Citation Nr: 21003664 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 13-32 199 DATE: January 22, 2021 ORDER Entitlement to service connection for a neurological disorder of the left upper extremity, as secondary to degenerative disc disease of the cervical spine (neck disability), is granted. Entitlement to service connection for headaches, as secondary to a neck disability, is granted. Entitlement to an initial rating in excess of 40 percent for degenerative joint disease of the lumbar spine (back disability) is denied. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. From March 21, 2012, entitlement to a total disability rating due to individual unemployability (TDIU) is granted. REFERRED Entitlement to service connection for a neurological disorder of the right upper extremity is raised by the record. See August 2013 Dr. D.D. Opinion. This issue is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. See 38 C.F.R. § 19.9 (as in effect prior to February 19, 2019). REMANDED Entitlement to a rating in excess of 30 percent for left pneumothorax is remanded. Entitlement to a compensable rating for residuals of a sternum injury is remanded. Entitlement to service connection for a left shoulder 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 bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for erectile dysfunction (ED), as secondary to service-connected disabilities, is remanded. Entitlement to special monthly compensation (SMC) based on loss of use of a creative organ is remanded. Entitlement to SMC at the housebound rate is remanded. FINDINGS OF FACT 1. The Veteran’s neurological disorder of the left upper extremity is proximately due to a neck disability. 2. The Veteran’s headaches are proximately due to a neck disability. 3. Throughout the appeal, the Veteran’s back disability was not manifested by ankylosis of the thoracolumbar or entire spine. 4. Throughout the appeal, the Veteran’s PTSD did not more closely approximate total occupational or social impairment. 5. From March 21, 2012, the Veteran’s service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a neurological disorder of the left upper extremity, as secondary to a neck disability, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for headaches, as secondary to a neck disability, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. Throughout the appeal, the criteria for entitlement to an initial rating in excess of 40 percent for a back disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 4. Throughout the appeal, the criteria for entitlement to an initial rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.126, 4.130, DC 9411. 5. From March 21, 2012, the criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1962 to November 1964. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision by an AOJ of the Department of Veterans Affairs (VA). In June 2015, the Board remanded the appeal to afford the Veteran his requested hearing. The Board also explained that the issue of entitlement to a TDIU was raised by the record and was part and parcel of the increased rating claims on appeal. See June 2015 Board Remand at 2. In September 2018, the Veteran’s representative withdrew the Board hearing request and requested that the Board issue a decision based on the evidence of record. See September 2018 Third Party Correspondence. The Board is honoring the representative’s request and is issuing a decision without further delay. The Board has recharacterized the claim of entitlement to service connection for a sternum injury as seeking entitlement to a compensable rating for residuals of a sternum injury, as the Veteran’s sternum injury is service-connected. See February 1973 Rating Decision. The issues of entitlement to SMC and entitlement to service connection for ED are raised by the record and are part and parcel of the increased rating claims on appeal. See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019) (VA’s duty to maximize benefits may require exploring secondary service connection and entitlement to SMC). 1. Entitlement to service connection for a neurological disorder of the left upper extremity, as secondary to a neck disability, is granted. 2. Entitlement to service connection for headaches, as secondary to a neck disability, is granted. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection generally requires evidence showing (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Secondary service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The Veteran submitted an opinion from Dr. D.D., who explained that the Veteran experienced a cervical spine injury in service during a parachuting accident and that the current neck disability was a result of that injury. Dr. D.D. further explained that as a result of the Veteran’s neck disability he experienced headaches as well as left and right upper extremity peripheral neuropathy, with the left arm being more affected than the right arm. Dr. D.D. ultimately opined that it was at least as likely as not that the Veteran’s neck disability was the result of injuries incurred in service and stated that his neck disability should be service-connected and that the Veteran’s headaches and right and left upper extremity peripheral neuropathy were a result of his neck disability. See August 2013 Dr. D.D. Opinion. In October 2013, the AOJ granted entitlement to service connection for a neck disability based on Dr. D.D.’s medical opinion. See October 2013 Rating Decision. Here, the evidence shows that the Veteran has a current disability of headaches and left upper extremity peripheral neuropathy. In this regard, Dr. D.D. is competent to diagnose peripheral neuropathy, as he is a physician specializing in emergency and family medicine. See October 2013 SHARE Print Screens. Moreover, Dr. D.D. also diagnosed headaches, which can be diagnosed by a layman or medical professional. Moreover, Dr. D.D.’s opinion linking the Veteran’s left upper extremity peripheral neuropathy and headaches to his service-connected neck disability is the only medical opinion of record as to the etiology of those disabilities. Thus, as all the probative evidence is in favor of the claim, entitlement to service connection for headaches and left upper extremity peripheral neuropathy, as secondary to a neck disability, is warranted. The Board acknowledges that Dr. D.D. also diagnosed right upper extremity peripheral neuropathy secondary to a neck disability. As noted above, this matter has been referred to the AOJ for initial adjudication. 3. Entitlement to an initial rating in excess of 40 percent for a back disability is denied. The Veteran’s former representative argued that the Veteran’s back disability symptoms are more consistent with the criteria for a 50 percent rating. See, e.g., July 2013 Notice of Disagreement (NOD); November 2013 VA Form 9. The Veteran is in receipt of an initial 40 percent rating for a back disability under DC 5242 (degenerative arthritis of the spine). The period on appeal is from March 21, 2012, the effective date of service connection. Under DC 5242, a 40 percent rating is warranted where forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or where there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted where there is unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a, DC 5242 (General Rating Formula for Diseases and Injuries of the Spine). The rating schedule provides that objective neurologic abnormalities are rated separately from limitation of motion. See id., Note 1. Initially, the Board observes that the Veteran’s objective neurologic abnormalities were rated separately by the AOJ, in compliance with Note 1 of the General Rating Formula for Diseases and Injuries of the Spine. See June 2013 Rating Decision. The Veteran did not appeal ratings assigned for associated neurologic abnormalities. Accordingly, the Board will focus the present decision on the back disability. In any event, the Board observes that this approach does not prejudice the Veteran as he does not argue (and the record does not show) why a higher rating would be warranted for neurologic abnormalities. A rating in excess of 40 percent is not warranted for a back disability. A rating in excess of 40 percent under DC 5242 requires ankylosis of the spine; here, the Veteran does not assert, and the record does not show, the presence of ankylosis of the spine. See August 2012 and September 2014 VA examination reports. Moreover, as the Veteran is in receipt of the maximum rating based on limitation of motion, any lack of specificity in the examination reports of record as to whether the examiner conducted all range of motion testing directed by VA regulations is not prejudicial. See Johnston v. Brown, 10 Vet. App. 80 (1997). Thus, the former representative’s argument that the Veteran should have been provided an adequate examination is inapposite, as in the absence of ankylosis there is no plausible basis for the award of a 50 percent rating under DC 5242. Additionally, although the August 2012 VA examiner identified Intervertebral Disc Syndrome, a higher rating under DC 5243 is unavailable, as the examiner identified no incapacitating episodes over the prior twelve months requiring prescribed bedrest. See 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 4. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. The Veteran’s former representative argued that the Veteran’s PTSD symptoms are more consistent with the criteria for a 100 percent rating. See, e.g., July 2013 NOD; November 2013 VA Form 9. The Veteran is in receipt of an initial 70 percent rating for PTSD under DC 9411 (PTSD). The period on appeal is from March 21, 2012, the effective date of service connection. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating of 100 percent. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran’s symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. Under DC 9411, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: 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; or memory loss for names of close relatives, own occupation or own name. In May 2012, a private psychologist diagnosed the Veteran with PTSD related to a parachuting accident in service, as well as other psychiatric diagnoses. The psychologist noted the Veteran’s initial anxiety with rapport slowly attained and his friendly but distant manner. The Veteran’s mood was upbeat and he denied suicidal ideation and exhibited spontaneous, logical, and coherent thought processes. His exhibited good grooming and hygiene and his speech was relevant and appropriate. The examiner noted mild impairment in delayed recall. Concentration was noted as moderately to significantly impaired. The Veteran denied symptoms of psychosis, including hallucinatory activity, and delusions were no observed. The psychologist found the Veteran to be capable of completing his basic activities of daily living. See May 2012 Private Psychological Assessment. A September 2014 VA-contracted examiner diagnosed the Veteran with PTSD and stated that the Veteran’s impairment was best summarized as occupational and social impairment with reduced reliability and productivity. The examiner noted the Veteran’s report of irritability with his wife but never physical aggression. He reported no close friendships but stated that he had good relationships with his children, with whom he spoke regularly during telephone conversations. The examiner noted symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner also noted that the Veteran had significant concentration problems that would require close supervision in an occupational setting. See September 2014 Psychological Examination Report. Here, the severity, frequency, and duration of the Veteran’s symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. In this regard, all specifically identified symptoms were consistent with the frequency, duration, and severity of a rating of 70 percent or less. Additionally, the examiner noted that the Veteran had significant concentration problems but stated that the Veteran could perform certain types of tasks under supervision. This residual occupational functioning more closely approximates a rating of 70 percent or less. Likewise, the Veteran’s social relationships with his wife and children, while not unimpaired, demonstrate social functioning that is inconsistent with a finding of total social impairment. Thus, as the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 100 percent rating, an initial rating in excess of 70 percent for PTSD is denied. 5. From March 21, 2012, entitlement to a TDIU is granted. The Veteran, through his former representative, asserts that he is entitled to a TDIU. See, e.g., July 2013 Third Party Correspondence; June 2014 VA Form 21-8940. The Board agrees. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran is in receipt of a 70 percent rating for PTSD from March 21, 2012 and meets the schedular criteria for TDIU from that date based on his PTSD alone or in combination with other disabilities. He is also in receipt of service connection for lumbar spine degenerative joint disease (back disability), traumatic left pneumo-thorax, radiculopathy of the right and left lower extremities, a neck disability, healed fractures of 3-5 ribs left side, headaches, and left upper extremity peripheral neuropathy. Prior to implementation of the awards of service connection for headaches and left upper extremity peripheral neuropathy, he is in receipt of a combined 90 percent disability evaluation from March 21, 2012. The Board observes that even if the Veteran is awarded a total schedular combined disability evaluation as a result of these awards of service connection, the issue of entitlement to a TDIU would not be moot. See Buie v. Shinseki, 24 Vet. App. 242 (2011). The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran’s ability to secure or follow substantially gainful employment, including factors such as the veteran’s history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Before relying on an examiner’s finding that a veteran is capable of sedentary work to deny a TDIU, the Board must explain how it interprets that concept in the context of the case. See Withers v. Wilkie, 30 Vet. App. 139, 148 (2018). Here, the Board interprets “sedentary work” in its usual sense, specifically white-collar office-type work. This definition is consistent with a definition used by a VA examiner, who noted that when she referred to “sedentary work” she meant work “such as using a computer.” See September 2014 VA Back Examination Report. The Veteran reports that he worked for General Motors for 30 years and then retired, and that he subsequently worked as a driver for “J&D’s” for seven years and retired in 2010. See, e.g., June 2014 VA Form 21-8940; September 2014 VA Back Examination Report. Thus, as the Veteran is not shown to be receiving income from employment, the economic component of a TDIU is met. Turning to the noneconomic component, the Veteran has an associate degree and two years of trade school education as a Master Machinist and tool and die maker. See June 2014 VA Form 21-8940. He reports that he engaged in a computer education class in 2000-2001 but was unable to complete the course. See id. The September 2014 VA back examiner noted the Veteran’s report that he stopped working as a driver because of nonservice-connected diabetes mellitus and hypertension. See September 2014 Examination Report at 2. However, the Board observes that the key question is not the impact of nonservice-connected disabilities, but rather whether the Veteran would be precluded from work by reason of his service-connected disabilities. An August 2012 VA examiner explained that the Veteran’s back disability prevented any significant lifting, bending, and stretching. See August 2012 VA Back Examination Report at 6. The September 2014 VA examiner explained that the Veteran’s moderate obstructive lung disease would affect his ability to due manual labor but would not hinder his ability to do sedentary work “such as using a computer.” See September 2014 VA Back Examination Report at 2; see also September 2014 VA Respiratory Examination Report (moderate obstructive lung defect due to service-connected pneumothorax). The September 2014 examiner further explained that the Veteran’s back disability and radiculopathy may hinder his ability to seek gainful employment and may contribute to an inability secure gainful employment in combination with other disabilities such as diabetes mellitus and hypertension. See September 2014 VA Back Examination Report at 9. However, the examiner noted that there was no evidence showing that the Veteran was unable to stand, sit, or ambulate for 15-20 minutes or less, or that the Veteran required rest periods. See id. A VA-contracted psychologist explained that the Veteran’s PTSD was productive of symptoms of depressed mood, anxiety, chronic sleep impairment, panic attacks more than once a week, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner explained that the Veteran’s impairment in concentration results in difficulties in communication and reading, as well as task distraction, and that these difficulties would limit his occupational functioning to routine, repetitive tasks under close supervision. See September 2014 Psychological Examination Report at 6-7. Here, the evidence shows that the Veteran’s service-connected physical disabilities prevent employment involving physical tasks, but do not preclude the Veteran from sedentary work such as using a computer. However, the evidence shows that the Veteran is unable to secure or follow a substantially gainful occupation involving such sedentary work. In this regard, the Veteran’s PTSD precludes him from working alone or performing complex or novel tasks. Indeed, the Veteran was unable to complete a computer education class. Additionally, the Board observes that the Veteran could not return to his previous occupation as a driver, as that role does not permit close supervision. The Board emphasizes that no examiner opined that the Veteran’s service-connected disabilities would preclude him from securing and following a substantially gainful occupation. However, the ultimate determination as to entitlement to a TDIU is made by VA adjudicators rather than medical examiners. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Indeed, the Board stresses that the only employment considered by VA examiners involved the use of computers, a skill that the Veteran was unable to learn. Accordingly, entitlement to a TDIU is warranted from March 21, 2012, the earliest date of schedular eligibility. The Board emphasizes that while the present decision considered entitlement to a TDIU based on all the Veteran’s service-connected disabilities, this decision does not reflect the Board’s judgment that the Veteran’s PTSD alone would not preclude him from securing and following a substantially gainful occupation and is without prejudice to such a determination. Rather, to avoid prejudice to the Veteran, the issue of entitlement to SMC is addressed in the remand section below. REASONS FOR REMAND 6. Entitlement to a rating in excess of 30 percent for left pneumothorax is remanded. Remand is necessary, as the Veteran could be entitled to a rating in excess of 30 percent based on exercise capacity. However, the August 2012 VA examiner stated that exercise testing was not performed but did not explain why that was so. See August 2012 VA Respiratory Examination Report at 8. On remand, this deficiency should be addressed. Outstanding VA treatment records should also be secured. 7. Entitlement to a compensable rating for residuals of a sternum injury is remanded. The Veteran is in receipt of a noncompensable rating for healed fractures of the ribs related to a parachuting accident in service. Moreover, the evidence shows that he experiences chronic pain in the left lateral rib area secondary to these fractures. See August 2012 VA Respiratory Examination Report at 5. On remand, the Veteran should be afforded an examination as to the nature and severity of any current sternum residuals of his in-service parachuting accident, including his reported chronic pain in the left lateral rib area. 8. Entitlement to service connection for a left shoulder disability is remanded. 9. Entitlement to service connection for a left hip disability is remanded. 10. Entitlement to service connection for a right knee disability is remanded. 11. Entitlement to service connection for a left knee disability is remanded. The Veteran competently and credibly reported pain in the left shoulder, left knee, and left and right knees that he attributes to his parachuting injury in service. See, e.g., May 2012 Private Psychological Assessment at 2. On remand, he should be afforded an examination and medical opinions should be secured. 12. Entitlement to service connection for bilateral hearing loss is remanded. 13. Entitlement to service connection for tinnitus is remanded. The Veteran is competent to report the presence of tinnitus. Moreover, he is competent to report the presence of decrease hearing acuity, although he is not shown to be competent to diagnose hearing loss for VA compensation purposes. Additionally, his service examination reports show a change in recorded hearing thresholds. On remand, he should be afforded an audiological examination and a medical opinion should be secured.   14. Entitlement to service connection for ED, as secondary to service-connected disabilities, is remanded. 15. Entitlement to SMC based on loss of use of a creative organ is remanded. Through his former representative, the Veteran asserts that he experiences ED as secondary to medications for his service-connected disabilities. See, e.g., July 2013 Third Party Correspondence. The AOJ did not issue a decision on this claim, as it recognized it was part of the issues on appeal. See October 2014 Notification Letter. The AOJ secured an opinion as to whether the Veteran’s ED is proximately due to PTSD, to include medication. However, this opinion is adequate as it failed to address aggravation. On remand, an adequate opinion should be obtained. 16. Entitlement to SMC at the housebound rate is remanded. Action on this issue is deferred so that the AOJ may consider entitlement to SMC at the housebound rate in the first instance. The matters are REMANDED for the following action: 1. Secure all outstanding VA treatment records. 2. After completing #1, refer the claims file to an examiner for preparation of an addendum opinion as to the severity of the Veteran’s respiratory disability. No further examination of the Veteran is necessary unless the examiner deems otherwise. The examiner should explain why exercise testing is unnecessary to accurately assess the severity of the Veteran’s respiratory disability. A rationale for this conclusion should be provided. If and only if the examiner does not state why exercise testing is unnecessary, i.e. if the examiner says testing is necessary or if no adequate addendum opinion can be obtained, the Veteran should be scheduled for a respiratory examination. 3. After completing #1, schedule the Veteran for an examination to determine the nature and severity of any disability or functional impairment manifested by chronic left lateral rib pain. The claims file should be made available to and should be reviewed by the examiner. All findings should be reported in detail. The examiner should address the following: (a) Diagnose any current disorder or functional impairment of the sternum resulting from the Veteran’s parachuting injury in service, to include his reported chronic pain in the left lateral rib area. The examiner is advised that for purposes of this question, pain that is productive of a functional impairment may represent a current disability even in the absence of a diagnosed disorder. (b) For each disorder or functional impairment diagnosed in subpart (a), please assess the severity of this disability. 4. After completing #1, schedule the Veteran for an examination to determine the nature and etiology of his claimed left shoulder disability. The claims file should be made available to and should be reviewed by the examiner. Any necessary testing should be performed. The examiner should address the following: (a) Please diagnose any current disorder or functional impairment of the left shoulder. The examiner is advised that for purposes of this question, pain that is productive of a functional impairment may represent a current disability even in the absence of a diagnosed disorder. (b) For each disorder or functional impairment diagnosed in subpart (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that such impairment had its onset during or is otherwise etiologically related to the Veteran’s active service, to include his parachute accident therein. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 5. After completing #1, schedule the Veteran for an examination to determine the nature and etiology of his claimed left hip disability. The claims file should be made available to and should be reviewed by the examiner. Any necessary testing should be performed. The examiner should address the following: (a) Please diagnose any current disorder or functional impairment of the left hip. The examiner is advised that for purposes of this question, pain that is productive of a functional impairment may represent a current disability even in the absence of a diagnosed disorder. (b) For each disorder or functional impairment diagnosed in subpart (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that such impairment had its onset during or is otherwise etiologically related to the Veteran’s active service, to include his parachute accident therein. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 6. After completing #1, schedule the Veteran for an examination to determine the nature and etiology of his claimed left and right knee disabilities. The claims file should be made available to and should be reviewed by the examiner. Any necessary testing should be performed. The examiner should address the following: (a) Please diagnose any current disorder or functional impairment of the left and right knees. The examiner is advised that for purposes of this question, pain that is productive of a functional impairment may represent a current disability even in the absence of a diagnosed disorder. (b) For each disorder or functional impairment diagnosed in subpart (a), please opine as to whether it is at least as likely as not (50 percent or greater probability) that such impairment had its onset during or is otherwise etiologically related to the Veteran’s active service, to include his parachute accident therein. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 7. After completing #1, schedule the Veteran for an audiological examination to determine the nature and etiology of his claimed hearing loss and tinnitus. The claims file should be made available to and should be reviewed by the examiner. Any necessary testing should be performed. The examiner should address the following: (a) Assess the Veteran’s hearing acuity and diagnose whether there is a hearing loss disability pursuant to 38 C.F.R. § 3.385 and/or tinnitus. (b) Please opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a current hearing loss disability that had its onset during or is otherwise etiologically related to his active duty service, to include military noise exposure. (c) Please opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has tinnitus that had its onset during or is otherwise etiologically related to his active duty service, to include military noise exposure. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 8. After completing #1, refer the claims file to an examiner for preparation of an addendum opinion as to the nature and etiology of the Veteran’s ED. No further examination of the Veteran is necessary unless deemed otherwise by the examiner. The examiner should address the following: (a) Please opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s ED is proximately due to service-connected disabilities, to include as a result of medication for such disabilities. (b) Please opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s ED has been aggravated (worsened beyond natural progression) by service-connected disabilities, to include as a result of medication for such disabilities. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.M. Badaczewski, Associate 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.