Citation Nr: 18152350 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 15-03 680 DATE: November 21, 2018 ORDER Entitlement to service connection for right foot disability, to include as secondary to service connected back and knee disabilities, is denied. Entitlement to service connection for left foot disability, to include as secondary to service connected back and knee disabilities, is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to Special Monthly Compensation (SMC) based on loss of use of a creative organ is denied. FINDINGS OF FACT 1. The Veteran’s right foot conditions of metatarsalgia and degenerative arthritis, which manifested many years after service, are not caused by service or any service-connected disability, and have not been worsened beyond their normal progression due to any service-connected disability. 2. The Veteran’s left foot conditions of metatarsalgia and degenerative arthritis, which manifested many years after service, are not caused by service or any service-connected disability, and have not been worsened beyond their normal progression due to any service-connected disability. 3. The Veteran’s erectile dysfunction is not caused by service or any service-connected disability, and was not worsened beyond its normal progression due to any service-connected disability. 4. The Veteran has loss of use of a creative organ, but this is not due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right foot disability, to include as secondary to service connected back and knee disabilities, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. The criteria for entitlement to service connection for left foot disability, to include as secondary to service connected back and knee disabilities, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for entitlement to service connection for erectile dysfunction, to include as secondary to service-connected back condition, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for entitlement to SMC based on loss of use of a creative organ have not been met. 38 U.S.C. §§ 1114(k), 5107; 38 C.F.R. §§ 3.102, 3.350(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1961 to December 1963. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Under applicable VA law, service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for arthritis, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of a 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.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309(a)). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling Leopoldo v. Brown, 4 Vet. App. 21 (1993), and Tobin v. Derwinski, 2. Vet. App. 34 (1991). SMC SMC is warranted if a veteran has suffered either the anatomical loss or the loss of use of one or more creative organs as the result of service-connected disability. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). The VA also acknowledges that an award for SMC based on loss of use of a creative organ in a male Veteran can be established if loss of erectile power is shown. The loss of erectile power must be secondary to a service-connected disease process. Once the evidence has been assembled, it is the Board’s responsibility to determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed.Cir.1996). The Board assesses both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. 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); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for right foot disability, to include as secondary to service connected back and knee disabilities. 2. Entitlement to service connection for left foot disability, to include as secondary to service connected back and knee disabilities. The Veteran contends that his current bilateral foot conditions are related to his military service. Specifically, the Veteran “reports gradual onset of bilateral toe and forefoot pain over the course of duty which he attributes to repetitive trauma from parachute jumps. He estimates he made around 30 jumps in service. He was treated conservatively for these complaints in service and has had progressively increasing pain ever since. He has undergone bilateral osteotomies and arthroplasties since discharge in 1998 and 1999.” As an initial matter, the Board finds that the Veteran meets the first element of service connection, both on a direct and secondary basis, as he has a current diagnosis of metatarsalgia and degenerative arthritis. See 38 C.F.R. § 3.303(a). Service treatment records reveal no complaints of, treatments for, or diagnoses of any foot conditions, to include pain, at any time during service although the Veteran reports being “treated conservatively in service.” Nonethless, the Veteran’s November 1963 medical examination report reflects normal clinical evaluations for his feet. At that time, the Veteran specifically denied having ever had or having now foot trouble. Medical treatment records dated between December 1999 and May 2000 reflect that the earliest indication of foot pain and treatment appears in records dated in December 1999. The Veteran complained of foot pain and bunions for “6 years.” At that time, the Veteran was referred for a podiatry consult and surgery on the right foot. The Veteran underwent foot surgery in 1998 and 1999. In June 2017, the Veteran underwent a VA examination to determine the nature and etiology of his claimed foot conditions. The examiner offered diagnoses of bilateral metatarsalgia and degenerative arthritis. The examiner considered the Veteran’s contentions that he experienced a gradual onset of bilateral toe and forefoot pain over the course of his service which he attributed to repetitive trauma from over 30 parachute jumps, for which he had been conservatively treated. The VA examiner conducted a physical examination of the Veteran, and reviewed his service and post service treatment records. In evaluating the claimed condition, the examiner determined that “the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.” The examiner provided a rationale that the service treatment records did not disclose foot injuries and complaints during service, and that “there is no gait or weight bearing disturbance on exam to suggest the veteran’s knee and back conditions as etiology for any foot condition. Current foot condition(s) [are] more likely due to typical senescent wear and tear over time since discharge.” The Board notes there are no medical opinions to the contrary. Based upon a review of the record, the Board finds that service connection for right and left foot disabilities, to include metatarsalgia and degenerative arthritis, are not warranted in this case because the evidence does not show a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability, and current disability being proximately due to service-connected disability. At the outset, the Board observes that the Veteran is competent to report conservative treatment for foot pain in service. However, his current recollections of chronic foot symptoms are inconsistent. In this respect, the Veteran specifically denied foot trouble upon separation with a clinical evaluation indicating normal feet. The post service medical records first reflect treatment in 1999, which is many years after service, wherein the Veteran described foot pain and bunions for “6 years.” The Board places greater probative weight to the Veteran’s statements in 1963 as they bear the indicia of reliability as being made in the context of obtaining appropriate medical evaluation upon discharge, and being contemporaneous in time to the time period in question. See Lilly’s An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). This lay report is consistent with the physical examination findings at that time which reflected a normal clinical evaluation of the feet. On the other hand, the Veteran’s current recollections of chronic foot pain since service are not consistent with his report of medical history in 1963 or his 1999 report of a 6-year history of foot pain and bunions. Thus, the most credible lay and medical evidence at discharge weighs against a finding of the onset of a chronic right and/or left foot disorder in service. In this context, the Board accords significant probative weight to the VA medical examination provided in June 2017. The examination and corresponding opinion reflects the examiner reviewed the Veteran’s pertinent medical history, and rendered findings consistent with the remainder of the evidence. In particular, the June 2017 the examiner acknowledged the Veteran's statements regarding onset, but noted that STRs were negative for any complaints of and/or treatment of any foot condition, and that the Veteran's November 1963 separation examination was notable for normal examination of the feet. Additionally, on his separation Report of Medical History, the Veteran marked that he had not had “foot trouble.” In light of the foregoing, the examiner concluded that the evidence of record does not support the Veteran’s lay statements, and opined that the claimed conditions are less likely than not incurred in or caused by military service. The Board finds that the factual history relied upon by the VA examiner is accurate for the reasons described above. The examiner also found that the Veteran’s right and/or left foot disorders were not caused or aggravated beyond the normal progress of the disorder by service-connected disabilities. In this respect, the examiner did not find a sufficient gait abnormality to provide a causal connection and also found that the current findings were consistent with being due to typical senescent wear and tear over time since discharge. On the other hand, the only evidence tending to support an association of right and/or left foot disability to service are the Veteran’s own contentions. The Board has considered the Veteran’s statements regarding onset of foot pain since service, but has held above, found his most credible recollection consists of his report at separation from service specifically denying foot trouble. As the credible evidence is against a finding of chronicity of symptoms since service, an award of service connection under the continuity provisions of 38 C.F.R. § 3.303(b) or the presumptive provisions applicable to chronic diseases manifesting within the first postservice year under 38 C.F.R. § 3.309(a) is not warranted. Walker, 708 F.3d 1331 (2013) Additionally, to the extent the Veteran is diagnosing an insidious disability or addressing questions of medical causation of any foot disability, the Board finds his statements are not competent lay evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Notwithstanding, the probative medical evidence outweighs the lay statements. Based on a review of the foregoing evidence, and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran’s claims of service connection for right and left foot disabilities. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claims for service connection, that doctrine is not helpful to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to service connection for erectile dysfunction The Veteran asserts that he is entitled to service connection for erectile dysfunction and for SMC for loss of use of a creative organ, both secondary to his service-connected back disability. After review of all of the evidence of record, lay and medical, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for erectile dysfunction. As an initial matter, the Board finds that the Veteran meets the first element of service connection, both on a direct and secondary basis, as he has a current diagnosis of erectile dysfunction. See 38 C.F.R. § 3.303(a). Service treatment records reveal no complaints of, treatments for, or diagnoses of erectile dysfunction at any time during service. In fact, the Veteran's STRs were negative for any complaints of and/or treatment of any foot condition, and that the Veteran's November 1963 separation examination was notable for normal clinical evaluations for the genitourinary system. Furthermore, the Veteran does not contend that his erectile dysfunction began during service, but rather that he began experiencing erectile problems many years after service. Post-service medical treatment records reflect that the earliest indication of erectile dysfunction is April 1995. In February 2014, the Veteran underwent a VA examination to determine the nature and etiology of his claimed condition. The VA examiner conducted a physical examination of the Veteran, and reviewed his service and post service treatment records. In evaluating the claimed condition, the examiner acknowledged the Veteran’s statements regarding onset, but noted that STRs were negative for any complaints of and/or treatment of erectile dysfunction, and that the Veteran’s November 1963 separation examination was notable as normal. Notably, as discussed above, the Veteran does not contend that his erectile dysfunction was incurred in service, nor does the evidence indicate such. As such, there is no basis for an award of service connection under the continuity provisions of 38 C.F.R. § 3.303(b) or the presumptive provisions applicable to chronic diseases manifesting within the first postservice year under 38 C.F.R. § 3.309(a). Regarding the Veteran’s specific contentions that his erectile dysfunction is secondary to his back disability, the Board finds that he is service-connected for back disability. See 38 C.F.R. § 3.310. However, the Board finds that there is insufficient evidence showing that the Veteran’s s erectile dysfunction is proximately due to, the result of, or aggravated by, his service-connected back disability. In the February 2014 VA examination, the examiner specifically explained that there was no connection between the Veteran’s erectile dysfunction and service-connected back disability under the circumstances of this case, based on the fact that his erectile dysfunction appeared to be caused by his benign prostatic hypertrophy. In evaluating the claimed condition, the examiner determined that “the condition claimed was less likely than not (less than 50% probability) proximately due to or the result of the service-connected condition. The examiner provided a rationale noting that “the only way that this veteran could have erectile dysfunction caused by his back condition would be if there was a disruption of the autonomic nerve system which controls the ability to obtain an erection. If so, he would also have issues with bowel and bladder control. There is an entry in his record that he has no bowel or bladder symptoms related to his back condition. He does, however, have urinary symptoms related to his benign prostatic hypertrophy. 15 to 25 percent of men over 65 have some degree of erectile dysfunction caused by the aging process.” The Board affords this rationale comprehensive and the opinion has significant probative value. Additionally, the Board notes the Veteran’s contentions that his erectile dysfunction is directly related to his service-connected back disability. However, as a lay person the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder, which requires both knowledge of the causes of erectile dysfunction and of the effects of his back disability on other bodily systems. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Under the circumstances of this case, the determination of the nature or etiology of his erectile dysfunction involves medically complex disease processes because of its multiple possible etiologies, require specialized testing to diagnose, and manifest symptomatology that may overlap with other disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Therefore, the Veteran is not competent to opine as to any medical nexus between his current erectile dysfunction and the service-connected back condition. As such, there is no competent, probative, or persuasive evidence contradicting the VA examiner’s opinion as to the nexus element. Therefore, the evidence weighs against a finding that the Veteran’s erectile dysfunction is related to active duty service or his service-connected back disability in any way. Accordingly, service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 4. Entitlement to SMC due to loss of creative organ The Veteran contends that he is entitled to SMC based on loss of use of a creative organ as he contends that service connection is warranted for erectile dysfunction as secondary to his service-connected back disability. The Veteran’s claim for SMC based on loss of use of a creative organ must be denied, as service connection for erectile dysfunction has not been established, and any such additional benefit may not be granted. Entitlement to SMC based on loss of use of a creative organ can also be granted based on erectile dysfunction. However, as service connection has not been awarded for erectile dysfunction, the Veteran's claim for SMC based on loss of use of creative organ is without legal merit and must be denied. See Sabonis, supra. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. REMANDED Entitlement to an initial rating in excess of 20 percent for degenerative disc disease of L5-S1, prior to August 29, 2008, is remanded. Entitlement to a rating in excess of 40 percent for degenerative disc disease of L5-S1, from August 29, 2008, to June 3, 2017, is remanded. Entitlement to a rating in excess of 20 percent for degenerative disc disease of L5-S1, from June 3, 2017, is remanded. Entitlement to a rating in excess of 20 percent for left knee instability, prior to June 3, 2017, is remanded. Entitlement to a rating in excess of 0 percent for left knee instability, from June 3, 2017, is remanded. Entitlement to a rating in excess of 10 percent for left knee arthritis is remanded. Entitlement to an initial rating in excess of 10 percent for right knee arthritis is remanded. Entitlement to an effective date earlier than September 14, 1999, for the award of a total disability rating based upon individual unemployability due to service connected disability (TDIU) is remanded. Entitlement to an effective date earlier than September 14, 1999, for the award of Dependents' Educational Assistance (DEA) is remanded. Entitlement to service connection for digestive disorder, claimed as diarrhea, is remanded. REASONS FOR REMAND The Board’s review of the record reveals that additional development on the remaining claims on appeal is warranted, even though such will, regrettably, further delay an appellate decision on the remaining matters on appeal. 1. Entitlement to an initial rating in excess of 20 percent for degenerative disc disease of L5-S1, prior to August 29, 2008, is remanded. 2. Entitlement to a rating in excess of 40 percent for degenerative disc disease of L5-S1, from August 29, 2008 to June 3, 2017, is remanded. 3. Entitlement to a rating in excess of 20 percent for degenerative disc disease of L5-S1, from June 3, 2017, is remanded. 4. Entitlement to a rating in excess of 20 percent for left knee instability, prior to June 3, 2017, is remanded. 5. Entitlement to a rating in excess of 0 percent for left knee instability, from June 3, 2017, is remanded. 6. Entitlement to a rating in excess of 10 percent for left knee arthritis is remanded. 