Citation Nr: 23044690 Decision Date: 08/10/23 Archive Date: 08/10/23 DOCKET NO. 16-29 523 DATE: August 10, 2023 ORDER Service connection for a left foot disorder is denied. Service connection for a right shoulder disorder is denied. REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a respiratory disorder, to include allergic rhinitis and claimed as due to environmental exposure, is remanded. Entitlement to service connection for obstructive sleep apnea with insomnia is remanded. FINDINGS OF FACT 1. Symptoms of a left foot disorder were not continuous or recurrent in service or since service separation; arthritis did not manifest to a compensable degree within one year of active service; a foot disorder is not otherwise related to active service; and the Veteran did not become disabled due to a left foot injury incurred or aggravated in the line of duty during a period of active duty for training (ADT) or inactive duty for training (IADT). 2. A right shoulder disorder was not incurred during a period of active duty, and the Veteran did not become disabled due to a right shoulder injury incurred or aggravated in the line of duty during a period of ADT or IADT. CONCLUSIONS OF LAW 1. The criteria for service connection for a left foot disorder have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1111, 1112, 1113, 1131, 1153, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Army National Guard from November 1979 to February 1980, in May 1992, from January 2003 to December 2004, July 2006 to June 2008, and December 2008 to August 2010, with additional periods of ADT and IADT. He had service in Kosovo from February 2009 to May 2010. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an October 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a December 2019 Board hearing. A transcript of the hearing is associated with the claims folder. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In this case, as discussed below, the medical evidence of record demonstrates a diagnosis of arthritis. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). However, for the reasons set forth below, the Veteran was not diagnosed with arthritis within one year of separation from service, nor has there been continuity of symptomatology. With specific regard to continuity of symptomatology, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as arthritis, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The remaining conditions at issue are not among the "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to those disorders. See Walker, 708 F.3d 1331. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Active military service for service connection purposes includes active duty, any period of ADT during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of IADT during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. §§ 101(21), (24); 38 C.F.R. § 3.6(a), (c), (d). ADT means full-time duty in the Armed Forces performed by Reserves for training purposes or, in the case of members of the Army National Guard of any state, full-time duty under sections 316, 502, 503, 504, or 505 of Title 32. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). IADT means duty (other than full-time duty) prescribed for Reserves by the Secretary concerned under section 206 of title 37 or any other provision of law, special additional duties authorized for Reserves by an authority designated by the Secretary concerned and performed by them on a voluntary basis in connection with the prescribed training or maintenance activities of the units to which they are assigned, and, in the case of a member of the National Guard of any state, duty (other than full-time duty) under sections 316, 502, 503, 504, or 505 of Title 32. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Presumptive periods for service connection do not apply to ADT or IADT. Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Thus, service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty or ADT, from an injury incurred or aggravated while performing IADT, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during a period of IADT. 38 U.S.C. §§ 101(24), 106, 1110, 1131. 1. Service connection for a left foot disorder is denied. The Veteran contends that he injured his left foot while stationed in Kosovo from February 2009 to May 2010. Specifically, at the Board hearing, he testified that he slipped and landed on a rock with his left foot while carrying heavy gear, and that this incident caused his current left foot problems. For the reasons discussed below, the Board finds that the most persuasive evidence is against a finding of a medical nexus between the claimed left foot disability and active service, or that a left foot injury was incurred during a period of ADT or IADT. Thus, a grant of service connection for a left foot disability is not warranted. Service treatment records are silent for reports, symptoms, findings, treatment, or diagnosis of a left foot problem. The Veteran specifically denied foot trouble on Reports of Medical History filled out in November 1990, June 1995, April 2001, January 2003, and July 2006. Significantly, a May 2010 Medical Questionnaire - completed just two days after completion of his deployment to Kosovo - indicates right foot problems but is silent for left foot symptoms or injuries. Following separation from active duty service, in November 2012, the Veteran reported left foot pain of three weeks' duration, explaining that he was currently training for an upcoming Physical Training (PT) test for the National Guard and that the left foot hurt when he was running. On physical examination, he had pain localized to the plantar surface below the second and third metatarsophalangeal (MTP) joint. The clinician assessed left plantar fasciitis, most likely attributable to his recent start of training (running) for the upcoming PT test. A May 2013 VA treatment note reflects pain in the left plantar forefoot present since September 2012 with no known history of trauma. The Veteran described aching pain in area of the second MTP joint. At a September 2013 VA foot examination, the examiner diagnosed capsulitis of the MTP joint, left (2013). The Veteran reported that he had jumped onto 1.5 inches of gravel, wearing 100 pounds of gear, and injured his left foot. Since then, he stated his left foot continued to have a dull, aching pain. He had been evaluated at a private podiatry clinic in May 2013 with the subsequent diagnosis of left second MTP joint capsulitis. In January 2014, a VA treatment note reflects that x-rays had shown enthesopathy, capsulitis of the 2nd MTP joint, left, improving, and arthritis of the second and third MTP joints. The Veteran underwent surgery in 2014 (left second MTP joint cheilectomy). Treatment records reflect ongoing left foot pain and treatment for same. At a June 2020 VA foot conditions examination, the examiner diagnosed bilateral pes planus (2020), and status post left foot cheilectomy (2014). The Veteran reported he had stepped off of a high deck into a rock and snow, landing with all his gear on his left side/left foot. The examiner opined that the left foot disorder was not related to active service, reasoning that the Veteran currently worked as a farmer and machine operator in his full-time civilian job versus his National Guard duty which consisted of only two days a week and two weeks per year. The examiner stated his civilian work was more likely that cause of his left foot problem. The examiner also observed that current x-ray studies of the left foot did not show arthritis, and that the prior reading was in error. The Board acknowledges that in November 2015, the Veteran submitted an undated statement that was handwritten on a Medical Record form but lists "N/A" for the name of the hospital or medical facility. The form is signed by two individuals - a Sgt. R. and another individual whose signature is illegible. The note states that the Veteran reported that since he came back from Kosovo, his left foot had still been hurting him since he injured himself stepping off a step deck while on mission in Kosovo. His medics gave him Ibuprofen which reduced the pain enough to where he was able to manage it and complete the mission and return to the U.S. He still had left foot pain. On examination, the individual writing the statement told him to walk to the end of the bay and back and noticed that he had an altered gait. He had swelling and limited motion of the left foot and tenderness to palpation of the second and third MTP joints. The assessment was osteoarthritis of the left foot. The individual indicated that he was prescribing Ibuprofen; no running; and ice as needed. After a review of all of the evidence, lay and medical, the Board finds that the weight of the evidence is against a finding that there is a medical nexus between the claimed left foot disability and active service, or that a left foot injury was incurred during a period of ADT or IADT. Left foot disorder symptoms were not continuous or recurrent during active service. As noted above, service treatment records are silent as to any left foot symptoms, providing highly probative evidence against such a finding. Next, the Board finds that symptoms of a left foot disability were not continuous or recurrent since separation from the Veteran's last period of active duty in August 2010. Following service separation, the evidence of record shows no mention of left foot symptoms until November 2012, as described above. The absence of post-service complaints, findings, diagnosis, or treatment for more than one year after service separation until November 2012 is one factor that tends to weigh against a finding of continuous symptoms of sleep apnea after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Other evidence of record showing that symptoms of the left foot disability were not continuous or recurrent since service includes the Veteran's own statements regarding the history of his left foot symptoms made when he sought treatment in 2012. Specifically, as noted above, in November 2012, he reported that the left foot pain started three weeks prior when he started training for a PT test. In addition, the May 2013 VA treatment note reflects left foot pain since September 2012 with no inciting injury. These statements are highly probative evidence against a finding of continuous left foot symptoms since active service. See Cucuras v. Secretary of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993) ("Medical records, in general, warrant consideration as trustworthy evidence. The records contain information supplied to or by health professionals to facilitate diagnosis and treatment of medical conditions. With proper treatment hanging in the balance, accuracy has an extra premium. These records are also generally contemporaneous to medical events"). The Board also finds that the most persuasive evidence demonstrates that the Veteran's left foot arthritis did not manifest to a compensable degree within one year of service separation. The evidence demonstrates no symptoms of the left foot disability during the one-year period after service, and no diagnosis or findings of arthritis of any severity during the one-year post-service presumptive period. For these reasons, the Board finds that arthritis did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for the claimed arthritis are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. Regarding the Veteran's claim of continuous or recurrent symptoms of the claimed left foot disability since service, the Board finds that, while the Veteran is competent to report the onset of his left foot symptoms, his more recent assertions made in the context of the current disability claim of continuous or recurrent left foot symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertion of continuous or recurrent left foot disability symptoms after service is not probative because it is outweighed by other evidence of record that includes the more contemporaneous service treatment records which are negative for left foot disability symptoms and show that the Veteran specifically denied foot trouble on multiple occasions, as outlined above; the lack of any report of left foot symptoms until November 2012, more than one year after separation from active duty service; and the history of symptoms provided by the Veteran when he sought treatment for left foot problems in 2012, placing inception of symptoms still more than one year after service separation. As such, the Board finds that the evidence does not sufficiently support continuous or recurrent left foot symptomatology since service so as to warrant a grant of service connection, nor does the medical evidence of record otherwise suggest a medical nexus between the current left foot disability and active service. The Board also finds that weight of the evidence demonstrates that the Veteran did not become disabled due to a left foot injury incurred or aggravated in the line of duty during any period of ADT or IADT in the National Guard. Importantly, there is no line of duty investigation pertinent to any period of ADT or IADT relevant to the claimed left foot disability. The Board acknowledges the Veteran's belief that his left foot disability is related to active service. However, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau, 492 F.3d 1372. The June 2020 VA examiner's opinion regarding the etiology of the claimed left foot disability, discussed above, is more probative than the Veteran's lay assertions. The VA examiner has expertise, education, and training that the Veteran is not shown to have. As such, the examiner's etiology opinion is afforded more weight. Indeed, the 2020 VA opinion is the most probative evidence of record on the question of whether there is a nexus between the current left foot disability and active service. The VA opinion is competent and probative medical evidence because it is factually accurate and is supported by an explanation. The VA examiner was informed of the pertinent evidence, reviewed the Veteran's claims file, and fully articulated the opinion in the report. As noted above, the Board acknowledges the undated statement submitted by the Veteran in 2015; however, the VA examiner's opinion holds more probative value as the date of the statement and the credentials of the person who wrote the statement are unknown. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for a left foot disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for a right shoulder disorder is denied. The Veteran contends that he injured his right shoulder while loading artillery in approximately 1999; he testified at the Board hearing that he had experienced continuous right shoulder symptoms since that incident. For the reasons discussed below, the Board finds that the most persuasive evidence is against a finding of a medical nexus between the claimed right shoulder disability and active service, or that the Veteran became disabled from a right shoulder injury was incurred during a period of ADT or IADT. Thus, a grant of service connection for a right shoulder disability is not warranted. Service treatment records include a notation of a "shoulder problem, 1987, Dr. W." on a November 1990 periodic examination report, with no additional information provided. A June 1994 Statement of Medical Examination and Status indicates that the Veteran incurred an injury in the line of duty while cleaning a howitzer tube consisting of a right-sided chest strain and sprain to the back and shoulder area. A subsequent December 1994 service treatment record indicates that the Veteran injured his right shoulder and had right shoulder pain and dysesthesia. On examination, he had full shoulder motion. The clinician assessed rule out thoracic outlet syndrome. The Veteran specifically denied a painful or "trick" shoulder on a June 1995 Report of Medical History and clinical evaluation of the upper extremities was marked as normal. In October 1999, the Veteran reported a five-day history of right-sided upper back spasms after a period of ADT/IADT working with heavy artillery and cleaning the breach of a large weapon. Assessment was muscle spasm. In December 1999, the Veteran reported some ache into the right upper extremity after first treatment for his neck. He had tenderness to palpation of the right levator. The clinician assessed a cervical strain/sprain. In February 2000, the Veteran reported a mild ache in his right trapezius and had tenderness to palpation of the right levator muscle. In April 2001, it was noted that the Veteran was last seen in February 2000. He stated that he "was good until 10 days ago," but now had increased symptoms into the right trapezius and neck. On examination, he had pain in the right trapezius and rhomboid. The clinician continued the cervical strain/sprain diagnosis. Several days later during an over 40 examination, the Veteran specifically denied a painful or "trick" shoulder on a Report of Medical History, and clinical evaluation of the upper extremities was marked as normal. In September 2001, a treatment record reflects neck, upper back, and right shoulder pain associated with a worker's compensation injury related to the Veteran's civilian employment. The pain appeared to be caused by muscle spasm with radiculopathy running down the right arm. The clinician stated he either had a cervical disc compression or more distal nerve compression along the medial nerve. Another September 2001 treatment record indicates increased pain in the right upper back with radiation into the forearm and index and ring fingers, noting that this had been a chronic problem for several years. On examination, the right shoulder girdle was depressed on