Citation Nr: 21064427 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 15-00 194A DATE: October 20, 2021 ORDER Entitlement to right carpal tunnel syndrome is granted. Entitlement to service connection for a left thumb disorder is denied. REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a respiratory disorder, to include as due to exposure to environmental hazards in the Persian Gulf, is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise that the Veteran's right carpal tunnel syndrome began during active service, or is otherwise related to an in-service injury, event, or disease. 2. The preponderance of the evidence of record is against finding that the Veteran has had a left thumb disorder at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for right carpal tunnel syndrome have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a left thumb disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had long-term service with the California Army National Guard (ARNG), which included periods of active duty for training from August 1982 to December 1982, and active duty service in May 1992 and from September 2004 to October 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office. In June 2020, the Board remanded the issues set out above to the RO for evidentiary development. Specifically, the issues were remanded to obtain updated treatment records, a VA examination regarding the nature and etiology of the claimed right shoulder disorder and left thumb disorder. Updated VA treatment records have been associated with the record and an August 2020 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain records on her behalf. VA shoulder and finger examinations were conducted in September 2021. Following the requested development, a supplemental statement of the case (SSOC) was issued in September 2021. The Board therefore determines that there has been substantial compliance with its previous remand with regards to the issues decided herein. A September 2021 rating decision granted the Veteran's claims for service connection for a lumbosacral strain, left knee patellofemoral syndrome and right knee patellofemoral syndrome and assigned an initial rating for each disability. As this decision represents a full grant of the benefits sought with respect to these claims for service connection, such issues are no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) 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"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for a current disability is satisfied if the disability is shown at any time subsequent to filing the claim, even if not shown currently. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations refers to 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, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e). For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). There are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). A medically unexplained chronic multi-symptom illnesses is defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that VA determines meets the criteria in paragraph 3.317(a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A medically unexplained chronic multi-symptom illness means 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. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Veteran can provide competent reports of factual matters of which she has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id., see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for right carpal tunnel syndrome The Veteran essentially contends that she has right carpal tunnel syndrome in her which developed as a result of the duties she performed in service. The Veteran asserts that she developed pain in her wrists and forearm due to working on a computer from six in the morning to 10 in the evening during her deployment to Iraq; she maintains that the pain has continued since that time. The Board notes that the Veteran's military occupational specialty (MOS) was Automated Logistical. Service treatment records do not indicate complaint, treatment, or diagnosis of a right-hand carpal tunnel syndrome. Post-service treatment records reflect that the Veteran was seen in October 2006 with complaints of pain in both arms; she also complained of weakness. An April 2011 VA treatment note indicated that the records show bilateral carpal tunnel syndrome and the assessment was possible carpal tunnel syndrome. Turning to the question of whether there is an etiological relationship between the Veteran's service and her diagnosed right carpal tunnel syndrome, the Board notes that the record contains two etiology opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board will consider each of these opinions below. A June 2021 VA examiner opined that the Veteran's carpal tunnel syndrome was less likely than not incurred in or caused by the claimed an in-service injury, event or illness. The examiner stated that, on the basis of the records reviewed, current examination, reported history and available evidence, it was his opinion that the records do not reveal the genesis of the Veteran's carpal tunnel syndrome of the right hand due to any event of service. The examiner stated, absent any complaints, evaluations, diagnoses to establish her currently diagnosed carpal tunnel syndrome, it is therefore less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, this examiner did not address the Veteran's reports that her carpal tunnel syndrome symptoms began in service and appeared to rely on the absence of any reports of pain in her service treatment records. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). As such, the Board is affording this opinion little probative weight. In a second June 2021 opinion, a VA examiner opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that, while there is a dearth of records found related to her claimed carpal tunnel syndrome, she had continuous complaints associated with symptoms which are currently diagnosed as carpal tunnel syndrome. The examiner noted that the Veteran's records fail to reveal any alternate or possible alternate causes of her condition and it is likely that her complaints in service, and as noted in her personal statements/testimony, reflect the insipient event which was on active duty and would then therefore be the genesis of her condition. Therefore, the examiner concluded that it is at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). This opinion is therefore afforded great probative weight. In sum, based on the evidence of record, the Board finds that the evidence presently before it is sufficient to grant the appeal, as the Veteran has been diagnosed with right carpal tunnel syndrome and an etiology opinion have found that the condition had its onset during service. The Board further notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). Thus, resolving the benefit of the doubt in favor of the Veteran, the Board finds the evidence is at least in relative equipoise as to whether her right carpal tunnel syndrome is related to service. As such, service connection for right carpal tunnel syndrome is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to service connection for a left thumb disorder The Veteran contends that she has a left thumb disorder which was incurred during her period of active duty service in Southwest Asia. Service treatment records reflect the Veteran was treated for complaints of pain and swelling of the left thumb in September 2005 and the diagnosis was left distal phalangeal joint pain. Post-service treatment records are negative for complaints, treatments or diagnoses related to a left thumb disorder. A June 2021 VA examination reflected a normal physical examination despite the Veteran's reports of joint and muscle pain. The Veteran indicated during this examination that she injured her thumb when she tripped over a very large piece of wood that the Air Force uses in cargo yards, bracing herself from hurting her face or head. Following an examination, the examiner stated that the Veteran does not have a current diagnosis associated with the left thumb. A June 2021 VA Gulf War examination found that there were no diagnosed illness for which no etiology was established, that there were no additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multi-symptom illness and that there were no functional impacts related to additional signs and/or symptoms that may represent an undiagnosed illness or a medically unexplained chronic multisymptom illness. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131's requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. However, as the record does not reflect a current diagnosis of any left thumb disorder, the cornerstone element of service connection has not been met, and service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board is cognizant of the recent holding in Saunders v. Wilkie which stated that where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In sum, pain alone resulting in functional impairment is in fact a disability and should not be summarily discounted as a bar to benefits based on a finding of no current diagnosis. However, the Veteran does not claim, nor do her medical records show that she experiences, any functional impairment due to her claimed left thumb disorder. As such, the Veteran's complaints of a left thumb disorder does not amount to a functional impairment of earning capacity, and Saunders is not applicable in this case. In addition, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). Moreover, the June 2021 VA examiner determined there were no diagnosed illnesses for which no etiology was established, that there were no additional signs and/or symptoms that may represent an undiagnosed illnesses or diagnosed medically unexplained chronic multi-symptom illnesses and that there were no functional impacts related to additional signs and/or symptoms that may represent an undiagnosed illnesses or a medically unexplained chronic multisymptom illnesses. The Board acknowledges the statements of the Veteran as to the existence and etiology of her left thumb injury and acknowledges that the Veteran is competent to give evidence about what she experienced. For example, she is competent to discuss the fact that she experiences symptoms of thumb pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, while the Veteran is competent to report her current symptoms, as a lay person she does not have the education, training, experience to diagnose or opine as to the etiology of the condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377-78 (Fed. Cir. 2007). Hence, the Board finds that she is not competent to provide a medical opinion to support this claim on the basis of her assertions alone. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence. In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). Therefore, as the evidence of record shows that the Veteran does not have a left thumb disorder, the Board concludes that service connection is not warranted, and no further discussion of the remaining elements is necessary. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."); see also Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (finding that the absence of any one element will result in denial of service connection). Accordingly, the Board finds that the preponderance of the evidence is against the claim and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 3. Entitlement to service connection for a right shoulder disorder The Veteran contends her right shoulder disorder is related to service. In an August 2013 submission, the Veteran wrote that she was required to carry her weapon everywhere she when during her deployment and that the gear and weapons put a strain on her shoulders. In June 2020, the Board remanded the instant matter to obtain an etiology opinion as to the claimed right shoulder disorder. The Board directed the VA examiner to opine as to whether the Veteran's right shoulder disorder pre-existed service, whether such pre-existing disorder was aggravated by her service and whether a right shoulder disorder had its onset in or was caused by service. Such an opinion was obtained in June 2021 The VA examiner noted that there were two notes which documented that the Veteran had the onset of her shoulder pain as early as 2001, prior to service from 2004 to 2005. The examiner noted that given that the right shoulder disorder was pre-existing to this period a revealed by the records it is therefore pre-existing. In regard to any evidence of aggravation, the examiner found that there is no evidence to suggest that the Veteran had any chronic or continuous complaint and, additionally, she does not carry the same diagnosis on current examination. The examiner noted that the current diagnosis is unrelated to this pre-service injury and that absent any compelling evidence to support aggravation, it is therefore less likely than not aggravated beyond its natural progression by an in-service injury, event, or illness. The Board finds that this opinion is inadequate and contradictory. In that regard, the June 2021 VA examiner found both that the Veteran's current right shoulder disorder pre-existed service and was not aggravated by service and that her current right shoulder disorder did not preexist service. The Board cannot reconcile these contradictory findings. As such, the Board finds this opinion to be inadequate for the purpose of adjudicating the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007). On remand, an addendum opinion must be obtained. 4. Entitlement to service connection for a respiratory disorder, to include as due to exposure to environmental hazards in the Persian Gulf The Veteran asserts that she has a respiratory disorder, to include as due to an undiagnosed illness, due to environmental exposures, such as sand, pit smoke and oil fires, while serving in the Southwest Asia Theatre of Operations. A September 1994 treatment report related a history of bronchiospasm that requires the use of an inhaler and the Veteran indicated that the problem began during physical training. In December 1995, an annual medical certificate noted problems with wheezing while running. A December 1999 medical report noted a diagnosis of bronchitis, for which the Veteran uses an inhaler. A retention examination in July 2004 noted a mild case of bronchitis, resolved. In June 2020, the Board remanded the instant matter to obtain an etiology opinion regarding the etiology of the claimed respiratory disorder. A June 2021 Gulf War examination found that there was no diagnosis as there are no findings, signs or symptoms to support a diagnosis. A June 2021 VA respiratory disorder examiner found a diagnosis of restrictive lung disease. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed inservice injury, event, or illness as the Veteran's records failed to reveal any formal evaluations, diagnoses or treatment for any chronic or continuous respiratory complaints. The examiner further noted that the Veteran had derangement on pulmonary function testing, which does not elucidate the etiology or diagnosis and that this was currently an undiagnosed condition. The examiner indicated that the Veteran will need complete evaluations to include full spirometry and Diffusion Capacity of the Lung for Carbon Monoxide (DLCO). Currently, outside of abnormal pulmonary function testing, she has no known diagnosable condition in which to attribute to any event of service. There is no indication of record that the Veteran was afforded additional evaluation, including a full spirometry and DLCO. Therefore, the Board finds the June 2021 VA examination is not sufficient for adjudication purposes. For this reason, out of fairness to the Veteran, another opportunity for an examination should be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following actions: 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 her representative and afford him an opportunity to submit any copies in her 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 an examination by an appropriate clinician to determine the nature and etiology of any claimed respiratory disorder. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner must identify any and all respiratory diagnoses. If the examiner determines that the Veteran does not suffer from a respiratory disorder, they must reconcile the abnormalities found on the Veteran's June 2021 pulmonary function testing. The examiner must provide an opinion regarding the following questions: (A) The examiner should indicate whether the Veteran's symptoms are consistent with (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology; or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology. The term medically unexplained chronic multisymptom illness means 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. Examples include, but are not limited to, the following: chronic fatigue syndrome; fibromyalgia; and functional gastrointestinal disorders. The response to this question should include a discussion of the pathophysiology and etiology of the Veteran's claimed disability and/or reported symptomology. Pathophysiology is defined as the physiology of abnormal states; specifically, the functional changes that accompany a particular syndrome or disease. Consideration of pathophysiology and etiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. (B) If the Veteran's disability pattern is consistent with either (iii) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (iv) a disease with a clear and specific diagnosis, etiology, and pathophysiology, opine as to whether it is at least as likely as not (a 50 percent or greater probability) that said disability incurred in, or is otherwise related to service, to include environmental exposures, such as sand, pit smoke and oil fires. 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 opinion must support the conclusions reached with an analysis that is adequate 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. 3. Following the receipt of outstanding records, the claims file, including a copy of this remand, should be sent to an appropriate examiner for opinion as to the nature and etiology of the Veteran's claimed right shoulder disorder. The opinion should be rendered by an appropriate medical professional. The examiner should review the record and note such review in the examination report. The opinion should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. The need for further in-person examination is left to the discretion of the examiner. The examiner must provide an opinion regarding the following questions: (A) With regard to each diagnosed right shoulder disorder, is it clear and unmistakable (i.e., undebatable) that such disability had onset prior to the Veteran's entrance into active duty in September 2004? (B) If the answer to Question (A) is "YES," is it also clear and unmistakable (i.e. undebatable) that each such right shoulder disorder was not aggravated beyond its natural progression during the Veteran's active service from September 2004 to October 2005? (C) If the answer to either Question (A) or (B) is "NO," then is it at least as likely as not (i.e., a 50 percent or greater probability) that each such right shoulder disorder had its onset in, or is otherwise related to, her active duty service from September 2004 to October 2005? In rendering an opinion, the examiner should consider the Veteran's relevant lay statements of record, to include her statements during the March 2012 shoulder and arm conditions VA examination that she experienced bilateral shoulder pain in 2005 during her deployment to Iraq; and her statements in the August 2013 letter that she was required to carry weapons everywhere during her deployment to Iraq which put a strain on her shoulders along with all the gear she had to wear. 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). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate 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 Suzie S. Gaston, 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.