Citation Nr: 18147346 Decision Date: 11/06/18 Archive Date: 11/02/18 DOCKET NO. 15-29 695 DATE: November 6, 2018 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for left wrist disability is denied. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for deep vein thrombosis (DVT) is denied. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for headaches is granted. Entitlement to an increased rating of 70 percent, but not higher, for the period of the appeal, for posttraumatic stress disorder (PTSD), is granted. Entitlement to an effective date earlier than October 1, 2000, for service connection of left hand second degree burns is denied. Entitlement to an effective date earlier than October 1, 2000, for service connection for a left hand ring finger disability is denied. Entitlement to an effective date earlier than October 1, 2000, for service connection for a right wrist disability is denied. Entitlement to an effective date earlier than July 28, 2014, for service connection for PTSD is denied. Entitlement to an earlier effective date of October 1, 2000, but not earlier, for service connection for right hand limitation of function, status-post right wrist laceration with right thumb disability is granted. Entitlement to an earlier effective date of October 1, 2000, but not earlier, for service connection for painful scars of the left hand and right wrist is granted. Entitlement to an earlier effective date of October 1, 2000, but not earlier, for service connection for chronic diarrhea is granted. REMANDED Entitlement to service connection for a skin disability is remanded. Entitlement to a rating in excess of 20 percent for a right shoulder disability is remanded. Entitlement to a rating in excess of 10 percent for a lumbar spine disability is remanded. Entitlement to an increased rating in excess of 10 percent for a left knee disability is remanded. Entitlement to an increased rating in excess of 10 percent for chronic diarrhea is remanded. Entitlement to an rating in excess of 10 percent for painful scars of the left hand and wrist is remanded. Entitlement to an rating in excess of 10 percent for a right thumb disability is remanded. Entitlement to a compensable rating for residuals of a torn tendon in the left-hand ring finger and consideration of an earlier effective date for increased rating is remanded. Entitlement to a compensable rating for a right wrist disability is remanded. Entitlement to a compensable rating for residuals of burns of the left hand is remanded. FINDINGS OF FACT 1. The Veteran’s diagnosed GERD did not manifest in service, and is not shown to be related to service. 2. The preponderance of the evidence is against a finding that the Veteran has a currently diagnosed left wrist or neck disability. 3. The preponderance of the evidence is against a finding that the Veteran’s currently diagnosed DVT is etiologically related to active service. 4. The weight of the probative evidence of record is at least in equipoise with regard to demonstrating that the Veteran has current disabilities of sleep apnea and headaches that are etiologically related to his service-connected PTSD. 5. The Veteran’s PTSD is manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, but not total occupational and total social impairment. 6. The Veteran filed his original claim for service connection for left hand burns, left ring finger disability, and right wrist laceration on August 10, 2000, and separated from service on September 30, 2000. 7. The Veteran filed an original claim for service connection for a mental disorder of PTSD on July 28, 2014. 8. The Veteran filed an original claim for service connection for chronic diarrhea, right thumb disability, and painful scars, on August 10, 2000, and separated from service on September 30, 2000. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a neck disability have not been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for DVT have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for sleep apnea, as secondary to PTSD, have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 6. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for headaches, as secondary to PTSD, have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 7. The criteria for a staged increased rating of 70 percent, but not higher, for PTSD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. 8. The criteria for an earlier effective date than October 1, 2000, for service connection for a left ring finger disability, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 9. The criteria for an earlier effective date than October 1, 2000, for service connection for right wrist disability, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 10. The criteria for an earlier effective date than October 1, 2000, for service connection for burns, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 11. The criteria for an earlier effective date than July 28, 2014, for service connection for PTSD, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 12. The criteria for an earlier effective date of October 1, 2000, but not earlier, for service connection for a right thumb disability, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 13. The criteria for an earlier effective date of October 1, 2000, but not earlier, for service connection for painful scars, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. 14. The criteria for an earlier effective date of October 1, 2000, but not earlier, for service connection for chronic diarrhea, have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.816. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1974 to September 2000. Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of elements necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in a December 2014 letter. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by claimant or representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the most recent May 2018 statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Service connection may be presumed for certain chronic diseases, such as arthritis, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of that disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. 3.307, 3.309(a). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. That does not mean that any manifestations in service will permit service connection. To show 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 as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing a service connection claim. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Continuity of symptomatology applies only to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The first requirement for any service connection claim is evidence of the presence of a disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992). 1. Entitlement to service connection for GERD The Veteran contends that he developed GERD as the result of active service. However, a close review of the competent medical evidence of record, to include a VA examination and opinion, demonstrates that the Veteran’s GERD is not etiologically related to any aspect of the Veteran’s service, or that GERD arose during service and continued until the present. As an initial matter, the Board notes that the Veteran has been diagnosed with GERD during the pendency of the claim. Specifically, VA medical records and a March 2015 VA gastrointestinal examination show a diagnosis of GERD. Therefore, a current disability is shown. However, during a March 2015 VA examination, the examiner, after a noted review of the medical history and claims file, ultimately concluded that the Veteran’s GERD was less likely than not (less than 50 percent probability) incurred in or caused by any aspect of the Veteran’s active service or any claimed inservice injury, event, or illness. The rationale provided was lack of evidence showing inservice incident or treatment for GERD, or any gastrointestinal issues. The examiner noted that the inservice medical record and post-service medical record immediately following service, showed no complaints or treatment for stomach issues, to include no diagnosis or mention of GERD or acid reflux. The Board acknowledges that the Veteran contends that GERD is due to his active service deployment in Iraq. The Veteran is competent to testify that he had stomach pain while in service, and current VA records show a diagnosis of GERD. However, to the extent that he has even claimed possible in service symptoms related to GERD, the Veteran is not competent to provide a medical opinion linking a current disability to service, or any event, injury, or disease during service. Providing a medical opinion does not involve a simple identification that a layperson is competent to make. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There are many possible causes of gastrointestinal disabilities and the Veteran is not shown to have the competence to medically diagnose them or to opine that any current GERD is related to service or any symptoms during service. A medical nexus opinion has been adequately provided by a trained VA medical examiner, who determined that GERD was not related to any aspect of the Veteran’s service. The Veteran has also not submitted any competent medical evidence showing that GERD is at least as likely as not related to service or any event, injury, or disease during service. The Board find that the most persuasive evidence is the VA medical opinion because of the medical training of the examiner. Therefore, the Board finds that the preponderance of the evidence is against a finding that GERD is related to service. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for left wrist and neck disabilities The Veteran claims that he incurred left wrist and neck disabilities that during service. The Board finds that a review of the competent medical evidence of record does not show that the Veteran currently has diagnosed left wrist or a neck disabilities. Therefore, the claim for service connection for both disabiltiies must be denied. Generally, to prevail on a claim of service connection, there must be competent evidence of (1) 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 or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). The threshold question that must be addressed is whether the Veteran has a current disability of the left wrist or neck. In the absence of proof of a present disability there is no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). A review of the competent service medical records, post-service VA and private medical records, shows no treatments, complaints, or diagnosis for any left wrist or neck disability, during or after service. A review of lay statements from family and friends, and the Veteran himself, also shows no additional competent evidence supporting a diagnosis or symptoms of a disability relating to his left wrist or neck. Other than a cursory note of some pain in the neck and left wrist in a December 2014 statement, the Veteran has provided no statement or evidence, lay or otherwise, that may shows any diagnosable disability of the neck or left wrist, or symptoms of any neck or left wrist disability. A review of a March 2014 general physical examination for the purposes of the Veteran’s VA claims found no neck or left wrist disability. During that array of examinations, the Veteran’s back, neck, hands, and wrists were specifically examined. In both examination reports, the examiner noted no diagnosis of any left wrist disability, or any abnormalities, to include range of motion, related to the left wrist. With regards to the neck, no cervical, or neck, disabilities were noted during the spine examination performed during the VA examinations. During