Citation Nr: 20071663 Decision Date: 11/05/20 Archive Date: 11/05/20 DOCKET NO. 17-54 366 DATE: November 5, 2020 ORDER Service connection for a left shoulder disability is denied. Service connection for a right shoulder disability is denied. Service connection for a left hip disability is denied. Service connection for a right hip disability is denied. Service connection for a right knee disability is denied. An initial compensable disability rating for service-connected respiratory problems, including difficulty breathing, prior to September 13, 2019, is denied. REMANDED Entitlement to an initial disability rating greater than 10 percent for service-connected left foot sprain is remanded. Entitlement to an initial disability rating greater than 10 percent for service-connected right foot sprain is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a left shoulder disability began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that a right shoulder disability began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a left hip disability began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a right hip disability began during active service, or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that a right knee disability began during active service, or is otherwise related to an in-service injury or disease. 6. Prior to September 13, 2019, the Veteran’s service-connected respiratory problem, including difficulty breathing, was not manifested by forced expiratory volume in one second (FEV-1) of 71 to 80 percent predicted; the ratio of FEV-1 over forced vital capacity (FEV-1/FVC) of 71-80 percent of the predicted amount, or; FVC of 71-80 percent of the predicted amount, or; intermittent inhalational or oral bronchodilator therapy used. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a left hip disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a right hip disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for an initial compensable disability rating for service-connected respiratory problems, including difficulty breathing, prior to September 13, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97 Diagnostic Code 6602. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1985 to February 1992. His decorations include the Combat Infantryman Badge and the Bronze Service Star For Parachutist Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2017 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Winston-Salem, North Carolina. In April 2019, the Veteran testified at a personal hearing over which the undersigned presided while at the RO. A transcript of the hearing is of record. This matter was previously before the Board in August 2019 at which time it was remanded for additional development. It is now returned to the Board. In February 2017, the RO, in pertinent part, denied service connection for a neck disability and for tinnitus. The Veteran timely expressed disagreement with each issue, respectively, in the March 2017 notice of disagreement and in the October 2017 Appeal To Board Of Veterans’ Appeals (VA Form 9). A Statement of the Case was not provided to the Veteran as to those issues following receipt of the notices of disagreement. See Manlincon v. West, 12 Vet. App. 238 (1998). In the August 2019 Board Remand, the RO was directed to issue a Statement of the Case. A Statement of the Case was issued to the Veteran in July 2020. The Veteran has not yet filed a VA Form 9 regarding the respective issues. As such, the issues are not currently before the Board. The issues on appeal had previously included entitlement to service connection for a low back disability and for obstructive sleep apnea. During the pendency of this appeal, by rating action dated in July 2020, service connection for each was granted. As this represents a complete grant of the benefits sought on appeal, and the Veteran has not expressed disagreement with the assigned initial disability ratings, the issues are not before the Board. With specific regard to the issue of obstructive sleep apnea, VA regulations prohibit separate ratings for certain disabilities within the same body system. As such, a separate rating may not be assigned for obstructive sleep apnea and asthma (the service-connected respiratory problems, including difficulty breathing, currently on appeal). Therefore, pursuant to the July 2020 rating decision, the disabilities were combined, effective as of September 13, 2019, and an initial 50 percent disability rating was assigned as of that date. The Veteran has not expressed disagreement with the combined rating. As a result, the issue regarding an increased disability rating for the service-connected respiratory problems, including difficulty breathing, before the Board will specifically address the level of disability prior to September 13, 2019. Service Connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In order to prevail on the issue of service connection for a disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Service connection for certain chronic diseases, such as arthritis, may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d). To establish service connection, there must be medical evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In such cases, not only is the combat injury presumed, but so are the consequences of that injury at least in service. See Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). 1. Entitlement to service connection for a left shoulder disability. 2. Entitlement to service connection for a right shoulder disability. 3. Entitlement to service connection for a left hip disability. 4. Entitlement to service connection for a right hip disability. 