Citation Nr: 21068082 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 13-13 060 DATE: November 9, 2021 ORDER Entitlement to a rating of 30 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm is granted. Entitlement to a separate rating of 50 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm manifesting in limitation in range of motion of the arm is granted. Entitlement to a rating of total disability due to individual unemployability based upon service-connected disorders (TDIU) is granted. REMANDED Entitlement to service connection for a right wrist disorder, claimed as a fracture of the right fifth metacarpal, to include as secondary to service connected residuals of a mid-shaft ulna fracture of the right forearm and residuals of a mid-shaft ulna fracture of the right forearm manifesting in limitation in range of motion is remanded. Entitlement to service connection for a left arm disorder is remanded. Entitlement to service connection for gastroesophageal reflux disorder (GERD) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's residuals of a mid-shaft ulna fracture of the right forearm manifested as the right hand in full pronation, and in limitation of flexion of the right (dominant) forearm of 20 degrees but without ankylosis. 2. Resolving all reasonable doubt in the Veteran's favor, the evidence of record suggests that the Veteran is unable to gain or maintain substantially gainful employment due to his right forearm disability. 3. Throughout the period on appeal, the Veteran's service connected disabilities prevented him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating of 30 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.59, 4.68, 4.63, 4.71a, Diagnostic Codes 5299, 5213, 5125. 2. The criteria for entitlement to a separate rating of 50 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm manifesting in limitation in range of motion of the arm have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.59, 4.63, 4.68, 4.71a, Diagnostic Codes 5299, 5206, 5125. 3. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1987 to May 1987, and then again from April 1988 to April 1990. These matters come to the Board of Veterans' Appeals (Board) on appeal from multiple rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the instant matters in December 2015 and October 2017 for additional development, to include obtaining the Veteran's Social Security Administration (SSA) records and to obtain VA examinations. The Veteran was most recently issued a Supplemental Statement of the Case (SSOC) on December 4, 2020. The Veteran's attorney submitted a waiver of their right to have evidence reviewed by the RO in the first instance. See Third Party Correspondence (rec'd Feb. 5, 2021 ). The Board accordingly asserts jurisdiction. The Veteran has continuously prosecuted a claim for increased ratings for a right forearm disorder since a December 2010 rating decision that assigned an initial 10 percent rating effective November 19, 2009. The Veteran has continuously claimed that he is entitled to a TDIU due to this disorder. The Board infers a claim for a TDIU as part and parcel of this claim for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). 1. Entitlement to a rating of 30 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm is granted. 2. Entitlement to a separate rating of 50 percent, but no higher, for residuals of a mid-shaft ulna fracture of the right forearm in limitation in range of motion of the arm is granted. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; see generally, 38 C.F.R. Part IV. 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. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; see Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (holding that pain "must actually affect some aspect of 'the normal working movements of the body' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating). With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997) Moreover, the intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See 38 C.F.R. § 4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id.; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this case, the Veteran was afforded a 10 percent rating under Diagnostic Code 5299-5213. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. This diagnostic code was used because his specific disability was not listed in the disability rating schedule. Then, as now, unlisted disabilities were rated by analogy using hyphenated diagnostic codes pursuant to 38 C.F.R. § 4.27. With respect to the first set of digits before the hyphen, the first two digits are derived from the part of the rating schedule most closely identifying the part, or system, of the body involved, with the last two digits being "99" for all unlisted conditions. The second diagnostic code listed after the hyphen would be the basis for the evaluation assigned. In this case, the use of diagnostic code 5299-5213 indicates that the service-connected disability was rated as analogous to impairment of pronation of the hand. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Therefore, the Board will evaluate the Veteran's right forearm disability under the diagnostic code that will provide the most favorable rating, mindful not to pyramid and overly compensate him for the same symptom. See, e.g., Esteban v. Brown, 6 Vet. App. 259, 261 (1994). In evaluating the Veteran's right forearm disorder, the Board notes that the Veteran is right-handed. Diagnostic Codes 5205 through 5213, for disorders of the elbow and forearm, 38 C.F.R. § 4.71a, all differentiate between the major axis for the dominant hand and minor axis for nondominant hand. Only the major axis applies in this case, because the Veteran is right-handed and is seeking increased ratings for the service-connected right forearm disorder. The Board further finds that prior to November 12, 2012, separate 10 percent ratings are warranted for limitation of flexion and limitation of pronation and supination, for the reasons that follow. Assigning separate ratings for these limitations of motion does not violate the rule against pyramiding. Cf. VAOPGCREC 9-2004. Preliminarily, the Board notes that normal range of motion of the elbow is from zero degrees of extension to 145 degrees of flexion. 38 C.F.R. § 4.71, Plate I. Normal pronation of the forearm is from zero to 80 degrees, and normal supination of the forearm is from zero to 85 degrees. Id. Under Diagnostic Code 5206 as is in effect throughout the period on appeal, limitation of flexion of the forearm to 45 degrees is assigned a 50 percent rating for the major extremity. Limitation of flexion to 55 degrees is assigned a 40 percent rating for the major extremity. Limitation of flexion to 70 degrees is assigned a rating of 30 percent for the major extremity. Limitation of flexion to 90 degrees is assigned a rating of 20 percent for the major extremity. Limitation of flexion to 100 degrees is assigned a 10 percent rating for both arms. Limitation of flexion to 110 degrees is assigned a zero percent rating for both arms. 38 C.F.R. § 4.71a. Diagnostic Code 5213 applies to impairment of supination and pronation. See id. Under Diagnostic Code 5213, a 40 percent rating is assigned when the hand is fixed in supination or hyperpronation with respect to the major extremity. Id. A 30 percent rating is assigned for the major extremity when the hand is fixed in full pronation. Id. A 20 percent rating is assigned for the major extremity when the hand is fixed near the middle of the arc or moderate pronation. Id. A 30 percent rating is assigned for the major extremity when there is loss of pronation from beyond the middle of the arc. Id. A 30 percent rating is assigned for the major extremity when there is loss of pronation from beyond the last quarter of the arc, where the hand does not approach full pronation. Id. Limitation of supination to 30 degrees or less is assigned a 10 percent rating for both arms. Id. Finally, in all forearm and wrist injuries rated in Diagnostic Codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to separately rated and combined not to exceed rating for loss of use of hand. See 38 C.F.R. § 4.71a, at Note. Diagnostic Code 5125 reveals that the loss of use of the dominant hand (in the major axis) is rated as 70 percent disabling. The Board also notes that under the "amputation rule" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. The Veteran's right forearm was examined on August 18, 2020. The evidence of record clearly states that flexion was limited to 20 degrees. See VA Exam (Aug. 18, 2020) (rec'd Aug. 25, 2020), at Question No. 3a. As this is less than 45 degrees at the major axis, but because ankylosis was explicitly ruled out as not applicable, see id. at Question No. 5a, a 50 percent rating is warranted based on limitation of motion of the right forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Meanwhile, the same examiner also noted that the Veteran's right hand is fixed in full pronation, but not supination or hyperpronation. See VA Exam, supra, at Question No. 6a. This yields a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5213. These two disabilities combine for one 70 percent rating for impairment of the dominant forearm. 38 C.F.R. § 4.25(a). As 70 percent is the appropriate rating for loss of use of the dominant hand, see Diagnostic Code 5125, the Board concludes that this is a maximum rating; therefore, no higher ratings are warranted based upon the examination results of August 2020. See 38 C.F.R. § 4.68. The Board now shifts its attention to evidence of record prior to August 2020, so that the Veteran's disability can be properly staged. Here, the Board concludes that with the evidence of record being evenly balanced to suggest that the disability was so consistently disabling, this 70 percent rating is granted throughout the period on appeal. On October 26, 2011, the Veteran submitted to an examination of the right shoulder, but he was unable to perform any of the specific tests for rotator cuff conditions. See VA Examination (Oct. 26, 2011), at Question No. 10 et seq. The Board also notes that flare-ups were endorsed, see id. at Question No. 3, but there is no estimate of additional range of motion lost in terms of degrees due to them. See id. at Question No. 6; Sharp v. Shulkin, 29 Vet. App. 26 (2017). Even though the shoulder is not the forearm and thus not on appeal, the Board notes that the Veteran claimed in August 2020 that "[h]e is unable to utilize a writing instrument, grasp with the right upper extremity, or lift/push/pull with the right upper extremity." See VA Exam (Aug. 18, 2020), at Question No. 12. He further claims that due to his extremely limited use of the right upper extremity, he is unable to reach his face with his right hand due to limited elbow motion. See Vocational Opinion by Dr. S.G.B. (Dec. 18, 2020) (rec'd Feb. 5, 2021), at Page 2, Final Paragraph. The Board concludes that the October 2011 