Citation Nr: 21069569 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 11-31 409 DATE: November 18, 2021 REMANDED 1. Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder with secondary depression, panic disorder with shortness of breath, and alcohol abuse (PTSD), is remanded. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1984 to March 1988 and from August 1988 to September 1992. In a July 2015 Board decision, the Board initially denied the claim for service connection for erectile dysfunction and remanded the claims for entitlement to service connection for the bilateral knee disability. The Veteran appealed the Board decision denying the claim for service connection for erectile dysfunction to the U.S. Court of Appeals for Veterans Claims (Court). In March 2016, the Court granted a joint motion for remand (JMR), vacating the Board's decision as it related to the issue on appeal, and remanded the matter for compliance with the instructions in the JMR. In July 2016, the Board then remanded the claim for service connection for erectile dysfunction for further development consistent with the March 2016 JMR. A July 2020 Board decision denied the claims for service connection for erectile dysfunction and a bilateral knee disability. The Veteran appealed the Board decision to the Court. In June 2021, the Court granted a JMR, vacating the Board's decision as it related to the issues on appeal, and remanded the matters for compliance with the instructions in the JMR. The July 2020 Board decision also denied claims of entitlement to (1) service connection for bilateral hand numbness; (2) a rating in excess of 30 percent for heartburn; (3) a rating in excess of 70 percent for PTSD; (4) an extension of convalescence under 38 C.F.R. § 4.30 after July 31, 2013 for right shoulder impingement status post arthroscopic subacromial depression; (5) an effective date earlier than August 13, 2009 for the grant of service connection for right shoulder impingement status post arthroscopic subacromial depression; (6) an effective date earlier than August 13, 2009 for the grant of service connection for limitation of extension due to lateral epicondylitis of the right elbow; (7) an effective date earlier than August 13, 2009 for the grant of service connection for impairment of supination and pronation due to lateral epicondylitis of the right elbow; (8) SMC prior to June 17, 2013 based on being housebound; (9) and SMC based on being housebound after July 31, 2013. These issues were not appealed to the Court and are final. The July 2020 Board decision also remanded issues of entitlement to (1) a rating in excess of 10 percent for residuals of a right ankle fracture with degenerative joint disease; (2) a rating in excess of 20 percent for right shoulder impingement status post arthroscopic subacromial decompression prior to June 17, 2013 and from August 1, 2013; (3) an initial compensable rating for limitation of extension due to lateral epicondylitis of the right elbow; (4) an initial rating in excess of 10 percent for impairment of supination and pronation due to lateral epicondylitis of the right elbow; (5) service connection for sleep apnea; and (6) a total disability rating for compensation based on individual unemployability. A review of the file notes that the AOJ is still completing development as to these issues. As they have not been returned to the Board, the Board does not have jurisdiction of these issues at this time. 1. Entitlement to service connection for erectile dysfunction, to include as secondary to PTSD, is remanded. Before addressing the two JMRs, the Board notes that in reviewing the evidence in the Veteran's claims file, it noticed that VA attempted to obtain Dr. Joel Kaufman's records, who is a urologist, who treated the Veteran for erectile dysfunction and appears to be the one who assisted the Veteran with his penile implant. However, it appears that only one request for Dr. Kaufman's treatment records were made. See November 16, 2010 Third Party Correspondence. The regulation requires that VA make two attempts to obtain non-VA medical records if no response is received following the first request. Based on the Board's review of the file, Dr. Kaufman did not respond to the request and VA did not send a second request following the November 2010 initial request. Thus, the Veteran will be asked to complete a VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), to allow VA to obtain treatment records from Dr. Joel Kaufman formerly in Aurora, Colorado, and now on 11960 Lionness Way, Suite 210, in Parker, Colorado, as these records are relevant to the claim. Within the June 2021 JMR, the Veteran and the Secretary of VA (parties) agreed the Board failed to provide adequate reasons and bases to find that the September 2018 VA examination was adequate. By way of history, the Veteran was provided a VA examination in September 2010. At this examination, the Veteran reported that he first began experiencing erectile dysfunction in 1995 during his second marriage and during a period of