Citation Nr: 18159178 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-31 513 DATE: December 19, 2018 ORDER Entitlement to service connection for bilateral knee joint pain, to include neuropathy is denied. Entitlement to service connection for limited motion of the left ankle, to include neuropathy is denied. Entitlement to service connection for limited motion of the right ankle is denied. REMANDED Entitlement to service connection for bilateral neuropathy of the upper extremities, to include as secondary to service-connected follicular cell Non-Hodgkin’s Lymphoma, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence reflects that Veteran does not possess a current diagnosis for bilateral knee joint pain, to include neuropathy, as such the Board finds the claimed disability is not etiologically related to a disease, injury or even in service nor is the condition due to or aggravated by a service-connected disability. 2. The preponderance of the evidence reflects that Veteran does not possess a current diagnosis for limited motion of the left ankle, to include neuropathy, as such the Board finds the claimed disability is not etiologically related to a disease, injury or even in service nor is the condition due to or aggravated by a service-connected disability. 3. The preponderance of the evidence reflects that Veteran does not possess a current diagnosis for limited motion of the right ankle, to include neuropathy, as such the Board finds the claimed disability is not etiologically related to a disease, injury or event in service nor is the condition due to or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral knee joint pain, to include neuropathy, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for entitlement to service connection for limited motion of the left ankle, to include neuropathy, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 3. The criteria for entitlement to service connection for limited motion of the right ankle, to include neuropathy, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Marine Corps from August 1979 to July 1983. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, KY, which denied the claims on a direct and secondary service connection basis because the records do not show objective evidence of a current diagnosis for any of the claimed conditions. The Veteran filed a Notice of Disagreement in December 2013. A Statement of the Case (SOC) issued in May 2016 continued the claims denial, finding a lack of medical evidence to establish a diagnosis. The Veteran timely perfected his substantive appeal in June 2016. A Supplemental Statement of the Case (SSOC) issued in August 2018 reaffirmed and continued the denial of all claims. In an October 2018 Informal Hearing Presentation (IHP), the Veteran, through his representative, argued that the Board should award him service-connection entitlement solely based on his lay statements, and argued that in the alternate, his claims should be granted secondary service connection based on his service-connected follicular cell Non-Hodgkin’s Lymphoma disability. Further, the Veteran argued that in the event of a denial, he should be afforded another VA examination or medical opinion. In a second IHP, November 2018, the Veteran argued that he is entitled to service connection for the claimed conditions as secondary to his service-connected follicular cell Non-Hodgkin’s Lymphoma and argued there is more persuasive evidence of record than the single negative VA examination of record to support of his claims. Service Connection Service connection generally requires (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a causal relationship, or nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303 (2017); see Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability which is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310 (2017); Allen v. Brown, 1 Vet. App. 439 (1995). To establish secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing a medical relationship between the service-connected disability and the current disability for which compensation is sought. See Wallin v. West, 11 Vet. App. 509 (1998). The necessary medical relationship may be shown by evidence that the nonservice-connected disability is proximately due to or the result of a service-connected disability, or that the nonservice-connected disease or injury is aggravated (increased in severity due) to a service-connected disability. 38 C.F.R. § 3.310 (2017). 38 C.F.R. § 3.310(b) (2017). 1. Entitlement to service connection for bilateral knee joint pain, to include neuropathy The Veteran contends that his bilateral knee join pain, to include neuropathy, was caused by his military service, or in the alternate, is a disability secondary to his service-connected follicular cell Non-Hodgkin’s Lymphoma disability. As an initial matter, the Board notes that the record does not contain any medical evidence of a bilateral knee joint pain, neuropathy or radiculopathy disability at any point during the appeal. Review of the Veteran’s service treatment records evidences no complaints of, treatment, or diagnosis for any knee joint pain condition. The Veteran’s service treatment records demonstrate: (1) an August 1980 in-service occurrence of a posterior dislocation of the bilateral elbow; (2) a March 1981 diagnosis of partial ankylosis of the left arm, secondary to posterior dislocation; (3) complaints of the left arm falling asleep in July 1981; (4) complaints of parasthesia in the bilateral upper arm down to the wrist, including upper extremities numbness in August 1981, followed by a neurological examination and nerve conduction studies in