Citation Nr: 21064768 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 17-34 427 DATE: October 21, 2021 ORDER Entitlement to service connection for a left ankle disability is denied. Entitlement to restoration of a 20 percent rating for a lumbar spine disability, so including considering the propriety of the reduction in rating for this disability from 20 to 10 percent from October 1, 2017 onward, is granted. Entitlement to a rating in excess of 10 percent for a right knee disability is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a bilateral arm disability is remanded. Entitlement to service connection for a right chest disability is remanded. Entitlement to service connection for a right flank disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a rating in excess of 20 percent for the lumbar spine disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has had a left ankle disability at any time since filing this claim or proximate to that. 2. Following a September 2015 VA examination, in a rating decision that same month the local Regional Office (RO) proposed to reduce the rating for the Veteran's lumbar spine disability from 20 to 10 percent. 3. In a subsequent July 2017 rating decision, the RO implemented the reduction in rating for this lumbar spine disability, prospectively effective October 1, 2017, based on the results of that September 2015 VA examination. 4. It is not sufficiently shown, however, that the disability had improved, and further that the improvement would be maintained under the ordinary conditions of life and work. 5. The Veteran's right knee disability is manifest by no worse than a full range of motion with painful motion and x-ray evidence of arthritis. CONCLUSIONS OF LAW 1. The criteria are not met for entitlement to service connection for a left ankle disability. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. However, the criteria are met for restoration of the prior 20 percent rating for the lumbar spine disability as of October 1, 2017, the date the rating for this disability was reduced. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.2, 4.3, 4.7, 4.10, 4.13, 4.97, Diagnostic Code (DC) 5242. 3. But the criteria are not met for a rating higher than 10 percent for the right knee disability. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, ,4.45, 4.59, 4.71a, DC 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1982 to April 1988. This appeal to the Board of Veterans' Appeals (Board) is from November 2011, August 2013, and July 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in May 2019, at which time the claims were remanded back to the RO (Agency of Original Jurisdiction (AOJ)) for further development and consideration including to obtain updated treatment records, to have the Veteran reexamined regarding his hearing loss, lumbar spine, and right knee disabilities, and to obtain addendum opinions concerning his left hip, left knee, left ankle disabilities. Unfortunately, there was not compliance, even the acceptable substantial compliance, with the remand directives at least as concerning his lumbar spine, hearing loss, left shoulder, or left hip claims, so these claims again must be remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Further, the Board finds that remand is additionally warranted concerning the claims for right ankle disability, right elbow disability, bilateral arm disability, right chest disability, and right flank disability. Still other claims for service connection for a left knee disability and a right hip disability were previously part of this appeal. However, during the pendency of this appeal, both of those claims, as well as a claim for service connection for radiculopathy of the left lower extremity, were granted in an April 2021 rating decision. If the Veteran disagrees with the ratings and/or effective dates assigned for those now service-connected disabilities, he must separately appeal these "downstream" issues. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Service Connection 1. Entitlement to service connection for a left ankle disability The Veteran filed a claim asserting that he has a current left ankle disability that is due to his military service. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or an injury; and (3) a causal relationship ("nexus") between the current disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Here, though, the Board concludes that the Veteran does not have a current diagnosis of a left ankle disability and has not had one at any time during the pendency of this claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Establishing he has this disability is the most fundamental requirement of this claim, else, for all intents and purposes there is no present disability to in turn relate or attribute to his military service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). In March 2021, the Veteran underwent a VA ankle examination pursuant to the Board's May 2019 remand directive. But during this examination the examiner found no indication of a left ankle disability. Further, the Veteran conceded that his left ankle is not impaired and that "he does not want to have a DBQ or claim for this condition." The DBQ reference was to Disability Benefits Questionnaire and is the form used for VA compensation examinations to provide needed information. Thus, even by his own admission, the Veteran does not have a left ankle disability. Moreover, although he previously filed a claim for this disability, or however this claim came about, he since has made it clear that he does not believe he has a left ankle disability, much less because of his military service, and this was confirmed by the March 2021 VA compensation examiner on remand. Thus, entitlement to service connection for a left ankle disability is not warranted. Rating Reduction 2. Entitlement to restoration of a 20 percent rating for a lumbar spine disability, so including considering the propriety of the reduction in rating for this disability to 10 percent as of October 1, 2017 The Veteran asserts that the reduction in rating for his service-connected lumbar spine disability (intervertebral disc herniation at L4-L5 and lumbar spine spondyloarthropathy) was unwarranted since based solely on the results of just one medical examination. He is requesting restoration of the prior 20 percent rating for this service-connected disability as of October 1, 2017, the date the rating for this disability was reduced. The law provides that, where a rating reduction was made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, in a rating reduction case the erroneous reduction must be vacated, and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. 38 U.S.C. § 1155. When a veteran's disability rating is reduced by the RO without following the applicable regulations, the reduction is void ab initio. Greyzck v. West, 12 Vet. App. 288, 292 (1999). Prior to reducing a veteran's disability rating, VA is required to comply with several general VA regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. 38 C.F.R. §§ 4.1, 4.2, 4.10. These provisions impose a clear requirement that VA rating reductions be based upon review of the entire history of the veteran's disability. Schafrath, 1 Vet. App. at 594. Such review requires VA to ascertain, based upon review of the entire recorded history of the condition, whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating-reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Faust v. West, 13 Vet. App. 342, 350 (2000). In certain rating reduction cases, VA benefit recipients are to be afforded greater protections, as set forth in 38 C.F.R. § 3.344. The provisions of § 3.344(c), however, specify that the provisions of 38 C.F.R. § 3.344(a) and (b) are only applicable for ratings that have continued for long periods at the same level (five years or more). Here, the Veteran was awarded a 20 percent rating for his lumbar spine disability effective from December 14, 2010. This means that his rating had been in effect for more than five years at the time of the October 1, 2017 reduction to a 10 percent rating. Therefore, the requirements of 38 C.F.R. § 3.105(e) are for application. The RO informed him in the September 2015 proposed reduction that this reduction would reduce his overall combined service-connected disability evaluation to 30 percent. The RO also informed him of his due process rights prior to the reduction. Of note, he since has been awarded service connection for other disabilities, so when this reduction was enacted his overall rating did not actually decrease from 60 percent. The burden is on VA to justify a reduction in a rating. Brown v. Brown, 5 Vet. App. 413 (1993) (Board is required to establish, by a preponderance of the evidence and in compliance with 38 C.F.R. § 3.344, that a rating reduction is warranted; it is impermissible to, instead, place the burden on the Veteran of conversely showing his disability has worsened as is required in a typical increased rating claim). In a July 2017 rating decision, the RO reduced the Veteran's lumbar spine rating from 20 to 10 percent, prospectively effective as of October 1, 2017. The rating decision incorporated the reasoning similarly cited in the September 2015 rating decision that initially had proposed this reduction in rating. But the Board finds that the rating reduction was improper. The Veteran's lumbar spine rating had been in effect for more than five years and, thus, was afforded greater protections under 38 C.F.R. § 3.344(a) & (b), which prohibit a reduction based on a single examination. And, here, the rating reduction was based on a single VA examination in September 2015, resultantly, the rating reduction did not follow proper protocol. While the range of motion measurements during the September 2015 VA examination support a lesser 10 percent rating, the evidence at the time of the reduction did not reflect sustained and material improvement in this disability that would be maintained under the ordinary conditions of life and work especially in relation to when the rating was initially assigned based on private treatment records dating from 2010 and 2011. More specifically, the private treatment records that formed the basis of the Veteran's initial 20 percent rating showed that he complained of lumbar spine pain, was treated with steroid injections, had pain radiating down his leg, had flare ups of pain, and consequent functional loss including pain with prolonged sitting, standing, and walking. He reiterated those same complaints during his September 2015 VA examination, so little had changed in these regards. Therefore, based on all of the foregoing, the Board finds that restoration of the Veteran's 20 percent rating for his lumbar spine disability is warranted effective October 1, 2017, the date the rating for this disability was reduced. Increased Rating 3. Entitlement to a rating in excess of 10 percent for the right knee disability The Veteran contends that his right knee disability is more severe than contemplated by his current 10 percent rating. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations 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. When evaluating the severity of a disability, it is essential the disability is considered in the context of its entire recorded history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But if the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings, then separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings and is employed for initial or established ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's right knee disability is rated under DC 5003-5260. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the hyphenated DC represents degenerative arthritis (DC 5003) and limitation of flexion of the knee (DC 5260). While portions of the Rating Schedule addressing the musculoskeletal system were revised effective February 7, 2021, neither DC 5003 nor 5260 was changed. Under DC 5260, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The United States Court of Appeals for Veterans Claims (Court/CAVC) explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40 ), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45 ). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board additionally notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other DCs assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Moreover, in Mitchell, the Court held that the evaluation of painful motion as limited motion only applies when limitation of motion is 0-percent disabling (i.e., noncompensable) under the applicable DC. The Court further explained that, although painful motion is entitled to a minimum 10 percent rating under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), when read together with DC 5003 regarding arthritis, it does not follow that the maximum rating is warranted under the applicable DC pertaining to range of motion simply because pain is present throughout the range of motion. See id. This is significant because the Veteran's current 10 percent rating for his right knee disability is based on painful motion as his limitation of motion has at no point during the pendency of this appeal been severe enough to, in turn, otherwise warrant this minimum compensable rating under DC 5260. See 38 C.F.R. § 4.71a, DC 5003, providing for assignment of this minimum 10 percent rating in this circumstance. In Correia v. McDonald, 28 Vet. App 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee limitation of flexion. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain during flare-ups, swelling, and pain while walking, standing, or sitting for long periods. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has flare ups five times per week, lasting on average six hours each, would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Veteran previously underwent VA knee examinations in July 2013 and May 2017. However, as discussed in the May 2019 Board remand, these examinations are inadequate for rating purposes because they do not comply with the examination requirements in Sharp or Correia. That being said, neither examination shows a compensable limitation of motion in the right knee that would support a higher rating to, conversely, be used in support of the Veteran's claim. At the July 2013 examination, the Veteran had right knee flexion to 90 degrees, with pain starting at 70 degrees. At the May 2017 examination, he had right knee flexion to 110 degrees. The Veteran again underwent a VA knee examination in March 2021. At this examination, he reported that he suffers flare ups of right knee pain five times per week, lasting around six hours. He treats the flare ups by elevating his leg, using an ice pack, and over the counter medicine. He further reported that his right knee disability results in swelling at work, where he is required to be on his feet and walking around throughout the day, and that he has trouble sitting, standing, or walking for long periods. Upon range of motion testing the Veteran had a full range of motion in his right knee. The examiner observed pain on flexion, extension, and weight bearing, but the pain did not result in any loss in range of motion. There was no evidence of crepitus, no additional loss in range of motion on repetitive use testing, and the Veteran's statements did not support any loss in range of motion during repeated use over time. Additionally, the examiner noted the Veteran's reported flare ups, but that the procured evidence did not support that there was any loss in range of motion during flare ups. The examiner observed no additional contributing factors to the Veteran's right knee disability, no muscle atrophy, no ankylosis, and no joint instability. The Veteran reported a history of right knee arthroscopic surgery, although he was unsure of the reason for the surgery and there was no notation of any meniscal condition. This examination supports that the Veteran's right knee disability has manifested by painful motion, but no loss in range of motion, much less to a compensable degree. Pursuant to Mitchell, the Veteran's current 10 percent rating for his right knee disability is appropriate. See Mitchell, 25 Vet. App. 32. The Board also has considered the other DCs pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14, VA's anti-pyramiding regulation, prohibits paying compensation twice for the same symptoms or functional impairment). However, as discussed, the March 2021 VA examination report shows no ankylosis, subluxation or lateral instability, meniscal condition, limitation of extension, impairment of the tibia or fibula, or genu recurvatum. As such, a rating under the DCs pertaining to these other impairments is not warranted. See 38 C.F.R. § 4.71a, DCs 5256-5259, 5261-5263. In conclusion, then, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating greater than 10 percent for his right knee disability. In denying any higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 4. Entitlement to service connection for a left shoulder disability is remanded. 5. Entitlement to service connection for a left hip disability is remanded. The May 2019 remand directed that a VA examiner provide multiple opinions concerning the etiology of Veteran's left shoulder and left hip disabilities, including whether either was the result of the cumulative impact of the Veteran's duties of his military occupational specialty (MOS) which involved straining to lift missiles and bombs, one of the Veteran's contentions. In March 2021 the Veteran underwent VA examinations for these disabilities. While the examiner provided the requested opinions concerning secondary service connection, the Board finds that the opinions concerning direct service connection are inadequate. More specifically, the March 2021 examiner did not address the Veteran's contention that his MOS duties caused his disabilities in the rationale, as directed by the May 2019 remand. Thus, there has not been substantial compliance with the remand directives and another remand is necessary. See Stegall, 11 Vet. App. at 271. 6. Entitlement to service connection for a right ankle disability is remanded. The Veteran asserts that he has a current right ankle disability that is related to an injury during service. A review of the record shows that while the Veteran underwent a VA ankle examination in March 2021, the examiner only examined the Veteran's left ankle, not also his right, and did not provide an opinion as to service connection for a right ankle disability. The Veteran's service treatment records (STRs) show that he suffered a "right ankle trauma" in June 1983. As such, a VA examiner should clarify the current diagnosis, if any, of a right ankle disability and opine as to whether any current right ankle disability is related to his right ankle trauma during service. 7. Entitlement to service connection for a right elbow disability is remanded. 8. Entitlement to service connection for a bilateral arm disability is remanded. 9. Entitlement to service connection for a right chest disability is remanded. 10. Entitlement to service connection for a right flank disability is remanded. The Veteran asserts that he has current right elbow, bilateral arm, right chest, and right flank disabilities that are related to his service, including especially a motorcycle accident during service. The Veteran's STRs show that he was in a motorcycle accident in 1983 and immediately after was treated for abrasions to his right arm, right flank, right lower leg, right posterior chest, and left elbow. A review of the record does not show that the Veteran has undergone VA examinations for these claimed disabilities and as such, a remand to obtain VA examinations and opinions concerning these disabilities is necessary. 11. Entitlement to service connection for bilateral hearing loss is remanded. The May 2019 Board remand directed that a VA examiner opine as to the etiology of the Veteran's bilateral hearing loss, including specific discussion of the possibility of delayed onset hearing loss related to the Veteran's service and conceded acoustic trauma therein. In February 2021, the Veteran underwent a VA audiology examination and the examiner provided an opinion as to the etiology of the Veteran's hearing loss. However, the examiner did not address a potential delayed onset of hearing loss due to conceded acoustic trauma during service. As such, another remand is necessary for an examiner to address this contention in accordance with the May 2019 remand directive. See Stegall, 11 Vet. App. at 271. 12. Entitlement to a rating in excess of 20 percent for lumbar spine disability is remanded. The Veteran underwent a VA lumbar spine examination in March 2021. At this examination, the Veteran reported that he has flare ups of lumbar spine pain "almost daily" and that they last 15 to 45 minutes. The examiner noted that the examination was not conducted during a flare up, but then failed to provide an estimated range of motion during flare ups. In Sharp, the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. See Sharp, 29 Vet. App. 26. As such, the March 2021 VA examination is not compliant with the requirements in Sharp, and another examination is necessary for the examiner to provide, at a minimum, estimated range of motion during flare ups or an explanation as to why an estimate cannot be provided. Accordingly, these remaining claims are REMANDED for the following action: 1. If there are outstanding records concerning these remaining claims, obtain them and appropriately notify the Veteran if unable to obtain any additional records that he identifies with the required amount of information. 38 C.F.R. § 3.159(c) and (e). 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left shoulder disability is at least as likely as not related to his military service, including duties related to his MOS that included straining to lift missiles and bombs. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left hip disability is at least as likely as not related to his military service, including duties related to his MOS that included straining to lift missiles and bombs. 4. Schedule the Veteran for a VA examination for his right ankle disability. The examiner must review the claims file. The examiner is asked to opine on whether the Veteran's right ankle disability is at least as likely as not related or attributable to his service, including to his June 1983 right ankle trauma during service? Provide rationale supporting the opinion. 5. Schedule the Veteran for a VA examination for his right elbow disability, bilateral arm disability, right chest disability, and right flank disability. The examiner must review the claims file including a complete copy of this decision and remand. The examiner is asked to opine on whether any right elbow, bilateral arm, right chest, or right flank disability is at least as likely as not related or attributable to the Veteran's service, including his 1983 motorcycle accident? 6. Obtain an addendum opinion from an appropriate clinician regarding the possibility of "delayed onset" hearing loss following, but nonetheless related or attributable to, the Veteran's service. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbar spine disability. The examiner must provide a full description of this disability and report all signs and symptoms necessary for evaluating this disability under the applicable rating criteria. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, 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), or whatever other reason precludes a sufficiently definitive response. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Pak 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.