Citation Nr: 18146921 Decision Date: 11/02/18 Archive Date: 11/01/18 DOCKET NO. 15-21 713 DATE: November 2, 2018 ORDER Entitlement to service connection for a thyroid disability, claimed as hypothyroidism, is denied. Entitlement to a 10 percent rating for an abdominal scar, post hernia repair, is granted. Entitlement to an increased 70 percent rating for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a respiratory disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to an increased rating for bilateral medial tibial stress syndrome also claimed as shin splints is remanded. FINDINGS OF FACT 1. A current thyroid disability did not have its onset during any period of active duty service. 2. The Veteran’s abdominal scar, post hernia repair, is characterized by frequent painful episodes. 3. The Veteran’s PTSD is characterized by a depressed mood, heightened irritability and anxiety, and poor sleep, and suicidal ideation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a thyroid disability have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307. 2. The criteria for entitlement to a compensable rating for an abdominal scar, post hernia repair, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code2 7800-05. 3. The criteria for entitlement to an increased rating of 70 percent and no higher for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 1988 to October 1993, February 2002 to September 2002, May 2005 to December 2006, and May 2010 to July 2011. He also had unverified periods of active duty for training and inactive duty training between November 1988 to July 2011. He received the Combat Action Badge, among other decorations, for this service. 1. Entitlement to service connection for a thyroid disability The Veteran seeks service connection for a thyroid disability, claimed as hypothyroidism. He contends this disability was incurred in service, or as a result of a service-connected disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In the present case, the Veteran also had service in the Southwest Asia theater of operations during the Persian Gulf War. Service connection may also be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either 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, 2016; and (4) such symptomatology 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; 76 Fed. Reg. 81834-81836 (Dec. 29, 2011); Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004). Objective indications of a chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA’s Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(3-5). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i)(B). After considering the totality of the record, the Board finds the preponderance of the evidence to be against the award of service connection for a thyroid disability. Review of the Veteran’s service treatment records indicate that he was not diagnosed with or treated for a thyroid disorder during any period of active duty service. According to the Veteran’s private treatment records, he was first diagnosed with hyperthyroidism in early 2005, with radiation of the thyroid in March 2005. As the Veteran’s most recent period of active duty service ended in September 2002 and he did not return to active duty service until May 2005, service connection on a direct basis is not warranted, as the competent evidence of record does not indicate a thyroid disability had its onset during any such period, or became chronic or continuous during an active duty period. Thus, the record reflects the Veteran was not diagnosed with a thyroid disability until several years after separation from his most recent period of active duty service, ending in September 2002. This lengthy period without complaint or treatment is one piece of evidence that there has not been ongoing symptomatology, and weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, no competent expert has established that the Veteran’s current thyroid disorder began during service, has been chronic since that time, or manifested to compensable degree within a year of service separation. Thus, the Board must conclude that a thyroid disability did not have its onset during active duty service. Also, such a disability is not due to or the result of an in-service disease or injury. The Board also notes that while the Veteran had Persian Gulf service, his claimed hypothyroidism is not an undiagnosed chronic disability or a medically unexplained chronic multi-symptom illness; as such, service connection under 38 C.F.R. § 3.317 is not warranted. The Veteran himself asserts that his hypothyroidism began during active duty service. As a layperson, however, the Veteran is not capable of making medical conclusions; thus, his statements regarding causation are not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. Id; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, endocrine disorders are complex disorders which require specialized training for a determination as to diagnosis and causation, and they are therefore not susceptible of lay opinions on etiology, and the Veteran’s statements therein cannot be accepted as competent medical evidence. The Veteran is also not reporting an expert opinion as told to him, and his lay contentions have not subsequently been confirmed by a competent expert. In conclusion, the preponderance of the evidence is against the award of service connection for a thyroid disability, claimed as hypothyroidism, and the claim must thus be denied. Evidence has not been presented that such a disability began during any period of active duty service. As a preponderance of the evidence is against the award of service connection, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Increased Rating Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In adjudicating increased rating claims, the level of disability in all periods since the effective date of the grant of service connection must be taken into account, to include the possibility that a staged rating may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the Board will consider whether staged ratings are appropriate to the pending appeals. In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. 