Citation Nr: 21072958 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 14-07 145A DATE: December 7, 2021 ORDER Entitlement to an increased rating in excess of 30 percent for chronic right foot tendonitis with history of injury, metatarsalgia, hallux valgus and degenerative arthritis is denied. A separate 30 percent rating for right foot pes planus from October 1, 2009 is granted, subject to the laws and regulations governing the payment of monetary benefits. A separate 0 percent rating for right foot hammer toes from October 1, 2009 is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a left foot disability, to include pes planus and corns and calluses, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for a right ankle disability, to include as secondary to a service-connected disability, is remanded. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded. FINDINGS OF FACT The Veteran's right foot disability (other than right foot pes planus) has not been manifested by actual loss of use of the right foot. From October 1, 2009, the Veteran had pronounced right foot pes planus associated with his service-connected right foot disability. From October 1, 2009, the Veteran's right foot disability has manifested by 2-5th hammer toe. CONCLUSIONS OF LAW The criteria for a schedular disability rating in excess of 30 percent for right foot disability (other than right foot pes planus) have not been met for any part of the period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. The criteria for a separate 30 percent rating for right foot pes planus from October 1, 2009 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Code 5276. The criteria for a separate noncompensable rating for right foot 5th toe hammer toe from October 1, 2009 have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5282. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1978 to April 1984. The matters arise before the Board of Veterans' Appeals (Board) from rating decisions dated February 2011 and September 2013. The claims were remanded by the Board in October 2019. The Board notes a claim of entitlement to TDIU in connection with the Veteran's right foot disability was raised in an April 2010 VA Compensation and Pension Examination for the Feet. See April 2010 VA Compensation and Pension Examination for the Feet (noting the Veteran lost 7 weeks of work time in the last 12-month period due to pain in the right foot); see also Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, is part of a claim for increased compensation). Under Rice, the Board has jurisdiction over the TDIU claim, and for the purpose of clarity, has separately captioned the issue on the title page. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1115; 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Disability evaluations are based upon 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. See 38 C.F.R. § 4.10. Relevant Facts The Veteran underwent an April 2010 VA Compensation and Pension Examination for the feet. For her right foot disability, the Veteran identified as symptoms: pain in the ball of the foot, swelling in the latera aspect, stiffness in the lateral aspect, and generalized lack of endurance. She said she feels pain, weakness, heat, swelling, and lack of endurance, while standing and/or walking. The Veteran reported no flare-ups of the foot. The examiner diagnosed right foot tendonitis. The pain impacts occupational activities in that it increased the Veteran's absenteeism. The effects on the problems in daily activities are severe. She lost 7 weeks of work time in the last 12 month period due to pain in the right foot. A January 2011 private medical record shows pes planus (flexible flat foot) deformity of both feet with posterior tibialis tendon dysfunction, hammer toe deformity 2-5 on both feet, hallux abducto valgus with bunion deformity on both feet. A June 2016 VA Foot Conditions Disability Benefits Questionnaire (DBQ) shows diagnoses of right foot tendonitis and tenosynovitis. The Veteran described her pain as being "achy." She did not report having any functional loss or functional impairment of the foot. Her right flat foot causes pain on use of the foot and pain on manipulation of the foot. There was pain on physical exam, but she was noted to be able to have normal motion without pain; no pain noted with weight bearing; steady gait. The examiner noted no pain, weakness, fatigability or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time. A December 2018 VA Foot Conditions DBQ shows diagnoses of bilateral flat foot (pes planus), bilateral plantar fasciitis, right foot degenerative arthritis, and right foot chronic tendonitis. The Veteran reported that the pain in the bottom of her right foot has gotten worse. The pain is dull in nature. The Veteran does not have flare-ups that impact the function of the foot. The Veteran reported functional loss or impairment of the right foot in that she cannot walk for a long time. She has accentuated pain on use of the right foot, and accentuated pain on manipulation of the right foot. The Veteran has decreased longitudinal arch height on weight-bearing. The right foot pain severity is mild. The foot condition chronically compromises weight bearing. The foot condition requires arch supports or shoe modification. The examiner noted that the Veteran's symptoms are overlapping. An October 2020 VA Foot Conditions DBQ shows diagnoses of bilateral flat foot, right foot metatarsalgia, bilateral hammer toes, bilateral hallux valgus, right foot plantar fasciitis, right degenerative arthritis, bilateral plantar keratosis (corns and calluses), and right foot chronic tendonitis. The pain in the right foot is sharp or dull, mostly on the bottom, around 6/10, weakness, problem walking, calluses are painful. She has flare-ups that impact the function of the foot; "flare ups happen several times a week if I walk for a long time." She stated that she can't walk for too long. She has accentuated pain on the use of the right foot. She has accentuated pain on manipulation of the foot. She has characteristic calluses on the right foot. She has extreme