the examination, the examiner noted the Veteran explicitly reporting no issues with his neck. No history related to any neck or left wrist disability was noted by the VA examiner in any examination report at that time. The Board acknowledges that the Veteran, in the one statement initiating his claim, noted that he had neck and left wrist pain. However, the Veteran is not competent to provide medical evidence to either diagnose a current disability or relate a current disability to service. A diagnosable disability of the left wrist and neck is not shown. The Board notes that competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Bruce v. West, 11 Vet. App. 405 (1998); Layno v. Brown, 6 Vet. App. 465 (1994); Harvey v. Brown, 6 Vet. App. 390 (1994). Competent medical evidence means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). Even acknowledging the Veteran’s single lay statement noting pain, that evidence cannot be considered competent to establish a current disability, especially in light of the relative silence on a diagnosis by medical professionals throughout the claims period relating to any disability of the left wrist and neck. The Board finds that the examination that did not find any neck or left wrist disability is the most persuasive evidence because of the training of the examiner. Consequently, in the absence of competent evidence, such as a medical diagnose of a disability, the threshold requirements for substantiating a claim for service connection are not met. Therefore, the claims for service connection for neck and left wrist disabilities must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for deep vein thrombosis (DVT) The Veteran contends that he developed DVT as the result of active service. The Board notes that the Veteran was diagnosed with DVT during the pendency of the claim. However, a close review of the competent medical evidence of record, to include a VA examination and nexus opinion, does not show that DVT is etiologically related to any aspect of the Veteran’s service, or that DVT arose during service and continued until the present. Specifically, VA medical records and a March 2015 VA examination shows a diagnosis of recurrent DVT. Therefore, the Board finds that a current disability is shown. However, during a March 2015 VA examination, the examiner, after a review of the Veteran’s medical history and claims file, concluded that the Veteran’s DVT was less likely than not (less than 50 percent probability) incurred in or caused by any aspect of the Veteran’s active service or the claimed inservice injury, event, or illness. The rationale provided was lack of evidence showing in service incident or treatment for DVT, to include any type of blood clots. The examiner noted that the inservice medical record and post-service medical record immediately following service, showed no complaints or treatment. The Board acknowledges that the Veteran contends that current DVT is due to active service. However, the Veteran and his friends and family, are not competent to provide a medical opinion linking a current disability to service, or any event, injury, or disease during service. A medical nexus opinion regarding DVT does not involve a simple identification that a layperson is competent to make. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As noted by the VA examiner, DVT has multifaceted etiologies, with many possible causes. The Veteran, as a lay person, is not shown to have the competence to medically diagnose DVT, or to opine that any current DVT is related to any aspect of service or any symptoms during service. A medical nexus has been adequately provided by a trained VA medical examiner, who determined that DVT was not related to any aspect of the Veteran service. The Veteran has also not submitted any competent medical evidence suggesting that any current DVT is at least as likely as not related to service. Therefore, the Board finds that the preponderance of the evidence is against a finding that DVT is related to service. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for sleep apnea and headaches. The appellant seeks service connection for sleep apnea and chronic headaches, to include as result of, or aggravated by, service-connected PTSD. A review of the complete medical evidence of record, to include a VA examination and opinion, and a private medical opinion, shows that the competent medical evidence to be at least in equipoise with regard to the diagnosis and etiology of the Veteran’s headaches and sleep apnea. Therefore, as the evidence is in relative equipoise, the Board must resolve reasonable doubt in favor of the Veteran, and the claims for service connection for both disabilities must be granted. In order to establish service connection, three elements must be established. There must be medical evidence of a disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303; Hickson v. West, 12 Vet. App. 247 (1999). Alternatively, secondary service connection may be established for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439 (1995). Both VA and private medical evidence, to include VA examinations, shows adequate diagnoses of chronic headaches and obstructive sleep apnea. In a March 2015 VA examination, the Veteran was not only diagnosed with headaches and sleep apnea, but the examiner also provided an opinion with regard to the possible etiology of these conditions. Specifically, after a review of the Veteran’s medical history and claims file, the examiner found that both disabilities were less likely than not due to any aspect of the Veteran’s service. With specific regards to sleep apnea, the examiner noted that there was no evidence that the Veteran had symptoms of sleep apnea during, or immediately after service. The examiner noted that there was no evidence of any treatment or complaint for sleep apnea during service, and therefore, sleep apnea was not etiologically related to active service. The examiner also found that while there was evidence that the Veteran had headaches during service, those headaches was clearly acute due to other issues, specifically an eye condition. The examiner noted that a review of the service medical records showed that those headaches were ultimately resolved. Therefore, the examiner found that the chronic recurrent headaches were not due to service. However, the Board notes that neither VA examination report spoke to any potential secondary nexuses with regard to the service-connected PTSD. The Veteran submitted evidence from a private examiner who concluded that both the Veteran’s sleep apnea and headaches were the result of the service-connected PTSD. In an extensive April 2016 analysis of the Veteran’s PTSD, headaches, and sleep apnea, completed on VA medical forms, the private physician, Dr. H.S., explicitly noted that the Veteran’s headaches and sleep apnea were secondary to PTSD. The examiner noted extensive medical literature and included supporting articles on studies relating headaches and sleep apnea to psychiatric disabilities such as PTSD. After a thorough review of the claims file, the Board finds that the evidence of record is at least in equipoise with regard to the etiology of headaches and sleep apnea. Since the VA examiner did not address any secondary nexus with regard to either claimed disability, the April 2016 private examination opinion is the only examiner to have actually opined as to any potential secondary etiology, which the Board finds highly probative and persuasive. Consequently, as the nexus opinions of record are not actually in contradiction, the Board finds that the evidence establishes that while the Veteran’s headaches and sleep apnea did not arise from, or out of active service, headaches and sleep apnea are secondary to service-connected PTSD. Therefore, the Board finds that the evidence is at least in equipoise. Resolving reasonable doubt in favor of the Veteran, the Board must find that service-connection for headaches and sleep apnea is warranted, and service connection must be granted for headaches and sleep apnea. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to a rating in excess of 30 percent for PTSD. Increased Rating Disability ratings are determined by the application of the VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). Different ratings may be assigned for separate periods of time if distinct periods are shown by the competent evidence of record during the pendency of the appeal that warrants different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Whether lay evidence is competent and sufficient in a particular case is an issue of fact and that lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board has authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another provided that VA offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429 (1995). Diagnostic Code 9411 is used to rate PTSD and applies the General Rating Formula for Mental Disorders. A 50 percent rating is assigned when 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 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is assigned for 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is assigned 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. That portion of VA’s Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities was based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) IV prior to a change effective August 4, 2014. 38 C.F.R. § 4.130. The regulation has been changed to reflect the current DSM, the DSM-5. However, that change does not apply to this claim, which was pending at the time of the change. The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between 0 and 100, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. This case involves assignment of GAF scores and those assignments are relevant to the Veteran’s level of impairment due to his PTSD. In evaluating the evidence, the Board also considers the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61 to 70 indicates some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally reflects that a person is functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. A GAF score of 41 to 50 indicates there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals), or any serious impairment in social, occupational, or school functioning (e.g., no friends, inability to keep a job). The Board notes that an examiner’s classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered, but is not determinative in and of itself, of the percentage rating to be assigned. The Board observes that to adequately evaluate and assign the appropriate disability rating to the Veteran’s service-connected psychiatric disability, the Board must analyze the evidence as a whole, including the Veteran’s GAF scores and the enumerated factors listed in 38 C.F.R. § 4.130, Diagnostic Code 9411. Mauerhan v. Principi, 16 Vet. App. 436 (2002) (rating specialist is to consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV). The Veteran seeks entitlement to a higher rating than the 30 percent rating currently assigned for PTSD. The Board finds that an assessment of the relevant medical evidence of record shows that the Veteran’s PTSD, for the entire claims period has been consistent in both the frequency and severity of symptoms to be productive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, which warrants a higher 70 percent rating. Therefore, the claim for an increased rating must be granted. The evidence for this period includes a January 2015 VA examination, a February 2016 private psychiatric opinion, VA medical records, and lay statements from the Veteran’s friends and family. VA examination conducted in January 2015 noted a diagnose of PTSD, with symptoms such as depressed mood, trouble