DIABETES MELLITUS

CHRISTOPHER A. WENDELL · 2026 · Case ID: A26000473

MIXED

Summary

The veteran, who served in the U.S. Army from August 1988 to April 1991, appeals the denial of service connection for multiple conditions and an increased rating for his right knee osteoarthritis. The Board granted service connection for diabetes mellitus type II on a secondary basis, finding that the veteran's obesity, potentially linked to his service-connected somatic symptom disorder with mixed anxiety and depressed mood, was a substantial factor. The Board found the initial VA opinions inadequate for failing to provide aggravation opinions and for conclusory rationale regarding the link between psychological conditions and diabetes. However, a subsequent VA opinion indicated that psychological issues can contribute to weight gain and obesity, which in turn increases the risk of diabetes. The Board applied the benefit of the doubt, finding the evidence in approximate balance and granting service connection for diabetes mellitus type II. The remaining claims, including bilateral ankle conditions, headaches, GERD, IBS, lumbar spine condition, right lower extremity condition, erectile dysfunction, left knee condition, and increased ratings for the right knee, were remanded. The Board found the VA opinions for these remanded conditions inadequate, primarily for failing to provide aggravation opinions for secondary claims or failing to adequately address the full evidence of record, including lay statements and the presumption of soundness. Remand was ordered for new or supplemental opinions to address these deficiencies, including specific instructions on evaluating the Veteran's reported symptoms, continuity of symptomatology, and the impact of obesity and psychological conditions on diabetes.

Rationale

Service connection granted based on secondary factors.; Obesity as an intermediate step between psychological condition and diabetes.; Benefit of the doubt applied due to approximate balance of evidence.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250129-516754

Full Decision Text

Citation Nr: A26000473
Decision Date: 01/05/26 Archive Date: 01/05/26

DOCKET NO. 250129-516754
DATE: January 5, 2026

ORDER

Service connection for diabetes mellitus type II is granted.

REMANDED

Entitlement to service connection for a right ankle condition is remanded.

Entitlement to service connection a left ankle condition is remanded.

Entitlement to service connection for a headaches condition is remanded.

Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded.

Entitlement to service connection for irritable bowel syndrome (IBS) is remanded.

Entitlement to service connection for a lumbar spine condition is remanded.

Entitlement to service connection for a right lower extremity condition is remanded.

Entitlement to service connection for erectile dysfunction is remanded.

Entitlement to service connection a left knee condition is remanded.

Entitlement to an increased disability evaluation rating in excess of 10 percent for service connected right knee joint osteoarthritis is remanded.

Entitlement to an initial compensable rating, including the effective date thereof, for service connected right knee osteoarthritis limited extension is remanded.

FINDING OF FACT

The evidence is in approximate as to whether the Veteran's diabetes mellitus type is secondary to the Veteran's service-connected somatic symptom disorder with mixed anxiety.

CONCLUSION OF LAW

The criteria for entitlement to service connection for diabetes mellitus type II have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3,309, 3.10.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1988 to April 1991.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2024, February 2024 and January 2025 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2025, the Veteran perfected appeal to the Board by filing a VA Form 10182 Notice of Disagreement (NOD), selecting Direct Review of the evidence by a Veterans Law Judge. Thus, the Board will review evidence as of the date of the January 2024, February 2024 and January 2025 rating decisions.

Service Connection

The Veteran seeks entitlement to service connection for diabetes mellitus type as due to a service connected condition.

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical 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) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303.

Service connection may also be established by evidencing a chronic disease in service, including arthritis, which requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required. Id. The provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

In addition to direct service connection, a disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) resulting from or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. See also Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (establishing "but-for" causation standard broader than proximate cause, which is not limited to a single cause and effect, but rather contemplates multi-causal links). Any medical opinion which addresses secondary service connection must include an aggravation opinion. Aggravation of a non-service-connected disability can be established by any incremental increase in disability attributable to a service-connected disability. Ward v. Wilkie, 31 Vet. App. 233, 239-40 (2019); see 38 C.F.R. § 3.310(b).

VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, there must be a showing that the evidence is not in approximate balance and is persuasively against the Veteran's claim. See 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F. 4th 776, 781 (Fed. Cir. 2021).

Service connection for diabetes mellitus type II is granted.

The Veteran contends that obesity was an intermediate step as related to his service connected right knee condition, as well as his acquired psychological condition that caused his claimed diabetes mellitus.