tenderness of plantar surfaces on both feet. She has decreased longitudinal arch height of one or both on weight-bearing. She has objected evidence of marked deformity on both feet. There is marked pronation on both feet that is not improved by orthopedic shoes or appliances. The weight-bearing line falls over or is medial to the great toe. There is inward bowing of the Achilles' tendon. Additionally, the Veteran has marked inward displacement and severe spasm of the achilles tendon on manipulation of the right foot. The Veteran does not have Morton's neuroma. The Veteran has right foot metatarsalgia. She has right foot hammer toe: second toe, third toe, fourth toe, and little toe. She has mild or moderate symptoms due to right foot hallux valgus condition. The severity of her right foot disabilities is moderate. The foot condition chronically compromises weight bearing and requires arch supports or shoe modification. There is pain on physical exam. There is functional loss and limitation of motion for the right foot: weakened movement, excess fatigability, incoordination (impaired ability to execute skilled movements smoothly), pain on movement, pain on weight-bearing, swelling, disturbances of locomotion, and interference with standing. She reported intermittent swelling. She has pain, weakness, fatigability or incoordination that significantly limits functional ability during flare-ups: she has impaired ability to stand and walk for prolonged periods of time. 1. Entitlement to an increased rating in excess of 30 percent for chronic right foot tendonitis with history of injury, plantar fasciitis, metatarsalgia, hallux valgus and degenerative arthritis is denied. The Veteran filed her claim for an increased rating on October 1, 2009; therefore, the evidence consideration will begin on October 1, 2008, the date VA received the increased rating claim plus a one-year look-back period. 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Here, the Veteran's right foot disability is currently rated 30 percent disabling under Diagnostic Code 5284. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See 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. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In this case, the Board finds that the evaluation of the foot disability with degenerative arthritis under Diagnostic Code 5003-5284 to be more appropriate, as the Veteran has a degenerative arthritis of the right foot diagnosis, and it would allow VA to maximize the Veteran's benefits by assigning additional separate ratings. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, there are no specific diagnostic codes for limitation of motion of the feet. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. Diagnostic Code 5282 assigns a noncompensable rating for single toe hammer toe and a 10 percent rating for unilateral hammer toe of all toes without claw foot. 38 C.F.R. § 4.71a. Diagnostic Code 5284 provides ratings for foot injuries of 10, 20 and 30 percent for moderate, moderately severe, and severe foot disability, respectively. The Board notes that the rating criteria do not define moderate, moderately severe, or severe. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. Finally, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). Beginning February 7, 2021, the rating schedule for the feet includes Diagnostic Code 5269 specifically for plantar fasciitis. Diagnostic Code 5269 provides for a 10 percent rating for unilateral or bilateral plantar fasciitis, a 20 percent rating for unilateral condition with no relief from both non-surgical and surgical treatment, and a 30 percent rating for a bilateral condition with no relief from both non-surgical and surgical treatment. 38 C.F.R. § 4.71a. Legal Analysis and Conclusion Based on a review of the evidence, the Veteran's chronic right foot tendonitis with history of injury, metatarsalgia, hallux valgus and degenerative arthritis does not warrant a rating in excess of 30 percent under Diagnostic Code 5003-5284. The Board finds the Veteran's chronic right foot tendonitis with history of injury, metatarsalgia, hallux valgus and degenerative arthritis is "severe" based on the pain and functional loss due to pain of the right foot noted in the evidence of record. See April 2010 VA Compensation and Pension Examination (the effects of the Veteran's right foot pain on her daily activities are severe); December 2018 VA Foot Conditions DBQ (the Veteran's symptoms of pes planus, plantar fasciitis, degenerative arthritis and chronic tendonitis are overlapping and require arch supports or shoe modification and render her unable to walk for a long time). Moreover, a maximum schedular rating of 40 percent is not warranted under Diagnostic Code 5003-5284, as the evidence does not show loss of use of the right foot. The Veteran stated that she feels pain while standing and walking, and cannot walk for a long time. See, e.g., December 2018 VA Foot Conditions DBQ; October 2020 VA Foot Conditions DBQ. This level of pain, in addition to her use of arch supports or shoe modifications, is consistent with a rating based on a "severe" right foot disability. See, e.g., December 2018 VA Foot Conditions DBQ. Notably, there is no evidence in the record indicating that the Veteran's right foot disability is equivalent to amputation with prothesis. The Board has also considered the Veteran's general assertion that a higher disability rating is warranted due to her physical restrictions. The Veteran has reported that she is limited in activities because of her right foot pain. The Veteran is competent to report symptomatology relating to the right foot disability because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the question of the severity of her right foot disability is medically complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, to the extent that the Veteran alleges greater severity, the Board finds that the probative value of her allegations is outweighed by the examiners' findings. Competent evidence concerning the nature and extent of the Veteran's right foot disability has been provided by VA examiners for this