Citation Nr: 18160761 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 16-06 829 DATE: December 28, 2018 ORDER Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right knee disability, is denied. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disability (TDIU) is granted. REMANDED Entitlement to service connection for a foot disorder, to include plantar fascitis, is remanded. Entitlement to an increased rating in excess of 10 percent for the Veteran’s right elbow strain is remanded. Entitlement to service connection for a right ankle disorder, to include as secondary to the right knee, is remanded. Entitlement to an increased rating in excess of 10 percent for the Veteran’s right knee strain is remanded. FINDINGS OF FACT 1. A left knee disorder was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 4.9 (2017). 2. The Veteran meets the schedular requirement for TDIU, and the combined effects of his service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. A left knee disorder was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 4.9 (2017). 2. The criteria for TDIU have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2002 to October 2004. This case comes before the Board of Veterans’ Appeals (Board) on appeal from April 2013, September 2014, and March 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2013, the RO denied an increase in evaluation for the Veteran’s right knee and right elbow (both originally service connected in March 2009), and denied service connection for the left knee and right ankle. In a September 2014 rating decision, the RO denied service connection for a foot disorder. The appeal streams were merged by the RO. The Veteran also was denied TDIU initially in a March 2017 rating decision which remains a separate appeal stream. However, as the claim for TDIU is partly based upon the increased rating claim issues on appeal, the Board finds that the issue of entitlement to TDIU is currently on appeal and jurisdiction is proper. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection – Left Knee Disorder 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. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish entitlement to service connection for a disability, a veteran must show: (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, 1166-67 (Fed. Cir. 2004). For the showing of 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. If chronicity in service is not established for a chronic disease as enumerated for VA compensation purposes, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for an enumerated “chronic disease” listed under 38 C.F.R. § 3.309(a) can also be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service, such as arthritis. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). That is, under 38 C.F.R. § 3.303(b), with an enumerated “chronic disease” shown in service (or within the presumptive period under § 3.307), subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. See also Groves v. Peake, 524 F.3d 1306, 1309 (2008). This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear cut clinical entity, at some later date. For the showing of 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.” To determine that a chronic disease was “shown in service,” the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b). As arthritis is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not necessarily accorded to each piece of evidence contained in the record; every item of evidence does not necessarily have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. In considering the evidence of record under the laws and regulations, the Board concludes that the Veteran is not entitled to service connection for the claimed left knee disorder. The Veteran’s service treatment records are silent for left knee symptoms, complaints, treatment, or diagnoses. On an October 2004 Report of Medical History, the Veteran responded that he did not experience knee trouble. In service, he suffered a fall from a ladder in December 2003 and his right hand, right wrist, right elbow, right knee, and right eyebrow were treated. His right knee is service connection under limitation of flexion due to chronic knee strain from August 2008. Post-service medical records show a January 2012 examination write up from a private medical doctor, Dr. J.L., who diagnosed the Veteran’s knees with bilateral plicas and scarring of the articular lining, right knee. Dr. J.L. wrote that the Veteran’s knees pop and click when he walks, giving him pain and upon examination the bilateral knees show popping plicas posteriorly and pain and palpation. The Veteran did not ambulate with any antalgia and radiographic imaging revealed he had no significant abnormalities for his age with normal joint spaces and no evidence of prior fractures. The Veteran was afforded a VA examination in February 2013. The VA examiner recognized diagnoses of a 2009 right knee chronic strain and plica syndrome bilaterally from 2012, and she provided a negative opinion on secondary service connection. The rationale contained that while the right knee is service connected for a strain, both knees are affected by plica, diagnosed bilaterally after service. It was found that the service-connected right knee strain is less likely than not a cause of the Veteran’s left knee plica because the right knee strain has not resulted in an abnormal gait, which, if a gait abnormality was noted on examination, would increase weightbearing on the non-affected side, but even then, the plica affects both knees. Finally, it was noted that the Veteran’s left knee plica is currently asymptomatic and the Veteran’s X-Ray results were normal. The Board notes that the value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support [her] opinion.” Bloom v. West, 12 Vet. App. 185, 187 (1999). A medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record). The Board finds that the February 2013 VA opinion is the most probative evidence of record. The examiner provided a medical opinion supported by rationale and a discussion of the Veteran’s medical history and evaluation results. In addition, she observed the Veteran’s gait and offered an opinion based upon his specific gait. The Board has considered the Veteran’s statements regarding his left knee disorder onset, specifically that his left knee aches when his right knee flares up and that he experiences popping bilaterally. See February 2013 VA examination at 26. The Veteran is competent in this case to provide testimony regarding his symptoms. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of his current left knee disorder and whether or not it was caused by his right knee disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming the Veteran’s lay assertions regarding etiology were competent, the Board nevertheless finds the VA examiner’s opinion more probative, as it is based on a review of the record and the examiners’ medical expertise. The examiner provided a thorough rationale after examining the Veteran, soliciting a history from him, and analyzing the Veteran’s gait. Therefore, the Board finds that the evidence of record does not show that the Veteran has a current left knee disorder that is directly related to his service or that is due to his service-connected right knee disorder. The Board also notes that the evidence of record also does not support a diagnosis of a degenerative knee disorder (or arthritis), within one year of separation from service. Indeed, there is no evidence showing that arthritis manifested to a compensable degree within one year of his military service. As such, presumptive service connection is also not warranted. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the reasons outlined above, the Board concludes that the weight of the evidence is against a finding of entitlement to service connection for a left knee disorder. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether she or he can find employment. Van Hoose, 4 Vet. App. at 363. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is entitled to TDIU. The Veteran is currently service-connected for dysthymic disorder evaluated at 70 percent, right elbow strain evaluated at 10 percent, and right knee strain evaluated at 10 percent, and an overall combined rating of 80 percent. Thus, the Veteran has met the schedular criteria for TDIU. Accordingly, the remaining question is whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disability. A review of the evidence of record reflects the Veteran has worked as a construction electrician and completed a high school education prior to service. The Veteran’s career in construction required squatting, crawling, going up and down structures, and climbing ladders. A February 2009 examination noted that the Veteran’s history of chronic right knee pain bothers his work with a result of increased absenteeism with effects of the problem on usual daily activities. A January 2012 letter from Doctor J.L. shows that the Veteran’s right elbow causes pain when attempting to push heavy objects at work. The Veteran was afforded VA examinations in February 2013. Pertaining to the right elbow, the Veteran reported that using a screwdriver or big wrenches, the elbow would begin to hurt and throb. Functional loss including pain on movement. The VA examiner included that work is affected during flare-ups, he is unable to have his weight on the elbow during certain kinds of work, he is limited in using a wrench or tightening or loosening nuts and bolts due to pain, and is unable to sustain work without taking breaks. A functional loss of the right knee also included pain on movement. The Veteran reported swelling, popping, and having a problem with steps, ladders and squatting due to his knees. The VA examiner included that the right knee affects work in that the Veteran is required to be on concrete all day to run conduits, and be on his hands and knees on rollers. During flare ups all work activities are slowed down. Additionally, in construction when the knee is in a flare he operates much slower and thus less efficiently due to pain. A February 2014 medical opinion by Doctor H.H.G. accompanied the Veteran’s Notice of Disagreement for his plantar fasciitis service connection claim. The doctor found that the Veteran would miss three or more days per month and would have to leave early from the workplace three or more days per month due to mental problems. She also found that for more than three days per month the Veteran would not be able to stay focused for at least seven of eight hours in a workday and that about once per month the Veteran would respond violently if subjected to normal pressures and constructive criticisms of a job. The RO has denied TDIU because the Veteran did not return a completed VA Form 21-8940. However, records from the Social Security Administration (SSA) have been associated with the claims file which reflect the most recent year the Veteran had reportable income was 2013. In a document received February 2016, a letter written by Doctor H.H.G. dated February 2014 contains the opinion that the Veteran cannot sustain the stress from a competitive work environment and cannot be expected to engage in gainful activity secondary to severe dysthymic disorder, and also that the chronic pain and limited mobility related to his service-connected injuries have exacerbated and perpetuated his dysthymic disorder. She cited to medical literature detailing the connection between injuries with chronic pain and limited mobility with dysthymic disorder and to support the notion that individuals become disabled due to the holistic effect of medical and psychiatric disturbance. She wrote that the service-connected elbow, knee, and dysthymic disorders render the Veteran incapacitated. She opined that based on interview and review of the claims file that the Veteran’s service-connected knee and elbow injuries are aggravating the dysthymic disorder, and continues to be aggravated. A June 2018 opinion by vocational consultant and doctor of rehabilitation S.B. contains that following a review of the entire claims file, Doctor S.B. opines that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected dysthymic disorder, right elbow strain, and right knee strain. She also noted that the record supports this finding as far back as the date of filing. She supported her finding based on the Veteran’s medical history, including the examinations of record of the Veteran’s service-connected right elbow and right knee, and facts such as that his wife helps manage finances, his wife does the housekeeping and food shopping, and his wife states that the Veteran is incapable of helping. Doctor S.B. cited to research findings, including that most employers will tolerate variable rates of absence but most allow for no more than eight days per year and depending on the industry the figures can range from a half day per month to one day per month but the Veteran would be expected to exceed those number of absences due to his physical and mental symptoms. Although medical examiners are responsible for providing a full description of the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013), the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator, Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The Board finds that the totality of the evidence demonstrates that the Veteran cannot maintain gainful employment due to his service-connected disorders. Accordingly, entitlement to TDIU is warranted. REASONS FOR REMAND 1. Service connection for a foot disorder The Veteran has been diagnosed with plantar fasciitis and evidence in the claims file shows treatment for the diagnosed disorder. However, the Veteran has not been afforded a VA examination in connection with his claim and the record does not contain sufficient information to make a decision. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, a remand is necessary. 2. Service connection for the right ankle The Veteran was afforded a VA examination for his right ankle service connection claim in February 2013. The examiner provided an opinion addressing secondary service connection, but did not discuss direct service connection. The Veteran’s service treatment records reflect he injured his right ankle in February 2004. Post-service medical records show he has a current diagnosis of chronic tenosynovitis. On remand, the VA examiner should be asked to provide an addendum opinion on direct service connection. 3. Increased ratings for right elbow strain and right knee strain Additionally, a remand is necessary for the increased rating claims on appeal in order to comply with Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the Court concluded that 38 C.F.R. § 4.59 required VA examinations to include joint testing for pain on both active and passive range of motion, as well as with weight-bearing and nonweight-bearing. Although the Veteran was afforded VA examinations in February 2013, the examinations did not include all testing required under Correia. Thus, additional examinations must be provided. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his bilateral foot, right elbow, right knee, and ankle disorders that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral foot disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current bilateral foot disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should refer the Veteran’s claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of the Veteran’s right ankle disorder. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, February 2013 VA examination, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any right ankle disorders that may be present. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. In rendering his or her opinion, the examiner should consider the service treatment records showing treatment to the right ankle after falling off a ladder, when the Veteran felt a “pop” and experienced pain. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected right elbow disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the right elbow under the rating criteria. In particular, the examiner should provide the range of motion in degrees of the elbows. In so doing, the examiner should test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing of both elbows. 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 so in the report. The examiner should also comment on whether there is any form of ankylosis. He or she should further state whether there is any impairment of the clavicle or scapula, such as malunion, nonunion with or without loose motion, or dislocation; whether there is any flail joint or other impairment of the elbow, radius, or ulna; and whether there is any impairment of supination or pronation of the elbows. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examination conducted during the appeal period in February 2013. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected right knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the right knee disability under the rating criteria. In particular, the examiner should provide the range of motion of the left and right knees in degrees on 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 provide an explanation for this determination in the report. The examiner should also indicate whether there is any ankylosis; dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; or the symptomatic removal of semilunar cartilage. He or she should also address whether the Veteran has recurrent subluxation or lateral instability, and if so, comment as to whether such symptomatology is slight, moderate, or severe. The examiner should further state whether the Veteran has any impairment of the tibia and fibula. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examination conducted during the appeal period. See February 2013 VA examination. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. T. BERRY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Kuczynski, Associate Counsel