Citation Nr: 18142424 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 11-21 700 DATE: October 15, 2018 ORDER Service connection for a right hip disability, diagnosed as degenerative changes of the hip joint, as secondary to lumbosacral strain, is granted. Service connection for a left hip disability, diagnosed as degenerative changes of the hip joint, as secondary to lumbosacral strain, is granted. REMANDED Entitlement to service connection for residuals of a concussion, to include memory loss, is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to an increase in a 10 percent rating for a right gastrocnemius muscle tear is remanded. Entitlement to an increase in a 10 percent rating for pes planus is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s right hip disability, diagnosed as degenerative changes of the hip joint, is caused by his service-connected lumbosacral strain. 2. The Veteran’s left hip disability, diagnosed as degenerative changes of the hip joint, is caused by his service-connected lumbosacral strain. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disability, diagnosed as degenerative changes of the hip, as secondary to lumbosacral strain, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317 (2017). 2. The criteria for service connection for a right hip disability, diagnosed as degenerative changes of the hip, as secondary to lumbosacral strain, have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from October 1985 to November 1998, including service in Southwest Asia. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, that determined that new and material evidence had not been received to reopen claims for entitlement to service connection for a right hip disability (listed as a right hip condition); residuals of a concussion, to include memory loss (listed as memory loss, claimed as residuals of a concussion); and for tinnitus. By this decision, the RO also denied service connection for a left hip disability (listed as a left hip condition); denied an increase in a 10 percent rating for a right gastrocnemius muscle tear; and increased the rating for the Veteran’s service-connected from noncompensable to 10 percent, effective March 17, 2008. The Board observes that the September 2008 RO decision (noted above) determined that new and material evidence had not been received to reopen claims for entitlement to service connection for a right hip disability (listed as a right hip condition); residuals of a concussion, to include memory loss (listed as memory loss, claimed as residuals of a concussion); and for tinnitus. The Board notes that service connection for a right hip disability; residuals of a concussion, to include memory loss (then listed as memory loss); and for tinnitus, was previously denied in a final April 2000 RO decision. Therefore, the Board must address whether new and material evidence has been received to reopen the Veteran’s claims for service connection for a right hip disability; residuals of a concussion, to include memory loss; and for tinnitus. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). As discussed above, the Board observes that service connection for a right hip disability; residuals of a concussion, to include memory loss; and for tinnitus were previously denied in a final April 2000 RO decision. The Board finds, however, that new and material evidence has been received to reopen those claims pursuant to 38 C.F.R. § 3.156 (a). Therefore, this decision will address the merits of the underlying service connection claims for a right hip disability; residuals of a concussion, to include memory loss; and for tinnitus. In March 2018, the Board requested a Veterans Health Administration (VHA) opinion, as to the issues of entitlement to service connection for right hip disability and entitlement to service connection for a left hip disability, and the VHA opinion was obtained in March 2018. In April 2018, the Veteran and his representative were provided with a copy of the March 2018 VHA opinion, as to those issues. The Veteran and his representative did not submit any additional argument or evidence in support of his appeal. Right Hip Disability and Left Hip Disability Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a Veteran’s symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Veteran is service-connected for patellofemoral syndrome of the right knee; patellofemoral syndrome of the left knee; a right gastrocnemius muscle tear; and for bilateral pes planus. He is also service-connected for lumbosacral strain; chronic sinusitis; allergic rhinitis; headaches; and for a fracture of the right fifth distal metacarpal. The Veteran contends that he has a right hip disability and a left hip disability that are related to service, or, more specifically, that are related to his service-connected patellofemoral syndrome of the right knee; patellofemoral syndrome of the left knee; and right gastrocnemius muscle tear. He specifically reports that his right hip problem was first noted following a repelling incident while he was performing physical training during his period of service. The Veteran essentially asserts that he had right hip problems, and apparently left hip problems, during service and since service. The Veteran served on active duty in the Army from October 1995 to November 1998, including service in Southwest Asia. The service treatment records refer to a possible right hip problem, but do not specifically show complaints, findings, or diagnoses of any left hip problems. On a medical history form at the time of a June 1998 medical board examination, the Veteran checked that he had swollen or painful joints, and a bone, joint, or other deformity. The examiner indicated that the Veteran’s swollen or painful joints referred to disorders, including occasional pain in the right hip. The objective June 1998 medical board examination report includes a notation that the Veteran’s lower extremities were abnormal. As to a summary of defects and diagnoses, the examiner indicated that the Veteran had a painful right hip by history. Post-service VA treatment records, including a VA examination report, show diagnoses of arthritis of the right hip and arthritis of the left hip. The Board determined that a VA medical opinion, pursuant to a June 2008 VA orthopedic examination report, was insufficient to decide the Veteran’s claims on the merits and in March 2018 sought an opinion from a VHA expert as to the etiology of the Veteran’s claimed right hip disability and left hip disability. A March 2018 VHA opinion was provided by an orthopedist. The VHA expert discussed the Veteran’s medical history in some detail. The VHA expert reported that the Veteran’s claimed right hip disability and left hip disability were attributable to a known clinical