marital discord and moderate alcohol use. The Veteran also reported that he had an on-the-job injury in 1997 in which he landed on his back. He had surgery on his lumbar spine in 1998, and he reported that his erectile dysfunction worsened after the spine procedure and a penile implant was ultimately placed due to damage following his on-the-job spine injury. The September 2010 VA examiner opined that the onset of the erectile dysfunction became worse after the spine injury and the spine injury was the primary cause of the erectile dysfunction, and thus, the erectile dysfunction was less likely than not caused by or the result of PTSD. The examiner noted that although the Veteran had some erectile dysfunction prior to the spine injury, this was most likely due to marital discord and alcohol use. Within the March 2016 JMR, the parties determined the September 2010 VA examination was inadequate, as the examiner did not address whether the service-connected PTSD aggravated the erectile dysfunction. Additionally, the parties also found that the September 2010 VA examination was inadequate because the examiner did not provide an opinion as to whether the mild erectile dysfunction prior to the spinal injury was caused or aggravated by the service-connected PTSD. The Veteran was provided another VA examination in September 2018. The VA examiner opined that erectile dysfunction could have organic and psychogenic causes, and, in this case, the onset of the erectile dysfunction prior to the workplace spine injury occurred at a time in which the Veteran was experiencing discord with his wife as well as increased alcohol use, which likely contributed to his erectile dysfunction, and thus, his erectile dysfunction was not at least as likely as not caused or aggravated by his PTSD prior to the workplace injury. As noted by the parties, a rationale was not provided for this opinion, making this opinion inadequate. Furthermore, the September 2018 examiner opined that because the erectile dysfunction got markedly worse after the lumbar spine surgery, leading to the penile implant surgery, it is "abundantly clear that the spinal surgery is the primary cause of the erectile no-function[,] and it is less likely than not caused by, the result of, or aggravated by his service-connected PTSD." The Board finds this opinion is inadequate, as the examiner did not provide a rationale for why the erectile dysfunction, despite being found to be primarily caused by the lumbar spine injury, is not further aggravated by the service-connected PTSD. Aggravation is different from causation in that it did not cause the disability but that it caused an increase in severity that is not due to the natural progress of the disability. Additionally, neither VA examiner addressed the Veteran's statements documented within the October 2010 VA examination report for his sleep disorder and the March 2011 Notice of Disagreement, in which the Veteran reported that, despite his physical function being restored after the surgery, he still has issues with his erectile dysfunction, which the Veteran attributed to his mental health; nor did either examiner address the articles submitted by the Veteran through his representative in March 2011, which suggest a possible link in persons with PTSD having a higher rate of erectile dysfunction. In remanding this claim, the Board will not be asking the examiner for an opinion as to whether the service-connected PTSD caused or aggravated the erectile dysfunction prior to the July 1997 work-related low back injury, as it finds that the Veteran's report of such fact is not credible, and the explanation for this determination follows. Prior to the July 1997 work-related low back injury, the Veteran did not report having erectile dysfunction. He was treated regularly by the Family Practice Clinic from 1996 to 2004. After the July 1997 injury, he was treated in August 1997, September 1997 (four times), October 1997 (three times), November 1997 (three times), and December 1997 (two times). These approximately 13 appointments occurred prior to the April 1998 lumbar spine surgery. At no time did the Veteran report erectile dysfunction, despite reporting other symptoms he was experiencing as a result of the July 1997 post-service low back injury. For example, in October 1997, the Veteran denied any loss of control of bowel or bladder. In an April 1999 treatment record, the examiner wrote, "Has had lower back surgery and[,] related to his back injury[,] had developed impotence and has required a penile implant after a urologic evaluation and other efforts were made to assist him." (Italics added.) This April 1999 report was written by a medical professional from the Family Practice Clinic that had been treating the Veteran since at least 1996 and is found to be highly probative as to the onset of the Veteran's erectile dysfunction. Further, it is supported by a July 1998 medical record from Spine Consultants, where the examiner documented the Veteran reported erectile dysfunction and that, "[H]e has had this since his