Citation Nr: 20034564 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 14-25 717 DATE: May 18, 2020 ORDER Service connection for a left elbow condition is denied. Service connection for a right elbow condition, to include as secondary to the right knee disability, is denied. Service connection for a gastrointestinal disorder is denied. REMANDED A rating higher than 20 percent for a right shoulder condition is remanded. A rating higher than 20 percent for a left shoulder condition is remanded. A rating higher than 10 percent for a right hip condition is remanded. A rating higher than 10 percent for a left hip condition is remanded. A rating higher than 10 percent for a left knee condition is remanded. A rating higher than 10 percent for a right knee condition is remanded. A compensable rating for a right ankle condition prior to November 27, 2018, is remanded. A compensable rating for a left ankle condition prior to November 27, 2018, is remanded. A rating higher than 10 percent for a right ankle condition from November 27, 2018, is remanded. A rating higher than 10 percent for a left ankle condition from November 27, 2018, is remanded. FINDINGS OF FACT 1. The competent and probative evidence is against a finding that the Veteran’s current left elbow condition, diagnosed as arthritis, had its onset during active duty service or is related to such service; or that the arthritis was manifested within one year of the Veteran’s discharge from active duty service. 2. There is no competent and probative evidence that the Veteran’s current right elbow condition had its onset during active duty service or is related to such service; and the Board finds that the Veteran’s assertions concerning the fall during which his right elbow was injured are simply not credible. 3. Gastrointestinal symptoms have been attributed to a known clinical diagnosis, namely diverticulitis; and the competent and probative evidence is against a finding that the Veteran’s diverticulitis had its onset during active duty service or is related to such service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left elbow condition have not been met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for a right elbow condition have not been met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2019). 3. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. §§ 3.303, 3.317 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service from March 1994 to February 2012, with service in the Southwest Asia theater of operations from March 2005 to November 2006 and again from September 2009 to August 2010. These matters come before the Board of Veterans Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in January 2013 and November 2014. The January 2013 rating decision denied the claims for service connection. The November 2013 rating decision continued the initial ratings assigned for the service-connected conditions. The Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge in February 2017. A transcript is of record. The claims were remanded by the Board in April 2018 for additional development. The Board also remanded a claim for service connection for hypertension that was granted in a March 2019 rating decision. That issue is no longer before the Board. The March 2019 rating decision also granted a 20 percent rating for the right shoulder condition effective February 24, 2012, the date on which service connection was originally established. In a May 2019 rating decision, the left shoulder condition was also increased to 20 percent effective February 24, 2012, and the right and left ankle conditions were increased to 10 percent effective November 27, 2018. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Where a veteran served continuously for 90 days or more during active service and arthritis or peptic ulcer becomes manifest to a degree of 10 percent within one year from the date service terminated, the arthritis will be presumed to have been incurred in service even though there is no evidence of arthritis during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Under legislation specific to Persian Gulf War veterans, service connection may be established for a qualifying chronic disability resulting from an undiagnosed illness that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more during a presumptive period. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of any of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; (C) any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants presumptive service-connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Such chronic disability must have manifested either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of at least 10 percent or more no later than December 31, 2021, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 C.F.R. § 3.317(a)(1). Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Compensation shall not be paid, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf war; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or events that occurred between the appellant’s most recent departure from active duty in the Southwest theater of operations during the Persian Gulf war and the onset of the illness; or if there is affirmative evidence that the illness is the result of the appellant’s own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(c). Since the Veteran served in the Southwest Asia theater of operations, he qualifies for consideration for presumptive service connection for disabilities resulting from undiagnosed illness or unexplained chronic multi-symptom illness. 