August 1981 and March 1982; (5) a chronic history of bilateral neurological involvement in hips to posterior beginning in 1982; (6) an electromyographic diagnostic (EMG) of the left lower extremities in March 1982; and (7) complaints of sharp pain the bilateral buttock with pressure on the insider of the bilateral foot in June 1983. Likewise, the Veteran’s private medical treatment record does not reflect any knee joint disability. Although, records from January 2005 demonstrate the Veteran complained of aching knees, private treatment history shows that a physical assessment of the Veteran found no peripheral edema. In fact, the Veteran’s treatment records are devoid of a diagnosis or treatment or follow-up for any knee joint disability. Furthermore, private records from May 2011 and April 2012 indicate the Veteran denied any lower extremities edema, numbness, or muscle weakness, and did not report or seek treatment for any knee joint condition. The Veteran was afforded VA examination in September 2015. The examiner conducted an in-person evaluation, reviewed the Veteran’s claims file, and concluded that the evidence of record is negative for any complaints, treatment, or diagnosis for the claimed bilateral knee pain complaints during active duty service. The examiner also remarked that VA and private treatment records contain no objective evidence which warrant the establishment of any disability the Veteran’s bilateral knee joint pain because the examination findings were compatible with the Veteran’s plantar fasciitis diagnosis, not a knee joint disability. Further, the VA examiner found there was no functional impairment due to the Veteran’s reported symptoms. Remarking that pain, weakness, fatigability, or incoordination does not significantly limit functional ability, and noted that the Veteran denied having flare-ups so incapacitating limiting hs ability to perform activities of daily living. Cf. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (Finding that where symptoms result in a functional impairment a disability exists). The Board finds that the September 2015 VA examination report is probative. The Board finds that the weight of the evidence demonstrates that the Veteran does not have a current knee joint disability and service connection is not warranted. As noted above, the Veteran claims service connection for neuropathy. In his IHP brief’s the Veteran relies on the private the opinions from Dr. B., citing that the Veteran’s reports of muscle cramps and lower extremity were consistent with peripheral neuropathy, see Private Medical Treatment Record, March, November, and December 2013, and the listing of neuropathy as a problem in his private treatment records. See Carilion Clinic Treatment Records, October 2013. The Board acknowledges this argument and points that the March 2013 treatment records is not a conclusive diagnosis because Dr. B. referred the Veteran for an electromyography (EMG) and nerve conduction study (NCS) of his bilateral lower limbs. These neuropsychological tests were completed in December 2013, finding there was no clinical evidence of neuropathy or radiculopathy. The Board finds that the Veteran’s reliance on the private diagnosis of neuropathy is imprecise because it is not consistent with the objective medical evidence of record. Particularly, the Board finds that the September 2015 VA examiner’s opinion outweighs the private opinion and is more probative, because it is based on the negative neuropsychological diagnostic testing from December 2013, which found that the Veteran’s symptoms were compatible with his diagnosis of record for plantar fascial pain, and not a neuropathic condition. See VA Examination, September 2015. As such, based on the VA examiner’s negative opinion, which did not agree with the Veteran’s private neurologist’s diagnosis of bilateral lower extremity peripheral neuropathy, the Board finds that there is no current evidence of a lower extremities neuropathy or radiculopathy. The Board acknowledges that under certain circumstances, lay statements may support a claim by showing the occurrence of lay-observable events or the presence of disability, or symptoms of disability that are capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994) (finding lay evidence is competent if provided by a person with knowledge of the facts or circumstances and conveys matters that can be observed and described by a person without specialized knowledge or training); 38 C.F.R. § 3.159(a)(2) (2017). The Veteran credibly asserts that he experienced bilateral knee joint pain. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) and 38 C.F.R. § 3.159(a)(2) (2017). The Veteran is not competent to render a medical diagnosis of any bilateral knee joint pain or neurological condition as he does not have the specialized medical training or knowledge necessary for this determination. See Washington v. Nicholson, 19 Vet. App. 362 (2005). To the extent that the Veteran asserts that his bilateral knee joint pain is related to active service, such statements are of little probative value, as subjective pain in and of itself does not establish a current disability. Saunders, 886 F.3d 1356 (Fed. Cir. 2018). As discussed above, the Veteran does not have a current disability under the law, and as a result, direct service connection for a bilateral knee joint pain, to include neuropathy, disability cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Therefore, as there is no current disability, service connection on a presumptive basis or based on continuity of symptomatology is also not warranted. See 28 C.F.R. § 3.307, 3.309; Brammer, 3 Vet. App. 223; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013.) The Veteran’ Informal Hearing Presentations (IHP) argue that should a direct service connection claim fail, in the alternate, the claim should be granted pursuant to a secondary service connection based on his service-connected follicular cell Non-Hodgkin’s Lymphoma disability. The Board notes that in order to prevail under either theory, the Veteran must still provide evidence of a current disability. See Wallin, 11 Vet. App. 509 (1998). However, as discussed above, there is no objective medical evidence of record to show the Veteran has a current bilateral knee joint disability nor a current diagnosis for any neurologic condition. Moreover, as discussed above, the Veteran’s reliance on the private opinions to establish his claims is misguided because the referenced letters do not establish a current disability and do not show a medical relationship to the service-connected disability. Particularly, the February 2013 letter from Dr. B., does not establish a knee joint diagnosis nor does it establish a medical relationship between the claimed, and undiagnosed, bilateral knee joint condition and the Veteran’s service-connected follicular cell Non-Hodgkin’s Lymphoma. Expressly, Dr. B. states that it is his professional opinion that there is no way to clearly link the [Veteran’s] musculoskeletal complaints and findings with remote chemical exposure. (See Third Party correspondence, December 2013). Likewise, the July 2013 opinion from Dr. T. does not establish a diagnosis or nexus between the claimed bilateral knee joint disability and the Veteran’s service-connected disability. Dr. T. states that he is not able to opine as to the etiology of the [Veteran’s] musculoskeletal symptoms, but speculates, that common sense dictates that there may indeed be a causative relationship between the Veteran’s time of [chemical] exposure and the development of his cancer. (See Third Party Correspondence, December 2013). Moreover, as pointed by the VA examiner, the neuropsychological tests from December 2013 demonstrate there is no clinical evidence of record to support a finding of neuropathy or radiculopathy. Therefore, the Veteran’s claim for secondary service connection, based on his currently service-connected follicular cell Non-Hodgkin’s Lymphoma also fails because the evidence does not demonstrate a current disability. See Wallin, 11 Vet. App. 509 (1998). In light of the private etiology opinions referenced above discussing chemical exposure, the Board points that in October 2014 the Veteran clarified that he was not claiming his knee joint condition was caused by the contaminated water at Camp Lejeune. (See VA 27-0820, Report of General Information.) Finally, after careful consideration of all evidence in a given case, any reasonable doubt, meaning a point where there is an approximate balance of positive and negative evidence regarding any issue material to the determination (a legal condition called in equipoise), VA will resolve that doubt in the Veteran’s favor. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the weight of the evidence demonstrates a lack of a current diagnosis, as such the evidence weighs against the claim, and service connection on a direct and secondary basis for a bilateral knee joint pain disability must be denied. 2. Entitlement to service connection for limited motion of the left ankle, to include neuropathy The Veteran contends that his limited motion of the left ankle disability, to include neuropathy, was caused by his military service, or in the alternate, is a disability secondary to his service-connected follicular cell Non-Hodgkin’s Lymphoma disability. The record does not contain any medical evidence of a limited motion left ankle or neurologic disability at any point during the appeal. While as shown above, a review of the Veteran’s service treatment records evidences complaints of left ankle issues, a nerve conduction study of the left ankle, including the post-tibial and left peroneal nerves in March 1982, was within normal limits. An electromyographic diagnostic (EMG) of the left lower extremities in March 1982 also reports findings within normal limits. The most recent complaint involving the left limb, arises in June 1983, when the Veteran complained of sharp pain in the left buttock with pressure on the inside of his left foot. However, a physical examination report found the Veteran in normal condition, he was returned to full duty. No subsequent complaints or treatment for a left ankle condition are of record. The Veteran also claims service connection for neuropathy. The Board recognizes that the Veteran underwent a neurological examination and electromyographic diagnostic (EMG) and nerve conduction study (NCS) of the left ankle in March 1982; however, clinical evidence of record demonstrates these tests were all within normal limits. Moreover, as discussed above, while the Veteran relies on the private opinion of Dr. B. (see Private Medical Treatment Record, March, November, and December 2013), his reliance is unsound, because the March 2013 treatment record is not a decisive diagnosis of neuropathy. Rather, the record shows that Dr. B. referred the Veteran for bilateral electromyographic diagnostic (EMG) and nerve conduction study (NCS); however, these tests did not demonstrate a clinical finding of neuropathy or radiculopathy. See Private Treatment Records, December 2013; VA Examination, September 2015. Expressly, the Board notes that nothing in the record evidences the existence of a current left ankle disability. Moreover, since the neurological examination, electromyographic and nerve conduction diagnostics from March 1982 and December 2013 were all within normal limits; and the lack of subsequent complaints or treatment evidence an interruption in symptomatology since service separation for a left ankle condition. Indeed, in September 2015, the VA examiner provided a negative opinion, finding that the objective clinical evidence of record and lack of present symptomatology did not warrant the diagnosis of a left ankle disability, including no evidence of neuropathy or radiculopathy. While the examiner did not account for the Veteran’s in-service complaints during the early 1990s for a left ankle issue, this oversight is not prejudicial because of the lack of symptomatology and treatment since separation of service. Particularly, the Board notes that the Veteran complained of bilateral heel pain September 2014, however, his treatment records showed an objective examination revealed minimal point tenderness over the inferior aspect of bilateral heel, without masses, deformity, or edema. The rest of the foot, ankle and peripheral pulses were assessed as normal; a diagnosis of plantar fasciitis was rendered. The Board has considered the Veteran’s assertions that his left ankle disability, including neuropathy, is etiologically related to service. While the Veteran is competent to report symptoms, which are within the realm of his personal knowledge; he is not competent to opine on a complex medical question of etiology, as this requires medical expertise. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Consequently, the Veteran’s assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant the claim for service connection in this case. For this purpose, the Veteran’s statements have little probative value and the Board assigns more weight to the medical opinion by the 2015 VA examiner. Upon review of the evidence, the Board finds that the preponderance of the evidence is against the Veteran’s claim for direct service connection for limited motion of the left ankle, including neuropathy and radiculopathy. In this regard, the Board finds that the September 2015 VA medical opinion constitutes the most probative evidence of record. The VA examiner provided a reasoned analysis of the case and supported the conclusion that there is no objective medical evidence to support a finding that the Veteran has a current limited motion of the left ankle disability or neurologic condition, because of the absence of symptomatology during examination and because of the absence of limited motion of the left ankle complaints or treatment for many years after service. The Veteran does have a current disability under the law, and as a result, direct service connection for a limited motion of the left ankle, including neuropathy, cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Further, as there is no current disability, service connection on a presumptive basis or based on continuity of symptomatology is also not warranted. See 38 C.F.R. § 3.307, 3.309; Brammer, 3 Vet. App. 223; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013.) The Veteran’s claim for secondary service connection for limited motion of the left ankle, including neuropathy, based on his currently service-connected follicular cell Non-Hodgkin’s Lymphoma, also fails because the record does not demonstrate a current disability. See Wallin, 11 Vet. App. 509 (1998); supra 2, (direct service connection discussion). The preponderance of the evidence is against a finding that the Veteran has a current disability. Accordingly, the “benefit of the doubt” rule is not applicable, and the Board must deny the claim. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Entitlement to service connection for limited motion of the right ankle The Veteran contends that his limited motion of the right ankle, to include neuropathy, was caused by his military service, or in the alternate, is a disability secondary to his service-connected follicular cell Non-Hodgkin’s Lymphoma disability. The record does not contain any medical evidence of a limited motion right ankle disability at any point during the appeal. As shown above, a review of the Veteran’s service treatment records contains no complaints of, treatment, or diagnosis for any right ankle disability. Supra at 1. As discussed above, supra at 2, when the Veteran complained bilateral heel pain September 2014, upon examination his foot, ankle and peripheral pulses were assessed as normal, a diagnosis of plantar fasciitis was rendered. Furthermore, the claim for neuropathy also fails because the objective medical evidence of record shows that although the Veteran underwent a neurological examination, electromyographic and nerve conduction diagnostics in service in March 1982, post-service in December 2013, the impressions of both tests were all within normal limits. Supra at 2. Additionally, the VA examiner’s opinion from September 2015, which concluded that the Veteran did not have a definitive and objective diagnosis of peripheral neuropathy of the lower extremity, is more probative than the private opinion of Dr. B. (see Private Medical Treatment Record, March, November, and December 2013), because it is supported by objective diagnostic evidence of record finding. See VA Examination, September 2015; Private Treatment Records, October 2012 (noting the Veteran’s symptoms of pain mid heel, which stops at ball of his feet at the arches is related to his plantar fasciitis); Private Treatment Records, October 2012 (recording complaint of pain mid-heels stopping at ball of feet at arches, assessing the Veteran with [bilateral] plantar fasciitis); Private Treatment Records, April 2012 (denoting no complains of lower extremities edema, numbness in hands or feet, or muscle weakness); Private Treatment Records, May 2011 (denying denying lower extremities edema, numbness in feet; Private Treatment Records); May 2010 (denying numbness in feet); and Private Treatment Records, November 2008 (denying numbness in feet). While the Veteran is competent to report limited motion of the right ankle symptoms; he is not competent to opine on a complex medical question of etiology, as this requires medical expertise. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Consequently, the Veteran’s assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant the claim for service connection in this case. For this purpose, the Veteran’s statements have little probative value and the Board assigns more weight to the medical opinion by the 2015 VA examiner. Indeed, the Board finds that the September 2015 VA medical opinion finding that the objective medical evidence of record demonstrates that the Veteran does not have a current limited motion of the right ankle or neurologic disability constitutes the most probative evidence of record. The Veteran does not have a current disability under the law, and as a result, direct service connection for a limited motion of the right ankle, including neuropathy, cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Further, as there is no current disability, service connection on a presumptive basis or based on continuity of symptomatology is also not warranted. See 28 C.F.R. § 3.307, 3.309; Brammer, 3 Vet. App. 223; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013.). Likewise, the Veteran’s claim for secondary service connection for limited motion of the left ankle, based on his currently service-connected follicular cell Non-Hodgkin’s Lymphoma, also fails because the record does not demonstrate a current disability. See Wallin, 11 Vet. App. 509 (1998). The preponderance of the evidence is against a finding that the Veteran has a current limited motion for the right ankle disability. Accordingly, the “benefit of the doubt” rule is not applicable, and the Board must deny the claim. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for bilateral neuropathy of the upper extremities (claimed as paralysis of the median nerve) The Veteran seeks service connection for bilateral neuropathy of the upper extremities or in the alternate, secondary service connection to his service-connected follicular cell Non-Hodgkin’s Lymphoma. The Board acknowledges that the record contains instances when a physical examination of the Veteran’s lower extremities demonstrates no edema, numbness in hands or fee, muscle weakness, and peripheral pulses and flexes are normal. However, apposite to the examiner’s finding that there record contains no neuropathy diagnosis, the Veteran’s private record shows that in March 2013 he was diagnosed with neuropathy, and that condition remains listed as an ongoing medical problem. Moreover, throughout the appeal period the Veteran has maintained that he continues to experience neuropathy symptoms. The Veteran was afforded a VA examination in September 2015, to address the nature and etiology of his bilateral neuropathy of the upper extremities. The examiner offered a negative opinion. However, the Board finds that the examination report is incomplete. The examiner noted that the Veteran’s treatment records were negative for complaints, treatment, or diagnosis of the claimed condition during and after service separation. Further, the examiner remarked that an examination of the Veteran demonstrates that he does not have a definitive and objective diagnosis of peripheral neuropathy. However, there is no indication that the examiner considered the Veteran’s in-service history reporting upper extremities numbness in 1981; the examiner did not provide a rationale explaining why the Veteran’s private treatment records listing neuropathy as an ongoing medical problem since 2013 are not of significance in finding a current diagnosis; nor did the examiner address why the March 2013 private medical opinion from Dr. B. finding that the Veteran’s neurological exam was consistent with peripheral neuropathy is insufficient to support a current diagnosis of bilateral neuropathy of the upper extremities. VA’s duty to assist includes providing an adequate examination when such an examination is indicated. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). An examination is adequate if it takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). An examination must be based upon consideration of the Veteran’s past prior history and examinations. Stefl, 21 Vet. App. At 123. Since the opinion is not supported with sufficient reasoning, an opinion which specifically addresses the nature and etiology of the Veteran’s private treatment neuropathy diagnosis. The matter is REMANDED for the following action: Schedule the Veteran for an examination to determine the nature and etiology of VA bilateral neuropathy of the upper extremities disability. The Veteran’s claim file should be made available to the examiner prior to the examination, and the examiner must review the entire claims file in conjunction with the examination. The examiner should also note and discuss as appropriate the May 2013 neuropathy diagnosis reflected in the Veteran’s Carilion Clinic treatment records, consider the Veteran’s lay statements regarding continuous symptomatology, and discuss the Veteran’s service treatment records from 1981 detailing complaints of upper extremities numbness. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as deemed appropriate. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Steele, Associate Counsel