Citation Nr: 21063473 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 18-19 724 DATE: October 14, 2021 ORDER Entitlement to an initial rating of 10 percent, but not higher, for a residual scar of the left leg status post puncture wound is granted. REMANDED Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for allergic rhinitis as due as due to exposure to particulate matter while serving in Southwest Asia is remanded. Entitlement to service connection for a foot infection, to include as due to service in Southwest Asia, is remanded. Entitlement to service connection for a left shin injury, to include as due to service in Southwest Asia, is remanded. FINDING OF FACT Throughout the entire period on appeal, the Veteran had one left leg scar that was painful and unstable. CONCLUSION OF LAW 1. The criteria for a 10 percent rating, but no higher, for a left leg scar are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.118, Diagnostic Codes 7801-7805. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2002 to April 2004, to include service in Southwest Asia. These matters come to the Board of Veterans' Appeals (Board) on appeal from May 2017, March 2018, and January 2019 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Huntington, Alabama. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in August 2020. A transcript of the hearing has been associated with the claims file. In addition, in a July 2019 rating decision, the agency of original jurisdiction (AOJ) granted service connection for erectile dysfunction and assigned an initial rating. As this decision represents a full grant of the benefits sought with respect to this claim for service connection in the legacy appeal, such issue is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Specifically, the Board notes that in a September 2021 submission, the Veteran filed a claim for entitlement to a total rating based on individual unemployability due to service connected disability (TDIU). See VA 21-8940, September 8, 2021. Generally, the issue of entitlement to a TDIU can be raised by the record and added to the appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453, 54 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation); see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that a separate, formal claim is not required in cases where an informal claim for TDIU has been reasonably raised). In this instance, the Veteran claim entitlement to a TDIU pursuant to the combination of his service connected disability, to include a left leg scar and PTSD. However, given the temporal proximity of the Veteran's claim, and as the claims file indicates that the RO is currently developing the claim for entitlement to a TDIU, the Board declines jurisdiction of the issue despite the decision in Rice. Increased Rating Left Leg Scar The Veteran asserts that he should be in receipt of an initial compensable rating for his left leg scar as his symptoms are more severe than that which is reflected by the current rating assigned. Specifically, the Veteran stated that his left leg scar manifests in pain, burning, numbness as residuals of his left shin injury. See VA Form 9, April 6, 2016. Additionally, the Veteran testified that his left leg scar would open up during certain activities, such as walking, and pain. See Board hearing transcript, August 28, 2020. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary 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). The Veteran's left leg scar is currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7802. The Board acknowledges that the rating criteria for many skin disabilities were revised during this appeal, effective from August 13, 2018. They introduce a General Rating Formula for skin conditions and amend Diagnostic Codes 7801 and 7802 by characterizing multiple scars by 6 body zones affected rather than by extremity. Claims pending prior to the effective date, such as this one, may be rated under either the amended or pre-amended criteria, depending on which is more advantageous. Both the pre-amended and amended versions of Diagnostic Code 7800 apply to scars or other disfigurement of the head, face, or neck. As the scar is located on the Veteran's left leg, Diagnostic Code 7800 is not for application in this case. The pre-amended version of Diagnostic Code 7801 applies to scars that are deep and nonlinear and provides for a 10 percent disability rating when such scars cover an area or areas of at least 6 square inches (39 sq. cm.). Note (1) states that a deep scar is one associated with underlying soft tissue damage. The amended version also applies to scars that are associated with underlying soft tissue damage. Under the former code, a deep scar is defined as one associated with underlying soft tissue damage. Under pre-amended Diagnostic Code 7802, scars not of the head, face, or neck, that are superficial and nonlinear are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. Under amended Diagnostic Code 7802, scars not of the head, face, or neck, that are not associated with underlying soft tissue damage are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. In this case, the Veteran's scar covers an area that is significantly less than 144 square inches. Accordingly, this code is not for application. Diagnostic Code 7804 was not affected by the recent amendments. Under that code, scars that are unstable or painful can be assigned a rating of 30 percent with five or more scars that are unstable or painful. A rating of 20 percent requires three or four scars that are unstable or painful. A rating of 10 percent requires one or two scars that are unstable or painful. Turning to the evidence, the Veteran was afforded a VA examination in March 2018 for his knee. At that time, the examiner noted the Veteran had a scar on the left lower extremity, but that his extremity was otherwise normal. The Veteran reported he used coco butter so that his scar would not "rip open." The Veteran was afforded a VA examination in March 2018 for his left leg scar. At that time, the examiner found there was one scar on the left lower extremity. The examiner found the scar was not painful nor unstable, and was not due to burns. The scar measured 12 centimeters by .5 centimeters, and was superficial and non-linear; the scar approximated 6 centimeters squared. The examiner noted that the scar did not result in limitation of function. The scar was well healed and located on the left shin, there was no pain with palpation; the Veteran reported it was numb. The examiner noted the Veteran's left leg scar did not impact his ability to work. At his August 2020 Board hearing, the Veteran testified that he developed a scar following surgery for his left shin. He testified that his scar was in the front of his left leg, and approximately five inches long. He testified that the scar was creased, and it prevented him from doing any kind of activity, such as walking, for too long because the scar would swell, ache, and would open and bleed. He testified that his scar would take forever to heal once it reopened, and he would use butterfly bandages to treat it. He testified that his scar would open approximately six times a year, but that he had stopped "doing things to make it bust open." Finally, the Veteran testified that he would experience aching, swelling, and swelling in the knees and ankles due to his scar. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities to include his left leg scar. However, there is no indication from the treatment notes of record that the Veteran has reported scar symptoms that are worse than those noted above. Based on the foregoing, the Board finds an initial rating of 10 percent for a left leg scar is warranted for the entire period on appeal. In this regard, the evidence shows the Veteran had one scar on his left leg that was painful and unstable. Specifically, the Veteran testified that he experienced opening of the wound and aching. The evidence shows the Veteran's left leg scar totals approximately 6 centimeters squared. However, the evidence does not show that the Veteran has three or four scars that are unstable or painful to warrant a higher 20 percent rating. As such, the Board finds that the Veteran's left leg scar was painful and unstable, and does not measure 39 square centimeters, as to warrant a 10 percent initial rating, but not higher, for the entire period on appeal. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. The Board has considered whether a staged ratings under Hart, supra, is appropriate for the Veteran's service connected left leg scar; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating for such disability is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Accordingly, the Board finds that an initial compensable rating, but not higher than 10 percent, for a left leg scar is warranted, and the claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Increased Rating - PTSD The Veteran was most recently afforded an examination for PTSD in April 2017. Thereafter, at his August 2020 Board hearing, the Veteran testified that his PTSD had worsened since his most recent VA examination. In this regard, the Veteran testified that his PTSD symptoms manifested in a worsening temper, obsessive compulsive behaviors, social isolation, self-isolation, crowd avoidance, and impaired social and work relationships. As the above evidence indicates a possible worsening of that the Veteran's PTSD since his last VA examination, an additional examination should be afforded to gauge the current level of severity of his disability. 2. Service Connection Foot Infection The Veteran seeks entitlement to service connection for a foot infection as due to environmental hazard exposure during his service in Southwest Asia. See e.g. VA Form 9, August 14, 2019. Additionally, the Veteran testified at his August 2020 Board hearing that the exposure to burn pits, smoke, and sand during his service in Southwest Asia resulted in skin irritation, resulting in his toenails falling off, and that his symptoms continued following separation from active service. See Board hearing transcript, August 28, 2020 The Veteran was afforded a VA examination for his foot infection in December 2018. At that time, the examiner opined the Veteran's foot infection was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In this regard, the examiner noted that there was no record of a foot infection or rash of the feet in service, and there was no documentation for treatment of tinea after service. The Board finds the March 2018 VA opinion is incomplete to decide the claim. In this regard, the examiner failed to provide adequate rationale for the conclusions reached, failed to address the Veteran's contentions that his symptoms began during active service and have continued since, did not address direct service connection, and did not adequately address presumptive service connection based on environmental hazard exposure in Southwest Asia. Additionally, it appears that the examiners relied solely on the absence of diagnosis and treatment for a foot infection during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, the Board finds that a new VA medical opinion is warranted to address the nature and etiology of the Veteran's claimed foot infection. 3. Service Connection Allergic Rhinitis The Veteran seeks entitlement to service connection for allergic rhinitis as due to environmental hazard exposure during his service in Southwest Asia. See e.g. VA Form 9, August 14, 2019. Additionally, the Veteran testified at his August 2020 Board hearing that he developed symptoms of a respiratory illness, to include allergic rhinitis, during his active service; those symptoms had continued since. See Board hearing transcript, August 28, 2020. Specifically, the Veteran testified he had continuing sinus problems that required treatment with prescriptions during active service and since, and he developed those symptoms due to exposure to burn pits, smoke, and other environmental hazards during his time in Iraq. Id. Effective August 5, 2021, VA issued an interim final rule amending its adjudication regulations and establishing presumptive service connection for three chronic respiratory health conditions, to include asthma, in association with presumed exposures to fine, particulate matter. These presumptions apply to veterans with a qualifying period of service, i.e., who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, as well as in Afghanistan, Syria, Djibouti, or Uzbekistan, on or after September 19, 2001, during the Gulf War. See Presumptive Service Connection for Respiratory Conditions Due to Exposure to Particulate Matter, 86 Fed. Reg. 42724 (August 5, 2021), codified at 38 C.F.R. § 3.320. The Persian Gulf War began on August 2, 1990, and the Southwest Asia theater of operations encompasses Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, and the Red Sea. 38 C.F.R. §§ 3.2(i), 3.317(e)(2). The Veteran's military personnel records reflects that he served on active duty in Kuwait and Iraq from March 2003 to February 2004. Thus, the Veteran has a period of service that qualifies for the presumption as a result of his military service. The Veteran is therefore presumed exposed to fine, particulate matter during such service, and there is no affirmative evidence to establish he was not exposed to fine, particulate matter during such service. A qualifying disease shall be service-connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including non-compensable) within 10 years from the date of separation from military service. 38 C.F.R. § 3.320. The Board notes that the available clinical evidence shows that the Veteran was first diagnosed with allergic rhinitis in January 2017, more than 10 years following service discharge. Therefore presumptive service connection cannot be awarded at this time. The Veteran was afforded VA examinations for his allergic rhinitis in April 2017 and March 2018. The April 2017 VA examiner opined that the Veteran's allergic rhinitis was less likely than not related to a specific exposure event during his service in Southwest Asia. In that regard, the examiner noted that allergic rhinitis is a disease with a clear and specific etiology and diagnosis that is not presumptively related to service in Southwest Asia at that time; the examiner noted there was no known "specific" exposure event experienced by the Veteran during service in Southwest Asia. The March 2018 VA examiner opined that his allergic rhinitis was less likely than not incurred in or caused by active service because treatment for sinusitis was first shown in 2014, and then again in 2018, and noted other risk factors of the Veteran, such as smoking and childhood allergies. Additionally, the March 2018 VA examiner noted the Veteran reports that he had no exposure concerns during deployment, and that he had one week of intermittent exposure in the Gulf War. Therefore, the March 2018 VA examiner concluded that the Veteran's allergic rhinitis was more likely than not related to and aggravated by his 15 years of smoking history and continued tobacco use. The Board finds these VA opinions to be incomplete to decide the claim. In this regard, the examiners failed to provide adequate rationale for the conclusions reached, failed to address the Veteran's contentions that his symptoms began during active service and have continued since, did not address properly direct service connection, and did not adequately address presumptive service connection based on environmental hazard exposure in Southwest Asia. Additionally, it appears that the examiners relied solely on the absence of diagnosis and treatment for allergic rhinitis during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, the Board finds that a new VA medical opinion is warranted to address the nature and etiology of the Veteran's claimed allergic rhinitis. 4. Service Connection Left Shin Injury The Veteran seeks entitlement to service connection for a left shin injury as due to an injury sustained during his service in Southwest Asia. Specifically, the Veteran reported that he injured his left shin during a blast in Iraq, when a piece of rebar metal hit his leg. See VA Form 21-4138 Statement in Support of Claim, February 13, 2017. Additionally, the Veteran testified at his August 2020 Board hearing that he injured his left leg in July 2003 and never received medical attention for the injury until he returned from deployment. See Board hearing transcript, August 28, 2020. Moreover, the Veteran testified that, following surgical treatment, he continued to experience pain in his leg bone. Id. The Veteran was afforded a VA examination for his left shin injury in March 2018. At that time, the examiner opined the Veteran's reports of a paresthesias that affected his entire lower leg and foot was not consistent with the mechanism of injury when considering the location of the injury and nerve pathway and noted that the examination was normal and that his neurological exams were normal as shown in VA treatment records. Therefore, the VA examiner opined that "symptom magnification for secondary gain," must be considered, and stated that from a medical perspective, there was no anatomical or physiological connection between the Veteran's claimed symptoms and the injury in service. Additionally, the Veteran was afforded a VA examination for muscle injuries in March 2018. At that time, the examiner found the Veteran did not have a muscle diagnosis; a VA opinion was not rendered. The Board finds the March 2018 VA opinion incomplete to decide the claim. In this regard, the examiner failed to provide adequate rationale for the conclusions reached, failed to address the Veteran's contentions that his symptoms began during active service and have continued since, and did not adequately address presumptive service connection based on environmental hazard exposure in Southwest Asia. Notably, the examiner failed to address whether the Veteran's reports of numbness and aching is an undiagnosed illness, or is a disorder with a known etiology. Therefore, the Board finds that a new VA medical opinion is warranted to address the nature and etiology of the Veteran's left shin injury. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected PTSD. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected PTSD. A rationale for any opinion offered should be provided. 3. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of his allergic rhinitis. The need for further examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) Is it at least as likely as not (50 percent or greater probability) that such allergic rhinitis had its initial onset in service or is otherwise etiologically related to the Veteran's active service? (B) If the Veteran's symptoms of allergic rhinitis cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. (C) If the Veteran's symptoms of allergic rhinitis cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The examiner should specifically consider the Veteran's reports of environmental hazard exposure during his service in Southwest Asia. The examiner is reminded that the Veteran's exposure to environmental hazards during his service in Southwest Asia is presumed. The examiner should be sure to address the Veteran's lay statements and contentions regarding the onset and continuity of respiratory and/or rhinitis symptoms. The examiner is reminded that the absence of diagnosis and treatment for allergic rhinitis during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed foot infection. The need for further examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) For any diagnosed foot infection disorder, is it at least as likely as not (50 percent probability or greater) that such disorder had its initial onset in service or is otherwise etiologically related to the Veteran's active service? (B) If the Veteran's symptoms of a foot infection cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. (C) If the Veteran's symptoms of a foot infection cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The examiner should specifically consider the Veteran's reports of environmental hazard exposure during his service in Southwest Asia. The examiner is reminded that the Veteran's exposure to environmental hazards during his service in Southwest Asia is presumed. The examiner should be sure to address the Veteran's lay statements and contentions regarding the onset and continuity of foot and/or skin symptoms. The examiner is reminded that the absence of diagnosis and treatment for a foot infection disorder during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's left shin injury. The need for further examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) For any diagnosed left shin injury disorder, is it at least as likely as not (50 percent probability or greater) that such disorder had its initial onset in service or is otherwise etiologically related to the Veteran's active service? The examiner should specifically address the Veteran's reports of numbness after sustaining an injury to his left shin in Iraq. (B) If the Veteran's symptoms of a left shin injury cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. (C) If the Veteran's symptoms of a left shin injury cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The examiner should specifically consider the Veteran's reports of environmental hazard exposure during his service in Southwest Asia. The examiner is reminded that the Veteran's exposure to environmental hazards during his service in Southwest Asia is presumed. The examiner should be sure to address the Veteran's lay statements and contentions regarding the onset and continuity of foot and/or skin symptoms. The examiner is reminded that the absence of diagnosis and treatment for a left shin injury during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.