Citation Nr: 18155225 Decision Date: 12/03/18 Archive Date: 12/03/18 DOCKET NO. 10-43 871 DATE: December 3, 2018 ORDER As new and material evidence has not been received, the petition to reopen a claim of service connection for varicose vein of the left testicle is denied. New and material evidence having been received, the petition to reopen the claim of service connection for chondromalacia of the left knee is, to this extent only, granted. A rating of 70 percent, but no higher, for schizophrenia is granted, subject to regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for chondromalacia of the left knee is remanded. FINDINGS OF FACT 1. A July 1980 rating decision denied the Veteran’s claim of service connection for varicose vein of the left testicle; the Veteran did not appeal this decision, and new and material evidence was not actually or constructively received within a year of its issuance. 2. Evidence received since the July 1980 rating decision does not relate to an unestablished fact necessary to substantiate the claim of service connection for varicose vein of the left testicle; and does not raise a reasonable possibility of substantiating such claim. 3. A July 2004 rating decision denied the Veteran’s claim of service connection for chondromalacia of the left knee; the Veteran did not appeal this decision, and new and material evidence was not actually or constructively received within a year of its issuance. 4. Evidence received since the July 2004 rating decision relates to an unestablished fact necessary to substantiate the claim of service connection for chondromalacia of the left knee; and raises a reasonable possibility of substantiating such claim. 5. Throughout the period on appeal, the Veteran’s service-connected schizophrenia has been manifested by symptoms resulting in occupational and social impairment, with deficiencies in most areas, such as work, school family relations, judgment, thinking or mood. CONCLUSIONS OF LAW 1. The July 1980 rating decision that denied a claim for service connection for varicose vein of the left testicle is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. New and material evidence has not been received, and the claim for service connection for varicose vein of the left testicle is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The July 2004 rating decision that denied a claim for service connection for chondromalacia of the left knee is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 4. New and material evidence has been received, and the claim for service connection for chondromalacia of the left knee is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 5. Throughout the period on appeal, an increased disability rating of 70 percent, but no higher, is warranted for the Veteran’s service-connected schizophrenia. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.7, 4.21, 4.125, 4.130. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1975 to November 1978 and March 1981 to June 1982. These matters are before the Board of Veterans’ Appeals (Board) on appeal from December 2008 and July 2009 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). New and Material Evidence The Veteran asserts that he is entitled to service connection for varicose vein of the left testicle and chondromalacia of the left knee. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. “New” evidence means existing evidence not previously submitted to agency decision-makers. “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003). The United States Court of Appeals for Veterans Claims (Court) has held that the requirement of new and material evidence raising a reasonable possibility of substantiating the claim is a low threshold. The Court interpreted the language of 38 C.F.R. § 3.156(a), and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” See Shade v. Shinseki, 24 Vet. App. 110 (2010). 1. Whether new and material evidence has been received to reopen a claim of service connection for varicose vein of the left testicle The Veteran contends that he is entitled to service connection for varicose vein of the left testicle. The Veteran originally filed a claim for this condition in December 1978 and was denied service connection in a July 1980 rating decision based on a finding that “a single lifting injury [noted in service] is not felt to have caused a vericocele [sic] of the left testicle.” The Veteran did not file a notice of disagreement (NOD) and new and material evidence was not actually or constructively received within a year of the rating decision. Therefore, the July 1980 rating decision is final as to the denial of service connection for varicose vein of the left testicle. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103; see Turner v. Shulkin, 29 Vet. App. 207 (2018). The evidence of record at the time of the July 1980 rating decision consisted of the Veteran’s DD-214 and service treatment records (STRs). The evidence associated with the claims file after the July 1980 rating decision includes private treatment records, VA treatment records, and a June 2015 VA examination for male reproductive system conditions. The evidence listed above is new in that it was not of record at the time of the July 1980 rating decision. However, this evidence is not material as it does not indicate that any condition of the Veteran’s left testicle is related to the injury in service. Although a 1994 treatment record from Hospital Pavia indicates the Veteran had a left varicocele removed, this evidence is not material as it does not indicate that the removal was related to the Veteran’s in-service injury or otherwise related to his service. This evidence only reflects that the Veteran had a left varicocele, a fact which was established at the time of the July 1980 decision. The other VA and private treatment records and June 2015 VA examination report also do not indicate that the Veteran had any condition of the left testicle that was related to his service. As such, the new evidence does not relate to an unestablished fact necessary to substantiate the claim and is not material. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Shade, 24 Vet. App. 110. As new and material evidence has not been received to reopen the claim for service connection for varicose vein of the left testicle, reopening the claim is not warranted. 38 C.F.R. § 3.156(a). 2. Whether new and material evidence has been received to reopen a claim of service connection for chondromalacia of the left knee The Veteran also contends that he is entitled to service connection for chondromalacia of the left knee. The Veteran originally filed a claim for this condition in June 1982 and was denied service connection in a March 1983 rating decision based on a finding that chondromalacia was a congenital disability and did not warrant service connection. The Veteran did not file a NOD and new and material evidence was not actually or constructively received within a year of the rating decision. The Veteran filed a petition to reopen the claim in April 2000, and in an October 2000 rating decision he was denied service connection because the medical evidence did not reflect that the condition had an onset during service. The Veteran did not file a NOD and new and material evidence was not actually or constructively received within a year of the rating decision. The Veteran filed another petition to reopen his claim for service connection in January 2004. In a July 2004 rating decision, the Veteran was again denied service connection as there was no worsening of the condition in service. Therefore, the July 2004 rating decision is final as to the denial of service connection for chondromalacia of the left knee. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103; see Turner, 29 Vet. App. 207. The evidence of record at the time of the July 2004 rating decision consisted of the Veteran’s DD-214, STRs, VA treatment records, an April 2000 VA Form 21-4138, Statement in Support of Claim from the Veteran, and a VA examination from June 2000. The evidence associated with the claims file after the July 2004 rating decision includes updated VA treatment records and a September 2018 private medical nexus opinion from Dr. J.E. The evidence listed above is new in that it was not of record at the time of the July 2004 rating decision. Most pertinently, the September 2018 private nexus opinion is also material as the claim has been denied on the basis that chondromalacia was not a compensable disability, there was no indication that the condition began during service, and that military service did not permanently worsen the condition (which was noted in the July 2004 rating decision to have existed prior to service). The September 2018 private nexus opinion indicates that the Veteran has been complaining of knee problems since the mid-1970’s and that it is clear from the evidence that his left knee condition began in service, or at least was made worse during service. Since the September 2018 private nexus opinion relates to an unestablished fact necessary to substantiate the claim, it is also material. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also Shade, 24 Vet. App. 110. As new and material evidence has been received to reopen the claims for service connection for chondromalacia of the left knee, reopening the claim is warranted. 38 C.F.R. § 3.156(a).   Increased Rating Entitlement to an increased rating for schizophrenia In December 2008, the Veteran filed a claim for an increase to his schizophrenia rating. The July 2009 rating decision continued a 30 percent rating for schizophrenia. The Veteran appealed this decision. During the course of the appeal, in a May 2014 rating decision, the RO increased the Veteran’s rating to 70 percent, effective April 30, 2013. As a grant of 70 percent is not a full grant of the benefit sought on appeal and the 70 percent rating was not granted for the entire period on appeal, the claim before the Board is whether the Veteran is entitled to a rating in excess of 30 percent prior to April 30, 2013 and in excess of 70 percent from April 30, 2013. Disability ratings are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Lay statements may support a claim for an increased rating by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Veteran’s schizophrenia is currently rated pursuant to the general rating formula for mental disorders in 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent evaluation is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted 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 ideations; 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 work like settings); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Court’s interpretation of the criteria for rating psychiatric disabilities as set out in Mauerhan. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The Board notes that it has reviewed all the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to the appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran was provided a VA examination in January 2009 in response to his request for an increased rating. On examination, the VA examiner noted a diagnosis of paranoid schizophrenia. The Veteran reported paranoid delusions, insomnia, auditory hallucinations, irritability and frustration, all since service. The Veteran was cooperative, his affect was appropriate, he presented with a depressed mood, and was easily distracted with a short attention span. The examiner noted that the Veteran’s description of his symptoms was vague. The examiner concluded the Veteran had no delusions or hallucinations, understood the outcome of his behaviors, with average intelligence sleep disturbances that are managed with medication, and no obsessive or ritualistic behavior. The VA examiner also reported that