Citation Nr: 18146058 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-10 090 DATE: October 30, 2018 ORDER Service connection for muscle pain is denied. Service connection for chronic fatigue syndrome is denied. Service connection for a respiratory condition, to include asthma, is denied. Service connection for a cardiovascular disease is denied. Service connection for a gastrointestinal condition is denied. Service connection for a skin rash, anterior and posterior torso, is denied. Service connection for hair loss is denied. Service connection for headaches is denied. Service connection for a neurological condition, to include tingling and numbness of the extremities, is denied. Service connection for cognitive dysfunction is denied. An effective of June 6, 2012 for a 70 percent evaluation for posttraumatic stress disorder (PTSD) is granted. REMANDED The petition to reopen a previously denied claim of service connection for a bilateral foot condition is remanded. The petition to reopen a previously denied claim of entitlement to service connection for sleep apnea is remanded. The issue of entitlement to an evaluation in excess of 10 percent for chondromalacia patellofemoral syndrome of the left knee is remanded. The issue of entitlement to an evaluation in excess of 10 percent for chondromalacia patellofemoral syndrome of the right knee is remanded. The issue of entitlement to a total disability evaluation based on individual unemployability prior to June 6, 2013 is remanded. The issue of entitlement to an effective date earlier than June 6, 2013 for the establishment of eligibility to Dependents' Educational Assistance is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s headaches and muscle pains began during active service, or are otherwise related to an in-service injury, event, or disease. 2. The preponderance of the evidence is against finding that the Veteran has, or has had at any time during the appeal, diagnoses of chronic fatigue syndrome, a cardiovascular condition, cognitive dysfunction, or a neurological condition. 3. The preponderance of the evidence is against finding that the Veteran has a gastrointestinal condition, respiratory condition, skin rash, and hair loss due to a disease or injury in service. 4. With resolution of the doubt in his favor, for the period from June 6, 2012 through June 5, 2013, the Veteran’s service-connected PTSD with alcohol dependency resulted in deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, auditory hallucinations, and panic attacks. CONCLUSIONS OF LAW 1. The criteria for service connection for muscle pain are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for chronic fatigue syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for a respiratory condition, to include asthma, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for a cardiovascular disease are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for service connection for a gastrointestinal condition are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 6. The criteria for service connection for a skin rash, anterior and posterior torso, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 7. The criteria for service connection for hair loss are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 8. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 9. The criteria for service connection for a neurological condition, to include tingling and numbness of the extremities, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 10. The criteria for service connection for cognitive dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 11. The criteria to establish a 70 percent evaluation for posttraumatic stress disorder (PTSD) with alcohol dependence from June 6, 2012 through June 5, 2013 have been satisfied. 38 U.S.C. §§ 5103, 5103A, 5107, 5108, 5110, 7105 (2012); 38 C.F.R. §§ 3.156, 3.157, 3.158, 3.160 and 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1989 to October 1992. He served in Southwest Asia during the Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2014 and January 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices (RO). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires (1) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established for a qualifying chronic disability manifested by certain signs or symptoms which became manifest either during active 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, 2016, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). A “qualifying chronic disability” includes: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2)(B); 38 C.F.R. § 3.317. VA is responsible for determining whether the evidence supports the claim, with the veteran prevailing, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. A review of the Veteran’s service treatment records shows his April 1989 service entrance examination and August 1992 service separation examinations were normal, with the exception of a note regarding pes planus at entrance. In June 1991, the Veteran was noted to have symptoms related to hemorrhoids. 1. Entitlement to service connection for muscle pain and headaches The Veteran contends he is entitled to service connection for muscle pain and headaches, to include as due to Gulf War Syndrome However, the preponderance of the evidence weighs against finding that the Veteran’s muscle pains and headaches began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). VA medical records from March and November of 2010 indicate the Veteran reported having headaches. In July 2011, treatment notes show the Veteran had chronic headaches. Medical records are silent regarding complaints of or treatment for muscle pains. The Veteran was afforded a VA Gulf War examination in January 2014. He reported having generalized aches in his arms and legs for the past ten years, and that he takes over-the-counter Advil for relief. The Veteran also reported having daily headaches that last for two to three hours, and cause sensitivity to light and sound. Upon examination, the Veteran had full muscle strength of the bilateral upper and lower extremities. The VA examiner determined the Veteran did not have diagnoses associated with muscle pains or headaches. The VA examiner opined that the Veteran’s headaches and muscle pains were less likely as not caused by or a result of his military service, including his deployment during the Gulf War. In support of his opinion, the examiner noted no diagnoses of the claimed disorders; and no chronicity of symptomatology since service discharge. In particular, the examiner stated that the Veteran’s muscle aches are likely due to his sedentary lifestyle and deconditioned status, and his headaches have a multifactorial etiology that includes excessive alcohol consumption, disrupted sleep patterns, and difficulty finding employment. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran is competent to report headaches and muscle aches, which require only personal knowledge of what is observed by his senses, he is not competent to provide an etiology opinion. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). These issues are medically complex, as they require specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examination report. The claims of service connection for muscle pain and headaches must be denied. 2. Entitlement to service connection for chronic fatigue syndrome (CFS), a cardiovascular disease, cognitive dysfunction, and a neurological condition The Veteran contends that he is entitled to service connection for CFS, a cardiovascular disease, cognitive dysfunction, and a neurological condition, to include as due to Gulf War Syndrome. However, the Veteran does not have current diagnoses of CFS, a cardiovascular disease, cognitive dysfunction, or a neurological condition, and has not had any diagnoses associated with these conditions at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Except for reporting chest pains in March 2010, the medical records fail to show complaints of or treatment related to a cardiovascular disease, CFS, cognitive dysfunction, or a neurological condition. At the January 2014 VA Gulf War examination, the examiner noted that the Veteran had no diagnosis of CFS, and the Veteran was unable to identify any factors related to a claim for fatigue. The Veteran also does not have a diagnosis of a cardiovascular disease. The examiner acknowledged that the Veteran was treated for atypical chest pain, but test results were negative for ischemic heart disease. Regarding his claim of cognitive dysfunction, the Veteran reported his symptoms included memory loss and poor concentration. However, the examiner noted the Veteran has never been evaluated or treated for a cognitive condition, and the medical records do not reflect the presence of such condition. Additionally, the Veteran reported he is unaware of what his neurological condition might be, and the examiner stated the Veteran has not been treated for a neurological condition. The VA examiner opined that the Veteran’s claims of service connection for CFS, a cardiovascular disease, cognitive dysfunction, and a neurological condition are less likely as not caused by or the result of the Veteran’s military service, including his deployment during the Gulf War. The examiner explained that the Veteran’s reports of fatigue are likely due to deconditioning, a sedentary lifestyle, and excessive alcohol consumption. He also noted that the Veteran’s reports of chest pain more than 20 years after service discharge are not related to his military service. While the Veteran believes he has current diagnoses of CFS, a cardiovascular condition, cognitive dysfunction, and a neurological condition, he is not competent to provide diagnoses in this case. The issue is medically complex, as it requires specialized medical education, and the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377. The Veteran has not provided any additional medical evidence in support of his claim. Consequently, the Board gives more probative weight to the competent medical evidence in the VA examination report. The claims of service connection for CFS, a cardiovascular condition, cognitive dysfunction, and a neurological condition must be denied. 3. Entitlement to service connection for a gastrointestinal condition, respiratory condition, a skin rash, and hair loss The Veteran contends that he is entitled to service connection for a gastrointestinal condition, respiratory condition, a skin rash, and hair loss. However, while the Veteran has gastrointestinal and respiratory conditions, and has previously had a skin rash and experienced some hair loss, the preponderance of the evidence weighs against finding that these medical conditions began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). As noted above, the Veteran was treated for hemorrhoids during service. In March 2013, VA medical records show the Veteran was diagnosed with gastritis and esophagitis. He underwent a hemorrhoidectomy in April 2013, and complained of constipation after surgery. The medical records do not contain treatment notes regarding a respiratory condition, skin rash, or hair loss. At the January 2014 VA Gulf War examination, the VA examiner noted the Veteran’s diagnoses of gastritis and esophagitis, as well as his hemorrhoidectomy. The Veteran reported having diarrhea, constipation, nausea, and bloating due to Gulf War Syndrome. He also reported taking a daily stool softener and laxative, and stated he drinks alcohol to relieve bloating. The examiner determined that the Veteran’s gastritis and esophagitis are likely related to his alcohol consumption, and his laxatives contribute to diarrhea. At the examination, the Veteran reported developing respiratory symptoms and being diagnosed with asthma in 2011, and that he uses an inhaler daily. The Veteran also reported having a skin rash on his torso in 2010, and that it returned during the summer of 2013. He was not evaluated by a physician, but applied an over-the-counter ointment, which cleared the rash. The examiner noted a rash was not present during the examination. Regarding the Veteran’s claim for hair loss, he reported his hair loss began after he returned from deployment. The examiner stated the Veteran was bald on the top of his head, but had hair on the sides and back, as well as on his chest, arms, and legs. The examiner opined that the Veteran’s gastrointestinal condition, respiratory condition, skin rash and hair loss were less likely than not caused by or a result of his military service, including his deployment to the Gulf War. He explained there was no chronicity of symptomatology for any of these conditions. The examiner attributed the Veteran’s gastrointestinal conditions to his sedentary lifestyle and alcohol consumption. He also noted that the Veteran’s respiratory symptoms and skin rash occurred 20 years after service discharge, and are therefore not related to environmental exposures while deployed during the Gulf War. Regarding the Veteran’s hair loss, the examiner attributed this to aging and heredity. While the Veteran believes his gastrointestinal and respiratory conditions, skin rash, and hair loss are related to his military service, he is not competent to provide nexus opinions due to the medically complex nature of his conditions. Jandreau, 492 F.3d at 1377. Consequently, the Board gives more probative weight to the January 2014 VA examiner’s opinions. The claims of service connection for a gastrointestinal condition, respiratory condition, skin rash, and hair loss must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Effective Date and Increased Rating Criteria Generally, except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. However, a veteran could still potentially qualify for an increased rating up to one-year prior to the date of claim if it was factually ascertainable that the criteria for an increased rating were satisfied. 38 C.F.R. § 3.400 (o)(2); see also Harper v. Brown, 10 Vet. App. 125 (1997). The Board recites a summary of the procedural history of the claim below, as it is relevant to the Veteran’s earlier effective date claim. On February 13, 2012, the Veteran filed an informal claim for service connection for PTSD. A formal claim for service connection for PTSD was filed on May 11, 2012. The RO issued a February 2013 rating decision that granted service connection for PTSD, effective May 11, 2012. The Veteran did not file a Notice of Disagreement (NOD) regarding this decision. The Veteran filed a TDIU claim on June 6, 2013, claiming unemployability due to PTSD and a bilateral knee disability. On July 25, 2013, the Veteran filed a disability compensation application, listing PTSD as one of the claims. The RO construed these as a claim for an increased evaluation. In an April 2014 rating decision, the rating for PTSD was increased to 100 percent effective June 6, 2013. On April 6, 2015, the Veteran filed a NOD regarding the effective date of the 100 percent rating for PTSD. The RO issued a rating decision and a Statement of the Case (SOC) in January 2016, granting an earlier effective date for service connection for PTSD due to a clear and unmistakable error (CUE). Therefore, service connection for PTSD was granted at a 50 percent rating, effective February 13, 2012, the date of the informal claim of service connection. A 100 percent rating effective June 6, 2013, the date of the increased rating claim, was continued. The Veteran perfected an appeal in March 2016. The Board finds that June 6, 2013 is the established date of the increased rating claim. Thus, the Board must determine whether it is factually ascertainable that the Veteran met the criteria for a 100 percent disability rating one year prior to June 6, 2013. Consistent with the facts found, the Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). Disability evaluations are determined by applying the criteria set forth in the Schedule for Rating Disabilities to the Veteran’s current symptomatology. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. A 50 percent evaluation for PTSD requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). 4. Entitlement to an earlier effective date for an increased evaluation for posttraumatic stress disorder (PTSD) with alcohol dependence prior to June 6, 2013 Prior to June 6, 2013, the Veteran’s PTSD was rated at 50 percent disabling. In an August 2017 brief, the Veteran through his representative contends the Veteran is entitled to a 100 percent rating prior to June 6, 2013 due to symptoms including violence against his spouse, depression, poor concentration, and auditory hallucinations. VA medical records show that at an August 2011 psychiatric evaluation, the Veteran reported having flashbacks and nightmares about Desert Storm every other day. In September 2011, he was hospitalized for alcohol dependency, but was irregularly discharged in October 2011 due to unauthorized absence. Treatment notes from June 2012 indicate the Veteran reported having auditory hallucinations for the past two years. VA records from July 2012 show the Veteran participated in a vocational rehabilitation program, and was actively seeking employment. In January 2013, the Veteran reported having suicidal thoughts, and stated his last suicide attempt was in in 2011. The Veteran was afforded a VA examination in August 2012. He was diagnosed with PTSD, alcohol dependence, and major depressive disorder. The examiner stated it was not possible to differentiate which symptoms are attributable to each disability. The Veteran reported being hospitalized in July 2011 for four days due to depression and suicidal ideation. He also stated he consumes a 12-pack of beer and a bottle of tequila every day. His symptoms included depressed mood, anxiety, suspiciousness, weekly panic attacks, and difficulty establishing and maintaining effective work and social relationships. The examiner noted that the Veteran denied having auditory or visual hallucinations, yet also indicated the Veteran’s in-service traumatic events are persistently reexperienced through illusions and hallucinations. Though the examiner questioned the validity of the Veteran’s reported symptoms, he ultimately opined the Veteran has PTSD caused by his military service. The Board will grant the benefit of the doubt to the Veteran and assign a 70 percent rating from June 6, 2012 through June 5, 2013. Although the August 2012 examiner questioned the credibility of the Veteran’s reported symptoms, the record demonstrates the Veteran drank heavily, had suicidal ideation, and auditory hallucinations. A 70 percent rating, but no higher, is assigned for the period from June 6, 2012 through June 5, 2013. REASONS FOR REMAND 1. Petition to reopen previously denied claims of entitlement to service connection for a bilateral foot condition and sleep apnea are remanded. A review of the record shows that in July 2012, the Veteran submitted claims of entitlement to service connection for a bilateral foot condition and sleep apnea. The claims were denied in a February 2013 rating decision. The Veteran did not file a Notice of Disagreement following the issuance of the February 2013 decision. However, in June 2013, service treatment records were added to the claims file, followed by additional medical records submitted in July 2013. As the new evidence was submitted within one year of the original March 2014 denial, that rating decision did not become final. 38 C.F.R. § 3.156 (b) (2017). In a July 25, 2013 application for disability compensation, the Veteran listed service connection claims for sleep disturbance and foot pains. The RO interpreted these claims as petitions to reopen. In an April 2014 rating decision, the RO determined both claims were reopened, but the denials were continued. The Veteran submitted a Notice of Disagreement (NOD) in April 2015, and the RO issued a Statement of the Case (SOC) in January 2016. However, the SOC did not address the issues of service connection for a bilateral foot condition and sleep apnea. Remand is required for the RO to issue a SOC regarding the service connection claims for a bilateral foot condition and sleep apnea. See Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). 2. Entitlement to evaluations in excess of 10 percent for chondromalacia patellofemoral syndrome of the left and right knee are remanded. During VA examinations in August 2012 and January 2014, the Veteran reported having knee flare-ups. While the examiners noted that, in general, flare-ups would cause functional limitations, they did not estimate the loss of function during flare-ups. When an examination is not conducted during a flare-up, a VA examiner should estimate functional loss based on the Veteran’s descriptions of his additional loss of function during flare-ups, and based on a review of the medical records. See Sharp v. Shulkin, 29 Vet. App. 26, 35-36 (2017). Accordingly, upon remand, if the examination is not conducted during a flare-up, the VA examiner should be asked to estimate functional loss during flare-ups. Entitlement to individual unemployability (TDIU) prior to June 6, 2013 and entitlement to an effective date earlier than June 6, 2013 for the establishment of eligibility to Dependents’ Educational Assistance (DEA) are remanded. The claims for entitlement to a TDIU and earlier effective date for DEA prior to June 6, 2013 are inextricably intertwined with the Veteran’s increased rating knee claims. Thus, adjudication of the TDIU and DEA claims are deferred. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Issue a statement of the case (SOC) with respect to the claims of entitlement to service connection for a bilateral foot condition and sleep apnea. 2. Obtain all outstanding treatment records related to the Veteran’s bilateral knee disability from any government or non-government medical provider, and associate them with the claims file. 3. After any additional evidence is associated with the claims file, schedule the Veteran for a VA examination to determine the current severity of his bilateral knee disability. The claims file, to include a copy of this remand, must be made available to the examiner for review. The examination report should reflect that such a review was accomplished. The examiner should elicit a complete history from the Veteran. 4. All appropriate tests, studies, and consultation, should be accomplished and all clinical findings should be reported in detail. Specifically, as to any reported worsening, the examiner must provide a complete explanation as to findings. The examiner must specifically provide an opinion regarding whether the Veteran’s conditions would result in additional functional limitations following repetitive use and during periods of flare-ups. If the examination is not conducted following repetitive use or during a period of a flare-up, the examiner must provide an estimated opinion of additional functional limitations based upon the evidence of record, including the Veteran’s lay statements and medical evidence of record. If the examiner is unable to provide such an opinion, the inability to furnish an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. The examiner’s attention is drawn to the following: (a.) August 2012 VA Knee Examination Report (b.) January 2014 VA Knee Examination Report (c.) August 2015 Private Medical Records (PMRs) – Veteran had left knee arthroscopy, partial medial meniscectomy 5. After completion of the above and any other appropriate development deemed necessary, readjudicate the issues on appeal, including TDIU and DEA, based on the additional evidence. If the determinations remain adverse to the Veteran, he and his representative should be furnished with a Supplemental Statement of the Case. An appropriate period should then be allowed for a response before the record is returned to the Board for further review. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Miller, Associate Counsel