diagnosis. The expert stated that the known clinical diagnosis was age-related minimal degenerative changes of the hip joints, as well as chronic lumbosacral strain. The VHA expert also maintained that it was most likely as not that the Veteran’s right hip pain started in service, but that it was a part of his already service-connected lumbosacral strain and not a separate condition. The Board observes that the VHA expert’s opinions, are mostly negative in regard to the Veteran’s claimed right hip disability and left hip disability. The Board notes, however, that the VHA expert did specifically indicate that the Veteran’s right hip disability, diagnosed as degenerative changes of the hip joint, and his left hip disability, diagnosed as degenerative changes of the hip joint, were attributable to his service-connected lumbosacral strain. The Board finds that the opinion provided by the VHA expert is the most probative opinion of record. The Board thus finds that the Veteran’s right hip disability, diagnosed as degenerative changes of the hip, and his left hip disability, diagnosed as degenerative changes of the hip, are due to or the result of his service-connected lumbosacral strain. As such, secondary service connection is warranted. See 38 C.F.R. § 3.310. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for residuals of a concussion, to include memory loss; entitlement to service connection for tinnitus; entitlement to an increase in a 10 percent rating for a right gastrocnemius muscle; entitlement to an increase in a 10 percent rating for pes planus; and entitlement to a TDIU. The Veteran contends that he has residuals of a concussion, to include memory loss, and tinnitus that are related to service. He specifically maintains that he suffered memory loss after he had a concussion during his period of service. The Veteran reports that he was struck in the head with a weapon by a drill instructor in 1985, and that he was knocked unconscious at that time. The Veteran also essentially indicates that he has tinnitus as a result of acoustic trauma during service. The Veteran is competent to report that he suffered a head injury during service, and that he had memory problems during and since service. He is also competent to report that he had ringing in the ears during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran served on active duty in the Army from October 1995 to November 1998, including service in Southwest Asia. His DD Form 214 lists his occupational specialty as a patriot missile crewmember for eight years and eleven months. The Veteran’s service treatment records show treatment for a head injury and that he reported that he had memory loss. Such records do not show treatment for tinnitus, but do show right ear hearing loss, pursuant to 38 C.F.R. § 3.385 (2017). On a medical history form at the time of a June 1998 medical board examination report, the Veteran checked that he suffered a head injury and that he had memory loss or amnesia. The reviewing examiner reported that the Veteran suffered a head injury/concussion during his basic training phase. The reviewing examiner also indicated that the Veteran reported that he had loss of memory and loss of consciousness when he suffered a concussion in 1985. The objective June 1998 medical board examination report includes a notation that the Veteran’s neurological evaluation was abnormal. The examiner specifically reported that the Veteran had decreased muscle strength, 4/5, in his right lower extremity versus his left lower extremity. The examiner also indicated that the Veteran had a head injury, with positive loss of consciousness and loss of memory by history. The Veteran’s audiological evaluation results show hearing loss in the right ear, but not the left ear, pursuant to 38 C.F.R. § 3.385. Post-service VA treatment records, including examination reports, show treatment for complaints of memory problems and for tinnitus. A May 1999 VA brain and spinal cord examination report notes that no medical records were available for review. The Veteran reported that he suffered a head injury in 1985 when he was struck on the head with a weapon by a drill instructor. He stated that he did not know how long he was unconscious, but that he was pretty sure that it was less than a day. He maintained that he had suffered headaches since the injury. The examiner reported that the Veteran was unclear as to whether or not he experienced any memory loss after the head injury, but that he stated that he had trouble with certain aspects of his memory, more so than before his head injury. It was noted that the Veteran did not know whether his head injury caused his memory problems or not. The diagnosis was posttraumatic headaches, about a third of which were incapacitating. The examiner indicated that there were no significant objective findings of memory loss. The Board observes that the examiner did not review the Veteran’s claims file. Additionally, the Board notes that the although the examiner found that there were no significant findings of memory loss, the examiner did not specifically indicate if there were any residuals of a concussion other than the diagnosed headaches (for which the Veteran is service-connected). Additionally, the examiner did not address whether the Veteran had any disorders, such as memory loss, as a result of his service in Southwest Asia, pursuant to the provisions of 38 C.F.R. § 3.317. The Board notes that the Veteran has not been afforded a VA examination as to his claim for service connection for tinnitus. There is a notation in the claims file that a hearing loss and tinnitus examination that was requested in August 2015 remained open. A September 2017 supplemental statement of the case notes that an VA examination was requested in August 2015, and that notification was received of an inability to contact the Veteran. The Board emphasizes that it is important that the Veteran report for his scheduled VA examination(s). His failure to attend any scheduled VA examination(s) without showing good cause may adversely affect his claim. 38 C.F.R. § 3.655. Examples of good cause include, but are not limited to, the illness or hospitalization of a claimant and death of an immediate family member. 