Citation Nr: A19001572 Decision Date: 09/25/19 Archive Date: 09/25/19 DOCKET NO. 190416-12772 DATE: September 25, 2019 ORDER Readjudication of the claim for service connection for left leg shin splints is granted. Readjudication of the claim for service connection for right leg shin splints is granted. Readjudication of the claim for service connection for a right ankle disability is granted. Readjudication of the claim for service connection for a left ankle disability is granted. Readjudication of the claim for service connection for a right hip disability is granted. Readjudication of the claim for service connection for a left foot disability is granted. Readjudication of the claim for service connection for a right foot disability is granted. Readjudication of the claim for service connection for a right wrist disability is granted. Readjudication of the claim for service connection for a left shoulder disability is granted. Readjudication of the claim for service connection for a left knee disability is granted. Service connection for right lower extremity radiculopathy is denied. Service connection for left lower extremity radiculopathy is denied. Service connection for right wrist disability is denied. REMANDED Service connection for left hip disability is remanded. Service connection for right knee instability is remanded. Service connection for left leg shin splints is remanded. Service connection for right leg shin splints is remanded. Service connection for left ankle disability is remanded. Service connection for right ankle disability is remanded. Service connection for right hip disability is remanded. Service connection for left foot disability is remanded. Service connection for right foot disability is remanded. Service connection for left shoulder disability is remanded. Service connection for left knee disability is remanded. Entitlement to a rating in excess of 10 percent for thoracolumbar back strain from December 5, 2018 to April 4, 2019 is remanded. Entitlement to a rating in excess of 10 percent for right knee strain from December 5, 2018 to April 4, 2019 is remanded. Entitlement to a rating in excess of 10 percent for left wrist strain from December 5, 2018 to April 4, 2019 is remanded. FINDINGS OF FACT 1. New evidence was received after the June 2017 denial that is relevant to the issue of entitlement to service connection for bilateral shin splints, bilateral ankle disabilities, a right hip disability, bilateral foot disabilities, a right wrist disability, a left shoulder disability, and a left knee disability. 2. The preponderance of the evidence is against a finding that the Veteran has had left or right lower extremity radiculopathy during the appeal period. 3. A right wrist disability preexisted the Veteran’s period of active duty service and was not aggravated therein. CONCLUSIONS OF LAW 1. The criteria for readjudicating the claim for service connection for left leg shin splints have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 2. The criteria for readjudicating the claim for service connection for right leg shin splints have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 3. The criteria for readjudicating the claim for service connection for a left ankle disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 4. The criteria for readjudicating the claim for service connection for a right ankle disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 5. The criteria for readjudicating the claim for service connection for a right hip disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 6. The criteria for readjudicating the claim for service connection for a left foot disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 7. The criteria for readjudicating the claim for service connection for a right foot disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 8. The criteria for readjudicating the claim for service connection for a right wrist disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 9. The criteria for readjudicating the claim for service connection for a left shoulder disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 10. The criteria for readjudicating the claim for service connection for a left knee disability have been met. 84 Fed. Reg. 138, 169 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.156 (d)). 11. The criteria for service connection for right lower extremity radiculopathy have not been met. 38 U.S.C. § § 1110; 38 C.F.R. § §§ 3.303, 3.310. 12. The criteria for service connection for left lower extremity radiculopathy have not been met. 38 U.S.C. § § 1110; 38 C.F.R. § §§ 3.303, 3.310. 13. The criteria for service connection for right wrist disability have not been met. 38 U.S.C. § §§ 1110, 1153, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the rating decision on appeal was issued in March 2019. The Veteran selected higher-level review after receiving notice of this rating decision on April 4, 2019, and the RO issued a Higher-Level Review Decision in April 2019. In April 2019, the Veteran elected direct review under the modernized review system. 84 Fed. Reg. 138, 177 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 19.2 (d)). The Veteran served on active duty from January 2006 to January 2010. Evidence was added to the claims file during a period of time when new evidence was not allowed. Therefore, the Board may not consider this evidence. 84 Fed. Reg. 138, 182 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 20.300). The Veteran may file a Supplemental Claim and submit or identify this evidence. 84 Fed. Reg. 138, 182 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. In addressing whether new and relevant evidence was received, the Board notes that the March 2019 rating decision found new and relevant evidence had been received and readjudicated the issues on the merits. The April 2019 Higher-Level Review Decision determined new and relevant evidence had not been received and declined to readjudicate the claims. To alleviate any confusion, the Board will proceed to address whether new and relevant evidence has been received in this case.   1. Readjudication of the claim for service connection for left leg shin splints 2. Readjudication of the claim for service connection for right leg shin splints The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for left and right leg shin splints. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claim, in June 2017. VA examination in December 2018 addressed the Veteran’s bilateral shin splint complaints. This examination was not already of record and may prove or disprove the current disability element of the claim for service connection for bilateral leg shin splints. Readjudication of the claim is warranted. 3. Readjudication of the claim for service connection for a right ankle disability 4. Readjudication of the claim for service connection for a left ankle disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for right and left ankle disabilities. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claims, in June 2017. The Veteran’s representative submitted argument in December 2018 that the Veteran’s service-connected back and right knee disabilities have resulted in altered gait and overuse of other joints that has resulted in right and left ankle disabilities. These contentions were not already of record and may prove or disprove the nexus element of the claim for service connection for right ankle disability. Readjudication of the claim is warranted. 5. Readjudication of the claim for service connection for a right hip disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for right hip disability. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claim, in June 2017. The Veteran’s representative submitted argument in December 2018 that the Veteran’s service-connected back and right knee disabilities have resulted in altered gait and overuse of other joints that has resulted in right hip disability. These contentions were not already of record and may prove or disprove the nexus element of the claim for service connection for right hip disability. Readjudication of the claim is warranted. 6. Readjudication of the claim for service connection for a left foot disability 7. Readjudication of the claim for service connection for a right foot disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for left and right foot disabilities. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claims, in June 2017. The Veteran’s representative submitted argument in December 2018 that the Veteran’s service-connected back and right knee disabilities have resulted in altered gait and overuse of other joints that has resulted in left and right foot disabilities. These contentions were not already of record and may prove or disprove the nexus element of the claim for service connection for left foot disability. Readjudication of the claim is warranted. 8. Readjudication of the claim for service connection for a right wrist disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for right wrist disability. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claim, in June 2017. VA examination in December 2018 addressed the Veteran’s right wrist complaints. This examination was not already of record and may prove or disprove the current disability element of the claim for service connection for right wrist disability. Readjudication of the claim is warranted. 9. Readjudication of the claim for service connection for a left shoulder disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for left shoulder disability. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claim, in June 2017. VA examination in December 2018 addressed the Veteran’s left shoulder complaints. This examination was not already of record and may prove or disprove the current disability element of the claim for service connection for left shoulder disability. Readjudication of the claim is warranted. 10. Readjudication of the claim for service connection for a left knee disability The Veteran contends that new and relevant evidence warrants readjudication of the claim for service connection for left knee disability. VA will readjudicate a claim if new and relevant evidenced is presented or secured. AMA, Pub. L. No. 115-55, § 5108, 131 Stat. 1105, 1109. Relevant evidence is evidence that “tends to prove or disprove a matter in issue.” VA Claims and Appeals Modernization, 84 Fed. Reg. 138, 172 (Jan. 18, 2019) (to be codified at 38 C.F.R. § § 3.2501). The Board finds new evidence was received after the prior final rating decision in the legacy system that is relevant to his claim, in June 2017. VA examination in December 2018 addressed the Veteran’s left knee complaints. This examination was not already of record and may prove or disprove the current disability element of the claim for service connection for left knee disability. Readjudication of the claim is warranted. 11. Service connection for right lower extremity radiculopathy 12. Service connection for left lower extremity radiculopathy Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § § 1110; 38 C.F.R. § § 3.303. “To establish a right to compensation for a present 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’-the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 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). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § § 3.310. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a current disability is satisfied when the Veteran has a disability at the time he files his service connection claim or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the Veteran’s filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The United States Court of Appeals for the Federal Circuit has held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d at 1337. 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). The Veteran contends that he has radiculopathy of the right and left lower extremities that is secondary to his service-connected back disability. The service treatment records do not note complaints or diagnosis of radiculopathy of the lower extremities. The separation examination in December 2009 noted normal lower extremities and neurological examinations. At a VA back examination in May 2017 an examiner noted normal straight leg raising test bilaterally. The examiner noted that the Veteran did not have radiating pain or other signs or symptoms of radiculopathy. At a VA back examination in December 2018 an examiner noted normal straight leg raising test bilaterally. The examiner noted that the Veteran did not have radiating pain or other signs or symptoms of radiculopathy. The record does not contain a diagnosis of radiculopathy of either lower extremity. The threshold requirement here (as in any claim seeking service connection) is that there must be competent evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., radiculopathy of the left or right lower extremity. See 38 U.S.C. § § 1110. The record does not include any such evidence. Accordingly, there is no valid claim of service connection for such. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claims of service connection for right and left lower extremity radiculopathy. Accordingly, the claims must be denied. 13. Service connection for right wrist disability The Veteran seeks service connection for a right wrist disability. He contends that his period of service aggravated his right wrist condition. Specifically, he contends that he fell during service and injured his right wrist. However, for the reasons noted below, the Board finds that service connection is not warranted. Service connection may be granted for a disability resulting from disease or injury incurred in active service and for in-service aggravation of a preexisting injury or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. See 38 U.S.C. § § 1132; 38 C.F.R. § § 3.304 (b). Cases in which the condition is noted on entrance, as here, are however, governed by the presumption of aggravation of a preexisting disability contained in 38 U.S.C. § 1153. This statute provides that a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § § 1153; 38 C.F.R. § § 3.306. In such cases, the record must simply show by a preponderance of the evidence that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § § 1153; 38 C.F.R. § §§ 3.304, 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306 -07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Veteran’s December 2005 enlistment examination report and report of medical history note that the Veteran had a fractured right forearm and subsequent surgery in 2004. Therefore, he is not presumed sound upon entrance as it relates to his right wrist. 38 C.F.R. § § 3.304. As noted above, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § § 3.306. However, the evidence shows there was no increase in the severity of the preexisting right wrist fracture during service. The service treatment records do not include any complaints or findings related to the right wrist. The separation examination report in December 2009 noted normal upper extremities. Thus, the competent and contemporaneous evidence does not demonstrate an increase in the Veteran’s preexisting right wrist fracture residuals in service. A VA examiner in May 2017 opined that the Veteran did not have a right wrist disability that was incurred in service and stated: There is no documentation to support that Veteran was evaluated and treated for his right wrist condition during service time, even though there is documentation that Veteran had surgery for right wrist fracture in 2004 but that occurred prior to service. Given that Veteran did not seek medical care/no records that Veteran was evaluated/treated for his right wrist pain during service time, other than the statement that he had wrist surgery in the past (that was prior to the service time), Veteran’s right wrist condition is less likely than not incurred in during service. With respect to possible inservice aggravation, the May 2017 examiner opined: The claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. Rationale: There is no documentation to support that Veteran was evaluated and treated for his right wrist condition during service time, even though there is documentation that Veteran had surgery for right wrist fracture in 2004 which occurred prior to service. Since there is no record found that Veteran was evaluated/treated for his right wrist condition as a chronic disability pattern during service time, it is less likely than that Veteran’s right wrist condition is aggravated beyond its natural progression by pain/injury during service. A December 2018 VA wrists examination report noted the Veteran’s history of right wrist fracture prior to service. Although the Veteran can report what he saw or experienced firsthand, he has not been shown to possess the education, training, and experience to offer medical opinions on complex matters such as the ability determining the severity of right wrist fracture residuals, or to attest to the natural progression of such. Further, the notation of postsurgical right wrist fracture at entrance (but not at discharge) weighs against his lay assertion that his condition worsened during service. Accordingly, his assertion is not competent or probative evidence that his right wrist disability was permanently aggravated in service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As a whole, the Board finds that the medical evidence is more probative than the Veteran’s lay statement. In short, the competent and credible evidence of record does not reflect a permanent aggravation of the preexisting right wrist fracture residuals during service. As the preponderance of the evidence is against the claim for service connection; there is no doubt to be resolved and service connection for right wrist disability is not warranted. See 38 U.S.C. § § 5107; 38 C.F.R. § § 3.102. REASONS FOR REMAND Service connection for left leg shin splints is remanded. Service connection for right leg shin splints is remanded. Service connection for right ankle disability is remanded. Service connection for left ankle disability is remanded. Service connection for right hip disability is remanded Service connection for left hip disability is remanded Service