Citation Nr: 22014152 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 17-22 240A DATE: March 11, 2022 ORDER Entitlement to service connection for osteosarcoma is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for glaucoma is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for plantar fasciitis is remanded. FINDINGS OF FACT 1. The Veteran was not exposed to toxic chemicals during service, to include contaminated water at Camp Lejeune. 2. The Veteran's osteosarcoma did not begin in, and is not otherwise related to, his active service. 3. The Veteran's right shoulder disability is caused by his non-service-connected osteosarcoma; it did not have onset in, and is not otherwise related to, his active service. 4. The Veteran's right hip disability is caused by his non-service-connected osteosarcoma; it did not have onset in, and is not otherwise related to, his active service. 5. The Veteran's left eye glaucoma did not begin in, and is not otherwise related to, his active service. 6. The Veteran's bilateral hearing loss was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury or disease. 7. The Veteran's tinnitus was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for osteosarcoma are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for entitlement to service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 3. The criteria for entitlement to service connection for a right hip disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to service connection for glaucoma are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for tinnitus are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to July 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision by a Department of Veterans Affairs (VA) regional office, which is the agency of original jurisdiction (AOJ). In August 2020, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding is of record. The Board remanded these matters in April 2021 so that records from the Social Security Administration, as well as a VA examination and opinion with respect to bilateral hearing loss and tinnitus, could be obtained. The Board finds there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board also remanded entitlement to service connection for an acquired psychiatric disorder. As the AOJ subsequently granted service connection for major depressive disorder in an October 2021 rating decision, the claim has been granted in full and is no longer for appellate consideration. New VA treatment records have been added to the claims file since the last adjudication of the claims by the AOJ, but none are material to the claims decided below in terms of showing a relationship between the claimed disabilities and service. January & February 2022 CAPRI. Rather, the records only confirm the diagnoses of the claimed disabilities, which are not in dispute, and do not speak to the nature of the disabilities or to a nexus between the disabilities and service, which is the basis upon which these claims are decided. Accordingly, the Board finds no prejudice to the Veteran in proceeding with adjudication of the claims without further delay. 38 C.F.R. § 19.37(b) (2020). Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, VA has established certain rules and presumptions for chronic diseases, such as hearing loss and tinnitus. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. Entitlement to service connection for osteosarcoma. The Veteran asserts that he developed osteosarcoma as a result of toxic exposures during his military service. Specifically, he contends that he was exposed to contaminated water at Camp Lejeune, as well as fuel and explosives. As a preliminary matter, the record reflects that the Veteran was diagnosed with and underwent treatment for osteosarcoma after his military service. See, e.g., CAPRI May 2016. Upon review, however, the Board finds the evidence weighs persuasively against a finding that osteosarcoma is related to the Veteran's military service. With respect to an in-service injury, the Veteran contends that he was exposed to contaminated drinking water at Camp Lejeune. In that regard, 38 C.F.R. § 3.307(a)(7) provides that a veteran who served no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune between August 1, 1953, and December 31, 1987, are presumed to have been exposed to contaminants in the water supply, including TCE, PCE, benzene, and vinyl chloride, in the absence of affirmative evidence to the contrary. Once such exposure is established, service connection on a presumptive basis is available for certain diseases. 38 C.F.R. § 3.307(a)(7). The diseases that are deemed to be associated with exposure to contaminated water at Camp Lejeune are kidney cancer; liver cancer; Non-Hodgkin's lymphoma; adult leukemia; multiple myeloma; Parkinson's disease; aplastic anemia and other myelodysplastic syndromes; and bladder cancer. 