38 C.F.R. § 3.655(a). In light of the above, the Board finds that the Veteran should be afforded a VA examination, or examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the record, as to his claims for service connection for residuals of a concussion, to include memory loss, and for tinnitus. Such an examination or examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran’s pertinent medical history). As to the Veteran’s claim for an increased rating for his service-connected gastrocnemius muscle tear, the Board notes that he was last afforded a VA muscles examination in June 2008. The diagnosis was residuals of a gastrocnemius tear of the right calf. As to the Veteran’s claim for an increased rating for his service-connected pes planus, the Board notes that he was last afforded a VA feet examination in June 2008. The diagnosis was bilateral pes planus. The Board observes that the Veteran has not been afforded VA examinations, as to his service-connected residuals of a gastrocnemius tear of the right calf and pes planus, in over 10 years. Additionally, the record raises a question as to the current severity of his service-connected disabilities. As such, the Board finds it necessary to remand this matter to afford him an opportunity to undergo contemporaneous VA examinations. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Additionally, the Board notes that the U.S Court of Appeals for Veteran’s Claims (Court) has issued decisions in Correia v. McDonald, 28 Vet. App. 158, 166 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017) concerning the adequacy of VA orthopaedic examinations. The Court in Correia 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, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” In light of these decisions, and as the findings pursuant to the June 2008 muscles examination report and the June 2008 feet examination report, respectively, are inadequate, the Board finds that new VA examinations should be provided addressing the Veteran’s service-connected right gastrocnemius tear and pes planus. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Snuffer, 10 Vet. App. at 400, 403. Further, the Board notes that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board finds that the record raises the issue of a TDIU in this matter. In light of Rice and the remand of the claims for increased ratings for a right gastrocnemius muscle tear and pes planus, as well as the claims for service connection, the TDIU issue must be remanded because the claims are inextricably intertwined and must be considered together. Thus, a decision by the Board on the Veteran’s TDIU rating claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009). Additionally, the Board finds that a remand is required to request that the Veteran complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or in order for the Veteran to provide the information requested on such form. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for residuals of a concussion, to include memory problems; tinnitus; a right gastrocnemius muscle tear, and for pes planus, since March 2012. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Request that the Veteran to provide a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or a comparable statement as to the information requested on such form. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed residuals of a concussion, to include memory loss, and pes planus, as well as the nature, extent, and severity of his service-connected right gastrocnemius muscle tear and pes planus and the impact of those conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for a VA examination(s) to determine the nature, onset and likely etiology of his claimed residuals of a concussion, to include memory loss, and tinnitus. The claims file must be reviewed by the examiner(s). Based on the results of the examination, the examiner(s) is(are) asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran’s disability pattern is either (1) a diagnosable chronic multisymptom illness with a partially explained etiology, or (2) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated (made permanently worse or increased in severity) by any service-connected disability(ies)? If yes, was that increase in severity due to the natural progress of the disease. In responding to the above inquiries, please acknowledge and discuss the Veteran’s reported concussion and memory loss during his period of service, and any reports by the Veteran of treatment for his claimed residuals of a concussion, to include memory loss, and tinnitus during and since service. 5. Schedule the Veteran for a VA examination to determine the extent and severity of his pes planus. All indicated tests must be conducted and all symptoms associated with the Veteran’s service-connected pes planus must be described in detail. Specifically, the examiner must conduct a thorough orthopedic examination of the Veteran’s service-connected right foot and left foot disabilities and provide diagnoses of any pathology found. The examiner should describe any pain, weakened movement, excess fatigability, instability of motion, and incoordination that is present. The examiner must also state whether the examination is taking place during a period of flare-ups. If not, the examiner must ask the Veteran to describe the flare-ups he experiences, including the 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. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups 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). 6. Schedule the Veteran for an appropriate VA examination to determine the nature, extent and severity of his right gastrocnemius muscle tear. The claim file must be reviewed by the examiner. All signs and symptoms necessary for rating the Veteran’s service-connected right gastrocnemius muscle tear, must be reported in detail. The examiner must specifically state whether the Veteran’s service-connected right gastrocnemius muscle tear involves muscle damage, and if muscle injuries associated with the wound(s) are found, the examiner must name the muscle and muscle group number for each and should assess the severity of the muscle injuries. The examiner also must conduct a thorough orthopedic examination of the Veteran’s right leg and provide diagnoses of any pathology found. In examining the right leg, full range of motion testing must be performed where possible. The joints involved must be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joints. The examiner must also state whether the examination is taking place during a period of flare-ups. If not, the examiner must ask the Veteran to describe the flare-ups he experiences, including the 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. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups 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). As to the Veteran’s right gastrocnemius muscle tear, the examiner must also specifically indicate whether the impairment is in the nature of a neuritis, a neuralgia, and/or paralysis. If paralysis of any nerve is identified, the examiner must indicate whether the paralysis is complete or incomplete and, if it is incomplete, whether the incomplete paralysis is best characterized as mild, moderate, moderately severe, or severe. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel