Citation Nr: 18150793 Decision Date: 11/16/18 Archive Date: 11/15/18 DOCKET NO. 18-03 975 DATE: November 16, 2018 ORDER Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for chronic bronchitis as due to an undiagnosed illness is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. FINDINGS OF FACT 1. The Veteran does not have a confirmed diagnosis of a left shoulder disability or reported symptoms attributable to an undiagnosed illness at any time during the appeal period or in close proximity thereto. 2. The Veteran does not have a confirmed diagnosis of a right shoulder disability or reported symptoms attributable to an undiagnosed illness at any time during the appeal period or in close proximity thereto. 3. The Veteran’s claimed respiratory disorders have clear diagnoses, and the evidence of record does not show that the Veteran’s respiratory conditions, to include acute bronchitis and asthma, were incurred during service. 4. There is no competent evidence of record that shows the Veteran has hypertension. 5. The evidence is approximately evenly balanced as to whether the Veteran has PTSD that is related to a conceded in-service stressor. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317. 2. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for entitlement to service connection for a respiratory disorder, to include bronchitis, as due to an undiagnosed illness have not been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317. 4. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. 3.303, 3.304, 3.307, 3.309. 5. With reasonable doubt resolved in the favor of the Veteran, the criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1, 2005 to June 10, 2005, and from August 21, 2005 to November 4, 2006. A November 2018 Report of General Information reflects that the Veteran indicated that he wished to revoke Christopher Loiacono as his representative of record. The Board will thus further address this case with the understanding that the Veteran is pro se (not represented in his appeal). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 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). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be “competent”. However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases, including hypertension and arthritis, may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen’s disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term “chronic disease” refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309 (a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). For such diseases, the second and third elements of service connection may be established by demonstrating (1) that a condition was “noted” during service; (2) post-service continuity of symptoms; and (3) medical or, in certain circumstances, lay evidence of a link between the present disability and the continuity of symptoms. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d at 1340. If a chronic condition is noted during service or during the presumptive period, but the chronic condition is not “shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,” i.e., “when the fact of chronicity in service is not adequately supported,” then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed.” Walker at 1336; 38 C.F.R. § 3.303(b). Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1) (VA has adopted an interim final rule extending this date to December 31, 2016). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317 (a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Board notes that, effective July 13, 2010, VA has amended its adjudication regulations governing presumptions for certain Persian Gulf War Veterans. Such revisions amend § 3.317(a)(2)(i)(B) to clarify that chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are examples of medically unexplained chronic multisymptom illnesses and are not an exclusive list of such illnesses. Additionally, the amendment removes § 3.317(a)(2)(i)(B)(4) which reserves to the Secretary the authority to determine whether additional illnesses are ‘medically unexplained chronic multisymptom illnesses’ as defined in paragraph (a)(2)(ii) so that VA adjudicators will have the authority to determine on a case-by-case basis whether additional diseases meet the criteria of paragraph (a)(2)(ii). These amendments are applicable to claims pending before VA on October 7, 2010, as well as claims filed with or remanded to VA after that date. See 75 Fed. Reg. 61,997 (Oct 7, 2010). Compensation under 38 U.S.C. § 1117 shall not be paid if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran’s most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the Veteran’s own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317 (c). The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War and is a Persian Gulf Veteran. 38 C.F.R. § 3.317 (e). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 1. Entitlement to service connection for a left shoulder disability 2. Entitlement to service connection for a right shoulder disability The Veteran contends that he developed right and left shoulder disabilities due to service. Service treatment records are negative for any complaints or treatment related to the right or left shoulder. Post-service treatment records contain complaints of right and left shoulder pain. In 2012 a clinician noted that the Veteran presented with complaints of shoulder pain associated with myofascial dysfunction and extreme muscle tension relating to anxiety. Imaging studies of the shoulders were normal, bilaterally. On VA examination in October 2013 the Veteran reported onset of bilateral shoulder pain during service. He denied any specific traumatic incident. He described bilateral shoulder pain while lifting his arms above his head for an extended period of time. He also described shoulder popping. Examination of the shoulders revealed no degenerative changes and the Veteran retained full range of motion of both shoulders. The examiner concluded that there was no objective evidence of a bilateral shoulder condition. The examiner further noted that the Veteran’s subjective complaints during the examination appeared out of proportion to objective exam findings. On VA Gulf War examination in 2013, the examiner determined, following a review of the claims file and examination of the Veteran, that the Veteran did not present with an unexplained or partially explained chronic multi-system illness. There was no objective evidence or history or physical findings consistent with a qualifying chronic disability subject to exposure to environmental hazards in Southwest Asia. Review of the evidentiary record shows that there is no competent or probative evidence showing that the Veteran currently has a right or left shoulder disability or reported symptoms attributable to an undiagnosed illness. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability,” and held that “[i]n the absence of proof of a present disability[,] there can be no valid claim.”); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C. § 1131 requires existence of present disability for VA compensation purposes). To the extent the Veteran complains of shoulder pain, symptoms alone, the Board has considered whether the Veteran’s claimed symptoms are of such severity that these would be considered a “disability” as used in 38 U.S.C. 1110. While functional loss caused by pain is akin to functional loss caused by physical disability, in this case, the Veteran has not demonstrated evidence of an upper or lower extremity disability. Cf. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Simply stated, the best evidence in this case provides evidence against the existence of a current “disability” affecting the right or left shoulder at this time The Board has considered the Veteran’s reported history of symptomatology related to his shoulders throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, however, his statements do not rise to a level of competency to offer an opinion as to the existence of a current diagnosis or etiology to an undiagnosed illness. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Determining the etiology of the Veteran’s claimed bilateral shoulder condition requires medical inquiry into biological processes, pathology, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have training, expertise, or skills needed to make such a determination. As a result, the probative value of his lay assertions is low. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against this claim, the doctrine is not for application. See 38 U.S.C. § 5107 (b); Gilbert, supra. 3. Entitlement to service connection for chronic bronchitis as due to an undiagnosed illness The Veteran contends that he has respiratory condition of chronic bronchitis, a due to his period of service, to include as due to an undiagnosed illness. Service treatment records do not indicate complaint of or treatment for a respiratory condition, to include bronchitis. After service, treatment records after 2012 documented treatment for bronchitis, not otherwise specified, as well as asthma and chronic obstructive asthma, also unspecified. On VA examination in September 2013, the Veteran reported having bronchitis for the first time in 2005 or 2006 after an acute two-week episode of bronchitis that resolved with treatment. Reportedly, since that initial treatment, it became chronic and manifested every winter. He related in-service exposure to blowing sand and sandstorms. He wore goggles and covered his face with a bandanna. The examiner noted that in post-deployment health assessment and clinical evaluations, including in October 2006, December 2006 and February 2007, the Veteran consistently denied any respiratory conditions, or any exposures to smoke from oil fire, or smoke from trash or feces burning. In December 2006 he was treated for bronchitis that resolved within two weeks. Treatment records were consistent with likely chronic obstructive asthma, for which he was being treated with medication. Imaging studies of the lungs and pulmonary function testing revealed no abnormalities. The examiner noted episodic acute bronchitis with bronchospasm. The examiner found no evidence of a chronic respiratory condition or disability. The examiner cited to the medical literature finding that there was competent evidence in support of a causal connection between environmental exposures in Southwest Asia and the subsequent (post-exposure) development of respiratory conditions such as episodic acute bronchitis with bronchospasm. It was noted that the Veteran had no respiratory symptoms or findings upon his October 2006 separation medical assessment and specifically denied chronic cough and difficulty breathing in a February 2007 Post-Deployment Health Re-Assessment report that also included the Veteran’s report of being in better health than prior to deployment. On VA Gulf War examination in 2013, the examiner determined, following a review of the claims file and examination of the Veteran, that the Veteran did not present with an unexplained or partially explained chronic multi-system illness. There was no objective evidence or history or physical findings consistent with a qualifying chronic disability subject to exposure to environmental hazards in Southwest Asia. After review of the evidence, the Board has determined that the evidence weighs against a finding of service connection for a respiratory condition, to include acute bronchitis and asthma. The medical evidence of record indicates that the Veteran has diagnosable conditions which would not qualify as medically unexplained or nondiagnosable for the purposes of presumptive service connection under 38 C.F.R. § 3.317. Moreover, the Veteran’s claimed bronchitis was found to be acute in nature, and thus not chronic for the purpose of service connection under 38 C.F.R. § 3.317. Finally, the evidence does not show that the Veteran’s claimed respiratory disorder, including bronchitis or asthma, was incurred in service for the purposes of establishing direct service connection. The Board acknowledges the Veteran’s lay statements that he noticed respiratory symptoms since a deployment in Southwest Asia. Although the Veteran may sincerely believe that he has a respiratory disorder or symptoms of an undiagnosed illness or medically unexplained multi symptom illness, he is not competent to determine whether his respiratory symptoms are a result of his military service, to include exposure to environmental hazards in Southwest Asia. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107 (b); Gilbert, supra. 4. Entitlement to service connection for hypertension The Veteran claims that her hypertension was incurred in service. For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater. The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. The Veteran contends he has hypertension which is a result of his military service. The Veteran’s service treatment records are silent at to any complaints, treatment for or diagnosis of hypertension while in service. Post-service treatment records are negative for a diagnosis of hypertension. The medical evidence associated with the electronic claims file does not show a diagnosis of hypertension at any time during service, or since the Veteran’s separation from service, including within the one-year period subsequent to his discharge from service. The Board notes that a VA examination is not required for this claim as there is no credible lay evidence or competent medical evidence indicating that the Veteran had hypertension in service or that the Veteran has hypertension currently. 38 C.F.R. 3.159. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006); Duenas v. Principi, 18 Vet. App. 512 (2004). As there is no evidence to establish the presence of hypertension, service connection must be denied. See Brammer, 3 Vet. App. at 225. 5. Entitlement to service connection for PTSD There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Establishing service connection for PTSD requires “(1) a current medical diagnosis of PTSD; (2) a link between the current symptoms and an in-service stressor; and (3) ‘credible supporting evidence that the claimed in-service stressor occurred.’“ Kays v. Snyder, 846 F.3d 1208, 1211 (Fed. Cir. 2017) (citing 38 C.F.R. § 3.304 (f)). If a stressor claimed by a veteran is related to the veteran’s fear of hostile military activity, and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service and there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304 (f)(3). “Fear of hostile military activity” is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. An example of such an event or circumstance is incoming artillery, rocket, or mortar fire. See id. In this case, the Veteran reported several stressors, including coming under sniper fire while stationed in Iraq. While he evaded the oncoming fire, he stated that other people in his unit were shot and killed. In a November 2017 statement of the case, the RO conceded a stressor based on fear of hostile military or terrorist activity considering his service in Kuwait and Iraq. In addition, there has been conflicting evidence as to whether the Veteran has a valid PTSD diagnosis. Treatment records following discharge show that the Veteran reported some increased stress during a National Guard evaluation in 2009, but with no specific diagnosis was recorded at the time. VA treatment records after 2012 document sporadic mental health treatment that reflect a history of depression since service, along with diagnoses of mood disorder and depressive disorder, not otherwise specified. Earlier records contained positive PTSD screenings with an assessment of rule out PTSD. A VA examiner in September 2013 the examiner found that the Veteran did not have a mental disorder diagnosis. The examiner noted that treatment records after 2012 only noted “rule out” PTSD. The examiner also noted that the Veteran’s reported stressor of coming under enemy sniper fire while stationed in Iraq was not adequate to support a diagnosis of PTSD because in a September 2006 Post-Deployment Assessment he denied having witnessed anyone being wounded, killed or dead. He also denied being in great danger of being killed. As such, the examiner determined that the Veteran did not have exposure to a traumatic event. The examiner further found that the Veteran’s psychometric testing results suggested malingering. By contrast, multiple VA treatment records after 2013, reveal an Axis I diagnosis of chronic PTSD. The records show that the Veteran’s treating psychiatrist and staff psychologists diagnosed chronic PTSD associated with stressful events in Iraq. As such, the evidence is approximately evenly balanced as to whether the Veteran meets the diagnostic criteria for PTSD. See Cohen v. Brown, 10 Vet. App. 128, 139, 140 (1997) (mental health professionals are presumed to know the requirements applicable to their practice and to have taken them into account when diagnosing PTSD). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that the Veteran has a current diagnosis of PTSD associated with the conceded in-service stressor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Even though the opinion of the VA treating psychiatrist and psychologists did not explicitly describe the Veteran’s in-service stressor in great detail and did not provide extensive rationales, this does not render the opinions inadequate. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). In this regard, it is readily apparent that PTSD was diagnosed as a result of the Veteran’s claimed in-service stressor. Moreover, as the September 2013 VA examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD, there is no direct contrary medical opinion(s) in the record. For the foregoing reasons, the evidence is at least evenly balanced as to whether there is a link between the Veteran’s PTSD and his conceded in-service stressor. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, and each of the criteria of 38 C.F.R. § 3.304 (f) have therefore been met, entitlement to service connection for PTSD is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability is remanded. 2. Entitlement to service connection for a right knee disability is remanded. The Veteran contends that he developed right and left knee disabilities due to service. At the outset, the Board notes that private treatment record in August 2010 noted knee swelling with an assessment plica in the knees and tight hamstrings. VA treatment records in 2013 showed treatment for complaints of intermittent knee pain and swelling. The clinician noted that imaging studies were consistent with plica syndrome. He was issued knee braces. The Veteran also underwent a VA knee examination in October 2013, and the examiner indicated that there was no current pathology for a diagnosis for either knee. However, the VA examiner did not address the diagnosis of bilateral knee plica syndrome. Because the Veteran had the diagnosis during the appeal period, the VA examiner needed to address that diagnosis and whether it was accurate or in error. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, a VA addendum opinion is required to address the etiology of any urinary incontinence present at any point during the period on appeal or in close proximity to the Veteran’s claim for service connection. See Romanowsky v. Shinseki, 26 Vet. App. 289, 321 (2013). The matters are REMANDED for the following action: 1. Obtain the Veteran’s relevant VA treatment records since November 2017 and associate them with the claims file. If possible, the Veteran should submit these himself. 2. Forward the record and a copy of this remand to the examiner who conducted the October 2013 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any right and/or left knee disability is related to the Veteran’s active service. In providing the above opinion, the examiner should be mindful that even if the plica syndrome has resolved, an opinion is still required regarding the etiology of the diagnosed disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The examiner must indicate that the record was reviewed. A complete rationale must be provided for each opinion given. JOHN J CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs