200515-83608, 200515-83608

Veteran served on active duty May 1977–Mar 1978; sought Board review following a March 2020 RO rating decision (appeal via AMA Direct Review). Record closed as of the March 2020 decision.
Veteran asserts left knee pain beginning in service and continuing since (self-treated with knee braces); STRs largely negative except a Feb 1978 report of medical history showing unspecified swollen/painful joints; VA records document DJD/osteoarthritis and bilateral total knee arthroplasties decades later.
Veteran asserts sleep apnea began after a 1977 in‑service auto accident and alternatively is secondary to his service‑connected TBI; STRs include treatment after an auto accident and a 1978 complaint of frequent trouble sleeping.
Prior VA exams (Nov 2018, Feb 2020) provided negative nexus opinions for sleep apnea; Board found those opinions inadequate for failing to consider STR sleep complaints and submitted medical literature and for not addressing aggravation per El‑Amin.
Board concluded the AOJ committed pre‑decisional duty‑to‑assist errors: failed to obtain a VA knee examination despite the low McLendon threshold and retained inadequate sleep apnea opinions; remanded both claims for new development, examinations/opinions, and readjudication.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Entitlement to service connection for left knee disability (osteoarthritis/DJD)	Veteran: complained of left knee pain in service, continuous since service (self‑treated), STRs show swollen/painful joints; VA treatment shows later DJD/TKA	AOJ: previously denied; March 2020 decision treated claims on merits and found no service connection (no new/relevant evidence sufficient)	Remanded — AOJ failed to provide a VA exam (pre‑decisional duty to assist error). New examiner to identify knee conditions and opine on nexus, onset in service/within one year for arthritis, and consider lay statements and all evidence.
Entitlement to service connection for sleep apnea (direct and secondary to TBI)	Veteran: sleep problems began after 1977 auto accident; alternatively sleep apnea is caused/ aggravated by service‑connected TBI; representative submitted medical articles supporting TBI–sleep apnea link	AOJ: prior VA exam(s) found negative nexus; March 2020 confirmed/continued denial	Remanded — prior opinions inadequate (did not consider STR sleep complaints or submitted articles; failed to opine on aggravation). New examiner/opinion (and exam if needed) to address direct nexus and whether sleep apnea is caused or aggravated by TBI, with full rationale.

McLendon v. Nicholson, 20 Vet. App. 79 (2006) (establishes the low threshold for nexus to trigger VA's duty to provide an examination)
El‑Amin v. Shinseki, 26 Vet. App. 136 (2013) (requires adequate VA opinions addressing relevant theories, including aggravation)
Ward v. Wilkie, 31 Vet. App. 233 (2019) (clarifies that "aggravation" for secondary service connection does not require permanence and includes any incremental increase in disability)