The Board notes that VA's Office of General Counsel has held that obesity may be an "intermediate step" between a service-connected disability and a current disability that may be connected on a secondary basis. See Walsh v. Wilkie, 32 Vet. App. 300 (2020) (holding that obesity as an "intermediate step" in a causal chain for service connection can be established on either a causal or aggravation basis). In order to meet such criteria, the evidence must show that a previously service-connected disability caused a veteran to become obese; that obesity was a substantial factor in causing the secondary disability; and the secondary disability would not have occurred but for the obesity. See VAOPGCPREC 1-2017.

In this case, the record reflects that the Veteran underwent a VA diabetes mellitus examination in January 2024 at which time a diagnosis of diabetes mellitus type II was confirmed. An April 2024 VA medical center treatment record (VATR) reflects the providers note that the Veteran is obese. The Veteran is service connected for a right knee condition and somatic symptom disorder with mixed anxiety and depressed mood.

Accordingly, as the record establishes that the Veteran has been diagnosed with diabetes mellitus type II and is service connected for a right knee condition and somatic symptom disorder with mixed anxiety and depressed mood, the first two Shedden elements have been met. The remaining question is whether a nexus exists between the two.

Turning to the medical evidence of record, the above examiner opined that the Veteran's claimed diabetes mellitus type II condition is less likely than not due to or the result of the Veteran's diabetes mellitus. The examiner rationalized that the claimed conditions are not medically related as diabetes mellitus type II is a separate entity entirely and unrelated. The examiner found that a thorough review of the medical literature failed to demonstrate a causal relationship.

As the examiner did not provide the opinion as requested, thus providing an erroneous opinion, an addendum opinion was requested to correct such error.

In a February 2024 addendum opinion, a separate VA examiner opined that the claimed diabetes mellitus condition is less likely than not due to or the result of the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood. The examiner rationalized that the conditions of diabetes mellitus type II and symptom disorder with mixed anxiety and depressed mood are not medically related. The examiner explained that diabetes mellitus type II is a separate entity entirely from the somatic symptom disorder with mixed anxiety and depressed mood and unrelated to it. The examiner indicated that common characteristics of diabetes mellitus type II include obesity, family history, overeating, history of cardiovascular disease or hypertension, low high density lipoprotein (HDL) cholesterol, high triglycerides and physical inactivity. The examiner found that it is noted that the Veteran has a strong family history of diabetes mellitus type II in his mother, mothers brother and grandmother and he also has a history of alcohol and cannabis abuse, which are significant risk factors that caused the Veteran to develop diabetes mellitus type II. The examiner explained that somatic symptom disorder is when a person has significant focus on physical symptoms such as pain, it includes excessive thoughts. The examiner indicated that this is a mental condition and unrelated to diabetes mellitus type II.

In a February 2024 opinion, a VA examiner opined that the claimed diabetes mellitus condition is less likely than not due to or the result of the Veteran's TERA in service. The examiner rationalized that common characteristics of diabetes mellitus type II include obesity, family history, overeating, history of cardiovascular disease or hypertension, low HDL cholesterol, high triglycerides and physical inactivity. The examiner found that it is noted that the Veteran has a strong family history of diabetes mellitus type II in his mother, mothers brother and grandmother and he also has a history of alcohol and cannabis abuse, which are significant risk factors that caused the Veteran to develop diabetes mellitus type II. The examiner indicated that medical literature fails to show a connection of TERAs and the diabetes mellitus type II.

In an October 2024 opinion, a VA examiner opined that the claimed diabetes mellitus type II condition is less likely than not due to or the result of the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood. The examiner rationalized that the conditions of diabetes mellitus type II and somatic symptom disorder with mixed anxiety and depressed mood have no direct link, causal relationship or cause and effect and the examiner found that the Veteran has a strong family history of diabetes mellitus type II. However, the examiner also rationalized that somatic symptom disorder does not directly cause diabetes but can produce symptoms that are similar to those of a physical illness, hence the term psychosomatic. The examiner explained that mental health includes emotional, psychological, and social well-being. The examiner indicated that diabetes mellitus type II is more likely to develop if not physically active and overweight or have obesity. The examiner stated that people with diabetes are more likely to experience depression, anxiety, and stress and the psychological issues can also contribute to weight gain and obesity. The examiner provided an illustration and said that for example, people with psychological issues may have impaired coping skills, which can lead to maladaptive coping strategies like emotional eating that causes weight gain due to the unequal energy balance of calories in and what the body actually uses and does not store as fat.