2. Entitlement to a compensable rating for an abdominal scar, post hernia repair The Veteran contends that a higher rating is warranted for a service-connected abdominal scar, post-hernia repair. The Veteran’s scar is rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7804. The rating criteria for evaluating scars are set forth at 38 C.F.R. § 4.118, DCs 7800-7805. DC 7805 provides that scars (including linear scars) not otherwise rated under DCs 7800-7804 are to be rated based on any disabling effects not provided for by those codes. In addition, the effects of scars otherwise rated under DCs 7800-7804 are to be considered. 38 C.F.R. § 4.118, DC 7805. Therefore, the Board has considered all applicable DCs, as discussed further herein. DC 7800 contemplates burn scars of the head, factor or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800. As the Veteran’s scar is located on the abdomen, a rating is not warranted under DC 7800. Under DC 7801, scars, not of the head, face or neck, that are deep and nonlinear warrant the following evaluations: area or areas exceeding 144 square inches (929 sq. cm), 40 percent; area or areas exceeding 72 square inches (465 sq. cm), 30 percent; area or areas exceeding 12 square inches (77 sq. cm), 20 percent; area or areas exceeding 6 square inches (39 sq. cm), 10 percent. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note (1). Scars in widely separated areas, as on two or more extremities or anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25. Id. Note (2). DC 7802 provides that scars, not of the head, face, or neck, that are superficial and nonlinear warrant the following evaluations: area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802, Note (1). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. Note (2). Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating. A 20 percent rating requires three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) for that code provides that if one or more scars are both unstable and painful, 10 percent is added to the evaluation based on the total number of unstable or painful scars. Note (3) under that provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. 38 C.F.R. § 4.118, DC 7804. After a full review of the record, and as discussed below, the Board concludes that a rating for the hernia scar of 10 percent and no higher is warranted. According to the most recent VA medical examination, dated in March 2014, the Veteran’s surgical scar of the abdomen is well-healed, with no abnormalities noted. The Veteran reported frequent pain at the site of the scar. The scar was not noted to be greater than 6 square inches. The examiner found that there were no other pertinent physical findings, complications, conditions, signs or symptoms associated with any scar or disfigurement of any part of the body. Based on the Veteran’s reports of frequent painful episodes of his surgical scar, the Board affords him all reasonable doubt and concludes a compensable rating of 10 percent and no higher is warranted under DC 7804 for this surgical scar. The preponderance of the evidence is against a disability rating in excess of 10 percent, however. The Board finds that the medical examination findings are of greater probative value than the Veteran’s allegations regarding the severity of his scar disability. The Veteran does not meet the DC 7804 criteria for a 20 rating because he has not been shown to have at least 3 or more scars that are painful or unstable. The Board has also considered whether higher or separate Diagnostic Codes are applicable. The evidence of record indicates that the Veteran’s service-connected scar disability is primarily manifested by one painful scar. The Veteran’s scar is on his abdomen, and not on the head, face, or neck. Thus, the criteria of DC 7800 are not applicable. The objective findings of record also indicate the Veteran’s scar does not involve an area of at least 6 square inches. As such, the criteria of DCs 7801 or 7802 do not apply. Based on the foregoing, the Board concludes that the Veteran’s scar disability warrants no more than a 10 percent rating. All evidence has been considered and there is no doubt to be resolved. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an increased rating for PTSD The Veteran seeks a disability rating in excess of 30 percent for his service-connected PTSD. He asserts this disability results in impairment in social and occupational functioning, and an increased rating is therefore warranted. PTSD is rated under Diagnostic Code 9411, and utilizes the General Rating Formula for Mental Disorders. Under this Code, a 30 percent disability rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. A 50 percent rating is warranted where there is 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 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 rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; 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 inability to establish and maintain effective relationships. A 100 percent evaluation for a psychiatric disability is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. In