sleeping, anxiety, hypervigilance, irritability, detachment, and some memory loss. The examiner noted that the Veteran’s symptoms did amount to clinically significant distress or impairment, however, the Veteran has not shown to manifest any indications of suicidal or homicidal ideations, hallucinations, difficulty understanding complex commands, impaired judgment or thought process, obsessive rituals, or disorientation. The examiner found the Veteran to be fully oriented, with normal thought process, and appropriate hygiene. Ultimately, the examiner noted his condition was only productive of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In support of his claim, the Veteran has provided statements from his friends and family that outline both his psychological struggles since his return from service. To this end, the Board notes that much of such accounts included changes in mood and behavior towards others, specifically a lack of interest in socializing and hobbies, and issues with crowds. Overall, such lay statements outline increased isolation and detachment by the Veteran, with some exception for close family and friends. Of particular note was a December 2014 letter from the Veteran’s brother, which outlined struggles with depression, to include suicidal ideations and intrusive thoughts of hurting others. The Veteran was described as irritable and had thoughts of hurting people who disagreed or confronted him. The brother also noted hypervigilance especially in public where there were crowds. The Veteran’s increased ill temperament was further noted by the Veteran’s friend and fellow soldier from his active service. In a letter, the Veteran’s friend noted again the Veteran’s short temperament since his service, to include issues with his anger and concentration. The friend noted a changed person since the Veteran left service, with increased irritability and anger. In February 10, 2016, the Veteran provided VA with a psychiatric examination conducted by Dr. H. G., a private treating psychologist. The examination report, completed on a VA PTSD Report, VA Form 21-0960P-3, noted symptoms such as depressed mood, poor concentration, issues with memory and attention, hyperarousal, avoidance, sleep issues, and isolation. Most importantly of note, the examiner noted the Veteran’s suicidal ideations, unprovoked irritability, inability to establish meaningful relationships, impaired impulse control with periods of violence, persistent delusions, and in danger of hurting self and others. Dr. H. G. ultimately concluded that based on the Veteran’s symptoms and considering totality of both the psychiatric history, that the Veteran’s PTSD was productive of severe impairment to functioning, to include deficiencies in areas such as work, family relations, thinking, and mood. During the interview with the Veteran, and examiner noted that the Veteran described a previous instance in which his suicidal ideation was so severe that he found himself pressing a loaded gun to his head. With regards ot his relationships, the examiner noted that the Veteran was socially isolated and withdrawn, and could only perform some daily living task; the Veteran maintains some familial and close friendly relationships, with much of his daily chores taken up by his son. The examiner also noted that the Veteran’s irritability and unpredictable mood prevents him from obtaining or maintaining employment of any kind. Finally, the examiner explicitly noted that this level of severity with regard to the Veteran’s PTSD, and its associated symptoms and manifestation, directly relates back to the Veteran’s service. To this end, the examiner explicitly notes on several occasions in the report that these symptoms and their relative severity has existed since the Veteran filed his claim, and probably earlier, since service. The Board notes that a 70 percent rating is assigned for conditions that are productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Under those criteria, consideration is given to symptoms such 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. However, those symptoms are not an exclusive list and the focus is on the levels of social and occupational impairment caused by the psychiatric symptoms. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board finds that a 70 percent rating is warranted for the Veteran’s PTSD for the entire appeal period. The Board finds that while not all the symptoms for a 70 percent rating have been fulfilled, that is not necessary to warrant the higher rating. The symptoms listed in the criteria act more as examples, than an exhaustive list of requisite manifestations of a psychiatric disability. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Princzi, 16 Vet. App. 436 (2002). The Board notes that psychiatric professionals have evaluated the totally of the Veteran’s PTSD for the appeal period, in a February 2016 private examination, the examiner not only specifically found that the Veteran’s PTSD rose to the level productive of a 70 percent rating, but also explicitly noted that such array of manifestations has been present since his service. The Board finds that the latter February 2016 private examination and analysis of the severity of the Veteran’s PTSD to be at least in equipoise with regards to the earlier January 2015 VA examination. While the two examinations determined different levels of impairment, the Board finds that the evidence to be in relative equipoise. Specifically, the February 2016 examiner found and evidence of severe irritability, suicidal ideations, increased isolation, and potential for violent behavior. Such behavior and manifestation is corroborated by the lay statements provided by the Veteran’s friends and family around the time of the earlier examination in late 2014 and early 2015. Specifically, in a December 2014 letter from the Veteran’s brother, those exact manifestations of wanting to hurt other, and himself, were described. A close review of such letter, reveals that such letter was not received, date stamped, by the VA until a few weeks after the January 2015 VA examination. Therefore, the earlier examination did not have the full array of evidence prior to determining the full severity of the Veteran’s PTSD. Therefore, the Board finds both examinations to be at least equally probative, and as further review of the remaining VA medical records reveal no additional evidence of increase or decrease in symptoms, and that the evidence is in relative equipoise. The Board finds both examinations are well-reasoned with comprehensive understanding of the Veteran’s medical condition at the time, and both reports demonstrate knowledge of the Veteran psychiatric history. Therefore, as the evidence is in equipoise, the Board finds that the latter private examination by Dr. H. G., which found the Veteran’s condition to more approximate occupational and social impairment with deficiencies in areas such as work, family relations, thinking, and mood, to be most in the Veteran’s favor, and therefore, a higher 70 percent rating is warranted. 38 C.F.R. § 4.7. Finally, the Board finds that a higher 100 percent rating for PTSD is not warranted. Specifically, there is no evidence that the Veteran had total occupational and social impairment due to PTSD. There is no indication that the psychiatric disability was so severe that he could not maintain his personal hygiene, or lost orientation of time and space. The Board notes that while the Veteran’s PTSD may prevent him from maintaining work, due to his mood and irritability, the Veteran was noted to have had some hobbies, and maintains a relationship with his family and some close friend. In letters from his brother and friends, it was noted that the Veteran travelled and met with friend, and still went out socially, even though with some hypervigilance. While there is evidence that the Veteran requires help with daily chores, it is unclear whether such is due to some combination of his physical disabilities. Records have always demonstrated that the Veteran was appropriately dressed, was oriented to time and place, with normal speech, and was cooperative. Therefore, even considering the totality of the Veteran’s condition, the functional impairment of the psychiatric disability does not amount to more nearly approximating a total occupational and social impairment. Therefore, the Board finds that a 100 percent rating is not warranted. Consequently, a higher 70 percent rating, but not higher, for the entire appeal period, must be granted. However, the Board finds that the preponderance of the evidence is against the assignment of any higher rating. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to an effective date earlier than October 1, 2000, for service connection of right wrist laceration, left hand second degree burns, and left-hand ring finger disability, The Veteran contends that an earlier effective date is warranted for service connection for a right wrist disability, left hand burns, and left ring finger disability. Generally, the effective date for a grant of service connection is the date of receipt of the claim or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The effective date of an evaluation and award of compensation on an original claim for compensation will be the day following separation from active duty service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a)-(b)(1); 38 C.F.R. § 3.400(b)(2). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, the duly authorized representative, or a person acting as next friend who is not sui juris may be considered an informal claim. An informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. The Veteran’s claim for service connection for all the aforementioned service-connected conditions were granted pursuant to an original claim received by the VA in August 2000. The Veteran separated from service in September 2000. As such, in the December 2000 rating decision granting service connection for all three claims, the effective date of the entitlement was set at October 1, 2000, the first date after the Veteran separated from service. Here, as October 1, 2000 is the first day after the Veteran separated from service, no earlier date can be assigned for service connection, regardless of the date the initial claim was filed. Therefore, as an earlier date for the Veteran’s service-connected disabilities related to his right wrist, left hand burns, and left right finger, is not warranted, the Veteran’s claim for an earlier effective date must be denied. 7. Entitlement to an effective date earlier than July 28, 2014, for service connection of a right thumb disability and PTSD The Veteran contends that an earlier effective date is warranted for service connection for PTSD. Generally, the effective date for a grant of service connection is the date of receipt of the claim or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Here, the Board finds that the Veteran’s claim received, date stamped, July 28, 2014, is the first instance, formal or informal, in which a claim for service connection for a psychiatric condition can be construed. An extensive and thorough review of the all available evidence of record reveal no other communications, formal or informal, verbal or in writing, that can be construed as a claim for service connection for a psychiatric condition. In this regard, the Board points out that the Veteran has also not provided any evidence or statements alleging an earlier claim was submitted, or to this end, presented any arguments noting why an earlier effective date is warranted. Consequently, as there is no evidence of an earlier dated claim for service connection for PTSD, the effective date of July 28, 2014, the date his original claim was received, is proper. Therefore, as the preponderance of evidence is against an earlier effective date for the granted of service connection for PTSD, the claim must be denied. 