The examiner further opined that the claimed diabetes mellitus type II is less likely than not due to or the result of the Veteran's service connected right knee condition. The examiner rationalized that diabetes mellitus type II and right knee osteoarthritis are not medically related and diabetes mellitus type II is a separate entity from the right knee joint osteoarthritis and unrelated to it. The examiner found that a thorough review of the medical literature failed to demonstrate a causal relationship. However, the examiner further rationalized that diabetes mellitus type II is more likely to develop if not physically active and overweight or have obesity. The examiner indicated that extra weight sometimes causes insulin resistance and is common in people with diabetes mellitus type II while genetics also increases the risk of diabetes mellitus type II.

Here, the Board finds that the January 2024 and February 2024 unfavorable opinions are inadequate. First, the opinions are inadequate on the face of the opinions, as the aggravation prong of a secondary service connection opinion was not provided. Notably, any medical opinion which addresses secondary service connection must include an aggravation opinion. See Allen v
of the medical literature failed to demonstrate a causal relationship. However, the examiner further rationalized that diabetes mellitus type II is more likely to develop if not physically active and overweight or have obesity. The examiner indicated that extra weight sometimes causes insulin resistance and is common in people with diabetes mellitus type II while genetics also increases the risk of diabetes mellitus type II.

Here, the Board finds that the January 2024 and February 2024 unfavorable opinions are inadequate. First, the opinions are inadequate on the face of the opinions, as the aggravation prong of a secondary service connection opinion was not provided. Notably, any medical opinion which addresses secondary service connection must include an aggravation opinion. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. Second, for the causation opinion provided, the January 2024 VA examiner failed to provide the opinion requested in its entirety as the examiner provided an opinion as to whether diabetes mellitus is related to diabetes mellitus. Once the VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at minimum, notify the claimant why one will not or cannot be provided. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Third, although the February 2024 VA examiner acknowledged that amongst the common characteristics of diabetes mellitus type II is obesity, the examiner failed to discuss the entirety of the facts of the case, including the Veteran's claim as to obesity being an intermediate step between his service connected somatic symptom disorder with mixed anxiety and depressed mood and thus provided conclusory rationale. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). In this regard, a medical examination report must contain not only clear conclusions with supporting data, but also a well-reasoned, medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Thus, the Board finds that the opinions are inadequate and affords the opinions no probative value. Id.

However, while at first glance, the October 2024 VA examiner provided unfavorable opinions, the examiner indicated that that psychological issues can also contribute to weight gain and obesity. Significantly, the examiner provided an illustration and said that for example, people with psychological issues may have impaired coping skills, which can lead to maladaptive coping strategies like emotional eating that causes weight gain due to the unequal energy balance of calories in and what the body actually uses and does not store as fat. The examiner indicated that diabetes mellitus type II is more likely to develop if not physically active and overweight or obese.

Here, the Veteran's VATRs reveal that he is obese. While not elaborately detailed, the opinion and rationale above sufficiently inform the Board of the medical expert's judgment on the medical question and the essential rationale for that opinion, and such rationale is easily discernable. Nieves-Rodriguez, 22 Vet. App. at 301. The opinion indicates that the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood is a psychological issue that can also contribute to weight gain and obesity. The examiner provided that people with psychological issues may have impaired coping skills, which can lead to maladaptive coping strategies like emotional eating that causes weight gain due to the unequal energy balance of calories in and what the body actually uses and does not store as fat. The examiner concluded that diabetes mellitus type II is more likely to develop if not physically active and overweight or obese.

Thus, while the evidence cannot be stated to be certain that the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood caused the Veteran to become obese; and that obesity was a substantial factor in causing the secondary disability of diabetes mellitus type II; and the secondary disability of diabetes mellitus would not have occurred but for the obesity, there is evidence in the record that is indicative of such finding.

There is no existing medical evidence in the record to contradict such statements and the Board has no basis to contradict the conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991).

After affording the Veteran the benefit of the doubt, the Board finds that the evidence is in approximate balance as to whether the Veteran's the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood caused the Veteran to become obese; and that obesity was a substantial factor in causing the secondary disability of diabetes mellitus type II; and the secondary disability of diabetes mellitus would not
not have occurred but for the obesity, there is evidence in the record that is indicative of such finding.

There is no existing medical evidence in the record to contradict such statements and the Board has no basis to contradict the conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991).