1. Service connection for a left elbow condition 2. Service connection for a right elbow condition, to include as secondary to the right knee disability The Veteran seeks service connection for a bilateral elbow condition. He reports that both elbows were treated in service and that they still cause problems today. The Veteran has also asserted that he has a right elbow condition secondary to his right knee disability, describing a hard fall after his right knee went out/failed to function and caused him to fall. He testified that a few months after his discharge, he went to his daughter’s school to talk to her principal, walked out to where their recess was and his knee went out as they were walking, causing an injury to his right elbow. The Veteran also testified that his left elbow was injured in service when he was on a jump and his parachute collapsed, causing him to hit his elbow several times, with problems since then. Service treatment records document that the Veteran was seen in February 1996 with complaint of left elbow pain after injuring it during a jump. The assessment was left elbow contusion. X-ray of the left elbow was normal. A May 2007 post-deployment health assessment documents that the Veteran had no swollen, stiff or painful joints and no muscle aches. He did report going to sick call for swollen, stiff or painful joints during a July 2010 post-deployment health assessment, and also indicated that he was still bothered by swollen, stiff or painful joints at that time, though neither elbow is specifically referenced in this document. During a January 2011 post-deployment health assessment, the Veteran denied swollen, stiff or painful joints, but reported muscle aches. At the time of his April 2011 discharge examination, the Veteran reported painful shoulder, elbow or wrist; arthritis, rheumatism or bursitis; and swollen or painful joints, but the notations referenced his left leg and upper back without mentioning either elbow specifically. Clinical evaluation of his upper extremities in April 2011 was normal. The post-service medical evidence of record shows that the Veteran injured his right elbow in March 2012, the month following his discharge from service. Records from a private emergency room indicate that it was injured while he was playing soccer at his daughter’s school and slipped/fell. X-ray showed fracture. The Veteran has not sought post-service treatment for his left elbow. The Veteran underwent a VA examination in December 2012, at which time he was diagnosed with post traumatic arthritis of the right elbow with radial head implant. He reported falling on the playground at his daughter’s school fracturing the radial head of his right elbow approximately one month after discharge. The examiner determined that the right elbow condition was moderate to severe in intensity but that the right elbow condition was not related to service because it occurred after service. It appears that the left elbow was not examined because the Veteran was noted to have denied any problems, though the VA examiner did acknowledge the in-service left elbow contusion. The claim involving the left elbow was remanded by the Board in April 2018 to schedule a new VA examination that considered the Veteran’s testimony that he does have left elbow problems and that there was a miscommunication with the December 2012 VA examiner, as well as for the examiner to consider his status as a Veteran of the Southwest Asia theater of operations. A VA examination was conducted in November 2018. The Veteran was diagnosed with degenerative arthritis of both elbows and post traumatic arthritis of the right elbow with radial head implant. He reported his left elbow was injured in service as a result of parachute training, that he was seen for it and placed on cast and splint, and that he has pain in his left elbow that is on and off. The Veteran reported that his right elbow was injured approximately 90 days after his discharge from service when his right knee went out and he went to catch himself with his right elbow to brace the fall. The right elbow pain was constant and there was also decreased range of motion since surgery. The examiner noted that the right elbow degenerative joint disease seen on x-ray was a progression of his diagnosed right elbow condition. It was the examiner’s opinion that the left elbow condition is less likely than not to have been incurred in or caused by the claimed in-service injury, event or illness. The rationale was that review of service treatment records show that he was seen once for left elbow contusion and treated conservatively in 1999 without records showing a chronic left elbow condition between then and his separation. The examiner explained that since there is a temporal gap of approximately 19 years between initial complaints of left elbow pain to the complaint of pain today and the development of mild left elbow degenerative joint disease as seen on x-ray, it is not likely that the original complaint of pain in 1999 is related to his current elbow condition. The preponderance of the evidence is against the claim for service connection for a left elbow condition on a presumptive basis because there is no evidence of left elbow degenerative arthritis within one year of the Veteran’s December 2012 discharge from active duty service. The preponderance of the evidence is also against the claim for service connection for a left elbow condition on a direct basis because although the service treatment records document treatment for a left elbow contusion during active duty service in 1996, not 1999 as alluded to by the examiner, there is no evidence to support a finding that the Veteran had chronic left elbow problems during service after that injury. More specifically, there is no evidence of complaint or treatment involving the left elbow between the contusion he suffered in 1996 until his discharge from service approximately 16 years later in April 2011. Further, although the Veteran reported painful shoulder, elbow or wrist at the time of discharge, the written notations do not include reference to his left elbow specifically. There is also no indication that the Veteran had chronic problems involving his left elbow following his discharge from service since he denied having left elbow problems at the time of the December 2012 VA examination. The Board acknowledges that the Veteran has since indicated that was not true and there was a miscommunication with the examiner; however, the Veteran himself has not described his left elbow problems since service as chronic in nature, instead reporting that he experienced left elbow problems “on and off,” rather than consistent/chronic, during the November 2018 VA examination. Moreover, the November 2018 VA examiner provided an opinion against the claim for service connection for a left elbow condition on a direct basis, determining that the current left elbow condition is unrelated to service, to include the in-service injury. This opinion, which stands uncontroverted in the record, is afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). While the Veteran believes that his current left elbow condition is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of a left elbow condition are matters not capable of lay observation and require medical expertise to determine. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current disability is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (“Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”). Accordingly, the Veteran’s opinion as to the diagnosis or etiology of any left elbow condition, to include the assertion that his post-service problems are related to the in-service contusion documented in 1996, is not competent medical evidence. The Board also notes that the Veteran’s report at the time of the November 2018 VA examination that his left elbow was casted and splinted following injury is not corroborated by the service treatment records. In short, the Board finds the opinion of the November 2018 VA examiner to be significantly more probative than the Veteran’s lay assertions. Service connection is also not warranted for a right elbow condition on a direct basis since there is no evidence that the Veteran had any problems with his right elbow during active duty service and there is no probative evidence that his current right elbow condition is related to service, with the December 2012 VA examiner concluding that the Veteran’s right elbow condition was not related to service because it occurred after service. The Veteran has hinged his claim entirely on an assertion that he fell as a result of his service-connected right knee disability and that his right elbow condition is a result of that fall. The Board notes, however, that the record reflects inconsistencies in the Veteran’s description of the fall he asserts resulted in his right elbow injury. When seeking emergency treatment immediately following the injury, the Veteran reported that his right elbow was injured while playing soccer at his daughter’s school and he slipped and fell. No mention was made at that time that his right knee was the cause of the slip and fall. During the December 2012 VA examination, the Veteran reported that he had fallen on the playground at his daughter’s school fracturing the radial head of his right elbow, again making no mention that his right knee was the cause of his playground fall. In February 2017, however, he testified that a few months after his discharge, he went to his daughter’s school to talk to her principal about an issue she was having and he walked out to where their recess was and his knee went out as they were walking, causing an injury to his right elbow. During the November 2018 VA examination, the Veteran stated that his right elbow was injured when his right knee went out and he went to catch himself with his right elbow to brace the fall. The Board finds it questionable that when seeking medical treatment following the fall, the Veteran described the incident as one that occurred when playing soccer, without any mention of his right knee precipitating the fall, and that during the 2012 VA examination, he again made no mention of his right knee precipitating the fall, only that he had fallen on a playground; but when describing the incident to VA in connection with his claim for compensation, he indicated that he was merely walking when his right knee gave way. Considering the inconsistent statements regarding the circumstances that caused his fall, the Board finds that the Veteran’s assertions concerning the fall during which his right elbow was injured are simply not credible. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character.) The Board also places more probative value on the statements made when the Veteran was seeking emergency room treatment immediately after the fall than to the statements made since initiating a claim for VA benefits. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that interest in the outcome of a proceeding may affect the credibility of testimony). In the absence of credible evidence that the Veteran’s right elbow condition was caused or aggravated by his service-connected right knee disability, service connection for a right elbow condition is not warranted on a secondary basis. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claims for service connection for left and right elbow conditions, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 3. Service connection for a gastrointestinal disorder The Veteran seeks service connection for a gastrointestinal disorder. He reports being treated in service for gastroenteritis and that he still has problems today. The Veteran describes moderate to severe symptoms of gastroenteritis at least three to four times a week. He testified that he started noticing problems with his stomach cramping at the end of one of his deployments and that the condition worsened over time after more deployments. Service treatment records document numerous complaints related to the Veteran’s gastrointestinal functioning. In August 1995, he was seen twice, first with complaints of nausea and diarrhea and a few days later with complaint of abdominal pain, cramps, nausea and diarrhea. The assessment was viral gastroenteritis. Abdominal x-rays showed no bowel obstruction or perforation. The Veteran was seen in August 1996 with complaint of diarrhea, stomach cramps and vomiting; the assessment was mild gastroenteritis during that visit and on follow up the next day. In October 1996, he was seen after spitting up blood with white foam and was assessed with probable gastritis. A May 2007 post-deployment health assessment documents that the Veteran had no diarrhea, vomiting or frequent indigestion, and although he reported going to sick call for diarrhea in a July 2010 post-deployment health assessment, he indicated that the problem no longer bothered him at that time. A January 2011 post-deployment health assessment noted the Veteran’s denial of diarrhea, vomiting or frequent indigestion. At the time of his April 2011 discharge examination, the Veteran denied frequent indigestion or heartburn; stomach, liver, intestinal trouble or ulcer; gallbladder trouble or gallstones; and rupture/hernia, and clinical evaluation of his abdomen and viscera was normal. The Veteran underwent a VA examination in December 2012, at which time he reported treatment for recurring episodes of vomiting and diarrhea during active duty service while also reporting that the symptoms in service had resolved and he had not since then required any specific gastrointestinal treatment in recent years. He specifically denied any symptoms of gastroesophageal reflux disease, heartburn, or dyspepsia at the time of the examination, but recalled an episode of nausea/vomiting/diarrhea lasting almost two weeks occurring a year before without formal treatment. The VA examiner noted the in-service