5. Entitlement to service connection for a right knee disability. During the April 2019 Board hearing, the Veteran testified that he had experienced the respective musculoskeletal disabilities as a result of carrying heavy loads during parachute jumps during Operation Just Cause in Panama in December 1989, while carrying heavy loads during parachute jumps, as well as during Ranger School and in Southwest Asia during the Persian Gulf War thereafter. Service personnel records confirm service in the reported campaigns and that the Veteran was decorated for service on combat missions. A review of the Veteran’s service treatment records reveals that there is no evidence of treatment for any left or right shoulder, left or right hip, or right knee symptoms. Reports of medical examination dated in July 1985, January 1988, November 1988, May 1991, and July 1991 all show that clinical evaluation of the upper and lower extremities was normal. In the associated reports of medical history, the Veteran specifically denied having arthritis, rheumatism, or bursitis; lameness; bone, joint, or other deformity; painful or “trick” shoulder; or “trick” or locked knee. Similarly, his December 1991 separation report of medical examination showed that clinical evaluation of the upper and lower extremities was normal. Following active service, private outpatient treatment records from Fayetteville Family Medical Care dated from 2006 to 2015 show intermittent reports of joint pain. A history of osteoarthritis, mainly in the back and knees was also indicated. In correspondence dated in October 2016, the Veteran indicated that he had multiple joint pains due to the environmental hazards from his time in Saudi. A lay statement from the Veteran’s spouse dated in October 2016, in pertinent part, shows that it was indicated that the Veteran had knee pain as a result of his duties as an Airborne Ranger during active service. This was said to include jumping out of airplanes and training exercising including road marches. In February 2017, a VA examiner opined that the respective disorders were not the result of service because of an absence of the stated disorders in the service treatment records. In August 2019, the Board determined that the opinion of the VA examiner was inadequate as the examiner did not consider the Veteran’s combat service as a parachutist in rendering the opinion as to whether such symptoms were a manifestation of active service. A VA shoulder examination report dated in October 2019 shows that the Veteran reported his left and right shoulder symptoms began in 1989 after the Panama War as a result of the weight of his ruck sack and jumping. He described being unable to lift anything and or to stand or sit for long periods. He would have difficulty raising his arms due to pain in the shoulders. Physical examination revealed left and right shoulder impingement syndrome, rotator cuff tendonitis, and acromioclavicular joint osteoarthritis. The examiner opined the claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while he had a military occupational specialty of combat infantryman, there was no documented history of a shoulder condition while in service or within one year following service. The Veteran reported no symptoms on deployments subsequent to the Panama deployment. While he did indicate that he had been in close proximity to a blast during Desert Shield, there was no reference made to either shoulder. Following service, he worked as a firefighter for 20 years. There was no documented history of continuity of care to establish chronicity of the Veteran’s claimed shoulder conditions. The examiner concluded that based on review of the service records and the Veteran’s account of the mechanism of injuries that occurred during service, there was insufficient evidence to support that his claimed shoulder conditions incurred in or were caused by service. A VA hip examination report dated in October 2019 shows that the Veteran reported that his left and right hip conditions began in 1989 after jumping into Panama. He indicated that he had taken pain medicine, used heating pads, and undergone physical therapy and pain management since. He described current soreness of the hips and difficulty with standing, sitting, or bending. Physical examination revealed left and right hip osteoarthritis. The examiner opined that the claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while he had a military occupational specialty of combat infantryman, there was no documented history of a hip condition while in service or within one year following service. The Veteran reported no symptoms on deployments subsequent to the Panama deployment. While he did indicate that he had been in close proximity to a blast during Desert Shield, there was no reference made to either hip. Following service, he worked as a firefighter for 20 years. There was no documented history of continuity of care to establish chronicity of the Veteran’s claimed hip conditions. The examiner concluded that based on review of the service records and the Veteran’s account of the mechanism of injuries that occurred during service, there was insufficient evidence to support that his claimed hip conditions incurred in or were caused by service. A VA knee examination report dated in October 2019 shows that the Veteran reported that his right knee condition began in 1989 after jumping into Panama. He described having knee pain when walking because the bones would rub together. He reported wearing a knee brace intermittently for years and would take over-the-counter medication for relief. He was unable to walk long distances, run, or carry heavy items, as the bones would rub together. Physical examination revealed right knee strain and osteoarthritis. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that while he had a military occupational specialty of combat infantryman, there was no documented history of a right knee condition while in service or within one year following service. The Veteran reported no symptoms on deployments subsequent to the Panama deployment. While he did indicate that he had been in close proximity to a blast during Desert Shield, there was no reference made to the right knee. Following service, he worked as a firefighter for 20 years. There was no documented history of continuity of care to establish chronicity of the Veteran’s claimed right knee condition. The examiner concluded that based on review of the service records and the Veteran’s account of the mechanism of injuries that occurred during service, there was insufficient evidence to support that his claimed right knee condition was incurred in or caused by service. Having carefully considered the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claims of service connection for a left and right shoulder, left and right hip, and right knee disabilities. There is no medical evidence in the service treatment records that the Veteran sustained an injury or disease to either joint during active service or within one year following separation from service. During his April 2019 hearing before the Board, the Veteran asserted that his respective conditions had continued since service. However, the Board finds that the overall evidence does not support his contentions. The earliest evidence of reported joint pain was in the 2006 private treatment records that showed osteoarthritis in the knees. This is approximately 14 years following separation from active service. The Board finds probative the October 2019 opinions of the VA examiner as they were definitive, based upon a complete review of the Veteran's entire claims file (to include evidence of his combat service), and supported by detailed rationale. The Veteran has not provided any competent medical evidence to rebut the opinions against the claims or otherwise diminish their probative weight. The Board has considered the Veteran’s testimony in support of his claims. However, it would require medical or scientific expertise to say that the claimed disabilities were related to active service. This is not a matter that is subject to lay observation. There is no indication that the Veteran possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. 38 C.F.R. § 3.159 (a); see Jandreau, 492 F.3d at 1377 (lay evidence is competent); Barr v. Nicholson, 21 Vet. App. 303 (2007). Given that the medical evidence against the claim, for the Board to conclude that the Veteran’s asserted disabilities are manifested as a result of service would be speculation, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Overall, the evidence is not in relative equipoise, as the most probative evidence of record addressing the etiology and onset of the Veteran’s asserted symptoms weighs against service incurrence. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. The benefits sought on appeal are, therefore, denied. Increased Disability Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. 6. Entitlement to an initial compensable disability rating for service-connected respiratory problems including difficulty breathing prior to September 13, 2019. The Veteran asserts that his service-connected respiratory problems including difficulty breathing are more disabling than reflected by the assigned noncompensable disability rating prior to September 13, 2019. As indicated above, VA regulations prohibit separate ratings for certain disabilities within the same body system. As such, a separate rating may not be assigned for the service-connected respiratory problems, including difficulty breathing, and the recently service-connected obstructive sleep apnea. Service connection for obstructive sleep apnea was established by rating action dated in July 2020. The disabilities were combined, effective as of September 13, 2019, and an initial 50 percent disability rating was assigned as of that date. The Veteran has not disagreed with the assigned initial 50 percent disability rating, effective as of September 13, 2019. As a result, the issue regarding an increased disability rating for the service-connected respiratory problems, including difficulty breathing, before the Board will specifically address the level of disability prior to September 13, 2019. Prior to September 13, 2019, the service-connected respiratory problems including difficulty breathing were rated under 38 C.F.R. § 4.97, Diagnostic Code 6602 which provides the rating criteria for asthma. Under this diagnostic code provision, a 10 percent disability rating is warranted when pulmonary function testing shows FEV-1 is 71-80 percent of the predicted amount, or; FVC is 71-80 percent of the predicted amount, or; intermittent inhalational or oral bronchodilator therapy is used. A 30 percent disability rating is warranted where FEV-1 is 56 to 70 percent predicted; FEV-1/FVC is 56 to 70 percent; or there is daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication. A 60 percent disability rating is warranted where FEV-1 is 40 to 55 percent predicted; FEV-1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A maximum 100 percent disability rating is warranted with FEV-1 is less than 40 percent predicted, or; FEV-1/FVC is less than 40 percent or; more than one attack per week with episodes of respiratory failure, or; when the condition requires daily use of systemic high dose corticosteroids or immunosuppressive medications. The post-bronchodilator findings for these pulmonary function tests are the standard in pulmonary assessment, and VA assesses pulmonary function after bronchodilation. 38 C.F.R. § 4.96(d)(4). However, if the post-bronchodilator results are poorer than the pre-bronchodilator results, then the pre- bronchodilator results are used for rating purposes. 38 C.F.R. § 4.96(d)(5). A VA respiratory examination report dated in February 2017 shows that the Veteran was diagnosed with asthma. He stated that he had been told he snores. He was being evaluated by his primary care provider. He was not taking medication for the claimed respiratory problems. There had been no related surgical procedure. He was currently employed delivering automobile parts for the preceding one year. He had previously worked as a firefighter for 20 years until retiring in the prior year. The respiratory condition did not require the use of oral or parenteral corticosteroid medication, inhaled medication, oral bronchodilators, antibiotics, or outpatient oxygen therapy. He had not had any asthma attacks with episodes of respiratory failure in the preceding 12 months. He had not had any physician visits for required care of exacerbations. There were no other pertinent physical findings, complications, conditions, signs or symptoms. Chest X-rays revealed definite radiographic evidence of acute cardiopulmonary process. Pulmonary function testing (PFT) accurately reflected the Veteran’s current pulmonary function. Pre-bronchodilator pulmonary function testing revealed 89 percent predicted FVC, 90 percent predicted FEV-1, and 82 percent FEV-1/FVC. Post-bronchodilator PFT results were 90 percent predicted FVC, 92 percent predicted FEV-1, and 83 percent FEV-1/FVC. The examiner indicated that FEV-1/FVC most accurately reflected the Veteran’s level of disability. The Veteran did not have multiple respiratory conditions. Exercise capacity testing was not performed. The examiner added that the Veteran’s respiratory condition did not impact his ability to work. For the period prior to September 13, 2019, the findings pertaining to the Veteran’s respiratory disability closely correlate to the criteria for a noncompensable disability rating, but not the next higher 10 percent disability rating. Specifically, the medical evidence of record fails to establish that the Veteran’s respiratory disability was manifested by FEV-1 of 71-80 percent of the predicted amount, or; FVC of 71-80 percent of the predicted amount, or; intermittent inhalational or oral bronchodilator therapy used. The evidence of record does not show that the Veteran’s respiratory disability required at least monthly visits to a physician for required care of exacerbations; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids; or daily use of systemic high dose corticosteroids or immunosuppressive medications. The Board has considered the statements of the Veteran as to the extent of his symptoms. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Accordingly, the weight of the evidence reflects that the symptoms of the Veteran’s service-connected respiratory problems including difficulty breathing did not more nearly approximate the criteria for compensable disability rating at any time prior to September 13, 2019. REASONS FOR REMAND 1. Entitlement to an initial disability rating greater than 10 percent for service-connected left foot sprain. 2. Entitlement to an initial disability rating greater than 10 percent for service-connected right foot sprain. The Veteran asserts that his service-connected left and right foot sprains are each more disabling than reflected by the currently assigned 10 percent disability rating. Each foot disability is currently rated under Diagnostic Code 5284 which provides the rating criteria for foot injuries. The Veteran underwent a VA examination in October 2019 at which time the examiner indicated that for the VA established diagnosis of left and right foot sprains, the diagnosis was changed, and a new and separate diagnosis of plantar fasciitis and pes planus was established. Service connection has been established for left and right foot sprains. It is noted that in the March 2017 notice of disagreement, the Veteran described having plantar fasciitis in each lower extremity in addition to the service-connected left and right foot sprains. While a VA examiner in February 2017 specifically opined against a direct nexus between pes planus and active service, there is no opine as to whether the new diagnoses of plantar fasciitis and/or pes planus were secondary to the service-connected left and/or right foot sprains or whether the plantar fasciitis was directly etiologically related to the Veteran’s period of active service. Additionally, if the plantar fasciitis and/or pes planus are not directly related to active service or secondary to a service-connected disability, an opinion must be provided as to whether symptoms associated with each disability may be adequately separated from the symptomatology associated with the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As such, this matter must be remanded so that an addendum opinion may be provided. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran’s changed diagnosis from left and right foot sprains, to new and separate diagnoses of plantar fasciitis and pes planus as shown on VA examination in October 2019. Service connection has been established for left and right foot sprains. The examiner is requested to answer all of the following questions as definitively as possible: (a) Is it at least as likely as not that the Veteran's diagnosed pes planus and/or plantar fasciitis had onset in service or is otherwise the result of a disease or injury in service? (b) Is it at least as likely as not that the Veteran's diagnosed pes planus and/or plantar fasciitis was caused (in whole or in part) by the service-connected left and/or right foot sprains? (c) Is it at least as likely as not that the Veteran's diagnosed pes planus and/or plantar fasciitis is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by the service-connected left and/or right foot sprains? If the Veteran's current pes planus and/or plantar fasciitis is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. (d) If the plantar fasciitis and/or pes planus are not directly related to active service or secondary to a service-connected disability, the examiner is requested to specifically discuss which symptoms are due to the Veteran’s service-connected disability and which are due to the non-service-connected disabilities. The examiner should note that where non-service-connected symptoms cannot be separated from service-connected symptoms, all of the symptoms are to be treated as connected to service. If the examiner is unable to determine which symptoms are associated with which disease entity, he/she should so state and explain why The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. (Continued on the next page)   If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Orfanoudis, 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.