After affording the Veteran the benefit of the doubt, the Board finds that the evidence is in approximate balance as to whether the Veteran's the Veteran's service connected somatic symptom disorder with mixed anxiety and depressed mood caused the Veteran to become obese; and that obesity was a substantial factor in causing the secondary disability of diabetes mellitus type II; and the secondary disability of diabetes mellitus would not have occurred but for the obesity. In light of the foregoing, the Board concludes that the criteria for entitlement to service connection for diabetes mellitus type II on a secondary basis have been met, and the claim is thus hereby granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS FOR REMAND

1. Entitlement to service connection for a right ankle condition is remanded.

2. Entitlement to service connection a left ankle condition is remanded.

The Veteran contends that his claimed bilateral ankle condition is directly related to service, and alternatively, related to his service connected right knee condition.

Turning to the service evidence of record, the April 1985 report of medical history for enlistment notes the Veteran's report of broken bones, rupture/ hernia. The Veteran noted that he does not know whether there are issues as to car, train, sea or air sickness. The Veteran explained that he had a herniorrhaphy at age 10, a fractured ankle in 1984 and a right knee arthroscopic surgery in 1985. An August 1990 report of medical history physical reflects that the Veteran explained that he had a fractured right ankle in 1983. The accompanying April 1988 report of medical examination for enlistment notes asymptomatic pes planus and a status post a 1985 medial meniscectomy (right knee) repair. An orthopedic consultation was recommended.

The post service evidence of record reflects that the Veteran then underwent a VA ankle conditions examination in November 2023 at which time a diagnosis of resolved bilateral acute ankle sprain was rendered. The examiner noted that the Veteran reported an onset date of 1989. The examiner noted that the Veteran stated that through the years, he would put weight on his entire left extremity, which included the left knee and left ankle. The examiner noted that the Veteran reported that currently, he has pain in his knee and ankle, he feels his ankle is giving out on him, aches a lot more than it use too and he walks less because of the pain in the left ankle. The examiner opined that the Veteran's claimed bilateral ankle condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner rationalized that there is a lack of substantiating evidence supporting a nexus between the current diagnoses of knee strain and military service. The examiner indicated that without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology.

In a January 2024 addendum opinion, a VA examiner opined that the Veteran's claimed bilateral ankle condition is less likely than not due to or the result of the Veteran's service connected right ankle condition. The examiner rationalized that while the Veteran's April 1988 enlistment examination documented a pre-service fracture of the right ankle, which was not causing dysfunction, there is no mention of ankle issues during service. The examiner found that the Veteran's history of right ankle fracture was again noted at the time of the separation physical and again was still documented to have healed without further problems. The examiner found that review of the evidence reveals that the right ankle, though fractured prior to service, showed no objective abnormalities on either examination or imaging, and was not the focus of the Veteran's historical complaints at the time of his November 2023 VA examination. The examiner surmised that as a result, there is no basis for a current right ankle diagnosis at this time. claimed conditions are not medically related as diabetes mellitus type II is a separate entity entirely and unrelated. The examiner found that a thorough review of the medical literature failed to demonstrate a causal relationship.

The examiner opined that it is less likely than not that the Veteran's claimed left ankle condition is caused or aggravated by his service connected osteoarthritis of the right knee condition. The
evidence reveals that the right ankle, though fractured prior to service, showed no objective abnormalities on either examination or imaging, and was not the focus of the Veteran's historical complaints at the time of his November 2023 VA examination. The examiner surmised that as a result, there is no basis for a current right ankle diagnosis at this time. claimed conditions are not medically related as diabetes mellitus type II is a separate entity entirely and unrelated. The examiner found that a thorough review of the medical literature failed to demonstrate a causal relationship.

The examiner opined that it is less likely than not that the Veteran's claimed left ankle condition is caused or aggravated by his service connected osteoarthritis of the right knee condition. The examiner rationalized that in the absence of further diagnostic testing or any other documented diagnoses, a specific diagnosis cannot be assigned to the Veteran's claimed left ankle condition. The examiner explained that sprain, as documented by the previous examiner, is a reasonable explanation for the Veteran's mild reduction of left ankle range of motion, given that no basis for any other specific diagnosis is present. The examiner indicated that there is no significant ongoing gait disturbance found in the evidence of record and the November 2023 imaging showed no apparent asymmetrical wear or structural changes to the left ankle.

Under the Appeals Modernization Act (AMA) system, remand is required only to correct pre-decisional duty to assist errors. 38 C.F.R. § 20.802. As part of its duty to assist, VA is required to make reasonable efforts to assist a Veteran in obtaining evidence necessary to substantiate a claim. See 38 U.S.C. § 5103A, 38 C.F.R. § 3.159(c). As part of the assistance provided, VA shall make reasonable efforts to obtain relevant private records that the claimant adequately identifies and VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency. See 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159. Also, the assistance provided shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C. § 5103A(d). The Board may remand for correction of any other error by the agency of original jurisdiction (AOJ) in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802.

The Board finds that such is the case with the current appeal. Specifically, the Board finds that the November 2023 and January 2024 opinions are inadequate. First, the opinions are inadequate on the face of the opinions, as the aggravation prong of a secondary service connection opinion was not provided. See Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310. Second, for the opinion provided, the January 2024 VA examiner found no evidence of a currently diagnosed bilateral ankle condition but failed to address the complete evidence of record, including the Veteran's report of pain and that the condition began in 1989. The Board is mindful of Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018), in which the U.S. Court of Appeals for the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability.

Finally, while the examiner indicated that the Veteran's enlistment examination was documented to have right ankle healed without further problems, the examiner did not meet the criteria to make such finding, including discussion that the current condition had an onset in 1989. Of note, every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. Rebutting the presumption of soundness requires a two-part analysis. First, VA must demonstrate by clear and unmistakable evidence that a disorder preexisted military service. Second, VA must demonstrate by clear and unmistakable evidence that a preexisting disorder was not aggravated by military service. 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1093 (Fed.
, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. Rebutting the presumption of soundness requires a two-part analysis. First, VA must demonstrate by clear and unmistakable evidence that a disorder preexisted military service. Second, VA must demonstrate by clear and unmistakable evidence that a preexisting disorder was not aggravated by military service. 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1093 (Fed. Cir. 2004). Thus, the AOJ erred in not requesting such opinion thus constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

Thus, the Board finds that the opinions are inadequate. Id. The AOJ relied on the inadequate examination and opinions of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

3. Entitlement to service connection for a headaches condition is remanded.

4. Entitlement to service connection for GERD is remanded.

5. Entitlement to service connection for IBS is remanded.

The Veteran contends that his claimed headaches condition is secondary to his service connected acquired psychological condition.

The Veteran contends that his claimed GERD condition is secondary to his service connected right knee condition, including the chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) for his service connected right knee condition.

The Veteran contends that his claimed IBS condition is secondary to his service connected acquired psychological condition.

Turning to the service evidence of record, a May 1989 service treatment record (STR) notes the Veteran's complaint of diarrhea, blood in stool and headaches. The Veteran was assessed with gastroenteritis. An April 1990 STR notes the Veteran's complaint of upset stomach and headache.

As noted above, the Veteran's TERA has been conceded.

The Veteran underwent a VA headaches (including migraine headaches) examination in February 2023 at which time no headaches diagnosis was rendered. The examiner explained that no chronic headache condition has been diagnosed after extensive review of the Veteran's claims file.

The Veteran underwent a VA esophageal conditions examination in February 2023 at which time the examiner found that the veteran does not have an esophageal condition. The examiner indicated that the Veteran does have signs and symptoms of dysphagia, reflux and pain due to an esophageal condition. The examiner explained that the Veteran's current esophageal symptoms have not been evaluated by a primary care, urgent care or emergency department provider. The examiner found that after review of the Veteran's file, no chronic esophageal condition has been diagnosed. The Veteran was advised to see a provider.

The Veteran underwent a VA intestinal conditions examination in April 2023 at which time no diagnosis was rendered. The examiner explained that an extensive review of the Veteran's claims file do not reveal a diagnosis of a chronic gastrointestinal condition.

As noted above, the Board is mindful of Saunders, 886 F.3d at 1364. In this regard, the examiner failed to reconcile the Veteran's reported symptoms with the totality of the evidence. The AOJ relied on the inadequate examinations of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

6. Entitlement to service connection for a lumbar spine condition is remanded.

7. Entitlement to service connection for a right lower extremity condition is remanded.

The Veteran contends that his claimed lumbar spine condition is secondary to his service connected right knee condition.

The Veteran contends that his claimed right lower extremity condition is secondary to his claimed lumbar spine condition.

Turning to the service evidence of record, a May 1990 STR notes the Veteran's report of rash on leg, stomach and lower back. The Veteran was assessed with an allergic reaction.

The Veteran underwent a VA back (thoracolumbar spine) conditions examination in February 2023 at which time a diagnosis of chronic low back pain was rendered. The examiner opined that the Veteran's claimed lumbar spine condition is less likely than not due to or the result of the Veteran's service connected right knee condition. The examiner rationalized that degenerative changes in joints of one part of the body leading to degenerative changes in other
his claimed right lower extremity condition is secondary to his claimed lumbar spine condition.

Turning to the service evidence of record, a May 1990 STR notes the Veteran's report of rash on leg, stomach and lower back. The Veteran was assessed with an allergic reaction.

The Veteran underwent a VA back (thoracolumbar spine) conditions examination in February 2023 at which time a diagnosis of chronic low back pain was rendered. The examiner opined that the Veteran's claimed lumbar spine condition is less likely than not due to or the result of the Veteran's service connected right knee condition. The examiner rationalized that degenerative changes in joints of one part of the body leading to degenerative changes in other parts of the body, unless there is a severely altered gait. The examiner indicated that the Veteran's gait on examination was unaltered and an extensive review of the Veteran's claims file revealed no documentation of a severely altered gait.

In a May 2023 VA addendum opinion, the VA examiner opined that the claimed condition is less likely than not due to or the result of the Veteran's service connected right knee condition. The examiner rationalized that medical literature and research does not support the theory that degenerative changes in joints of one part of the body leading to degenerative changes in other parts of the body, unless there is a severely altered gait, referred to as a "Trendelenburg gait" which is characterized by the dropping of the pelvis on the unaffected side of the body. The examiner found that upon examination and extensive review of the claims file, the Veteran's gait was unaltered and there was no documentation of a severely altered gait found.

The Veteran underwent a VA back (thoracolumbar spine) conditions examination in January 2024 at which time diagnoses of degenerative arthritis and degenerative disc disease other than intervertebral disc syndrome were rendered. An opinion was not provided.

Here, the Board finds that the February 2023 and March 2023 opinions are inadequate as the opinions are inadequate on the face of the opinions, as the aggravation prong of a secondary service connection opinion was not provided. See Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310.

The AOJ relied on the inadequate opinions of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

8. Entitlement to service connection for erectile dysfunction is remanded.

The Veteran contends that his claimed erectile dysfunction condition is secondary to his service connected acquired psychological condition.

The Veteran underwent a VA male reproductive organ conditions examination in February 2023 at which time a diagnosis of erectile dysfunction was confirmed. The examiner opined that the Veteran's claimed erectile dysfunction is less likely than not due to or the result of the Veteran's service connected acquired psychological condition. The examiner rationalized that the Veteran has multiple risk factors and a nexus cannot be established.

The Veteran underwent a VA male reproductive organ conditions examination in January 2024 at which time a diagnosis of erectile dysfunction, with or without penile deformity was confirmed. No opinion was provided.

Here, the Board finds that the February 2023 opinion is inadequate on its face, as the aggravation prong of a secondary service connection opinion was not provided. See Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310. Second, the causation opinion provided negates discussion of the totality of the evidence to rest on the foundation that the Veteran has multiple risk factors and a nexus cannot be established. Such opinion is thus conclusive. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).

The AOJ relied on the inadequate opinion of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

9. Entitlement to service connection a left knee condition is remanded.

The Veteran contends that his claimed left knee condition is secondary to his service connected right knee condition.

The Veteran underwent a VA knee and lower leg conditions examination in October 2023 at which time the examiner noted that the examination pertains to the right knee condition. No left knee diagnosis was rendered and no opinion was provided.

9. Entitlement to service connection a left knee condition is remanded.

The Veteran contends that his claimed left knee condition is secondary to his service connected right knee condition.

The Veteran underwent a VA knee and lower leg conditions examination in January 2024 at which time a diagnosis of bilateral degenerative arthritis, other than post-traumatic was rendered. The examiner noted that the Veteran reported that he feels that he is overcompensating on his left due to issues of the right knee. The examiner opined that the Veteran's claimed left knee condition is less likely than not due to or the result of the Veteran's service connected knee and lower legs condition. The examiner rationalized that the claimed conditions are not medically related as the left knee is a separate entity entirely and unrelated. The examiner found that a thorough review of the medical literature failed to demonstrate a causal relationship.

Here, the Board finds that the January 2024 opinion is inadequate on its face, as the aggravation prong of a secondary service connection opinion was not provided. See Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310. Second, the causation opinion provided negates discussion of the totality of the evidence to rest on the premise that the claimed conditions are not medically related. Such opinion is thus conclusive. Stefl, 21 Vet. App. at 123.

The AOJ relied on the inadequate opinion of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

10. Entitlement to an increased disability evaluation rating in excess of 10 percent for service connected right knee joint osteoarthritis is remanded.

11. Entitlement to an initial compensable rating, including the effective date thereof, for service connected right knee osteoarthritis limited extension is remanded.

In a December 2022 statement, the Veteran said that the current symptoms of his right knee condition include pain with motion, swelling, buckling, weakness, stiffness and a feeling of the knee giving out. The Veteran further explained that he uses a knee brace and a cane for his right knee. The Veteran also said that he takes over the counter medication for his knee symptoms.

The Veteran underwent a VA knee and lower leg conditions examination in January 2023 at which time diagnoses of right knee meniscal tear and right knee joint osteoarthritis were confirmed. The examiner noted the Veteran's report of over the counter NSAIDs. Upon initial range of motion (ROM) testing, the examiner reported an active ROM of 120 degrees flexion and 0 degrees extension of the right knee. The examiner found that there is evidence of pain on active motion and passive motion that causes functional loss. Thee examiner noted that the Veteran reported having functional loss or impairment of the right knee and experiencing flare-ups of the right knee. Upon testing for observed repetitive use testing, repeated use over time and flare-ups, the examiner reported that the right knee was estimated in terms of ROM to be 110 degrees flexion and 0 degrees extension.

The October 2023 VA knee and lower leg conditions examination in reflects that the examiner noted the Veteran's report of over the counter NSAIDs. Upon initial range of motion (ROM) testing, the examiner reported an active ROM of 115 degrees flexion and 0 degrees extension of the right knee. The examiner found that there is evidence of pain on active motion, passive motion and weight bearing. Thee examiner noted that the Veteran reported having functional loss or impairment of the right knee. The examiner noted that the Veteran did not report flare-ups. Upon testing for repeated use over time, the examiner reported that the right knee was estimated in terms of ROM to be 110 degrees flexion and 5 degrees extension.

At the outset, the Board notes that the Veteran has reported use of NSAIDs. The Board acknowledges that in assigning a disability rating, VA may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56 (2012). More recently, "the Board [is] obligated to discount the beneficial effects of the medication taken for each disability and evaluate the baseline severity of those disabilities" as "Jones" applies in the evaluation of musculoskeletal disabilities where the relevant does not reference medication as a factor in
right knee was estimated in terms of ROM to be 110 degrees flexion and 5 degrees extension.

At the outset, the Board notes that the Veteran has reported use of NSAIDs. The Board acknowledges that in assigning a disability rating, VA may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56 (2012). More recently, "the Board [is] obligated to discount the beneficial effects of the medication taken for each disability and evaluate the baseline severity of those disabilities" as "Jones" applies in the evaluation of musculoskeletal disabilities where the relevant does not reference medication as a factor in evaluation." Ingram v. Collins, 38 Vet. App. 130 (2025). Here, the beneficial effects of the Veteran's medication and treatment are not known. See, e.g., Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2005).

Paramount, the Board notes that the VA examinations do not report the estimated ROM upon weight bearing and non-weight bearing.

However, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination.

When rating musculoskeletal disabilities based on limitation of motion, the Board must consider functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.40. The Board must also consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Nonetheless, even when the background factors listed in 38 C.F.R. § 4.40 or 38 C.F.R. § 4.45 are relevant when rating a disability, the rating is assigned based on the extent to which motion is limited.

Thus, the examination reports are not in compliance with Correia. The AOJ relied on the inadequate examinations of record in adjudicating the issues on appeal constituting a pre-decisional duty to assist error requiring remand for correction. 38 C.F.R. § 20.802.

The matters are REMANDED for the following action:

1. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the nature and etiology of the Veteran's claimed left ankle condition. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

A. Whether it is at least as likely as not that the claimed left ankle condition had its onset during active service or is otherwise related to active service. The examiner is asked to directly address the complete evidence of record, including the lay evidence noting the Veteran's report of pain and that the condition began in 1989.

B. Whether it is at least as likely as not that the claimed left ankle condition was either caused by or aggravated by his service-connected right knee disability.

A complete rationale for all opinions provided is required.

2. Obtain an addendum opinion for the November 2023 VA ankle conditions examination. The Veteran's electronic claims folder, including a copy of this remand must be provided to the examiner. The examiner is requested to address the following:

A. Opine as to whether it is clear and unmistakable (obvious, manifest, and undebatable) that the Veteran's claimed right ankle condition pre-existed active service.

B. If so, the examiner must state whether it is clear and unmistakable (obvious, manifest, and und
likely as not that the claimed left ankle condition was either caused by or aggravated by his service-connected right knee disability.

A complete rationale for all opinions provided is required.

A. Opine as to whether it is clear and unmistakable (obvious, manifest, and undebatable) that the Veteran's claimed right ankle condition pre-existed active service.