connection for left foot disability is remanded Service connection for right foot disability is remanded Service connection for left shoulder disability is remanded. Service connection for left knee disability is remanded The issues of entitlement to service connection for bilateral hip, bilateral ankle, bilateral feet, left shoulder, left knee disability, and bilateral shin splints are remanded to correct a duty to assist error that occurred prior to the April 2019 rating decision on appeal. The Veteran contends that his claimed left hip, right hip, right ankle, left ankle, left foot, right foot, left shoulder, or left knee disability, as well as shin splints of the left or right leg, may be secondary to his service-connected back and right knee disabilities. Specifically, his representative has argued that overuse/altered gait problems stemming from the service-connected disabilities has resulted in the claimed disabilities. The AOJ obtained medical opinions prior to the rating decision on appeal. However, these opinions do not provide an adequate rationale regarding whether the Veteran’s disabilities are caused or aggravated by his/her service-connected back and right knee disabilities. Service connection for right knee instability is remanded The issue of entitlement to service connection for right knee instability is remanded to correct a duty to assist error that occurred prior to the April 2019 rating decision on appeal. The AOJ obtained examinations in May 2017 and December 2018 prior to the rating decision on appeal. However, this examination report did not adequately consider all of the Veteran’s symptomology associated with the service-connected right knee disability. While the VA examiners in May 2017 and December 2018 have not found objective evidence of instability of the right knee, the Veteran has reported subjective complaints of instability, and he has been noted to wear a knee brace. On this point, objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As an aside, the Board notes that this issue may be more appropriately addressed as part and parcel of the Veteran’s pending appeal for an increased rating for service-connected right knee strain. Entitlement to a rating in excess of 10 percent for thoracolumbar back strain from December 5, 2018 to April 4, 2019 is remanded. Entitlement to a rating in excess of 10 percent for right knee strain from December 5, 2018 to April 4, 2019 is remanded Entitlement to a rating in excess of 10 percent for left wrist strain from December 5, 2018 to April 4, 2019 is remanded The issues of entitlement to higher ratings for back, right knee, and left wrist disabilities are remanded to correct a duty to assist error that occurred prior to the April 2019 rating decision on appeal. The AOJ obtained December 2018 examination reports prior to the rating decision on appeal. However, as the Veteran’s representative contends, the examinations of record have not provided sufficient information to properly rate the disabilities. Specifically, the December 2018 examinations did not comply with Sharp v. Shulkin, 29 Vet. App. 26, 34-35 (2017) (explaining that “the Court’s case law and VA guidelines anticipate that examiners will offer flare opinions based on estimates derived from information procured from relevant sources, including the lay statements of veterans”). As the December 2018 examination reports, while noting the Veteran’s reports of flare-ups of pain, did not include estimates of additional loss of motion, new examinations are necessary to ascertain the severity of the disabilities during the period on appeal. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and etiology of any current left hip, right hip, right ankle, left ankle, left foot, right foot, left shoulder, or left knee disability, as well as any shin splints of the left or right leg. The examiner is to conduct all necessary tests and studies. a) Provide an opinion as to whether it is at least as likely as not that any current left hip, right hip, right ankle, left ankle, left foot, right foot, left shoulder, or left knee disability, as well as any shin splints of the left or right leg, had onset during, or is otherwise related to, service. b) Provide an opinion as to whether it is at least as likely as not that any current left hip, right hip, right ankle, left ankle, left foot, right foot, left shoulder, or left knee disability, as well as any shin splints of the left or right leg, is proximately caused by OR aggravated beyond its natural progression by the Veteran’s service-connected thoracolumbar strain and/or right knee strain, to include any resultant overuse/altered gait issues attributable to a service-connected disability. The examination report must include a complete rationale for all opinions expressed. 2. Schedule the Veteran for a VA examination to determine the severity of his service-connected right knee, left wrist, and low back disabilities during the appeals period, to include specific findings regarding pain on range of motion testing and an estimation of functional loss, per Correia and Sharp. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing states. If for any reason the examiner is unable to conduct the required testing or concludes that the required testing is not necessary or is not medically appropriate in this case, he or she should explain why. The examiner should discuss the additional functional impairment that occurs during flare-ups or with repeated use overtime, including any additional loss of motion in degrees. If the Veteran is not being observed during a flare-up or after repeated use over time, the examiner must estimate any additional functional impairment based on the evidence of record and the Veteran’s lay descriptions of repeated use or flares’ severity, frequency, duration, and/or functional loss manifestations. The examiner is further advised that the inability to provide an opinion without resorting to speculation must be based the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. G. Mazzucchelli, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § § 20.1303.