Citation Nr: 21003397 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-32 360 DATE: January 21, 2021 ORDER For the period from April 7, 2010 to March 20, 2012, entitlement to a disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD) is denied. For the period from March 21, 2012 to January 30, 2014, entitlement to a disability rating in excess of 30 percent for PTSD is denied. For the period from January 31, 2014 to April 19, 2016, entitlement to a disability rating in excess of 50 percent for PTSD is denied. REMANDED Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for neuropathy, right foot, is remanded. Entitlement to service connection for neuropathy, left foot, is remanded. FINDINGS OF FACT 1. For the period from April 7, 2010 to March 20, 2012, the Veteran’s PTSD is manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, but without occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. For the period from March 21, 2012 to January 30, 2014, the Veteran’s PTSD is manifested by occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, with depressed mood, anxiety, and suspiciousness, but without occupational and social impairment with reduced reliability and productivity. 3. For the period from January 31, 2014 to April 19, 2016, the Veteran’s PTSD is manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, disturbances of motivation and mood, but without occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. For the period from April 7, 2010 to March 20, 2012, the criteria for a rating in excess of 10 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. 2. For the period from March 21, 2012 to January 30, 2014, the criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. 3. For the period from January 31, 2014 to April 19, 2016, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army National Guard, and had active service from October 9, 2001 to March 1, 2002, and from January 21, 2003 to April 22, 2004, which included service in the Persian Gulf. The Veteran’s PTSD has been rated 10 percent disabling from April 7, 2010 to March 20, 2012; 30 percent disabling from March 21, 2012 to January 30, 2014; and, 50 percent disabling from January 31, 2014 to April 19, 2016 per 38 C.F.R. § 4.130, Diagnostic Code 9411 (the General Rating Formula for Mental Disorders (General Formula)). Effective April 20, 2016, her PTSD is rated 100 percent disabling. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The General Rating Formula for Mental Disorders provides for a 10 percent rating for occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or PTSD affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to symptoms such as the following: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate disability evaluation to assign, however, the Board’s “primary consideration” is the Veteran’s symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. The Global Assessment of Functioning (GAF) score is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness.” See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.1994) (DSM-IV). VA implemented DSM-5, effective August 4, 2014, which no longer considers GAF scores. For claims certified prior to August 4, 2014, the scores assigned under the Global Assessment of Functioning (GAF) scale are an important consideration. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996). They reflect the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores between 61 and 70 reflect either some mild symptoms (e.g., depressed mood and mild insomnia); or some difficulty in social, occupational or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. By comparison, GAF scores between 51 and 60 reflect either moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks); or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers), and GAF scores between 41 and 50 reflect either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores between 31 and 40 reflect either some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). As the instant appeal was certified in January 2015, DSM-V applies, and consideration of GAF scores is not necessary. PTSD - 10 percent disabling from April 7, 2010 to March 20, 2012 For the period from April 7, 2010 to March 20, 2012, the Board finds that a disability rating in excess of 10 percent is not warranted. An April 2010 VA mental health intake reflects the Veteran’s complaints of increased irritability and acute anxiety at reminders of deployment. She described symptoms consistent with PTSD since discharge and worsening over the past year. On mental status examination, she was adequately dressed and groomed, and was cooperative and polite but anxious. She had good eye contact, was oriented to person, place, and time. Her intellectual/cognitive functioning appeared to be grossly intact, but this was not formally assessed. Her mood was euthymic and dysphoric; her affect was appropriate. There was no homicidal ideation. Her speech was normal, pressured and loud. Her thinking process was coherent. Her insight was adequate, and her judgment was intact. The examiner indicated that her PTSD was manifested by irritability, acute anxiety at reminders, and relational distress. In December 2010, the Veteran underwent a VA examination. She reported stresses in her marriage, losing her temper with her husband, but reported a supportive environment from family members. She socialized with family members and spent time with her children. A mental status examination reflected that her mood and affect were normal. She was cooperative, friendly, relaxed and attentive. She was oriented to person, time, and place. With regard to judgment, she understood the outcome of behavior and understood that she has a problem. She did not have insomnia or nightmares but reported awakening at any noise. She denied suicidal/homicidal thoughts. She denied panic attacks. She reported that irritability is the main symptoms that interferes with her ability to interact with her husband and children. She reported slight intrusive recollection of events in Iraq. The examiner characterized her symptoms as mild. The examiner found no reduced reliability and productivity due to PTSD symptoms; no occasional decrease in work efficiency nor intermittent periods of inability to perform occupational tasks due to PTSD symptoms; and, no symptoms that are transient or mild and decrease work efficiency or ability to perform occupational tasks. The examiner found that her PTSD symptoms do not require continuous medication, and her symptoms were not severe enough to interfere with occupational and social functioning. A June 2010 VA outpatient entry reflects that the Veteran had expressed interest in PTSD treatment but had not responded to VA outreach. She did attend with her husband group counseling sessions in February and March 2011. In October 2011, the Veteran underwent an initial visit with a new primary care provider. She denied current depression or acute anxiety but wondered if she felt overwhelmed with school and kids due to her PTSD. 11/02/2018 CAPRI at 143. The same month, she began attending group therapy but in December 2011 she indicated that she no longer wanted to attend group therapy but instead wanted to seek individual treatment. Id. at 131. The Veteran underwent an initial private session on March 21, 2012, which will be discussed below. For the period prior to March 21, 2012, a disability rating in excess of 10 percent is not warranted as the evaluations of record did not show occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, or mild memory loss. The subjective complaints of record and objective findings reflect that she was not experiencing panic attacks or chronic sleep impairment and she did not have any memory problems. It was not shown that she had intermittent periods of inability to perform occupational tasks due to a depressed mood or anxiety. As detailed, during this period the Veteran’s PTSD was mainly manifested by irritability with reported marital problems. Her diagnosed PTSD did not require the use of medication. She had social contacts with family and on examination her symptoms were noted as mild in degree. She assisted at her son’s school and helped with Little League. The 10 percent rating in effect compensates the Veteran for her mild and transient symptoms documented in VA treatment records and the December 2010 VA examination. PTSD – 30 percent disabling from March 21, 2012 to January 30, 2014 For the period from March 21, 2012 to January 30, 2014, the Board finds that a disability rating in excess of 30 percent is not warranted as while the evidence of record shows that the Veteran was experiencing increased anxiety, occupational and social impairment with reduced reliability and productivity was not shown. Specifically, on March 21, 2012, the Veteran sought VA individual outpatient treatment complaining of elevated anxiety and being triggered by seeing Middle Eastern individuals. As a result, she did not want to go anywhere. She denied any sleep problems but reported that she was nervous and “on edge.” She reported irritable, angry outbursts but reported that things were good with her husband and children and she felt supported by her extended family. On mental status examination, she was pleasant and cooperative; nicely dressed and groomed. Her speech rate, volume and rhythm were normal. Her mood was “blah” and “anxious” congruent with affect. Her thought process was coherent and logical. There were no indications of active psychosis, delusions, or paranoia. Her attention and concentration were good, and her judgment and insight were intact. She denied suicidal or homicidal ideation. 11/02/2018 CAPRI at 119. April 2012 evaluations showed minimal depression with complaints of impaired concentration, irritability, anger, and suspiciousness. On mental status examination, she was pleasant and cooperative, and nicely dressed and groomed. Her speech rate, volume, and rhythm were normal. Her mood was reported as a “little better” and “anxious” congruent with affect. Her thought process was coherent and logical. There were no indications of active psychosis, delusions, or paranoia. Her attention and concentration were good. Her judgment and insight were intact. There was no suicidal or homicidal ideation. Id. at 105, 111, 115. The Veteran did not undergo subsequent individual treatment due to financial difficulties with traveling to the appointments. For the period from March 21, 2012 to January 30, 2014, the medical evidence of record supports the 30 percent rating in light of her depressed mood, anxiety, and suspiciousness. A 50 percent rating is not warranted for this period as occupational and social impairment with reduced reliability and productivity was not shown when viewing her total mental disability picture. The competent and probative evidence weights against showing symptomatology such as flattened affect, speech issues, panic attacks more than once a week, difficulty understanding complex commands, impaired memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In fact, during the time in question she reported having a “really good relationship” with her husband. There is no other indication of a decline in social or family relationships during this period. While the Veteran was clearly experiencing increased anxiety and suspiciousness upon seeking treatment on March 21, 2012, the 30 percent rating in effect compensates her for this symptomatology shown on evaluations in March and April 2012. PTSD – 50 percent disabling from January 31, 2014 to April 19, 2016 On January 31, 2014, the Veteran underwent a C&P examination that provided support for the 50 percent rating in effect for her PTSD. For the period from January 31, 2014 to April 19, 2016, the Board finds that a disability rating in excess of 50 percent is not warranted. Indeed, while the evidence of record shows occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood is not shown. The January 31, 2014 C&P examination reflects the Veteran’s complaints of an increasing amount of anxiety; she was feeling anxious almost all of the time, especially over the last year. She reported being easily stressed out and was often edgy and irritable. She often worries and ruminates about current stressors (her children’s safety/welfare and finances, etc.). She reported hypervigilance when at public events/activities and she had continued to have distressing dreams that occur about one time per week. On mental status examination, the examiner found that the Veteran experiences the following symptoms: anxiety; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was alert and oriented in all spheres, but her mood and affect were slightly anxious during the exam. She denied a history of or current suicidal or homicidal ideation/intent and/or psychosis. It was again noted that she socialized with family and with her children. The examiner stated that her PTSD symptoms continued to be mild and do not cause significant impairment in occupational or social functioning (although her hyperarousal symptoms have increased in severity since her last exam and cause the Veteran marked distress). The examiner found that the Veteran experiences mild symptoms overall, generally functioning pretty well. An August 6, 2015 VA outpatient evaluation reflects the Veteran’s report that she did not benefit from group therapy and exposure therapy but would like individual treatment. She reported that she was prone to depression but was very busy with her kids. 09/13/2019 CAPRI at 79. The above-described symptoms support a 50 percent rating. The Board finds that a 70 percent rating is not warranted for the period from January 31, 2014 to April 19, 2016. Indeed, occupational and social impairment with deficiencies in most areas is not shown when viewing her total mental disability picture. The competent and probative evidence of record also weighs against showing various other symptomatology, such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; or, an inability to establish and maintain effective relationships. Indeed, the Veteran has consistently denied suicidal ideation. While acknowledging that the examiner indicated that she has impaired impulse control, such as unprovoked irritability with periods of violence, the Veteran’s description of her impaired impulse control was manifested by irritability but not violence. While the examiner indicated that she has difficulty in adapting to stressful circumstances, the Veteran reported being active with her children, to include at their school and at church, although at times she felt stressed out. While acknowledging that she may experience panic attacks, there is no indication that she experiences being in a state of near continuous panic or depression that affects her ability to function independently, appropriately or effectively. The evidence of record reflects that she has positive relationships with her spouse and children, family members, and her community, thus not amounting to an inability to establish and maintain effective relationships. Based on the foregoing medical and lay evidence, the Board finds that social and occupational impairment with reduced reliability and productivity is shown, but deficiencies in most areas have not been more nearly approximated for the period from January 31, 2014 to April 19, 2016. REASONS FOR REMAND Hips, knees, and neuropathy A December 8, 2001 ‘Screening Note of Acute Medical Care’ generated the day prior to her entry into active service reflects that the Veteran complained of foot, ankle and knee pain for the past five weeks. The ‘Record of Acute Medical Care’ reflects that she complained of left knee pain for three weeks and left foot pain for five weeks. There was mild tenderness to the arch of the left foot. The assessment was iliotibial band syndrome (ITBS)/metatarsalgia. 01/15/2015 STR-Reserve STR at 2, 4. A March 2004 Post-Deployment Health Assessment reflects that the Veteran checked the ‘Yes’ box for developing ‘numbness or tingling in hands and feet’ following deployment. Id. at 16. The Board notes that there are no other service treatment records available for review. A March 2010 VA treatment record reflects complaints of pain over the past four weeks related to her knees, hips, feet, back and tailbone. In April 2010, the Veteran complained of chronic pain in her hips and knees. 02/25/2011 Medical Treatment Record-Government Facility at 4, 9. An October 2011 VA treatment record reflects low back and hip pain since service. 09/13/2019 CAPRI at 199. An April 2012 VA treatment record reflects low back and hip pain since service. The impression was hip pain, stable. Reference is made to an August 2009 right lower extremity fracture. Id. at 156. An August 2013 VA treatment record references low back and hip pain since service. There is also reference to a right lower extremity fracture in August 2009 and that she has two plates in her leg. An August 2013 x-ray examination of the lumbar spine reflects that her bilateral hip joints were normal. Id. at 117-118. An August 2015 VA treatment record reflects complaints of constant pain in her hips. Id. at 82. In July 2020, the Veteran underwent a C&P examination pertaining to the hips. The examiner concluded that there was no diagnosis pertaining to the hips. The examiner opined that it is less likely than not that a bilateral hip condition is due to service, because there is no diagnosis for either hip condition and service treatment records are silent about chronic hip pain while on active duty. In July 2020, the Veteran underwent a C&P Gulf War examination wherein the examiner stated that for the claimed conditions of right and left hip disabilities, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness ,there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. In July 2020, the Veteran underwent a C&P examination pertaining to neuropathy. The examiner concluded that there was no diagnosis of neuropathy. The examiner opined that it is less likely than not that bilateral peripheral neuropathy is due to service, because there is no diagnosis for either hip condition and although service treatment records show numbness of the feet on active duty, there was no diagnosis of neuropathy. In July 2020, the Veteran underwent a C&P Gulf War examination wherein the examiner stated that for the claimed conditions of neuropathy, right and left feet, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. In July 2020, the Veteran underwent a C&P examination pertaining to the knees wherein the examiner diagnosed patellofemoral pain syndrome. The examiner stated that it is at least as likely as not that the Veteran’s patellofemoral syndrome is a diagnosable chronic multi-symptom illness with a partially explained etiology, and it is documented in the period of 2010-2012 after separation, so it is less likely than not that it is due to service. In July 2020, the Veteran underwent a C&P Gulf War examination wherein the examiner stated that for the claimed conditions of right and left knee disabilities, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. Initially, the opinions contained in the C&P Gulf War examination are inadequate as the examiner did not address whether any such signs and symptoms associated with the hips and feet represent an undiagnosed illness of the joints and muscular system, or a medically unexplained chronic multisymptom illness. Thus, further opinions must be sought. With regard to the left foot, due to the December 8, 2001 diagnosis of metatarsalgia, an opinion must be sought as to whether such pre-existing condition was aggravated beyond its natural progression by active service. With regard to the left knee, due to the December 8, 2001 diagnosis of ITBS, an opinion must be sought as to whether such pre-existing condition was aggravated beyond its natural progression by active service. In light of service connection being established for lumbar strain with degenerative disc disease L5-S1 (10% 04/07/2010), opinions should be sought as to whether his disabilities of the knees are due to or aggravated by the lumbar spine disability. In November 2018 and February 2020, VA requested that the Veteran complete releases pertaining to private medical providers; the Veteran did not respond. The Veteran should be given another opportunity to respond. On Remand, associate updated VA treatment records for the period from February 27, 2020. The matters are REMANDED for the following actions: 1. Associate updated VA treatment records for the period from February 27, 2020. 2. Ask the Veteran to complete a VA Form 21-4142 for all private medical providers with regard to the hips, knees, and feet. Make two requests for the authorized records from any identified private medical providers, unless it is clear after the first request that a second request would be futile. 3. Request that a clinician with appropriate expertise review the claims folder to assess the nature and etiology of her claimed disabilities of the hips. The virtual folders must be reviewed by the examiner so as to become familiar with the Veteran’s pertinent medical history and relevant facts. The examiner should respond to the following: a) As the right hip complaint is not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the joints and muscular system, or a medically unexplained chronic multisymptom illness? b) As the left hip complaint is not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the joints and muscular system, or a medically unexplained chronic multisymptom illness? Provide a comprehensive rationale for every opinion. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. An examination should be scheduled if deemed necessary by the examiner. 4. Request that a clinician with appropriate expertise review the claims folder to assess the nature and etiology of her claimed disabilities of the knees. The virtual folders must be reviewed by the examiner so as to become familiar with the Veteran’s pertinent medical history and relevant facts. The examiner should respond to the following: a) Opine whether ITBS of the left knee was at least as likely as not (50 percent or greater probability) caused by active service? The examiner should be made aware that the entirety of the Veteran’s service treatment records are not available for review. b) Is a left knee disability at least as likely as not (50 percent or greater probability) caused by her service-connected lumbar spine disability? c) Is a right knee disability at least as likely as not (50 percent or greater probability) caused by her service-connected lumbar spine disability? d) Is a left knee disability at least as likely as not (50 percent or greater probability) aggravated (i.e., worsened beyond the normal progression of the disease) by her service-connected lumbar spine disability? e) Is a right knee disability at least as likely as not (50 percent or greater probability) aggravated (i.e., worsened beyond the normal progression of the disease) by her service-connected lumbar spine disability? Provide a comprehensive rationale for every opinion. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. An examination should be scheduled if deemed necessary by the examiner. 5. Request that a clinician with appropriate expertise review the claims folder to assess the nature and etiology of her claimed disabilities of the feet. The virtual folders must be reviewed by the examiner so as to become familiar with the Veteran’s pertinent medical history and relevant facts. The examiner should respond to the following: a) As the right foot complaint is not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the joints and muscular system, or a medically unexplained chronic multisymptom illness? b) As the left foot complaint is not attributed to a known clinical diagnosis, is it at least as likely as not that any such signs and symptoms represent an undiagnosed illness of the joints and muscular system, or a medically unexplained chronic multisymptom illness? c) Opine whether metatarsalgia was at least as likely as not caused by service. The examiner should be made aware that the entirety of the Veteran’s service treatment records are not available for review. Provide a comprehensive rationale for every opinion. All pertinent evidence, including both lay and medical, should be considered. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. (Continued on the next page)   An examination should be scheduled if deemed necessary by the examiner. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, 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.