evaluating psychiatric disorders, the Board is mindful that the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA “intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms.” The Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” In the present case, the Veteran has been afforded April 2012 and March 2015 VA psychiatric examinations. Private and VA medical treatment records have also been obtained and reviewed. The Veteran has also provided written and oral testimony regarding his PTSD. As a layperson, the Veteran is competent to provide such testimony regarding observable symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). After a review of all the evidence, lay and medical, the Board finds that the Veteran’s service-connected PTSD warrants a disability rating of 50 percent and no higher. During his VA examinations and at his Board hearing, the Veteran has reported experiencing such symptoms as sleep problems, nightmares, poor focus and concentration, heightened anger, and emotional numbing. On objective evaluation, the Veteran was casually dressed and groomed, and he was fully alert and oriented. His speech was clear, his thought processes were logical and goal-directed, and his memory and concentration were intact. His mood was depressed, but the examiner characterized the Veteran’s affect as appropriate to the circumstances. His insight was good. Problems with anxiety and anger were reported by the Veteran. He reported past suicidal thoughts, but no plan. He denied any current suicidal or homicidal thoughts or plans. He also denied any hallucinations, delusions, or other signs of psychosis. No panic attacks or obsessive-compulsive symptoms were noted. He avoided crowds and did not go out much. The examiner determined the Veteran was competent to manage his funds and perform all tasks of daily living. The final impression was of PTSD characterized by moderate impairment. In an October 2015 statement, the Veteran’s wife wrote that since his return from overseas service, the Veteran has been withdrawn and depressed, socially detached, easily angered, and unmotivated. She described him as far different than the person she married prior to his active duty. Likewise, at his Board hearing, the Veteran reported significant personality changes since service. He no longer enjoyed social interaction, and experienced heightened irritability, anger, and hypervigilance. Thus, based on the above, the Board finds the evidence to be in relative equipoise between the criteria for 70 percent ratings. While the Veteran had worked for several years following service and maintained a stable home and family life, his PTSD also resulted in a depressed mood, heightened irritability, and interpersonal clashes both at home and in the workplace, as well as diminishment of his enjoyment of social and familial settings and suicidal ideation. Thus, in light of 38 C.F.R. §§ 4.3 and 4.7, a 70 percent rating is awarded for the entirety of the appeals period. Considering next entitlement to a disability rating in excess of 70 percent, the Board finds the preponderance of the evidence to be against such an award. The Board has considered the VA examination reports, as well as VA outpatient treatment records. After review of all evidence, both lay and medical, the Board concludes that the record does not reflect that the Veteran’s service-connected PTSD has been manifested by symptoms of such severity to warrant an evaluation in excess of 70 percent at any time during the pendency of the appeal. At no point since the initial grant of service connection does the evidence of record reflect symptoms that resulted in total occupational and social impairment. To the contrary, the evidence of record shows that the Veteran has, at all times of record, been alert and fully oriented, with adequate hygiene, normal speech, clear and logical thought processes, and generally adequate social interaction. Thus, in consideration of the evidence above, the Board finds that an increased initial rating to 70 percent, is warranted. A disability rating in excess of 70 percent is not warranted. Because the preponderance of the evidence is against the appeal for a higher disability rating in excess of 70 percent, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for a respiratory disability is remanded. The Veteran claims service connection for a respiratory disability, to include asthma and/or emphysema. On VA respiratory examination in April 2012, the Veteran reported a history of asthma, first diagnosed in late 2011, shortly after separation from active duty service in July 2011. The Veteran has reported that he first began to experience shortness of breath during his last period of active duty service. The Veteran is competent to report such lay-observable symptomatology. See Jandreau, 492 F.3d at 1372. The Board also notes, however, that VA regulation provides that for claims received after June 9, 1998, disability due to smoking and/or nicotine dependence may not be considered service related. 38 C.F.R. § 3.300. As the Veteran has an extensive history of smoking, the Board must also determine if any current respiratory disabilities are the result of smoking. Based on the above, a VA medical opinion is necessary to determine the date of onset and etiology of any current respiratory disability. 2. Entitlement to service connection for hypertension is remanded. The Veteran has asserted, in part, that his service-connected PTSD has caused or aggravated his hypertension. To date, VA has neither obtained a medical opinion regarding this assertion nor considered it as part of the Veteran’s claim. Thus, a VA medical opinion is necessary to address this deficiency. 