B. If so, the examiner must state whether it is clear and unmistakable (obvious, manifest, and undebatable) that the pre-existing claimed right ankle condition WAS NOT aggravated during service.

C. If not, the examiner must opine as to whether the Veteran's claimed right ankle at least as likely as not began in or are related to service.

D. If not, the examiner must opine as to whether the Veteran's claimed right ankle was either caused by or aggravated by his service-connected right knee disability.

A complete rationale for all opinions is provided.

3. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the nature and etiology of the Veteran's claimed headaches, gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) conditions. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

A. Whether it is at least as likely as not that the claimed headaches, GERD and IBS conditions had an onset during active service or is otherwise related to active service. The examiner is asked to directly address the complete evidence of record, including the service treatment records (STRs) noting gastroenteritis and headaches and the lay evidence noting the Veteran's report of dysphagia, reflux and pain due to an esophageal condition.

B. The selected examiner must provide an opinion addressing whether the claimed headaches, GERD and IBS conditions are at least as likely as not etiologically related to the Veteran's toxic exposure risk activities (TERA) in service.

C. Whether it is at least as likely as not that the claimed headaches, GERD and IBS conditions were either caused by or aggravated by his service-connected right knee disability, including the chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) or acquired psychological condition.

A complete rationale for all opinions provided is required.

4. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the nature and etiology of the Veteran's claimed lumbar spine and right lower extremity conditions. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

A. Whether it is at least as likely as not that the claimed lumbar spine and right lower extremity conditions had an onset during active service or is otherwise related to active service. The examiner is asked to directly address the complete evidence of record.

B. Whether it is at least as likely as not that the claimed lumbar spine and right lower extremity conditions were either caused by or aggravated by his service-connected right knee disability.

A complete rationale for all opinions provided is required.

5. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the nature and etiology of the Veteran's claimed erectile dysfunction condition. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

A. Whether it is at least as likely as not that the claimed erectile dysfunction condition had an onset during active service or is otherwise related to active service. The examiner is asked to directly address the complete evidence of record.

B. The selected examiner must provide an opinion addressing whether the claimed erectile dysfunction is at least as likely as not etiologically related to the Veteran's TERA in service.

C. Whether it is at least as likely as not that the claimed erectile dysfunction condition was
by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

B. The selected examiner must provide an opinion addressing whether the claimed erectile dysfunction is at least as likely as not etiologically related to the Veteran's TERA in service.

C. Whether it is at least as likely as not that the claimed erectile dysfunction condition was either caused by or aggravated by his service-connected acquired psychological condition.

A complete rationale for all opinions provided is required.

6. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the nature and etiology of the Veteran's claimed left knee condition. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. The necessity of an in-person examination is left to the discretion of the examiner. The examiner is asked to provide an opinion as to:

A. Whether it is at least as likely as not that the claimed left knee condition had an onset during active service or is otherwise related to active service. The examiner is asked to directly address the complete evidence of record.

B. Whether it is at least as likely as not that the claimed left knee condition was either caused by or aggravated by his service-connected right knee condition.

A complete rationale for all opinions provided is required.

7. Forward the claims file to an appropriately qualified VA clinician and request the clinician to determine the current level of severity of the Veteran's service-connected right knee disability. The clinician is asked to provide an addendum to the January 2023 and October 2023 VA knee and lower leg conditions examinations. The Veteran's claims file and a copy of this remand should be provided to the examiner and the examination report should reflect that these items were reviewed. The necessity of an in-person examination is left to the discretion of the clinician.

A. In compliance with Correia, the examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or non-weight-bearing can be estimated for the January 2023 and October 2023 VA knee and lower leg conditions examinations. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, they should clearly explain so in the report. Specifically, the examiner should determine whether the Veteran's range of motion results would have been reduced if tested in both active and passive motion and in weight-bearing and non-weight-bearing. To the examiner's best ability, the additional range of motion loss should be described in degrees. If the examiner is unable to provide the requested opinion in this case, they should clearly explain the basis for this decision.

B. In compliance with Sharp, the examiner should specifically interview the Veteran about functional loss associated with flare-ups and repeated use over time at the time of the prior January 2023 and October 2023 VA knee and lower leg conditions examinations. The examiner should provide a retrospective opinion as to any additional functional loss during flare-ups or with repeated use over time at these times and provide an estimate of that loss in terms of degrees reduction in range of motion.

A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion.

CHRISTOPHER A. WENDELL

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Alli, Q.

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.

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