the Veteran did not have panic attacks, homicidal or suicidal thoughts, or episodes of violence. He noted that the Veteran had good impulse control, ability to maintain personal hygiene, with a very depressed mood. Finally, the VA examiner noted that the Veteran had reduced reliability and productivity due to his mental disorder symptoms, such as paranoid delusions, insomnia, auditory hallucinations, and irritability and frustration. An August 2009 VA depression screen reflects that the Veteran had little interest or pleasure in doing things for several days and was feeling down, depressed, or hopeless for several days. In an April 2013 Mental Disorders Disability Benefits Questionnaire, the physician noted that the Veteran had occupational and social impairment with reduced reliability and productivity. He also noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, difficulty understanding complex commands, disturbances of motivation and mood, difficulty adapting to stressful situations, suicidal ideation on and off with previous attempts, impaired impulse control (such as unprovoked irritability with periods of violence), persistent delusions and hallucinations, anhedonia, labile mood, apathy, poor impulse control, crying spells, guilt, low self-esteem, and suspiciousness. On VA examination in December 2013, the VA examiner noted that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. He noted in the Veteran’s history that he works, but he sometimes feels people looking at him, and that in 2012 he could not sleep and was seeing ugly faces, feeling depressed, and wanted to kill himself. On examination, the VA examiner noted that the Veteran was suspicious (paranoid) and anxious during the examination; further, that he hears voices that give him directions, feels somebody touching him, and has hypervigilance. In a March 2015 private psychiatric note, Dr. H.C. reported that after service the Veteran required several hospitalizations due to persecutory delusions, auditory and visual hallucinations, periodic incoherence, aggression, poor impulse control, and severe deterioration in his social, family, and work functions. He indicated that since that time the Veteran had been treated recurrently with psychotropic drugs. In the July 2018 Appellant’s Brief, the Veteran’s representative argued that the Veteran’s schizophrenia has been manifested by paranoia, persistent delusions, and an intermittent inability to perform the activities of daily living, including maintenance of minimal personal hygiene. In a September 2018 opinion for a different disability, the private physician noted that the Veteran had been working as a postal carrier for the U.S. Postal Service since 1991. The Board finds that in resolving the benefit of the doubt in favor of the Veteran, he is entitled to a rating of 70 percent, but no higher, for the entire appeal period. As noted before, the Veteran filed his claim for an increased rating in December 2008, at which time he was rated at 30 percent. He was granted an increase to 70 percent in a May 2014 rating decision, effective April 30, 2013. As such, the analysis will consider the first period on appeal initially and then evaluate whether he is entitled to a rating in excess of 70 percent throughout the appeal period. The Board finds that prior to April 30, 2013 the symptomatology of the Veteran’s paranoid schizophrenia warrants an increased disability rating of 70 percent. To warrant a 70 percent rating, symptoms must result in 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 ideations; 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 work like settings); inability to establish and maintain effective relationships. On the VA examination in January 2009, the Veteran reported that he experienced paranoid delusions, insomnia, auditory hallucinations, irritability and frustration, all since service. While on examination he was cooperative and appropriate, he presented with a depressed mood, and was easily distracted with a short attention span. The Board notes that the VA examiner did not endorse that the Veteran had delusions or hallucinations, he did opine that the Veteran had reduced reliability and productivity due to his mental disorder symptoms, such as paranoid delusions, insomnia, auditory hallucinations, and irritability and frustration. Then in August 2009, on a depression screen, the Veteran reported little interest or pleasure in doing things for several days and was feeling down, depressed, or hopeless for several days. As such, and resolving any doubt in favor of the Veteran, the Board finds that the evidence, when taken together, most nearly approximates that the frequency, duration, and severity of the Veteran’s symptoms of his psychiatric disorder resulted in occupational and social impairment with deficiencies in most areas prior to April 30, 2013. Therefore, he is entitled to a higher 70 percent disability rating prior to April 30, 2013. In light of the grant of 70 percent prior to April 30, 2013, the Veteran is now at 70 percent for the entire period on appeal and the remaining analysis will focus on if he is entitled to a rating in excess of 70 percent at any point during the appellate period. In the July 2018 Appellant’s Brief, the Veteran’s representative argued that the Veteran’s schizophrenia has been manifested by paranoia, persistent delusions, and intermittent inability to perform activities of daily living. The 2013 Disability Benefits Questionnaire reflects that the Veteran presented with occupational and social impairment with reduced reliability and productivity with symptoms that included impaired impulse control, persistent delusions and hallucinations, and suicidal ideation with on and off attempts. In the December 2013 VA examination, the VA examiner noted that the Veteran currently works as a carrier at the US Post Office, and was hospitalized in 2008 or 2010 after an episode that caused hospitalization with tachycardia. Also, that he appeared paranoid and anxious during his interview and that he has auditory hallucinations. In the March 2015 private psychiatric note, Dr. H.C. reported that after the Veteran was discharged from service the Veteran had been hospitalized with delusions, auditory and visual hallucinations, aggression, poor impulse control, and severe deterioration of social, family, and work functions. However, he indicated that the Veteran’s symptoms were now managed with psychotropic drugs. In order to warrant a 100 percent rating, the frequency, duration, and severity of symptoms, such as persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) must result in total occupational and social impairment. The evidence of record reflects that the Veteran has experienced persistent delusions and hallucinations, periodic incoherence, suicidal ideations, poor impulse control, and intermittent inability to perform maintenance of minimal personal hygiene, all of which are symptoms included in the 100 percent rating criteria. However, the record reflects that he is still employed. The clinicians who have evaluated the Veteran, and have noted the above symptoms, including, the private psychiatrist who submitted a Disability Benefits Questionnaire in April 2013, have consistently noted that the frequency, severity, and duration of his symptoms result in either occupational and social impairment with reduced reliability or an occasional decrease in work and social efficiency. The evidence also reflects that the Veteran has been employed as a postal worker since 1991 and remains employed as recently as September 2018. As such, even while some of the Veteran’s symptoms are noted under the 100 percent disability rating, in light of the opinions of the examiners on the impact of the frequency, duration, and severity of those symptoms on the Veteran’s work and social impairment, and the evidence reflecting that the Veteran is still employed with the Postal Service as recently as September 2018, the Board concludes that the frequency, duration, and severity of the Veteran’s symptoms have not resulted in total occupational and social impairment. As such, the Board finds that the Veteran’s schizophrenia most closely resembles occupational and social impairment with deficiencies in most areas, but no more, and a 100 percent disability rating is not warranted at any time during the appellate period. As such, a 70 percent, but no higher, disability rating is warranted throughout the appellate period. REASONS FOR REMAND Entitlement to service connection for chondromalacia of the left knee is remanded. As the claim for service connection for chondromalacia of the left knee is reopened, the Board must now shift to evaluating the claim on the merits. Unfortunately, a remand is necessary. The Veteran was last provided a VA examination for his claimed chondromalacia of the left knee in June 2000. The evidence added to the record since that time reflects that the Veteran’s left knee condition may include arthritis, that his complaints began during his first period of service, and that his continued service may have worsened his knee condition. As such, the Board finds the Veteran is entitled to a new VA examination to determine the nature and etiology of the claimed chondromalacia of the left knee. Based on when the Veteran’s left knee disability appears in his service treatment records, and based on his own lay statements, the Board finds it is necessary to discuss whether the Veteran is to be presumed sound upon his entry to service. A Veteran is presumed sound upon entry to service when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The Board finds that the Veteran was in sound condition on entry to active duty service for both periods of service. The Board notes that in September 1981 there are service treatment records which reflect complaints of knee pain “since about 4 years, progressively, severe”. However, there is no explanation or discussion of causation or etiology of the Veteran’s complaints of knee pain and there is no indication of a knee disability. Additionally, this statement indicates a potential onset during his first period of active duty. Therefore, for purposes of this remand and obtaining an examination, the Board does not consider this to be clear and unmistakable evidence of existence prior to the second period of service; therefore, the examination requests will not address questions related to the presumption of soundness. As the evidence reflects that the Veteran is also in receipt of private treatment for his condition, on remand, and with any help necessary from the Veteran, updated treatment records should be obtained.   The matter is REMANDED for the following actions: 1. With any needed assistance from the Veteran, including securing from him completed VA Form 21-4142, obtain all records as identified by the Veteran. Obtain any updated VA treatment records since August 2013. 2. After completion of 1 above, schedule the Veteran for a VA examination by an appropriate VA clinician to determine the nature and etiology of the Veteran’s claimed chondromalacia of the left knee. The claims file must be made available to the examiner. Based on review of the pertinent evidence of record, (and any tests, studies or examination deemed necessary) the examiner should provide the following opinions: (a) Identify all current diagnoses of the left knee. (b) For each identified current diagnosis, is it at least as likely as not (50 percent or better probability) that any currently diagnosed left knee condition is related to either period of his active duty service or any incident therein, including that he began to have retropatellar pain as part of a lot of hiking and rappelling in service or pain that began during boot camp? A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD LM Stallings, Associate Counsel