3. Entitlement to an increased rating for bilateral medial tibial stress syndrome also claimed as shin splints is remanded. The Veteran seeks an increased rating for his bilateral medial tibial stress syndrome, also claimed as shin splints. Remand of this issue is required to afford the Veteran new VA examination to assess the functional impairment resulting from this disability. Specifically, the prior examinations are insufficient for determining the proper disability rating for the Veteran’s service-connected orthopedic disability based on the recent holding of the U.S. Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Such an examination must, among other findings, determine range of motion on both active and passive motion, with and without weight-bearing, of the affected knees and ankles. Accordingly, remand of this issue is warranted so that a new examination may be conducted and appropriate findings obtained. The matters are REMANDED for the following action: 1. Schedule the Veteran for a respiratory examination by a physician or similar expert in respiratory disorders to determine the nature and etiology of any current respiratory disorders. The claims folder must be made available to and reviewed by the examiner in connection with the examination, and a complete history should be elicited from the Veteran. The examiner is reminded that the Veteran is competent to report such observable symptomatology as shortness of breath. All indicated tests and studies should be accomplished, if deemed necessary by the examiner. Upon review of the file, the examiner is asked to address the presence of any current respiratory disorders. For any disorder identified, the examiner is asked to specifically address whether it is as likely as not (a 50 percent or greater probability) that such a disorder had its onset during any period of active duty service (November 1988 to October 1993, February 2002 to September 2002, May 2005 to December 2006, and May 2010 to July 2011) or manifested within a year thereafter. The examiner must also state whether any diagnosed respiratory disorder is due to or the result of the Veteran’s smoking history. The examiner is asked to provide a rationale for his/her opinion. 2. Forward the Veteran’s claims file to a physician or similar expert in cardiovascular disorders to determine the nature and etiology of the Veteran’s hypertension. The Veteran need not be scheduled for an in-person examination unless deemed necessary by the examiner. The examiner must review the service treatment records, to include blood pressure readings taken therein. Upon review of the file, the examiner is asked to specifically address whether it is as likely as not (a 50 percent or greater probability) the Veteran’s hypertension had its onset during any period of active duty service (November 1988 to October 1993, February 2002 to September 2002, May 2005 to December 2006, and May 2010 to July 2011) or manifested within a year thereafter. The examiner is also asked to address whether the Veteran’s hypertension is due to or aggravated by his service-connected PTSD. For VA purposes, aggravation is defined as a permanent increase in disability beyond the natural progress of the disorder. The examiner is asked to provide a rationale for his/her opinion. 3. Schedule the Veteran for an appropriate VA examination so as to determine the current nature and extent of all impairment due to his service-connected bilateral shin splints. The record must be made available to and reviewed by the examiner in conjunction with the examination. The examiner must test and record the range of motion for the knees and ankles in active motion, passive motion, weight-bearing, and nonweight-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. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner is reminded that he/she should specify the degree of additional functional loss/motion due to pain, to include during flare-ups, or state why it was not feasible to provide such information, as required for an adequate examination. Additionally, as it relates to the knees, the examiner should determine whether the Veteran has ankylosis of the knee; instability or subluxation of the knee; nonunion of the tibia and fibula with loose motion and requiring knee braces; dislocated semilunar cartilages with frequent episodes of locking, pain, and effusion; or severe painful motion or weakness in either knee. As it relates to the instability/subluxation, the examiner is requested indicate whether the impairment is slight, moderate or severe in nature. As it relates to the ankles, the examiner should determine whether the Veteran has ankylosis of the ankle. The examiner is also requested to comment on muscle impairment as it relates to the one third of the interosseous ligament along the fibular component, increased fluid surrounding the tendon sheaths of the peroneus brevis and longus, flexor digitorum, flexor halluces longus tendons, and removal of the medial extensor digitorum brevis muscle belly and intramural cysts of the ankle. and whether the resulting impairment is slight, moderate, moderately severe, or severe in nature. (Continued on the next page)   To the extent possible, the examiner is asked to provide retrospective commentary on the Veteran’s impairment level of the bilateral shin disabilities during the appeal period, to include the prior VA examinations performed in conjunction with this claim, and to comment on the range of motion movements that would be painful on passive use, in weight-bearing and non-weight-bearing. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel