Citation Nr: 21004213 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 15-16 433 DATE: January 26, 2021 ORDER Service connection for a right hip disorder as secondary to the service-connected left ankle and foot disabilities is denied. Service connection for posttraumatic stress disorder (PTSD) and adjustment disorder with anxiety and depression is granted. FINDINGS OF FACT 1. The Veteran has a current right hip disability of degenerative arthritis, bursitis, and iliotibial band (ITB) syndrome. 2. The right hip disorder is not caused or worsened by the service-connected left ankle and left foot disabilities 3. The Veteran has a current acquired psychiatric disorder of PTSD and adjustment disorder with anxiety and depression. 4. The Veteran experienced a traumatic event related to fear of hostile military or terrorist activity during service. 5. The current acquired psychiatric disorder is related to the in-service traumatic event. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disorder as secondary to the service-connected left ankle and foot disabilities have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for PTSD and adjustment disorder with anxiety and depression have been met. 38 U.S.C. §§ 1110, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from November 1990 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision from the Regional Office (RO), which denied service connection for a right hip disorder and an acquired psychiatric disorder. Service connection for a right hip disorder and an acquired psychiatric disorder were previously before the Board in August 2018. In the August 2018 Board Decision, the Board denied service connection for a right hip disorder and remanded service connection for an acquired psychiatric disorder for additional development. The Veteran appealed the matter to the U.S. Court of Appeals for Veterans Claims (Court). In an October 2019 Joint Motion for Remand (JMR), the parties agreed that a remand was warranted for the Board to provide adequate reasons and bases regarding the claim for service connection for a right hip disorder, particularly the Board reliance on the March 2015 VA opinion report, which included a statement that the right hip condition is “at least as likely as not” proximately due to or the result of the left ankle and foot disabilities, and a statement that the right hip disorder is “less likely than not” proximately due to or the result of the left ankle and foot disabilities. In June 2020 The Board remanded the issue of service connection for a right hip disorder for an addendum medical opinion, including to address the etiology of the right hip ITB syndrome. The Board finds that the Agency of Original Jurisdiction (AOJ) substantially complied with the June 2020 Board Remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). In this case, the Veterans Claims Assistance Act of 2000 (VCAA) notice requirements were satisfied by way of the February 2011 notice letter. The VCAA duty to assist has been met in this case. The complete service treatment records and all identified post-service treatment records are associated with the record. VA right hip examinations and medical opinions were provided in June 2014 and March 2015, and an additional VA examination and medical opinion was obtained in October 2020 with adequate rationale. The representative contends that the October 2020 VA aggravation opinion is inadequate because the examiner opined that a baseline level of severity could not be determined for the right hip disability because the medical evidence is not sufficient, and the claim of aggravation is subjective. See December 2020 representative brief. However, this mischaracterizes the examiner’s opinion. While the examiner indicated that a baseline level of severity for the right hip disorder prior to a period of aggravation cannot be bet determined based on the evidence of record, the examiner wrote that, regardless of any established baseline, it is not likely that the right hip was aggravated by the service-connected left ankle and foot disability and provided supporting rationale for the opinion based on examination of the Veteran as well as review of the evidence of record and medical literature. As such, the opinion is adequate to adjudicate the claim for service connection for a right hip disorder. With regard to service connection for an acquired psychiatric disorder, the duties to notify and assist have been rendered moot by the grant of service connection for an acquired psychiatric disorder, which is a full grant of the benefit sought on appeal. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in the appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the appeal. In view of the foregoing, the Board will proceed with appellate review. Service Connection Legal Authority Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. 38 C.F.R. § 3.310(c). Service connection for PTSD requires the following three elements: (1) a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor in accordance with 38 C.F.R. § 4.125(a)), (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran’s military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran “engaged in combat with the enemy.” Id. If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran’s lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f)(2). No further development or corroborative evidence is required, provided that the claimed stressor is “consistent with the circumstances, conditions, or hardships of the veteran’s service.” Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran’s lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran’s testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. Fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3). If a veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, and the stressor is not related to “fear of hostile military or terrorist activity,” then the veteran’s testimony alone is not sufficient to establish the occurrence of the claimed stressors and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). Furthermore, service department records must support, and not contradict, the claimant’s testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). Under 38 C.F.R. § 3.304(f)(5), if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Under 38 C.F.R. § 3.304(f)(5), VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff’d on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of PTSD is a question of fact for medical professionals, and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. 1. Service Connection for a Right Hip Disorder The Veteran generally contends that service connection for a right hip disorder is warranted as secondary to the service-connected left ankle and foot disabilities. See 38 C.F.R. § 3.310. Specifically, the Veteran contends that she has compensated pain from the service-connected left ankle and foot disabilities by shifting weight to the right side of her body, causing right hip pain and stiffness that has progressively worsened over the years. See May 2015 VA Form 9; December 2012 correspondence, and June 2011 Claim. At the outset, the Board finds that service treatment records do not reflect evidence of symptoms, clinical signs, or diagnosis of a right hip disorder during service to even suggest a direct service connection theory. See generally, service treatment records. Further, the Veteran has only advanced the theory of service connection for a right hip disorder secondary to the service-connected left ankle and left foot disabilities in this case. See June 2011 Claim, December 2012 correspondence, and May 2015 VA Form 9. Therefore, the question in this case is whether the right hip disorder was caused or aggravated by the service-connected left foot and left ankle disabilities. 38 C.F.R. § 3.310(a). The evidence shows current right hip diagnoses of mild osteoarthritis, right trochanteric bursitis, and iliotibial band (ITB) syndrome. See June 2014, October 2020 VA examination reports, see also July 2016 VA treatment record. After reviewing all the evidence of record, both lay and medical, the Board finds that the weight of the evidence is against finding that the right hip disorder was caused by or worsened in severity by the service-connected left foot and ankle disabilities. Imaging of the service-connected left foot and ankle shows only mild arthritis in the foot and minimal tenosynovitis and retrocalcaneal bursitis, but is otherwise unremarkable. See June 2010, January 2017, December 2018 VA treatment records. VA treatment notes dated January and February 2011 reflect the Veteran’s lay reports of gradual right hip pain on and off for the past three months, and that she believed the pain in her right hip was due to off-loading the weight from her left ankle and foot to the right leg due to the chronic left ankle problem. Examination revealed that the Veteran was able to heel and toe walk with some right hip pain and she had mildly limited right hip range of motion, but otherwise had full strength. Diagnosis was right trochanteric bursitis and ITB syndrome for which physical therapy was recommended. See January 2011 and February 2011 VA treatment records. An August 2012 magnetic resonance imaging (MRI) of the right hip also showed mild osteoarthritis. See August 2012 VA treatment record. Treatment notes over the years have shown some tenderness to palpation in the left foot on examination and some pain with range of motion of both hips on examination, but no swelling or deformity in the left foot or right hip. The Veteran also retained full range of motion in the left ankle without significant pain and full to mildly limited range of motion in the right hip. The right hip, left foot, and ankle disorders have been described as stable over the years, and the evidence has consistently shown the normal gait, good balance, and the ability to ambulate unassisted with no evidence of a limp on examination. See March 2015, May 2015, July 2015, July 2016, February 2018, August 2018, September 2018, January 2019, March 2019, May 2019, August 2020, December 2020 VA treatment records. The Veteran underwent a VA examination in June 2014. Upon interview and examination, the VA examiner diagnosed mild osteoarthritis of the right hip. The June 2014 VA examiner opined that the right hip disorder was less than likely due to the service-connected left ankle disability. The VA examiner reasoned that there was no evidence based on medical literature that suggests lateral instability of the left ankle caused osteoarthritis. The June VA 2014 VA examiner further explained that the Veteran does not have abnormal gait, imaging of the left ankle was normal, and a left ankle disorder anatomically cannot cause a hip condition. See June 2014 VA examination report. Following a review of the claims file, including VBMS and Virtual VA, an addendum VA medical opinion was provided in March 2015. A review of the March 2015 VA medical opinion report reflects a statement that the Veteran’s right hip condition is “at least as likely as not (50 percent or greater probability) proximately due to or the result of” the service-connected left ankle lateral instability and left heel calcaneal spur. However, this statement is listed under the section labeled “Restatement of Requested Opinion,” which suggests that the “at least as likely as not” statement is simply a restatement of the opinion or question that the RO requested the VA examiner to provide a response to, despite the fact that it was not specifically phrased in the form of a question. Under the “Type of Medical Opinion Provided” section, the VA examiner indicates that a secondary service connection opinion is being provided, and, in response to the question presented, the VA examiner opined that the right hip condition was less than likely caused by or the result of the service-connected left ankle and foot disabilities. The VA examiner in March 2015 specifically responded that “the condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran’s service connected condition,” and proceeded to provide rationale explaining why the right hip disorder was not caused by or the result of the service-connected left ankle and foot disabilities. See March 2015 VA examination report. Specifically, the VA examiner in March 2015 explained that, while the contention that one side of the body having pain causes a person to favor or “on load” on the other causing arthritis on the contralateral side is often cited, this theory is biomechanically incorrect and has been disproven in the orthopedic and occupational medicine literature. The VA examiner explained that arthritis formation would require increased speed and increased sheer forces across the joint, which is only seen in the paralytic or waddling gait abnormality. Additionally, the examiner noted that the veteran has intermittent pain in the left ankle but wears a brace for stability, offsetting any effect. Citing the American Academy of Orthopedic Surgeons (March 2014) to support the rationale, the VA examiner in March 2015 further reasoned that hip bursitis is caused by repetitive stress injury from sports, running, stair climbing, excess standing; direct injury to the hip; spine disease; significant leg length abnormality; rheumatoid arthritis; and prior hip surgery and hip tendon bone spurs. Additionally, the March 2015 VA examiner endorsed the same disclaimer concerning contralateral “favoring” as discussed above as relevant for arthritis, and explained that there is no plausible mechanism for a heel spur to cause any condition of the right hip. When the rationale provided by the VA examiner is read in context with the statement “the condition claimed is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition” which is noted immediately before the rationale, in addition to being included at the end of the rational provided, it is clear that the VA examiner opined there was no causal relationship between the right hip disorder and the service-connected left ankle or foot disorder. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that “examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion”). In October 2020, the VA examiner opined that it is less likely than not that the right hip disorder, to include right hip arthritis, bursitis, and ITB syndrome, was caused or aggravated by the service-connected left ankle and/or foot disabilities. The VA examiner acknowledged the VA physical therapist’s statement in support of the claim indicating that the Veteran’s right hip problem, which the physical therapist identified as osteoarthritis, is secondary to the left ankle disability due to adding stress on the right side to compensate pain in the left lower extremity. Upon review of the evidence of record, examination of the Veteran, and review of medical literature, the VA examiner noted that there is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy of more than 5 centimeters so that the individuals gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. See October 2020 VA examination report. While the examiner in October 2020 noted that the Veteran’s gait was antalgic on the day of the VA examination, there was no clinical evidence of Trendelenburg gait and, as such, the level of severity necessary for a causal relationship is not supported based on record review, history, or examination. The VA examiner in October 2020 further notes that it is not unusual for two joints to share properties in the same person, but one joint’s disease does not ‘spread’ to another or cause damage to it. Th VA examiner opined that the right hip arthritis, bursitis, and ITB syndrome are less likely than not related to the left ankle and/or left foot disabilities. In terms of aggravation, the VA examiner in October 2020 noted that a baseline level of severity for the right hip disorder prior to any claimed aggravation cannot be determined based on the medical evidence. Regardless of any baseline level of severity, the VA examiner responded “no” to the question of whether it was at least as likely as not that the right hip disorder was aggravated by the service-connected left ankle/foot disability. The rationale provided was that based on the clinical findings on the day of the examination, and for reasons explained above, the Veteran’s assertion of aggravation of the right hip is subjective only as objective findings on examination only show antalgic gait with no evidence of Trendelenburg gait, so does not indicate aggravation of the right hip disorder beyond a natural progression by the service-connected disabilities. See October 2020 VA examination report. When considered in light of the entire record, the Board finds the VA medical opinions to be highly probative, as they are supported by detailed rationale that considers the Veteran’s lay assertions in light of the orthopedic medical literature and a review of the evidence as a whole, including clinical reports that have shown unremarkable imaging of the left ankle, mitigation of left ankle and foot disabilities with bracing, and lack of significant gait abnormalities, including Trendelenburg gait, on examinations that would suggest a relationship between the right hip disorder and the service-connected left foot/ankle disability. In a February 2011 treatment note and a December 2012 letter, the Veteran’s treating physician and occupational therapist both opined that the Veteran’s right hip problem is secondary to the service-connected left ankle disability. They reasoned that the left ankle instability caused the Veteran to off-load or add more stress to her right side to help compensate the pain from her left foot and ankle disorder, and the Veteran now has osteoarthritis in the right hip. See February 2011 VA treatment record; December 2012 Third Party Correspondence. These opinions are of little probative value, as the treating VA medical providers did not indicate what evidence they relied upon other than the lay history provided by the Veteran to support the opinions. The treating medical providers did not identify any medical evidence or literature that supports the opinion that the Veteran has added more stress on the right hip to compensate pain in the left foot and ankle, particularly given evidence showing that the Veteran has demonstrated mostly normal gait with no evidence of a limp to suggest off-loading on the right hip to compensate pain in the left foot or ankle. Notably, the only time the Veteran is noted to have antalgic gait is during the October 2020 VA examination, but has otherwise generally demonstrated normal gait with no limp during clinical examinations before and after the VA examination. See, e.g., March 2015, May 2015, July 2015, July 2016, February 2018, August 2018, September 2018, January 2019, March 2019, May 2019, August 2020, December 2020 VA treatment records. For these reasons, the Board concludes that the weight of the evidence is against service connection for a right hip disorder as secondary to the service-connected left ankle or left foot disabilities, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. 2. Service Connection for an Acquired Psychiatric Disorder The Veteran generally contends that service connection is warranted for an acquired psychiatric disorder, claimed as PTSD. Specifically, the Veteran contends that she was deployed to Somalia with the 63rd Battalion from January 1993 to May 1993 in support of Operation Restore Hope in the midst of a civil war between rebel factions and the government in Somalia. The Veteran asserts that in January 1993, while deployed to Somalia, she was driving a vehicle in the convoy returning to base camp following a recon mission in Mogadishu, Somalia. She reports that a Jeep of Pakistani soldiers joined the convoy, falling in line behind her vehicle, and she noticed three Somalian men walking on the sidewalk during the drive. The Veteran testified that she witnessed the Pakistani soldiers open fire on the Somali civilians unprovoked, resulting in their death. The Veteran contends that she feared for her life in that moment and was subsequently on edge and fearful anytime she left the base camp or heard gun shots. The Veteran also testified that Somalians would sometimes throw rocks and bottles at the trucks during convoy missions, and that she was exposed to gunfire at times during convoy missions. She endorsed an onset of nightmares and hypervigilance from that time that continued when she returned to the US. See June 2018 Board hearing transcript, see also December 2012 Lay Statement, May 2015 VA Form 9. In this case the evidence shows a current diagnosis of an acquired psychiatric disorder, to include PTSD and adjustment disorder with anxiety and depression. See November 2011 Disability Benefits Questionnaire (DBQ), October 2019 private treatment record. The Board finds that the evidence is at least in equipoise on the question of whether the Veteran experienced an in-service traumatic event. The Veteran has consistently reported the occurrence of the above noted in-service traumatic events to mental health professionals and throughout the course of this appeal. See July 2013, February 2016 VA treatment records; September 2019, October 2019 private treatment records. The DD Form 214 and other military personnel records reflect that the Veteran served as a motor transport operator and was deployed to Somalia from January 1993 to May 1993. Website articles also indicate that US troops began arriving in Somalia for Operation Restore Hope in December 1992 and note intermittent episode of violence between US forces, Pakistani UN soldiers, and the Somali rebels during the mission. See representative brief. The Veteran’s treating psychologist in November 2020 assessed the stressor events experienced in service to be sufficient to support a diagnosis of PTSD and consistent with fear of hostile military or terrorist activity. See November 2020 DBQ and private treatment record. Additionally, statements from a fellow service member who was present during the convoy described the Veteran as being disturbed and full of angst after witnessing the fatalities of Somali citizens during service. See November 2020 Lay statements. The Board further finds that the weight of the evidence is at least in equipoise as to whether the currently diagnosed acquired psychiatric disorder is related to service. Treating mental health clinicians noted that the Veteran experienced extreme fear during deployment to Somalia in support of Operation Restore Hope due to fear of being assaulted by Somali citizens and exposure to small arms fire from United Nations forces shooting at Somali citizens during convoy missions. Treating clinicians noted that the Veteran experienced PTSD symptoms that have origins rooted in her deployment to Somalia including intrusive thoughts, anger, depression, anxiety, nightmares, isolation, and hypervigilance in crowded placed. In a November 2020 opinion, Dr. Creekmore opined that it is at least as likely as not that the Veteran’s PTSD and other issues are due to military service, as she witnessed the killing of Somali citizens and was harassed during convoys. Dr. Creekmore indicated that these stressors are consistent with fear of hostile military or terrorist activity and that the Veteran continues to have of PTSD and adjustment disorder with anxiety, depression, significant insomnia, flashbacks, and vigilance related to military service. See November 2020 DBQ; September 2019, October 2019, November 2020 private treatment record. While the Veteran initially filed a claim for service connection for PTSD, presently PTSD and adjustment disorder with anxiety and depression have been formally diagnosed. In this case, the Board is unable to differentiate the symptomatology of PTSD from adjustment disorder. In such a case of multiple diagnoses, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam); 38 C.F.R. § 4.130 (providing that all psychiatric disabilities are to be rated under one General Rating Formula). The practical effect of this Board decision is that all psychiatric symptomatology and impairment will be recognized as originating from the now service-connected PTSD and adjustment disorder with anxiety and depression, so will be considered in assigning the downstream initial rating. As such, the Board finds this to be a full grant of the benefit sought on appeal with respect to this issue. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Moore 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.