8. Entitlement to an effective date earlier than July 28, 2014, for service connection of painful scars status-post right wrist laceration and chronic diarrhea. The Veteran contends that an earlier effective date is warranted for service connection for painful scars, right thumb condition, status-post right wrist laceration, and chronic diarrhea. As noted above, the effective date of an evaluation and award of compensation on an original claim for compensation will be the day following separation from active duty service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a)-(b)(1); 38 C.F.R. § 3.400(b)(2). A claim is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA, from a claimant, the duly authorized representative, or a person acting as next friend who is not sui juris may be considered an informal claim. An informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. Here, the Veteran’s claim for service connection for his right thumb condition, painful scars, and chronic diarrhea were all granted in a June 2015 rating decision, pursuant to a claim received by the VA on July 28, 2014. The Board, however, finds that the claims for all three conditions were all previously raise in an August 2000 original claim for service connection related to the Veteran’s left-hand burns, right hand lacerations, and Gulf War Syndrome, to include chronic diarrhea. Specifically, with regards to the Veteran’s claim for scars and right thumb disability, the Board notes that both conditions were ultimately related to the Veteran’s in-service right-hand laceration in service, and the Veteran’s left-hand burns. Both conditions, were explicitly raised by the Veteran in his claim in August 2000, prior to leaving service. The Board construes the Veteran’s explicit claims for residuals of both left hand and right-hand conditions to encapsulate those claim for a right thumb disability, which is found to be a direct result of the right-hand laceration, and the painful scaring of both hand from the burns and lacerations. The Board finds that these are not later developed, delay onset problems, as presumably, the Veteran’s scars has remained since his injury during service. Therefore, as the Veteran’s original claim for service connection for scars and a thumb condition, as residuals of his inservice hand injuries, the Board shall consider the Veteran’s August 2000 claim for his right and left hand to encompass those ancillary, but separate condition. Consequently, as the Veteran’s separated from service in September 2000, an October 1, 2000 effective date shall be warranted for both conditions. Likewise, with regards to the Veteran’s claim for chronic diarrhea, the Board notes that in the Veteran’s August 2000 original claim, the Veteran explicitly raised the claim that he experienced chronic-recurrent diarrhea. The Board construes that such communication should be construed as a claim for service connection, and as diarrhea is of the type of condition in which the Veteran is competent to attest to, the Board finds that such condition arose at or around that time. Consequently, an October 1, 2000, the day after the Veteran separated from service, effective date for service connection of chronic diarrhea is warranted, and the Veteran’s claim for an earlier effective date must be granted. REASONS FOR REMAND 1. Entitlement to service connection for a skin condition is remanded. With regard to the claim for a skin condition, the Veteran was not provided a VA examination to assess the nature and etiology of the claimed disability. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Robinette v. Brown, 8 Vet. App. 69 (1995). In a claim for service connection, evidence that suggests a nexus, but is too equivocal or lacking in specificity to support a decision still triggers the duty to assist if it indicates that the Veteran’s condition may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that sufficient evidence is of record to trigger the VA’s duty to obtain a competent medical opinion with regard to any potential etiological relationship between his skin condition and active service. The Board notes that the Veteran has consistently expressed that his suffers from recurrent rashes on his skin since his active service. While there is no medical evidence of a diagnosis or treatment, the Board finds that the Veteran, as a lay person, is competent to speak to the existence of rashes on his skin, and that he has been experiencing those symptome since service. Accordingly, the Board finds that the claim must be remanded for further development. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, VA must acquire a VA medical opinion regarding the etiology of any skin condition as it relates to any aspect of the Veteran’s active duty. 2. Entitlement to an increased rating for lumbar spine, right shoulder, left right finger, right wrist, left knee, chronic diarrhea, left hand burns, painful scars, and a right thumb, disabilities are remanded. With regard to the claims for increased ratings, the Veteran was provided the most recent VA examinations for the service-connected disabilities in February 2015, more than three and half years ago. The Board recognizes that, generally, the mere passage of time is not a sufficient basis for a new examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007). However, when available evidence is too old for an adequate evaluation of the current condition, VA’s duty to assist includes providing more current examinations. Weggenmann v. Brown, 5 Vet. App. 281 (1993). The Board finds that not only are the most recent examinations remote, but those examinations appear to no longer indicate the Veteran’s current levels of disability. Consequently, after all outstanding medical records are associated with the claims file, a more contemporaneous examination is needed to rate the Veteran’s claims for increased ratings. Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). The matters are REMANDED for the following action: 1. Obtain all VA treatment medical records not already of record. 2. After obtaining appropriate authorization, obtain any private treatment records identified by the Veteran, to include any records from his private chiropractor that are not already of record. 3. Then, obtain a medical opinion from an appropriately qualified VA examiner to assess the nature and etiology of any skin disability. The examiner must review the claims file and should note that review in the report. The examiner is ask to provide an opinion regarding the nature and etiology of each skin condition diagnosed or found of record, and whether it is at least as likely as not (50 percent probability or greater) that any skin disability diagnosed during the pendency of the appeal, (1) is related to the Veteran’s service or any event, disease, or injury during service, to include exposure to herbicide agents, (2) is due to or the result of any service-connected disability, or (3) was aggravated (permanently increased in severity beyond the natural progress of the disorder) by any service-connected disability. Any additional tests that the examiner deems necessary should be performed. The rationale for all opinions expressed should be provided. 4. Then, schedule the Veteran for a VA examination of the service-connected back disability. The examiner must review the claims file and should note that review in the report. The examiner is asked to report on the current nature and severity of the Veteran’s back disability, to include a current diagnosis. A complete rationale for any opinion expressed should be included in the examination report. The examiner should provide range of motion of the back and should state whether there is any additional loss of function due to pain, excess motion, weakened motion, fatigability, incoordination, or on flare up. A complete rationale for any opinion expressed should be included in the examination report. 5. Then, schedule the Veteran for a VA examination for a right shoulder disability. The examiner must review the claims file and should note that review in the report. Any studies or tests deemed necessary should be performed. The examiner should provide a complete rationale for any opinions provided. The examiner is asked to report on the nature and severity of the Veteran’s left shoulder disability. The examination must include range of motion testing expressed in degrees for active motion, passive motion, weight-bearing, and nonweight-bearing, and for the opposing joint. The examiner is also specifically asked to describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, incoordination, or on flare up. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. 6. Then, schedule the Veteran for a VA examination of the service-connected hand disabilities. The examiner must review the claims file and should note that review in the report. The examiner is asked to report on the current nature and severity of the Veteran’s hand disabilities, to include a current diagnosis. A complete rationale for any opinion expressed should be included in the examination report. The examiner should provide range of motion of the hand, wrist, and fingers and should state whether there is any additional loss of function due to pain, excess motion, weakened motion, fatigability, incoordination, or on flare up. A complete rationale for any opinion expressed should be included in the examination report. 7. Then, schedule the Veteran for a VA examination of the service-connected skin and scars disabilities. The examiner must review the claims file and should note that review in the report. The examiner is asked to report on the current nature and severity of the Veteran’s hand disabilities, to include a current diagnosis. A complete rationale for any opinion expressed should be included in the examination report. A complete rationale for any opinion expressed should be included in the examination report. 8. Then, schedule the Veteran for VA examination to determine the nature and severity of any disabilities related to chronic diarrhea. The examiner must review the claims file and should note that review in the report. The examiner must explain the reasons for any opinion offered. 9. Then, schedule the Veteran for a VA examination of the knees. The examiner must review the claims file and should note that review in the report. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should provide a complete rationale for any opinions provided. The VA knee examination must include range of motion testing expressed in degrees for both knees for active motion, passive motion, weight-bearing, and nonweight-bearing. Correia v. McDonald, 28 Vet. App. 158 (2016). The examiner is also specifically asked to describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion should be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. The examiner is also asked to indicate whether there is recurrent subluxation or lateral instability of the right knee, and if so, the severity of any recurrent subluxation or lateral instability. The examiner should provide an opinion as to whether there is loss of use of the left leg such that no effective function remains other than that which would be equally well served by an amputation stump at the site of election, with use of a suitable prosthetic appliance. The determination should consider remaining function and whether acts such as balance and propulsion could be accomplished equally well by an amputation with prosthesis. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Zi-Heng Zhu, Associate Counsel