original [1997 work-related] injury." The examiner wrote that he wanted to have the Veteran see one of the urologists for evaluation of his impotency problem and explained, "Since these symptoms began after his work-related injury, I believe they are also related." (Italics added.) See also June 5, 1998 treatment record (noting the Veteran had reported some erectile dysfunction over the past month). Thus, the Board finds as fact that the Veteran was not having erectile dysfunction issues prior to the July 1997 work-related injury, and the Veteran's allegation in this regard is found not credible. Accordingly, the Board will not be asking the examiner about whether the service-connected PTSD caused or aggravated erectile dysfunction prior to the July 1997 post-service, on-the-job low back injury, as it finds there is no credible evidence of erectile dysfunction prior to the July 1997 work-related injury based on what is documented within the contemporaneous treatment records, which are found to be more probative than the Veteran's allegations of erectile dysfunction prior to the 1997 work-related injury. The Board had made a similar finding within the July 2015 decision regarding the Veteran's lack of credibility as to the onset of the erectile dysfunction. See July 23, 2015, Board decision on pp. 11-12 (noting that the allegations of erectile dysfunction prior to the 1997 work-related injury "are in direct conflict with the Veteran's contemporaneous statements to a private examiner in July 1998 indicating that such problems with erectile dysfunction began after his job-related injury sustained in 1997"). However, a similar finding was not made at the times of the July 2016 remand or the July 2020 decision. Thus, to the extent that the credibility analysis within this remand is a departure from the July 2016 remand and July 2020 decision, due process requires fair notice and an opportunity to respond when the Board purports to reverse prior assertions or impressions that evidence is credible or otherwise satisfactory to establish a fact necessary to the claim. See Smith v. Wilkie, 32 Vet. App. 332, 337-39 (2020); see also Thurber v. Brown, 5 Vet. App. 119, 123 (1993) ("[t]he entire thrust of the VA's nonadversarial claims system is predicated upon a structure which provides for notice and an opportunity to be heard at virtually every step in the process."). The Board finds that this remand constitutes the notice required by caselaw, and the Veteran shall have an opportunity to respond upon remand, if he deems a response is warranted. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. Within the June 2021 JMR, the parties stated the Board failed to provide an adequate statement of reasons and basis when it relied on the April 2016 VA examination. The April 2016 VA examiner diagnosed the Veteran with bilateral patellofemoral pain syndrome and noted that the Veteran reported a history of doing 40 to 45 jumps in his Airborne service as well as the requirement that he train with regular 12-mile ruck marches during his Special Forces service. The examiner opined that that the bilateral knee disability was less likely than not caused by the Veteran's service, as the Veteran made only one visit for knee pain while on active duty, and, despite making all those jumps, there were no findings of post-traumatic degenerative joint disease in the 2012 x-rays, which were performed 20 years after service discharge. The examiner noted that significant acute knee injury or repetitive joint trauma leads to long-term complications of osteoarthritis and osteoarthritis increases with time from the onset of the injury, and, given that radiographs taken when the Veteran was 50 years old did not support posttraumatic arthritis or degenerative changes, it was less likely than not that jumps made as a young man induced significant microtrauma as to produce a chronic knee condition. However, as pointed out by the parties within the June 2021 JMR, the April 2016 VA examiner, despite noting that there were no osteoarthritic or degenerative changes and, therefore, it was less likely than not that the current knee problems were due to the Veteran's in-service jumps, the examiner did not specifically opine whether the currently diagnosed patellar femoral pain syndrome was at least as likely as not caused by the in-service jumps and ruck marches. Thus, a remand is necessary to obtain this specific opinion. The matters are REMANDED for the following action: 1. Request the Veteran complete a VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), to allow VA to obtain treatment records from Dr. Joel Kaufman, 11960 Lionness Way, Suite 210, Parker, Colorado, as these records are relevant to the claim. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the erectile dysfunction after the July 1997 post-service lumbar spine injury and April 1998 low back surgery. If the clinician finds that an in-person examination is warranted, an examination should be scheduled. The examiner should be provided a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from March 1984 to March 1988 and from August 1988 to September 1992. The Veteran is service connected for posttraumatic stress disorder (PTSD) with secondary depression, panic disorder with shortness of breath without agoraphobia and alcohol abuse. The Veteran was diagnosed with erectile dysfunction in 1998. The Veteran alleges that the service-connected PTSD has aggravated his erectile dysfunction. In July 1997, the Veteran injured his low back while at work, and was treated regularly following the injury in August 1997, September 1997, October 1997, November 1997, and December 1997. He subsequently underwent surgery on his lumbar spine in April 1998. See VBMS entry with document type, " Medical Treatment Record Non-Government Facility," receipt date 02/23/2010, pp. 21-29. A January 1998 private treatment record shows the examiner documented that the Veteran had failed all forms of non-operative management and the examiner believed a work-up for surgical treatment was indicated. The examiner wrote, "Because of the spondylolisthesis, I have recommended he proceed with diagnostic discography at L4-5 and L5-S1. If this reproduces his typical symptoms[,] then I suggest he proceed with a spinal fusion at the L5-S1 area with Gill laminectomy." See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 12/03/2009, p. 18. In April 1998, the Veteran underwent an L5 Gill laminectomy followed by an anterior fusion L5 through S1 with iliac crest bone graft and the Gill laminectomy bone. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 12/03/2009, p. 13. A June 1998 treatment record from Spine Consultants shows that the Veteran reported pain and symptoms referrable to his left low back area where he had previous symptoms, which the examiner noted were compatible with sacroiliac joint dysfunction. The examiner added, "In addition, he has reported some erectile dysfunction over the past month," which the examiner noted corresponded with the use of Elavil. The examiner recommended the Veteran discontinue the use of this medication. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 12/03/2009, p. 11. A July 1998 treatment record from Spine Consultants shows that the examiner documented, "[The Veteran] continues to have erectile dysfunction and reports that he has had this since his original [July 1997 work-related] injury." The examiner wrote, "Because of failure to respond to withdrawal of the Elavil and decrease in his overall back pain symptoms, I would like him to see one of the urologists for evaluation of his impotency problem." The examiner added, "Since these symptoms began after his work-related injury, I believe they are also related." See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 12/03/2009, p. 10. In an April 1999 treatment record, the examiner wrote that the Veteran "[h]as had lower back surgery and[,] related to his back injury[,] had developed impotence and has required a penile implant after a urologic evaluation and other efforts were made to assist him." See VBMS entry with document type, " Medical Treatment Record Non-Government Facility," receipt date 02/23/2010, p. 20. (This particular page was scanned upside down, but you can click on the rotate function at the top of the page to read the document.) A May 2002 private treatment record shows that the Veteran reported having a severe back injury and consequently had a penile implant put in approximately two and one-half years ago. The examiner documented, "He reports that it is working well but he feels that he has decreased blood flow to his penis and has been prescribed Viagra previously by Dr. Clise and this helped with the problem." The examiner noted that there was a lengthy discussion between herself and the Veteran regarding the need to have the implant checked. The examiner also noted that the Veteran wanted to try Viagra prior to seeing Dr. Kaufman, the urologist. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 02/23/2010, p. 15. Thus, the Veteran's penile implant was placed during the second half of 1999, which would have been after April 1999, as the facts documented in the April 1999 treatment record clearly show that the implant procedure had not been performed. At a September 2010 VA examination, the Veteran estimated the onset of his erectile issues began in approximately 1995 during his second marriage in which he stated there was marital discord and that there may have been moderate to more alcohol use. See VBMS entry with document type, "VA examination," receipt date 09/22/2010, p. 2. At the September 2010 examination, the Veteran reported that in 1997, he had an on-the-job injury where he fell from a truck and landed on his back with acute low back pain and sacral pain. He reported he underwent surgery in 1998 on his lumbar spine, and that his erectile dysfunction worsened following this procedure even though his back pain and radicular leg pain improved. See VBMS entry with document type, "VA examination," receipt date 09/22/2010, pp. 2 3. In a March 2011 statement, the Veteran wrote