7. Entitlement to an initial rating in excess of 10 percent for right knee arthritis is remanded. In June 2017, the Veteran was afforded VA examinations to assess the severity of her service-connected orthopedic disabilities. However, the Boards finds the examinations are inadequate for adjudication purposes. The examiner noted that the Veteran's pain limited functional ability with repeated use over time, but did not describe the functional impairment in terms of range of motion because the Veteran was not examined immediately after repetitive use and repetitive use over time. Notably, the examiner did not use the information provided by the Veteran or obtain additional information from the Veteran or the treatment records such as the frequency, duration, characteristics, severity, or functional loss with repetitive use. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). Therefore, a new VA examination must be obtained before the claim can be decided on the merits. 8. Entitlement to an effective date earlier than September 14, 1999 for the award of TDIU is remanded. 9. Entitlement to an effective date earlier than September 14, 1999 for the award of DEA is remanded. Finally, the Board defers consideration of the claims for earlier effective dates for TDIU and DEA for completion of the development discussed above as such actions could potentially affect the merits of the remaining claims on appeal and are inextricably intertwined with the matters being remanded. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). 10. Entitlement to service connection for digestive disorder, claimed as diarrhea, is remanded. In a September 2014 remand, the Board directed the AOJ to obtain a VA examination to address the claim for service connection for diarrhea. The Board specifically stated that “the examiner should identify all manifested symptoms and address any resulting occupational and social impairment as a result of the disability.” The Veteran attended a VA examination in January 2015 regarding his digestive disabilities. The examiner provided a physical examination, clearly detailed the history of the Veteran’s digestive disabilities, to include complaints of diarrhea and abdominal pain and cramping. The examiner specifically noted that the digestive disorders and residual symptoms of hiatal hernia, Barrett’s esophagus, gastritis. However, the examiner did not distinguish all of the manifested symptoms, nor did the examiner address whether the claimed diarrhea was a symptom of these conditions, or due to another etiology. Additionally, the examination did not provide an opine on whether the diarrhea condition is related to service or to the Veteran’s service-connected conditions. Without any opinion that identifies all manifested symptoms, a review of the record indicates that the Board’s directives were not substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the issue must be remanded to obtain an addendum opinion to identify all symptoms, and also to address the question of service-connection for the claimed diarrhea condition. The matters are REMANDED for the following action: 1. The AOJ should contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any recent relevant medical records, for his service-connected disabilities. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. 2. Afford the Veteran an appropriate VA examination to determine the nature and severity of his service-connected back disability and bilateral knee disabilities. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran’s description of reduced range of motion during flares or repetitive use, to include repetitive use over time. Also, in order to comply with the Court’s decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the VA examination must include range of motion testing in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Related to the claim for increased rating for degenerative disc disease of L5-S1, the examiner is asked to review the records, including previous VA examinations and treatment records, and provide opinions on the appropriate level of severity for the following time periods: prior to August 29, 2008, from August 29, 2008 to June 3, 2017, and from June 3, 2017 to present. The VA examiner should provide a complete rationale for any opinions provided. Related to the claim for left knee instability, the examiner is asked to make current findings, complete with a supporting rationale, regarding the current level of left knee instability, if any. The examiner is also asked to review the records, including previous VA examinations and provide an opinion on whether there is any evidence of instability at any time prior to June 3, 2017. The VA examiner should provide a complete rationale for any opinions provided. 3. Return the claims file to the January 2015 VA examiner. If the examiner is not available, then provide the claims file to another VA examiner of similar or greater qualifications to obtain an addendum opinion on whether the Veteran’s digestive disorder, claimed as diarrhea, is a separate condition or is a symptom of the Veteran’s other service-connected digestive disorders. If a new examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file the examiner should provide an addendum opinion that addresses the following: a. Is the Veteran’s claimed diarrhea a symptom of his other service-connected digestive disabilities, or a separate condition? b. If the Veteran’s diarrhea condition is a separate condition, is it at least as likely as not that the Veteran's diarrhea is related to service or to his service-connected conditions? c. If the Veteran’s diarrhea condition is a separate condition, is it at least as likely as not that the Veteran’s diarrhea has been permanently worsened beyond normal progression (versus temporary exacerbation of symptoms) by his service-connected digestive disabilities? d. If the examiner finds the diarrhea condition has been permanently worsened beyond normal progression, the examiner should attempt to quantify the degree of worsening beyond the baseline level of the digestive disorder, to include diarrhea. A rationale should be provided for all findings and conclusions and should be set forth in a legible report. (continued on next page) 4. The AOJ should readjudicate the claims in light of all pertinent evidence and legal authority. If any benefit(s) sought on appeal remain(s) denied, furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them an appropriate time period for response. T. Mainelli Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael J. O'Connor