inability to complete specific rotator cuff tests is circumstantial evidence of limited range of motion for the forearm. Meanwhile, the Board is also in receipt of the initial examination upon which service connection and an initial rating was based. See VA Examination (Oct. 20, 2010). On one hand, it appears that the Veteran disclaimed flare-ups. See id. at Pages 1 and 4; Sharp, supra. On the other hand, the Board notes that the right forearm was measured as limited to 45 degrees of pronation and 40 degrees of supination. See id. at Page 5. The Board is unable to translate these ranges of motion to the criteria in Diagnostic Code 5213. Due to the unique facts of this Veteran's case and the uniquely long appellate history of the claim (including two remands), the evidence is evenly balanced to suggest that the disorder has been as severe as most recently examined during the appeal period. By affording a maximum 70 percent rating throughout the appellate period, the Board is ensuring that the Veteran is never undercompensated for the right forearm disorder; furthermore, a maximum rating also ensures that there is no prejudice in adjudicating the case in light of Stegall v. West, 11 Vet. App. 268, 271 (1998) or Sharp, supra. The Board has considered whether a staged rating under Hart, supra is appropriate for the Veteran's residuals of the right ulna fracture; however, the Board concludes that is not warranted. If the Veteran is awarded a maximum rating throughout the period on appeal, then that is more advantageous than any staged rating. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds that a 30 percent for residuals of a mid-shaft ulna fracture of the right forearm and a 50 percent for residuals of a mid-shaft ulna fracture of the right forearm manifesting in limitation in range of motion of the arm is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Entitlement to a rating of a TDIU is granted. The Veteran and his attorney have consistently contended that his service-connected disabilities renders him unemployable. See VA Form 21-8940 (rec'd Feb. 5, 2021); Third Party Correspondence (rec'd Feb. 5, 2021). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has been awarded service connection for a depressive disorder and an anxiety disorder, rated as 70 percent disabling as of May 20, 2015; migraines associated with depressive disorder and an anxiety disorder, rated as 50 percent disabling as of May 20, 2015; reflex sympathetic dystrophy of the right upper extremity, rated as 40 percent disabling as of July 26, 2011; residuals of a mid-shaft ulna fracture of the right forearm, now rated as 30 percent disabling since November 19, 2009; residuals of a mid-shaft ulna fracture of the right forearm manifesting in limitation in range of motion of the arm, rated as 50 percent disabling since November 19, 2009; tinnitus, rated as 10 percent disabling since May 20, 2015 and a forearm surgical scar, rated as noncompensably disabling since July 15, 2010. Thus, the schedular criteria for TDIU have been met for the entire period on appeal. A February 2021 VA Application for Increased Compensation Based on Unemployability (VA Form 21-8940) indicates that the Veteran had a high school education. He reported working in temporary labor jobs from 2003 to 2006, as a janitor for about three months in 2008 and that he worked as restaurant dishwasher from two months in 2009. An August 2018 opinion from Dr. H.S. indicates that the Veteran's right upper extremity reflex sympathetic dystrophy prevents him from performing work requiring the use of the right upper extremity and any work that requires bilateral manual dexterity and that his past work history shows that he is unable to perform light duty work requiring minimal skill despite his willingness to try. The provider noted that while the Veteran is able to stand and sit, he is unable to use both upper extremities for fine motor skills nor is he able to maintain focus and concentration to complete even one simple one handed tasks due to his distraction by pain and sleepiness and lack of focus from his medication. A December 2020 opinion from S.B. indicates that the Veteran is totally occupationally disabled from all competitive employment due to his service-connected depressive disorder, anxiety disorder, migraines, right upper extremity reflex sympathetic dystrophy, residuals of mid-shaft ulna fracture of the right forearm post open reduction/internal fixation, tinnitus and surgical scar. Based on the foregoing, and in consideration of the pertinent medical findings, including his reports at the various VA examinations of record and during treatment at VA medical centers, where he indicated his barriers to employment included an inability to perform work requiring manual dexterity or fine motor skills, being unable to maintain the focus and concentration to complete simple one handed tasks and lack of focus, the Board finds that the Veteran is unable to secure and follow a substantially gainful occupation by reason of his service connected disabilities. Therefore, based on the foregoing, the Board finds that the Veteran's service-connected disabilities do render him unable to secure and follow a substantially gainful occupation and entitlement to a TDIU is warranted. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to service connection for a separate right wrist disorder, claimed as a fracture of the right fifth metacarpal, is remanded. The Veteran's right wrist was examined in March 2019 to adjudicate a separate claim for service connection. See VA Exam ( Mar. 19, 2019 ). The pertinent evidence of record considered at that time is listed therein. See id. at Pages 1-2. This list does not list evidence in the service treatment records memorializing right wrist pain in June 1989. See STR (June 1989) (rec'd May 12, 2015). In addition, an opinion as to secondary service connection was not provided. See Stegall v. West, supra. The Board accordingly concludes that a remand is required to consider all evidence of record. 2. Entitlement to service connection for a left arm disorder is remanded. On October 16, 2017, the Veteran's claim for a left arm disorder was remanded for development. See BVA Remand (Oct. 16, 2017), at Pages 6-7; McLendon v. Nicholson, 20 Vet. App. 79, 81-86 (2006). On October 30, 2018, the Veteran appeared to have been diagnosed with a left shoulder disorder. See VA Exam (Oct. 30, 2018) (rec'd Nov. 5, 2018), at Page 10, Question No. 1a. For this disorder, the examiner stated that as the service treatment records are silent as to any left shoulder complaint, it should not be at least 50 percent likely that the Veteran's left shoulder disorder is attributable to service. See VA Exam (rec'd Dec. 12, 2018), at Page 2. Later, in August 2020, an examination of the elbows and forearms indicated disorders on the right only, but not left. See generally VA Exam (Aug. 18, 2020). To the extent that the more recent VA examiner appears to have relied on an absence of medical evidence, medical opinions that rely solely on absence of evidence from the record are inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006); Jandreau v. Nicholson, 492 F.3d 1372 (2007). Regardless, the VA examiner's opinion is also not fully supported by a well-reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2009); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis the Board can consider and weight against contrary opinion"). The Board concludes that a remand is accordingly warranted to confirm which portion of the left arm the Veteran claims on appeal, but if it is only the left shoulder, then an addendum is nonetheless required anyway. See Stegall, supra. 3. Entitlement to service connection for GERD is remanded. In November 2018, an examiner concluded that the Veteran's claim for entitlement to service connection for GERD could not be substantiated because the only evidence within the service treatment records was one receipt of Zantac in April 1989. See VA Exam (rec'd Nov. 5, 2018 ), at Page 7. The Board alternatively concludes that the Veteran complained of a sore throat in January 1988. See STR (Jan. 4, 1988) (rec'd May 12, 2015). An addendum opinion is required to consider the relevance or lack thereof of this evidence not previously considered. See Reonal v. Brown, 5 Vet. App. 458 (1993). The matters are REMANDED for the following action: 1. The Veteran should be given an 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 them an opportunity to submit any copies in their 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, obtain an etiology opinion by an appropriate clinician to determine the nature and etiology of the Veteran's claimed right wrist disorder and left arm disorder. The examiner should review the entire claims file and note such review in the opinion. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following questions: (A) Is it at least as likely as not (a 50% or greater probability) that any right wrist disorder began in or is otherwise related to the Veteran's military service? In light of the recent grant of service connection for reflex sympathetic dystrophy, the examiner is asked to comment on the Veteran's lay testimony that he injured his wrist due to right arm weakness. The examiner should also consider the impact, if any, of the complaints of right wrist pain in June 1989. (B) Is it at least as likely as not (a 50% or greater probability) that any right wrist disorder is caused or aggravated by a service connected disability, to include residuals of a mid-shaft ulna fracture of the right forearm? (C) Is it at least as likely as not (a 50% or greater probability) that any left arm disorder began in or is otherwise related to the Veteran's military service? Ensure that any medical opinion obtained includes a complete rationale for the conclusions reached. Any medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; any medical opinion 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. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. Following the receipt of outstanding records, obtain an etiology opinion by an appropriate clinician to determine the nature and etiology of the Veteran's claimed GERD. The examiner should review the entire claims file and note such review in the opinion. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following question: Is it at least as likely as not (a 50% or greater probability) that any GERD began in or is otherwise related to the Veteran's military service? The examiner should discuss the impact, if any, of the Veteran's complaints of a sore throat in January 1988. Ensure that any medical opinion obtained includes a complete rationale for the conclusions reached. Any medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; any medical opinion 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. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael B. Engle, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.