that despite the physical function being restored following the penile implant, he still had an emotional impairment that he believed was causing his erectile dysfunction. See VBMS entry with document type, "Notice of Disagreement," receipt date 03/24/2011, p. 2. The Veteran, through his representative, has submitted articles that suggest a possible link between persons with PTSD having a higher rate of erectile dysfunction. See VBMS entry entitled, "Correspondence," submitted 03/24/2011. While the Veteran has alleged he had erectile dysfunction prior to the July 1997 work-related injury, the Board finds such statement not credible, as the 1998 and 1999 private medical records from two, different medical facilities show that the Veteran reported erectile dysfunction developed after the 1997 work-related fall and 1998 low back surgery. Thus, the examiner is instructed to not consider that fact in answering the below questions. VA is in the process of attempting to obtain Dr. Joel Kaufman's, a urologist, treatment records, as this is the physician who the Veteran saw when seeking treatment for the erectile dysfunction, and appears to have been the medical professional who assisted the Veteran with getting a penile implant, and the records are not in the claims file. Thus, these records may have been added to the file since November 2021. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to opine: (a) Is it at least as likely as not (50 percent probability or higher) that the erectile dysfunction that occurred after the July 1997 work-related fall and 1998 lumbar spine surgery is aggravated by the service-connected PTSD? Aggravation is different from causation in that it did not cause the disability but that it caused an increase in severity that is not due to the natural progress of the disability. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (b) If the examiner finds that the service-connected PTSD aggravates the erectile dysfunction that developed after the July 1997 work-related fall and 1998 lumbar spine surgery, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the erectile dysfunction prior to aggravation. If the examiner is unable to establish a baseline for the erectile dysfunction prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the bilateral patellar femoral pain syndrome. If the clinician finds that an in-person examination is warranted, an examination should be scheduled. The examiner should be provided a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from March 1984 to March 1988 and from August 1988 to September 1992. A July 1984 service treatment record shows the Veteran reported sustaining a right knee injury the day before and that he aggravated it, where he twisted it while doing physical training. The examiner wrote there was no edema or effusion, but there was tenderness to the medial aspect of the right knee. The assessment was knee strain. See VBMS entry with document type, "STR Medical," receipt date 03/21/1988, with "#1" in the subject field, p. 2. A May 1988 VA examination report (performed between the two period of active duty) shows that the Veteran was reporting right ankle pain, right inguinal pain, and lumbosacral pain. The Veteran was not complaining of bilateral knee pain. The examiner documented the Veteran had 5/5 muscle strength in the lower extremities and had "good" motion in his knees. See VBMS entry with document type, "VA Examination," receipt date 05/19/1988. An October 2003 private treatment record shows the Veteran was presenting for a "DOT physical." The examiner documented that the Veteran had "no chronic medical problems." Physical examination showed the "extremities" were normal without deformity. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 02/23/2010, p. 12. In an August 2009 statement, the Veteran reported having problems with his knees, which he wrote was not one single incident but occurred over a period of time. The Veteran described having over 50 jumps and other numerous training exercises during service. He also noted that he would have to do 12-mile ruck sack marches while carrying 55 pounds. See VBMS entry with document type, "Correspondence," receipt date 08/17/2009. A September 2010 VA examination report shows the Veteran reported he did "nearly constant walking while at work in the state correction facility," most of which was done in the outdoor yard. He reported that, recreationally, he would walk one to one and one-half miles at a time and was able to stand for 10 to 15 minutes; otherwise, he was limited by chronic knee and low back pain. He stated he was able to climb one and two flights of stairs on a regular basis. The examiner documented that the physical examination of the lower extremities was normal. See VBMS entry with document type, "VA Examination," receipt date 09/22/2010. An April 2011 VA treatment record shows the Veteran reported worsening right knee pain for the past two months without any obvious injury. He reported he walked on concrete all day as a corrections officer. Physical examination revealed the right knee had no edema, no effusion, and no tenderness. There was some crepitus with range of motion. There was no gross abnormality. The assessment was new right knee pain with left knee pain mildly as well, but the right pain had been going on for two months with no particular injury. The examiner noted it may be more microtrauma from his job walking on concrete. The examiner documented she was setting the Veteran up for physical therapy and x-rays. She noted that if the x-rays do not show significant osteoarthritis, she may want to get an MRI. See VBMS entry with document type, "CAPRI," receipt date 03/13/2013, with "#1" in the subject field, p. 180-182. An April 2011 private treatment record shows that the Veteran was seen due to complaints of right leg pain for the past six weeks. The Veteran reported he was training for a marathon. The examiner stated the Veteran described the pain as being under the iliotibial band as it hooks into the knee, radiating around to the inferior patellar region. The Veteran stated that it started to hurt at about four miles and that prior to that, he had no pain. He stated he walked around without any pain. The examiner noted the Veteran admitted to going from 13 to 19 miles shortly before the pain started. The Veteran had full range of motion of the knee with stable ligaments. McMurray test was negative. The Veteran had a "little tightness of the iliotibial band," which was "not terribly severe." The examiner wrote the Veteran did not have any pain on palpation in the area where there is a bursa behind the iliotibial band at the knee. The examiner noted that he had taken x-rays of the knee to rule out any pathology and that they were normal. The impression was right iliotibial band syndrome. The examiner noted that he advised the Veteran to run a half marathon rather than a full marathon and then to take it easy on his training and gradually build up. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 07/08/2016, p. 7. A May 2011 VA treatment record shows the Veteran was seen for follow-up related to his right knee. The Veteran reported the pain was getting better. He described the pain as being mostly on the outer aspect of the kneecap and going down below the kneecap. Physical examination revealed moderate patellar grinding, no tenderness over the patellofemoral joint, medial joint line, or lateral joint line. There was some mild tenderness over the iliotibial track and there was slightly tight iliotibial track. The knee was stable to varus and valgus stress test and stable to anterior and posterior drawer. The examiner noted that he had reviewed the x-ray of the right knee, which did "not show any significant osteoarthritic changes." The examiner concluded the Veteran seemed to have some patellofemoral osteoarthritis as evidenced by grinding in the patellofemoral joint. See VBMS entry with document type, "CAPRI," receipt date 03/13/2013, with "#1" in the subject field, p. 168. An April 2016 VA examination report shows the examiner documented the Veteran reported that in the past year, he had mild right greater than left knee pain, mostly after a long day on his feet/walking. The examiner performed a file review and physical examination. The examiner diagnosed bilateral patellofemoral pain syndrome with right greater than left and found that it was less likely than not caused by service. See VBMS entry with document type, "C&P Exam," receipt date 06/30/2016. While the April 2016 examiner concluded that it was less likely than not that the Veteran's current right and left knee patellofemoral syndrome was caused by or due to military service, the examiner's explanation for the conclusion revolved around osteoarthritis. For example, the examiner wrote that radiographs of the bilateral knee taken when the Veteran was 50 years old did not support any posttraumatic arthritis or degenerative changes. She concluded it was less likely that the jumps the Veteran made as a young man induced sufficient microtrauma to produce a chronic knee condition or he would be more likely to exhibit osteoarthritis/degenerative joint disease of the knees during his fifth decade of life. In other words, the examiner's explanation was about why she thought osteoarthritis was not related to service, including the parachute jumps performed during service. The examiner did not provide a reason for the conclusion that the diagnosis of bilateral patellofemoral pain syndrome was less likely related to service, including the parachute jumps. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to provide a response to the following: Is it at least as likely as not that the bilateral patellar femoral pain syndrome is related to service, specifically, is it at least as likely as not that repeated jumps during Airborne service as well as regular 12-mile ruck marches carrying a heavy pack caused the currently diagnosed bilateral patellar femoral pain syndrome? The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Keninger, 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.