38 C.F.R. § 3.309(f). Notwithstanding the fact that osteosarcoma is not presumptively associated with exposure to contaminated water at Camp Lejeune, however, the Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1038 (Fed. Cir. 1994). While the Veteran's personnel records do not reflect that he was ever stationed at Camp Lejeune, he testified that, once per year during his military service, he was deployed to Camp Lejeune for training exercises. December 2013 Military Personnel Record; August 2020 Hearing Transcript. Upon review, this assertion is not borne out by the record. The Veteran submitted a Summary of Operations for his squadron, Fleet Composite Squadron Six (VC-6) for calendar years 1977, 1978, 1979, and 1981. June 2017 Military Personnel Record. The Summary of Operations shows that a unit within VC-6, Alpha Crew, was deployed to Camp Lejeune for approximately two weeks in 1977 (prior to the Veteran's entry to service), five days in 1978, nine days in 1979, and seven days in 1971. Id. However, the Veteran has provided no evidence that he was a part of Alpha Crew and, even if the Board were to assume that he was, this evidence would suggest less than 30 days of service at Camp Lejeune. Accordingly, the Board finds that the presumption of exposure does not apply, and the evidence weighs persuasively against a finding that the Veteran was exposed to contaminated water at Camp Lejeune. The Veteran has also asserted that he was exposed to many "elements," including fuel from the drones he worked on, which "may or may not have" played a part in the development of his osteosarcoma. October 2005 Correspondence. Generally, a layperson's assertions indicating exposure to certain chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). While the Veteran is competent to report what he experienced, he is not competent to determine whether he was exposed to harmful chemicals without supporting evidence, particularly when his assertions as to that exposure are vague in nature. Even if the Board accepted the Veteran's reports regarding toxic exposures or if such exposure is later established, there is no competent evidence of record linking such exposure to his osteosarcoma. Indeed, there is no evidence beyond the bare assertion of the Veteran that toxic exposures caused his cancer, and that osteocarcinoma and aplastic anemia, a condition presumptively associated with contaminated water at Camp Lejeune, are both conditions affecting the bone marrow so must be related. November 2018 VA 21-4138. The Veteran has not been shown to have the knowledge or expertise necessary to opine as to a relationship between toxic exposures and the development of osteosarcoma. This is a medically complex issue, requiring medical expertise to determine its etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, the Veteran's contentions do not constitute competent medical evidence as to a nexus for service connection purposes. The Board acknowledges that the Veteran has not been afforded a VA examination in connection with this claim. VA is generally obliged to provide an examination or obtain a medical opinion in a claim of service connection when, in pertinent part, the record indicates that a disability or signs and symptoms of disability may be associated with active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, however, the Board finds that no examination is necessary because, as noted above, there is no competent evidence indicating that this disability may be associated with service. The Veteran's generalized lay statements alleging a nexus between osteosarcoma and the purported toxic exposures do not meet the standard to warrant a VA examination. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Accordingly, as the Board finds the evidence persuasively supports a finding that the Veteran's osteosarcoma is not related to his military service, there is no benefit of the doubt to resolve in the Veteran's favor and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a right shoulder disability. 3. Entitlement to service connection for a right hip disability. The Veteran asserts that he has right shoulder and hip disabilities caused by his osteosarcoma. See July 2013 VA 21-4138. The record reflects that his osteosarcoma was located in the right arm, and resulted in a surgery of the humerus and insertion of a metal rod. See May 2016 CAPRI; August 2020 Hearing Transcript. Additionally, the Veteran testified that he has arthritis in the right hip because bone marrow was removed from his hip to fill his shoulder. August 2020 Hearing Transcript. The Veteran has not alleged, nor does the record suggest, that his right shoulder and hip disabilities are related directly to service. There is no competent evidence of record, medical or otherwise, to suggest that the Veteran's right shoulder and hip disabilities are related to anything other than his non-service-connected osteosarcoma. The Veteran has asserted no other theory of entitlement. As the Board herein denies the claim of service connection for osteosarcoma, the derivative claims of service connection for right shoulder and hip disabilities cannot be granted on a secondary basis as a matter of law. See 38 C.F.R. § 3.310. Additionally, as there is no competent evidence that the disabilities are directly related to service, the evidence weighs persuasively against a finding that service connection is warranted. As such, there is no benefit of the doubt to resolve in the Veteran's favor and the claims are denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for left eye glaucoma. The Veteran asserts that his left eye glaucoma is related to his active service. Specifically, he contends that service connection should be granted because he worked around "materials that send out emissions." April 2014 NOD. Upon review, the Board concludes that, while the Veteran has a diagnosis of left eye glaucoma, the evidence of record persuasively weighs against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran underwent surgery through VA to treat this condition. See November 2017 Medical Treatment Record Government Facility. While the Veteran initially asserted that glaucoma is due to "emissions" during service, during the August 2020 hearing the Veteran's representative testified that the Veteran was "not claiming necessarily that the glaucoma was caused by service." August 2020 Hearing Transcript. Instead, the Veteran indicated that his VA surgeon made an error such that he should be awarded benefits pursuant to 38 U.S.C. § 1151 (2012). See id. However, a claim for compensation under § 1151 is not an alternative theory of a claim for service connection for the same disability and must be adjudicated separately. Anderson v. Principi, 18 Vet. App. 371, 377 (2004). The Board referred the Veteran's claim for compensation pursuant to § 1151 to the AOJ for adjudication in its April 2021 remand, and it appears that the AOJ is currently processing the claim. See October 2021 Other. Accordingly, the Board will proceed with adjudication of the service connection claim. As a current disability has been established, the next question for resolution is whether there is competent evidence of an in-service injury. As the Board found above, the Veteran is not presumed to have been exposed to contaminated water at Camp Lejeune. Further, while he contends he was exposed to "materials that send out emissions," the Veteran has made no specific allegations regarding what "materials" he believes caused glaucoma and provided no further detail. Again, as noted above, a layperson's assertions indicating exposure to certain chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service. See Bardwell, 24 Vet. App. 36. While the Veteran is competent to report what he experienced, he is not competent to determine whether he was exposed to harmful chemicals without supporting evidence, particularly when his assertions as to that exposure are vague in nature. As the Veteran does not allege, and the record does not suggest, that any other event or injury related to service caused his glaucoma, the evidence weighs persuasively against a finding that left eye glaucoma is related to service. Accordingly, there is no benefit of the doubt to resolve in the Veteran's favor and the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for tinnitus. The Veteran asserts that his bilateral hearing loss and tinnitus were caused by acoustic trauma in service. The Veteran has current diagnoses of hearing loss and tinnitus, as shown by VA examinations conducted in February 2014 and June 2021. February 2014 C&P Exam; June 2021 C&P Exam. Hearing loss and tinnitus are enumerated conditions under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disabilities were not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and were not noted in service with attributable continuity of symptomatology. The Veteran has not asserted that his hearing loss and tinnitus began in and have continued since service, and the record does not show that he was diagnosed with these conditions during service or within one year of separation from service. Accordingly, service connection cannot be granted on a presumptive basis. 38 C.F.R. § 3.307(a)(7). Service connection for hearing loss and tinnitus may still be granted on a direct basis; however, the evidence of record persuasively weighs against finding that a medical nexus exists between the Veteran's disabilities and an in-service injury, event or disease. 38 U.S.C. § 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. As noted above, a current diagnosis of bilateral hearing loss and tinnitus have been established. Additionally, the Veteran's work in service assisting with drone launches would have placed him at risk of exposure to harmful noise. Accordingly, the remaining question is whether hearing loss and tinnitus are related to the in-service noise exposure. The Veteran first underwent VA examination in connection with these claims in February 2014. February 2014 C&P Exam. With respect to hearing loss, the examiner found a diagnosis consistent with hearing loss disability for VA purposes. See 38 C.F.R. § 3.385 (2020). However, the examiner opined that it was not related to the Veteran's military service. In support of the opinion, the examiner observed that audiometric testing performed at induction to and separation from service revealed normal hearing bilaterally, and that a comparison between the tests indicated that the Veteran experienced no significant changes in hearing for either ear during active duty. Further, the examiner stated that there is no known basis for the delayed onset of noise-induced hearing loss, and cited to an Institute of Medicine (IOM) report finding that there was an insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure would develop long after the noise exposure. The examiner indicated that the IOM panel concluded that, based on their current understanding of auditory physiology, a prolonged delay in the onset of noise-induced hearing loss was "unlikely." As such, the examiner found no evidence on which to conclude that the Veteran's current hearing loss was caused by or a result of the Veteran's military service, including noise exposure. When determining the adequacy and probative value of a medical opinion, the Board must consider whether the medical text evidence that the medical opinion relies on contains qualifying or contradictory aspects. McCray v. Wilkie, 31 Vet. App. 243 (2019). If the Board finds that a medical text that serves as the basis for a medical opinion contains apparent qualifiers or contradictions, or if the veteran raises the issue or it is reasonably raised from review of the evidence of record, the Board must address that issue and explain whether those aspects of the medical text diminish the probative value of the medical opinion evidence or render the opinion inadequate, and if not, why not. Id. Regarding the IOM study, the McCray Court noted that, although the report concluded that "based on current knowledge of cochlear physiology there was no sufficient scientific basis for the existence of delayed-onset hearing loss," the report also stated that "[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure" and that "definitive studies to address this issue have not been performed." The Court determined that these statements appeared to be contradictory or qualifying and that it was incumbent on the Board to discuss such apparent contradictions or qualifiers when providing adequate reasons and bases. The Board acknowledges that the February 2014 VA examiner relied, in part, on the IOM report as a basis for providing a negative opinion and the IOM report has apparently qualifying or contradictory statements, as noted in McCray. The Board finds that this does not render the opinion inadequate or diminish its probative value to zero. The IOM report concluded that "based on current knowledge of cochlear physiology there was no sufficient scientific basis for the existence of delayed-onset hearing loss" while also stating that "definitive studies to address this issue have not been performed." However, based on the evidence available, the report stated that it was "unlikely" that delayed hearing loss effects occur. This statement tends to show that the limitation was considered, but the IOM was confident in the available data (anatomical and physiological) to make a conclusion utilizing a strongly worded term ("unlikely"). Indeed, the committee noted its understanding of the mechanisms and processes involved in the recovery from noise exposure as it suggested "a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely." With respect to tinnitus, the February 2014 examiner noted that the Veteran reported recurrent tinnitus in both ears with onset about four years prior. The examiner opined that tinnitus was not related to in-service noise exposure, as a diagnosis of noise-induced tinnitus requires a diagnosis of noise-induced hearing loss, or an association between the onset of tinnitus and a specific noise-related event. As the Veteran experienced no hearing loss during military service and did not associate the onset of tinnitus with a specific event, the examiner opined that there was no basis for a nexus between the Veteran's current tinnitus and his military service. Pursuant to the Board's April 2021 remand, the Veteran again underwent VA examination in June 2021; the Board directed the examiner to consider the Veteran's reports of being exposed to significant amounts of harmful noise in service. April 2021 BVA Decision. The June 2021 VA examiner thoroughly considered the Veteran's reports of noise exposure, acknowledging that the Veteran's military occupational specialty indicated a high probability of hazardous noise exposure and estimating the level of exposure to be up to 113 decibels. June 2021 C&P Exam. However, the examiner ultimately opined that neither hearing loss nor tinnitus were related to the Veteran's service. In support of the opinion, the examiner noted in an addendum that there was no permanent positive threshold shift in either ear between the Veteran's entrance and separation from service. September 2021 C&P Exam. Further, the examiner observed that the Veteran's hearing loss is not consistent with the characteristic high frequency "noise notch" seen in individuals with high frequency hearing loss, nor is it consistent with a progression of noise-induced hearing loss as found in data from the IOM. Rather, the examiner opined that the Veteran's hearing loss is more consistent with presbycusis (age-related hearing loss), more specifically strial presbycusis, whose characteristics are a flat hearing loss across all frequencies and good speech recognition scores. With respect to tinnitus, the June 2021 VA examiner reiterated the Veteran's significant history of noise exposure, but ultimately opined that tinnitus was more likely than not associated with the Veteran's hearing loss. While the