Citation Nr: 18140529 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 14-32 399 DATE: October 3, 2018 ORDER Application to reopen a claim of service connection for depression is granted. Application to reopen a claim of service connection for a back disorder is denied. Application to reopen a claim of service connection for left leg varicose veins is denied. Entitlement to service connection for depression is granted. Entitlement to service connection for a sleep disorder including obstructive sleep apnea is granted. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to service connection for a right leg disability including varicose veins is denied. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a gastrointestinal disorder is denied. REMANDED Entitlement to an increased rating for a left knee disorder rated as 10 percent disabling is remanded. Entitlement to an increased rating for a right knee disorder rated as 20 percent disabling is remanded. FINDINGS OF FACT 1. A December 2005 rating decision earlier denied the Veteran’s claim of service connection for depression, a June 2008 rating decision earlier denied his claim of service connection for left leg varicose veins, and an August 2010 rating decision most recently denied his application to reopen a claim of service connection for a back disability; the claimant did not appeal or perfect his appeal as to these decisions; he did not thereafter submit new and material evidence within the one-year appeal period as to any of these decisions; and VA did not subsequently obtain and associate with the claims file VA treatment records generated within the one-year appeal period for any of these decisions. 2. Evidence received since the December 2005 rating decision is new, is related to an unestablished fact necessary to substantiate the claim of service connection for depression, and it raises a reasonable possibility of substantiating the claim. 3. Evidence received since the June 2008 and August 2010 rating decisions does not relate to an unestablished fact necessary to substantiate the claims of service connection for left leg varicose veins and a back disability. 4. Depression had its’ onset in service. 5. A sleep disorder diagnosed as obstructive sleep apnea is permanently aggravated by the Veteran’s service-connected depression. 6. The preponderance of the evidence shows that the Veteran was not diagnosed with a bilateral foot disability at any time during the pendency of the appeal. 7. The preponderance of the evidence shows that a neck disability, tinnitus, hypertension, a right leg disability diagnosed as varicose veins, and a gastrointestinal disorder were not present in service, were not present until many years after service, and they are not related to service or to an incident of service origin. CONCLUSIONS OF LAW 1. The December 2005, June 2008, and August 2010 rating decisions are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. Evidence submitted to reopen the claim of entitlement to service connection for depression is new and material and therefore the claim is reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. New and material evidence has not been submitted sufficient to reopen a claim of entitlement to service connection for left leg varicose veins and a back disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 4. The criteria for service connection for depression have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a sleep disorder diagnosed as obstructive sleep apnea have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for a bilateral foot disability, a neck disability, tinnitus, hypertension, right leg disability diagnosed as varicose, and a gastrointestinal disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from October 1976 to February 1981. The Applications to Reopen As to reopening a prior final decision, the law provides that if new and material evidence has been presented or secured with respect to matters which have been disallowed, these matters may be reopened and the former disposition reviewed. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that in determining whether the evidence is new and material, the credibility of the newly presented evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board is required to consider all the evidence received since the first denial of the claim in light of the totality of the record. See Hickson v. West, 12 Vet. App. 247, 251 (1999). In this regard, the Court in Shade v. Shinseki, 24 Vet. App. 110 (2010) held that the language of 38 C.F.R. § 3.156(a) created a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” Further, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The Court in Turner v. Shulkin, 29 Vet. App. 207 (2018), also recently held that for purposes of finality VA treatment records dated during the appeal period are consider in VA’s possession even if these records are not physically associated with the claims file until many years after the RO issued a rating decision if the RO had sufficient knowledge of the existence of the records within the one-year appeal period. The Court also held that these VA treatment records will thereafter only trigger VA’s duty under 38 C.F.R. § 3.156(b) if they are new and material evidence. With the above criteria in mind, the record shows that a December 2005 rating decision earlier denied the Veteran’s claim of service connection for depression, a June 2008 rating decision earlier denied his claim of service connection for left leg varicose veins, and an August 2010 rating decision most recently denied his application to reopen a claim of service connection for a back disability. The decisions denied his claims because, in substance, the record did not show that depression, left leg varicose veins, and a back disability were due to service even though service treatment records documented his complaints and treatment for back muscle strain. As to the left leg varicose veins, the June 2008 decision also denied the claim because the record did not show is was caused or aggravated by his service-connected knee disability. The Veteran did not appeal the December 2005 rating decision that denied his claim of service connection for depression and the June 2008 rating decision that denied his claim of service connection for left leg varicose veins. The Board also finds that the Veteran did not perfect his appeal to the August 2010 rating decision that most recently denied his application to reopen a claim of service connection for a back disability because he did not file a substantive appeal. The Board also finds that no new and material evidence was received by the RO in the first year following the issuance of these rating decision. See 38 C.F.R. § 3.156(b). In addition, the Board finds that VA did not subsequently obtain and associate with the claims file VA treatment records generated within the one-year appeal period for any of these rating decisions. See Turner, super. Accordingly, the Board finds that the December 2005, June 2008, and August 2010 rating decisions are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. Since this final December 2005, June 2008, and August 2010 rating decisions, the Veteran, his representative and/or VA obtained and associated with the claims file additional medical records and written statements in support of the claims. a. Depression As to the depression claim, the medical records added to the record since the time of the final December 2005 decision include for the first time an opinion that it is due to the Veteran’s military service. See June 2016 private psychiatric examination. Therefore, because a relationship between a post-service disability and service is a condition precedent for establishing service connection (see Hickson v. West, 12 Vet. App. 247, 253 (1999)) and because in determining whether the evidence is new and material the credibility of the newly presented evidence is to be presumed (see Justus, supra.), the Board finds that this medical evidence constitutes new and material evidence and the claim is reopened. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. § 3.156. b. The Left Leg Varicose Veins and a Back Disability As to the left leg varicose veins and the back disability, since the time of the final rating decisions, the written statements in support of the claim from the Veteran and his representatives state, in substance, that the appellant is entitled to service connection for these disabilities because they are due to his military service. These same claims were, in substance, already before VA at the time of the earlier June 2008 and August 2010 rating decisions. Therefore, the Board finds that these statements are neither new nor material evidence as defined by 38 C.F.R. § 3.156(a) because they are duplicative. Simply stated, the Veteran has repeated his claims without providing new evidence. His statements are not new. As to the additional medical records, since the time of the final June 2008 and August 2010 rating decisions they continue to document the Veteran’s post-service complaints and treatment for left leg varicose veins and a back disability. Tellingly, these same facts were before the regional office (RO) at the time of the earlier final rating decisions. And, more importantly, the record continues to be negative for evidence showing either disability had continued since service, arthritis in the back manifested in the first post-service year, and/or a relationship between the post-service disorders and his military service to include the documented treatment for back muscle strain that were in the service treatment records at the time of the earlier final rating decision. See 38 C.F.R. § 3.303; Hickson, supra. In fact, the April 2011 VA examiner opined that the Veteran’s current back disability was not due to his military service. Therefore, the Board finds that these medical records are neither new nor material evidence as defined by 38 C.F.R. § 3.156(a) because they are duplicative. In some cases, they provide evidence against this claim. In summary, the Board finds that the additional evidence added to the claims file since the time of the prior final June 2008 and August 2010 rating decisions do not provide credible evidence that either disorder is due to the Veteran’s military service. See 38 U.S.C. §§ 1101, 1112, 1113, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309; also see Hickson, supra. Instead, the Board finds that additional evidence added to the claims file since that time is, in substance, duplicative of evidence found in the record at the time of the prior final June 2008 and August 2010 rating decisions. Accordingly, these claims are denied. 38 C.F.R. § 3.156(a). The Service Connection Claims The Veteran claims, in substance, that he is entitled to service connection for depression, a sleep disorder, a bilateral foot disability, a right leg disability including varicose veins, a neck disability, tinnitus, hypertension, and a gastrointestinal disorder because they are due to his military service. As to the sleep disorder, it is also claimed it is due to his depression. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, hypertension, and a psychosis, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this regard, to establish service connection for the claimed disorders, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Where 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). a. Depression The record shows the Veteran being diagnosed with depression. See, e.g., VA treatment records dated in December 2002 and May 2003; June 2016 private psychiatric examination. The Board also finds the service treatment records that document the Veteran’s report of a history of depression as well as his treatment for alcoholism are sufficient proof of the in-service event/injury. See, e.g., service treatment records dated in December 1978 and September 1980. Lastly, the Board finds that the June 2016 private psychiatric examiner’s opinion that the Veteran’s current depression is due to his military service the most probative evidence of record because it is provided after a review of the record on appeal and an examination of the Veteran as well as supported by citation to evidence found in the record and not contradicted by any other medical evidence of record. See Owens, supra; Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Therefore, with affording the Veteran the benefit of the doubt, the Board concludes that service connection is warranted for depression and the appeal is granted. See 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. b. Sleep Disorder As discussed above, VA is granting the Veteran service connection for depression. The record also shows the Veteran being diagnosed with obstructive sleep apnea. See, e.g., VA sleep study dated in March 2010. Furthermore, in August 2016 Dr. Skaggs opined that the Veteran’s depression permanently aggravated his obstructive sleep apnea. The Board finds that the August 2016 opinion the most probative evidence of record because it is supported by citation to evidence found in the record, controlling medical literature, and it is not contradicted by any other medical evidence of record. See Owens, supra; Colvin. Given this record, the Board concludes that secondary service connection for a sleep disorder diagnosed as obstructive sleep apnea is warranted. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. c. Bilateral Foot Disability The service treatment records document the Veteran’s complaints and treatment for an ingrown toenail and a painful corn in November 1976, a painful ligament anterior to the right foot/ankle in December 1976, as well as athletes foot in March 1977. However, and most importantly, service treatment records, including the September 1980 examination, are negative for a foot injury as well negative a diagnosis of a chronic foot. In fact, when seen in December 1976 it was reported that there was no injury. Likewise, when examined in September 1980 the Veteran specifically told the examiner that he did not have any foot trouble and on examination it was opined that his feet and lower extremities were normal. This medical opinion is not contradicted by any other medical evidence of record. See Colvin, supra. Likewise, and even importantly, the post-service record is negative for a diagnosis of a bilateral foot disability. While the Veteran is competent to report on the symptoms he observes, he is not competent to diagnose a bilateral foot disability because diagnosing it requires special medical training that he does not have and therefore he cannot provide the missing diagnosis. See Davidson, supra. The Board also finds that given the above record that VA has no obligation to obtain an etiology opinion as to this claimed disorder. See Paralyzed Veterans of America, et. al., v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003) (holding that the criteria for obtaining an etiology opinion have not been met when the evidence of record does not establish that the veteran suffered an event, injury, or disease in service because no reasonable possibility exists that providing a medical examination or obtaining a medical opinion would substantiate the claim). Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not have a diagnosis of a bilateral foot disability at any time during the pendency of the appeal. Therefore, the Board finds that this claim must be denied. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. d. Neck Disability, Tinnitus, Hypertension, Right Leg Disability, and a Gastrointestinal Disorder The post-service record shows the Veteran’s being diagnosed with neck degenerative joint disease (see, e.g., cervical spine X-ray dated in April 2004), tinnitus (see, e.g., VA treatment record dated in April 2004), hypertension (see, e.g., VA treatment records dated in December 2001, September 2002, October 2002, and July 2003), right leg varicose veins (see, e.g., VA treatment record dated in July 2003), and gastrointestinal disorders (i.e., gastrointestinal bleeding/peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), and gastroenteritis) (see, e.g., Employment examination dated in May 2002; VA treatment records dated in October 2002, December 2002, July 2003, and April 2010). Additionally, service treatment records document his treatment for a fractured noise in December 1978 and neck pain in May 1979. Furthermore, the Board finds that the Veteran is competent to report on the manifestations of his disabilities, such as neck pain, ringing in his ears, dizziness, gastrointestinal upset, enlarged veins, and bloody stools because these symptoms are observable by lay persons. See Davidson, supra. However, none of the records surrounding the December 1978 treatment for a fractured noise document that the same injury caused tinnitus or included neck trauma. Additionally, the May 1979 report of neck pain was noted to be due to a skin irritation. In addition, the earlier and subsequent service treatment records, which include a September 2008 examination, are negative for a neck injury or other head trauma; complaints of neck pain, ringing in his ears, dizziness, enlarged veins in the right leg, gastrointestinal upset, and bloody stools; as well as negative for a diagnosis of a neck disability, tinnitus, hypertension, right leg varicose veins, and a gastrointestinal disorder. In fact, when examined in September 1980 the Veteran reported that he did not have any head injuries, heart trouble, frequent indigestion, or stomach trouble and on examination it was opined that the neck, heart, lower extremities, vascular system, and G-U system were normal as well as that his blood pressure was 118/72. (VA defines hypertension as for diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101.) This medical opinion is not contradicted by any other medical evidence of record. See Colvin, supra; also see 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Hensley, supra. The record also does not show the Veteran being diagnosed with neck arthritis and/or hypertension in the first post-service year. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Similarly, the record does not show that the Veteran had a continued problem with neck pain, ringing in his ears, dizziness, enlarged veins in the right leg, gastrointestinal upset, and bloody stools as well as negative for a diagnosis of a neck disability, tinnitus, hypertension, right leg varicose veins, and a gastrointestinal disorder in and since service. In fact, as reported above, the September 1980 examination is negative for complaints, diagnoses, or treatment for any of these disorders. Likewise, the post-service records, including the April 1981examinations are negative for a history, complaints, and/or a diagnosis of a neck disability, tinnitus, hypertension, right leg varicose veins and a gastrointestinal disorder until years after service. See, e.g., cervical spine X-ray dated in April 2004, VA treatment records dated in December 2001, September 2002, October 2002, December 2002, July 2003, March 2004, April 2004, and April 2010; also see 38 U.S.C. § 1131; 38 C.F.R. § 3.303(b). In fact, in his writings to VA the Veteran does not report having an ongoing problem with observable symptoms of his disabilities (i.e., neck pain, ringing in his ears, dizziness, gastrointestinal upset, and bloody stools) in and since service. See Davidson, supra. Furthermore, the record is negative for a competent and credible opinion that shows that the current neck disability, tinnitus, hypertension, right leg varicose veins and gastrointestinal disorder are due to the Veteran’s military service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(d); also see Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). Given the above record which is negative for complaints or treatment for any of the claimed disorders in-service and for years after service, the Board also finds that VA had no obligation to obtain an etiology opinion as to any of the claimed disorders. See Paralyzed Veterans of America, et. al., supra. The Board also finds that the Veteran is not competent to provide the missing nexus opinions because he does not have the required medical expertise to provide an answer to this complex medical question. See Davidson, supra. Accordingly, the Board finds that the preponderance of the evidence is also against the Veteran’s claims of service connection for a neck disability, tinnitus, hypertension, a right leg disability diagnosed a varicose veins, and a gastrointestinal disorder. 38 U.S.C. §§ 1101, 1112, 1113, 1131; 38 C.F.R. § 3.303. In reaching all the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claims, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert, supra. REASONS FOR REMAND Increased ratings for left and right knee disorders are remanded. As to the claims for increased rating ratings for left and right knee disabilities, the Board finds that these issues need to be remanded to provide the Veteran with VA examinations because the examinations found in the record do not included range of motion testing in both active and passive motion, weight-bearing, and non-weight-bearing situations as well as opinions as to the Veteran’s range of motion during flare-ups. See 38 U.S.C. § 5103A(d); Sharp v. Shulkin, 29 Vet. App. 26 (2017). When adjudicating the claim, the agency of original jurisdiction (AOJ) should be mindful of the fact that in precedent opinions by VA’s General Counsel it was noted that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability (see VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998)) as well as compensable lost extension and flexion (see VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004)). The AOJ should also be mindful of the Court’s holding in DeLuca v. Brown, 8 Vet. App. 202 (1995) regarding painful motion. While the appeal is in remand status, any outstanding VA and private treatment records should also be obtained and associated with the record on appeal. See 38 U.S.C. § 5103A(b). These issues are REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran himself should submit and new pertinent evidence the Board/VA does not have (if any). 3. Thereafter, schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of his left and right knee disabilities. All studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims file should be made available and reviewed by the examiner in conjunction with conducting the examination. After a review of the claims file, any needed testing, and an examination of the Veteran, the examiner should provide answers to the following questions: I. Range of Motion Testing (a) The examiner should identify all left and right knee disabilities pathology found to be present during the pendency of the appeal. (b) The examiner should conduct all indicated tests and studies, to include range of motion studies. Full range of motion testing must be performed where possible. The joint involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (c) The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. (d) The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. (e) Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional lost motion caused by functional loss during a flare-up and after repeated use over time in both the left and right knee. (f) If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups and/or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). II. Other Testing (g) The examiner should identify and characterize the severity of any left and/or right knee instability and/or subluxation. In providing the opinions, the examiner should consider the Veteran’s competent lay claims regarding observable symptomatology. The examination report must include a complete rationale for all opinions expressed. JOHN J CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Neil T. Werner, Counsel