gastrointestinal treatment but concluded that there were no current symptoms of an ongoing gastrointestinal condition at the time of the examination and no signs or symptoms due to any stomach or duodenum conditions. The Board remanded the claim in April 2018 for an examination that considers the Veteran’s testimony and status as a Veteran of the Southwest Asia theater of operations. A VA examination was conducted in November 2018. The Veteran was diagnosed with diverticulitis and the examiner noted that symptoms included left lower quadrant abdominal pain/nausea, vomiting/diarrhea, and occasional episodes of bowel disturbance with abdominal distress. It was the examiner’s opinion that the diagnosed diverticulitis, which is a disease with clear and specific etiology and diagnosis, is less likely than not to have been incurred in or caused by the claimed in-service injury, event or illness. The opinion was based on the fact that service treatment records document diagnosis and treatment for acute gastroenteritis, which was treated conservatively and resolved, and that gastroenteritis is a separate condition from diverticulitis. The examiner also noted that a May 2007 CT scan of the abdomen and pelvis was negative for abdominal pathology while a 2018 CT scan showed findings compatible with diverticulitis. The examiner cited medical literature showing that the prevalence of diverticulosis is age-dependent and that environmental and lifestyle factors are important risk factors for diverticular disease, noting that a diet high in total fat and red meat is associated with an increased risk of symptomatic diverticular disease. This opinion, which stands uncontroverted in the record, is afforded high probative value. See Nieves-Rodriguez, 22 Vet. App. at 302-04. The preponderance of the evidence is against the claim for service connection for a gastrointestinal disorder. Since diverticulitis is a known clinical diagnosis, service connection is not warranted for this disorder on a presumptive basis under the legislation specific to Persian Gulf War Veterans. Service connection is also not warranted on a direct basis since the probative evidence does not establish an etiological relationship between the diagnosed diverticulitis and the in-service gastrointestinal complaints. Rather, the November 2018 VA examiner explained that the in-service findings of gastroenteritis were acute and that the conditions of gastroenteritis and diverticulitis are separate conditions unrelated to each other. While the Veteran believes that his current gastrointestinal disorder is related to service, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau, 492 F.3d at 1376-77. In this regard, the diagnosis and etiology of a gastrointestinal disorder are matters not capable of lay observation and require medical expertise to determine. Accordingly, the Veteran’s opinion as to the diagnosis or etiology of any gastrointestinal disorder is not competent medical evidence. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current gastrointestinal disorder is also a matter that also requires medical expertise to determine. See Clyburn, 12 Vet. App. at 301. Thus, the Veteran’s own opinion regarding the etiology of his current gastrointestinal disorder is not competent medical evidence. The Board finds the opinion of the November 2018 VA examiner to be significantly more probative than the Veteran’s lay assertions. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claim for service connection for a gastrointestinal disorder, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. REASONS FOR REMAND 1. Entitlement to a rating higher than 20 percent for a right shoulder condition is remanded. 2. Entitlement to a rating higher than 20 percent for a left shoulder condition is remanded. 3. Entitlement to a rating higher than 10 percent for a right hip condition is remanded. 4. Entitlement to a rating higher than 10 percent for a left hip condition is remanded. 5. Entitlement to a rating higher than 10 percent for a left knee condition is remanded. 6. Entitlement to a rating higher than 10 percent for a right knee condition is remanded. 7. Entitlement to a compensable rating for a right ankle condition prior to November 27, 2018, is remanded. 8. Entitlement to a compensable rating for a left ankle condition prior to November 27, 2018, is remanded. 9. Entitlement to a rating higher than 10 percent for a right ankle condition as of November 27, 2018, is remanded. 10. Entitlement to a rating higher than 10 percent for a left ankle condition as of November 27, 2018, is remanded. The most recent VA examinations conducted in conjunction with the claims for increased rating do not comply with the Court’s holding in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), which held that in addressing the functional loss of a disability during periods of flare-ups, it was insufficient for an examiner to state that he or she is unable to offer such an opinion without resorting to speculation based solely on the fact that the examination was not performed during a flare-up. VA examinations that do comply are required. Updated treatment records should also be requested. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Schedule the Veteran for appropriate VA examinations to determine the current nature and severity of the bilateral knee, bilateral hip, bilateral shoulder, and bilateral ankle disabilities. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken for the Veteran’s knees, hip, shoulders and ankles, and should be tested actively and passively, in weight bearing, and after repetitive use. The examiner should state whether there is likely to be additional range of motion loss in the knees, hip, shoulders and ankles due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. 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 why that is so. The examiner must also address the frequency, duration, characteristics, severity, and functional loss during periods of flare-ups of the Veteran’s knee, hip, shoulder and ankle disabilities and should describe the additional loss, in degrees, if possible. The examiner should offer his or her flare opinion based on estimates derived from information procured from relevant sources within the claims file, including VA examination reports, VA treatment records, private treatment records, and lay statements of the Veteran. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Van Wambeke, 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.