ to obtain a knee examination of the Veteran with imaging studies and for the examiner to provide an opinion as to whether any current right knee disability (to include pain alone which results in functional impairment of earning capacity) was at least as likely as not incurred in or related to the Veteran's military service or was caused or aggravated (i.e., any increase in severity beyond its natural progression) by his service-connected left knee strain. At a June 2021 VA knee examination, the Veteran was diagnosed with right knee patellofemoral pain syndrome. With supportive rationale, the June 2021 VA examiner opined that the Veteran's currently diagnosed right knee patellofemoral pain syndrome was less likely than not incurred in or caused by the claimed in-service injury, event, or illness (as outlined in a June 2021 addendum). However, the June 2021 VA examiner did not provide adequate rationale for opining that the Veteran's currently diagnosed right knee patellofemoral pain syndrome was less likely than not proximately due to or the result of his service-connected left knee disability, because such rationale did not consider or address the Veteran's reports of having right knee disability due to favoring his right knee over his left knee (as outlined in a June 2021 addendum). In addition, the June 2021 VA examiner did not provide adequate rationale for opining that the Veteran's currently diagnosed right knee patellofemoral pain syndrome was not at least as likely as not aggravated beyond its natural progression by his service-connected left knee disability, because such rationale addressed only the lack of aggravation shown in service rather than the question of aggravation by the aforementioned service-connected disability (as outlined in a June 2021 addendum). Thereafter, X-rays of the Veteran's right knee in September 2021 did not reveal any abnormal findings. In October 2021, a VA physician opined that the Veteran's currently diagnosed right knee patellofemoral pain syndrome was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, and provided supportive rationale for this opinion. No secondary service connection opinions were provided by the VA physician. On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinions must be obtained. See Stegall, 11 Vet. App. at 268, 271. 6. Entitlement to service connection for a gastrointestinal/liver disability (to include GERD). The Board's February 2021 remand directed the AOJ to obtain a gastrointestinal/liver examination of the Veteran and for the examiner to provide an opinion as to whether any current gastrointestinal/liver disability was at least as likely as not incurred in or related to the Veteran's military service (to include consideration of his conceded exposure to contaminated water at Camp Lejeune). In May 2021, a VA physician opined that the claimed gastrointestinal/liver disability (to include GERD, dyspepsia, and fatty liver disease) was less likely than not caused by or a result of the Veteran's exposure to contaminated water at Camp Lejeune, and provided supportive rationale for this opinion. At a June 2021 VA liver examination, it was noted that the Veteran did not have a current liver diagnosis. At a June 2021 VA stomach examination, the Veteran was diagnosed with reflux (i.e., GERD). In a June 2021 addendum, the June 2021 VA examiner opined that the Veteran's currently diagnosed GERD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, the rationale provided for this opinion did not consider or address the Veteran's pertinent STRs (including a July 1980 STR noting hiatal hernia and a January 1986 STR noting gastroenteritis) or his allegations of continuity of symptomatology since his service (as he testified at his August 2019 Board hearing that his gastrointestinal problems started in service and that he still had them "to this day"). On remand, after any outstanding treatment records have been associated with the claims file, an addendum report with adequate medical opinion must be obtained. See Stegall, 11 Vet. App. at 268, 271. 7. Entitlement to service connection for a psychiatric disability. A June 2021 VA treatment record noted that the report of a June 26, 2021, outpatient individual psychotherapy consultation with a private social worker had been scanned into VistA Imaging. However, there is no viewable copy of this report currently in the claims file. On remand, all outstanding treatment records must be associated with the claims file. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for his claimed disabilities remaining on appeal at any time during the appeal period. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA treatment records for the period from October 2021 to the present, as well as a viewable copy of the report of his June 26, 2021, outpatient individual psychotherapy consultation with a private social worker which was scanned into VistA Imaging (as outlined above). Any negative search result should be noted in the record and communicated to the Veteran. 3. After all requested records have been associated with the claims file, obtain a medical opinion from an appropriate clinician(s), after review of the electronic claims file. If the clinician(s) determines that an examination is necessary to respond to any of the questions below, then the Veteran should be scheduled for such (or a telehealth interview if an in-person examination is not feasible). The clinician(s) is asked to respond to the following questions: (a.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's left ankle functional impairment from pain during flare ups and weakness began during his active service or is otherwise related to any incident of his active service, with specific consideration given to all pertinent STRs; (b.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's left ankle functional impairment from pain during flare ups and weakness was: (i) caused by his service-connected bone spur, left heel; or (ii) aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected bone spur, left heel; (c.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's right ankle functional impairment from pain during flare ups and weakness and diagnosed right ventral calcaneal spur began during his active service or is otherwise related to any incident of his active service, with specific consideration given to all pertinent STRs (including the September 1983 STR noting right heel tenderness in conjunction with left heel pain and bone spur); (d.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's right ankle functional impairment from pain during flare ups and weakness was: (i) caused by his service-connected bone spur, left heel; or (ii) aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected bone spur, left heel; (e.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed left elbow lateral epicondylitis was aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; (f.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed left elbow degenerative joint disease was: (i) caused by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; or (ii) aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; (g.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed right elbow lateral epicondylitis was aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; (h.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed right elbow olecranon spur was: (i) caused by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; or (ii) aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected lumbar spine degenerative arthritis with lumbosacral strain OR by his service-connected cervical spine degenerative changes/arthritis; (i.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed right knee patellofemoral pain syndrome was: (i) caused by his service-connected left knee strain, with specific consideration given to the Veteran's reports of having right knee disability due to favoring his right knee over his left knee; or (ii) aggravated beyond its natural progression (i.e., any increase in severity beyond the natural progression of the condition) by his service-connected left knee strain, with specific consideration given to the Veteran's reports of having right knee disability due to favoring his right knee over his left knee; and (j.) Whether it is at least as likely as not (approximately a 50 percent or greater probability) that the Veteran's currently diagnosed GERD began during his active service or is otherwise related to any incident of his active service, with specific consideration given to all pertinent STRs (including the July 1980 STR noting hiatal hernia and the January 1986 STR noting gastroenteritis) and his allegations of continuity of symptomatology since his service. A complete rationale for all opinions must be provided. If the clinician(s) cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician(s) must provide the reasons why an opinion would require speculation. The clinician(s) must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician(s) must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular clinician. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. B. Yantz, 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.