the left. The Veteran had a positive trigger point in the upper back at T2-T3 area near middle, radiating to the neck and shoulder. He also had generalized tenderness in the right scapular region. The clinician assessed myofascial pain syndrome and radicular pain with concern of cervical spine involvement. The Veteran ultimately underwent a C5-6 fusion. At a January 2003 retention examination, clinical evaluation of the upper extremities was marked as normal, and the Veteran specifically denied a painful shoulder. In May 2006, the Veteran reported that he had developed neck pain years ago, had a C5-6 fusion 5 years prior, and had periodic pain since with radiation into the right scapular area. A July 2006 periodic examination report indicates normal clinical evaluation of the upper extremities, and the Veteran specifically denied a painful shoulder. A September 2007 Post-Deployment Health Assessment indicates the Veteran reported that his health was excellent. A June 2008 Post-Deployment Health Assessment is also silent for right shoulder problems. A May 2010 Medical Questionnaire reflects that the Veteran reported neck problems but no shoulder symptoms. At a September 2011 post-deployment follow-up appointment, the Veteran reported that he occasionally took Tramadol for neck and shoulder pain. In February 2012, the Veteran was given a refill of medication for shoulder pain. At a September 2013 VA shoulder examination, the examiner diagnosed a right shoulder strain (1995). The Veteran reported that he injured the right shoulder at the same time he injured his neck. The muscles behind the shoulder and above the shoulder blade flared with pain and spasm approximately 5 to 6 times monthly, during which time he had limited motion. No nexus opinion was rendered. A June 2020 VA examiner diagnosed a right shoulder strain (2001), observing that the Veteran suffered a significant injury at his civilian job in 2001 that resulted in a workers' compensation claim. The examiner discussed the Veteran's contentions that he initially injured his right shoulder during a period of ADT or IADT in 1994 but opined that the current condition was not related to that injury or any other period of active service, ADT, or IADT, reasoning that the 2001 injury caused the current right shoulder disorder which continued from 2001 throughout the Veteran's time in the National Guard. After a review of all of the evidence, lay and medical, the Board finds that the most persuasive evidence is against a finding that there is a medical nexus between the claimed right shoulder disability and active service, or that the Veteran became disabled due to a right shoulder injury incurred during a period of ADT or IADT. Moreover, the most probative evidence of record shows that the right shoulder disability is related to a 2001 civilian work injury. As noted above, service treatment records show 1994 and 1999 right shoulder injuries during periods of ADT or IADT subsequently resolved, as demonstrated by the negative June 1995 examination report and the April 2001 treatment note reflecting that the Veteran had recovered until 10 days prior. These subsequent negative evaluations and the history provided by the Veteran provide highly probative evidence against a finding of continuous symptoms following the 1994 and 1999 injuries. Regarding the Veteran's claim of continuous or recurrent symptoms of the claimed right shoulder disability since service, the Board finds that, while the Veteran is competent to report the onset of his right shoulder symptoms, his more recent assertions made in the context of the current disability claim of continuous or recurrent right shoulder symptoms since the 1994 and/or 1999 injuries are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not probative. See Charles, 16 Vet. App. 370. The Board finds that the Veteran's assertion of continuous or recurrent right shoulder symptoms after service is not credible because it conflicts with other evidence of record that includes the contemporaneous service treatment records which, as discussed above, show that the Veteran denied shoulder symptoms in 1995 and 2001 until he reinjured the shoulder at his civilian job. The Board acknowledges the Veteran's belief that his right shoulder disorder is related to active service. However, as discussed above, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau, 492 F.3d 1372; see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau. The June 2020 VA examiner's opinion regarding the etiology of the claimed shoulder disability, discussed above, is more probative than the Veteran's lay assertions. The VA examiner has expertise, education, and training that the Veteran is not shown to have. As such, the examiner's etiology opinion is afforded more weight. Indeed, the 2020 VA opinion is the most probative evidence of record on the question of whether there is a nexus between the current right shoulder disability and active service. The VA opinion is competent and probative medical evidence because it is factually accurate and is supported by a thorough rationale. The VA examiner was informed of the pertinent evidence, reviewed the Veteran's claims file, and fully articulated the opinion in the report. The opinion is further supported by the medical records discussed above showing recovery of the right shoulder injuries incurred in 1994 and 1999. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for a right shoulder disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a lumbar spine disorder is remanded. The Board finds that remand is warranted to obtain an adequate etiological opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran contends that his lumbar spine disability is the result of his duties in active service which required wearing heavy body armor and moving ammunition including 100-pound projectiles. He also contends that his gait was altered due ot his service-connected right ankle disability and this caused back pain. A June 2020 VA examiner opined that the current lumbar spine disability was not related to either active service or to an altered gait due to a service-connected disability, instead relating the current disability to the September 2001 workers' compensation injury. However, review of the 2001 records pertaining to the workers' compensation injury reveal that that injury involved the neck, shoulder, and upper back - not the lumbar spine. The Board also observes that the VA examiner did not address a June 2008 service treatment record indicating that the Veteran reported back pain during his deployment. Therefore, the Board finds that the examiner's rationale is inadequate as it is based at least in part on an inaccurate premise. For this reason, a remand is necessary. 2. Entitlement to service connection for a respiratory disorder, including allergic rhinitis, and to include as due to environmental exposure, is remanded. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran has contended that he has a respiratory disability manifested by difficulty breathing and persistent coughing that is related to exposure to jet fuel and environmental exposure during his deployments to the U.S. border and Kosovo. For instance, in November 1990 and June 1995, the Veteran reported hay fever which was seasonal and induced by "smog." In July 2000, he reported shortness of breath, cough, and fatigue over the past 3 months. The clinician assessed a persistent cough, rule out asthma/TB/cardiomyopathy. The Veteran was given an inhaler for possible reactive airway disease, and the clinician suspected allergies based on his history. These symptoms continued over the next several months and the Veteran underwent a septoplasty with turbinate reduction in October 2000. In June 2008, the Veteran reported that he had a chronic cough and runny nose during deployment. In May 2012, the Veteran reported a history of recurrent sinusitis and sinus pressure, stating that the septoplasty performed in 2000 had helped but that he had lost any gains obtained from that surgery over time. The clinician concluded that he did not have evidence of active (acute or chronic) sinusitis at that time but complained of recurrent pressure associated with changing weather patterns/season. A CT of the sinuses was normal, and he was diagnosed with allergic rhinitis, for which he has been treated since. A June 2020 VA examiner opined that the Veteran did not now have, nor had he ever had a respiratory disability. However, the examiner did not address the extensive history of allergic rhinitis and similar symptoms that are documented during and following the Veteran's service in the National Guard. Therefore, the Board finds a remand is necessary to obtain a VA opinion regarding the nature and etiology of the claimed respiratory disability, to include allergic rhinitis. 3. Entitlement to service connection for obstructive sleep apnea with insomnia is remanded. The Board finds that remand is warranted as this issue is intertiwned with the issue of service conneciton for a respiratory disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). A June 2020 VA examiner observed that the Veteran was diagnosed with insomnia and treated with medication for same in May 2006, possibly earlier. The examiner then opined that the Veteran's sleep disturbance (insomnia) is directly attributable to the medical diagnoses of sleep apnea and his respiratory allergy. The Board finds, therefore, that the issue of entitlement to service connection for insomnia is inextricably intertwined with the claimed respiratory disability being remanded herein. The matters are REMANDED for the following action: 1. Obtain a VA opinion (and examination if deemed necessary by the examiner) from an appropriate specialist addressing the etiology of the Veteran's lumbar spine disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's lumbar spine disability was incurred during or caused by active service? The examiner should address the June 2008 service treatment record showing that the Veteran reported back pain during deployment in rendering the opinion and is advised that the Veteran is competent to describe symptoms that are observable by a lay person, such as noticing lumbar spine pain during active service. If the examiner rejects the Veteran's reports regarding his symptoms, the examiner must provide a reason for doing so. (b.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's current lumbar spine disability was caused or aggravated by an altered gait due to his service-connected right ankle disability? If the examiner finds that the lumbar spine disability was aggravated by service-connected disabilities, the examiner should determine, if possible, to what extent it was aggravated beyond the natural progression of the disorder. 2. Obtain a VA opinion (and examination if deemed necessary by the examiner) from an appropriate specialist addressing the etiology of the Veteran's respiratory disability, to include allergic rhinitis. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's respiratory disability, to include allergic rhinitis, was incurred during or caused by active service, to include as due to exposure to jet fuel and other environmental exposures at the U.S. border and in Kosovo? The examiner should address the service treatment records which show reports of hay fever, coughing, shortness of breath, and similar symptoms during and following the Veteran's National Guard service in rendering the opinion and is advised that the Veteran is competent to describe symptoms that are observable by a lay person, such as noticing shortness of breath and coughing during active service. If the examiner rejects the Veteran's reports regarding his symptoms, the examiner must provide a reason for doing so. K. MILLIKAN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.