Veteran believes his hearing loss and tinnitus are related to in-service noise exposure, he is not competent to provide an opinion as to their etiology. In that regard, while the Veteran is competent to report that he experienced hearing loss and tinnitus, he has not asserted that these conditions had onset in, or within one year of, service. Further, he is not competent to provide a nexus opinion as that is a medically complex issue requiring specialized medical education and, with respect to hearing loss, the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377. Consequently, the Board gives more probative weight to the competent medical evidence provided by the VA examiners, whose opinions include consideration of the Veteran's lay statements and complete rationale for the conclusions reached. Accordingly, as the evidence weighs persuasively against a finding that hearing loss and tinnitus are related to the Veteran's military service, there is no benefit of the doubt to resolve in his favor and the claims are denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND While further delay is regrettable, the Board finds remand of the remaining claims is again necessary before a decision may be rendered. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected disability. 2. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected disability. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disability. The Veteran asserts that his hypertension, diabetes, and erectile dysfunction are caused or aggravated by his service-connected major depressive disorder. Specifically, with respect to hypertension and diabetes, he has contended that his depression caused him to overeat and become obese, which in turn causes these disabilities. See August 2020 Hearing Transcript. With respect to erectile dysfunction, he indicated that it is caused by stress from his depression. The record reflects diagnoses of these conditions. See, e.g., May 2021 CAPRI. Accordingly, the Board finds remand is warranted so that VA examinations and opinions may be obtained. 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for plantar fasciitis. The Veteran asserts that he has a back disability and plantar fasciitis related to his military service. Specifically, he testified that he has experienced back and foot pain since active duty, which he relates to the heavy lifting of metal drone cases, standing on hard surfaces, and wearing boots. See August 2020 Hearing Transcript. The record reflects diagnoses of low back pain and plantar fasciitis. See, e.g., May 2021 CAPRI. As there are no medical opinions of record with respect to these claims, the Board finds remand is warranted so that they may be obtained. With respect to the back disability, the record reflects that the Veteran receives treatment from the Center for Interventional Pain and Spine. January 2022 CAPRI. VA treatment records reflect that records of this treatment have been uploaded to VistA, but they are not available for the Board to review. Accordingly, upon remand such records should be uploaded to the Veteran's claims file. Updated VA treatment records, as well as any relevant private treatment records identified by the Veteran, should be obtained and associated with the claims file. The matters are REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims. All identified VA records should be added to the claims file; this specifically includes records relevant to these claims that have been scanned into VistA. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether hypertension and diabetes had onset during service or are otherwise related to an in-service injury, event, or disease. If the disabilities are not directly related to service, the examiner should address: (a) whether the Veteran's service-connected major depressive disorder caused him to become obese or aggravated the Veteran's obesity, and if so, (b) whether the obesity or aggravation of obesity resulting from service-connected disability was a substantial factor in causing hypertension or diabetes, such that hypertension or diabetes would not have occurred but for the obesity caused or aggravated by service-connected major depressive disorder. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination to determine whether erectile dysfunction had onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether erectile dysfunction is (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected major depressive disorder, to include as a result of stress. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, schedule the Veteran for a VA examination to determine whether a back disability had onset during service or is otherwise related to an in-service injury, event, or disease, to include as due to heavy lifting. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings 5. After records development is completed, schedule the Veteran for a VA examination to determine whether plantar fasciitis had onset during service or is otherwise related to an in-service injury, event, or disease, to include wearing boots and standing on hard surfaces. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. D. Bruce, 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.