period. In this regard, the medical findings directly address the evaluation criteria for the disability. Accordingly, the Board finds that the medical examination findings are of greater probative value than the Veteran's allegations regarding the severity of her right foot disability, especially where those same statements made by the Veteran have been evaluated by a medical professional and an assessment of the disability has been rendered. Based on the foregoing, the Board finds that the preponderance of the evidence is against the award of a rating in excess of 30 percent for chronic right foot tendonitis with history of injury, plantar fasciitis, metatarsalgia, hallux valgus and degenerative arthritis prior to February 7, 2021. As stated above, various portions of 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The Board has considered whether these changes could result in staged increased disability ratings from the effective date of the regulation changes; however, the February 7, 2021 amendments do not alter the foot rating criteria beyond adding a new diagnostic code for plantar fasciitis, which is discussed in further detail below. 38 C.F.R. § 4.71a (2021). Separate Ratings The Board has also considered whether it may be appropriate to rate the Veteran's foot disability under other diagnostic codes. Hammer Toes The Board finds that a noncompensable rating for hammer toe under DC 5282 is warranted. Here, while the Veteran has hammer toes, she does not have hammer toe in all toes. See October 2020 VA Foot Conditions examination (showing the Veteran does not have hammer toe on the great toe of the right foot). Therefore, a separate noncompensable rating is warranted for right foot hammer toe is warranted under DC 5282. Right Foot Pes Planus In addition, the Board finds that the criteria for a separate rating of 30 percent for right foot pes planus has been met. A January 2011 private medical record shows the Veteran was diagnosed with right foot pes planus. The October 2020 VA examiner, who opined that the right foot pes planus is related to the Veteran's service-connected right foot disability, further stated that the Veteran had marked pronation, extreme tenderness, and accentuated pain on use and manipulation of the right foot, and that these symptoms were not improved by arch supports. Therefore, resolving any doubts in the Veteran's favor, the criteria for a 30 percent rating are met. Other Diagnostic Codes With respect to plantar fasciitis, as stated above, prior to an amendment to the regulation effective February 7, 2021, plantar fasciitis was not listed amongst the Diagnostic Codes for the feet. Beginning February 7, 2021, Diagnostic Code 5269 addresses plantar fasciitis and provides for a 10 percent rating for bilateral or unilateral condition, unless there has been no relief from non-surgical and surgical treatment, in which case a 20 or 30 percent rating is awarded for unilateral and bilateral plantar fasciitis, respectively. Prior to February 7, 2021, other injuries of the foot could receive a 10 percent rating for moderate, 20 percent rating for moderately severe, and 30 percent rating for severe impairment under Diagnostic Code 5284. 38 C.F.R. § 4.71a. The Board has considered the application of the amended regulations for the period beginning February 7, 2021. However, the Veteran has had, for the entire period on appeal, multiple foot disabilities, including plantar fasciitis, which was diagnosed back in 1999. Thus, the Board finds that the Veteran's disability rating is most appropriately assigned under the currently utilized 38 C.F.R. § 4.71a, Diagnostic Code 5284, as that rating criteria most closely contemplates the overall picture of the Veteran's symptomatology. See also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("We agree with the Veterans Court that two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology.") (citing Esteban v. Brown, 6 Vet. App. 259 (1994)). Moreover, here, the evidence of record for the Veteran's plantar fasciitis shows that due to her plantar fasciitis, she has been having pain on the plantar surfaces of her feet that are not fully relieved by orthopedic appliances. See, e.g., October 2020 VA examination report. Pain, and the functional effects of pain, including as due to the Veteran's plantar fasciitis, have been considered and compensated by the 30 percent rating under Diagnostic Code 5284 since the beginning of the period on appeal. Thus, assigning a separate rating for right foot pain under Diagnostic Code 5269 starting from February 7, 2021 would constitute impermissible pyramiding, as the Veteran's right foot pain due to plantar fasciitis is already captured by the 30 percent rating under Diagnostic Code 5284 for the period prior to and after February 7, 2021. Therefore, a separate rating for the right foot plantar fasciitis under the new Diagnostic Code 5269 is not warranted. With respect to corns and calluses, separate ratings for the Veteran's corns and calluses is not warranted. These conditions are not listed in the rating schedule, and as the Veteran's 30 percent rating is based on the entirety of her symptoms, a separate rating would be impermissible pyramiding. With respect to metatarsalgia, anterior metatarsalgia (Morton's Disease) is rated under DC 5279, and a 10 percent rating is warranted for unilateral or bilateral symptoms. Here, the Veteran was not diagnosed with Morton's neuroma, and metatarsalgia without Morton's neuroma is defined as "pain and tenderness in the metatarsal region." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1162 (31st ed. 2007). Pain in the ball of the foot is the basis for the Veteran's 30 percent award under DC 5284, and thus a separate rating under DC 5279 would result in impermissible pyramiding. REASONS FOR REMAND 1. Entitlement to a left foot disability, to include pes planus and corns and calluses, is remanded. As an initial matter, in October 2019, the Board remanded the claim for a VA medical opinion. VA etiology opinions were obtained in October 2020 and in March 2021. The Board finds these opinions inadequate as the negative October 2020 VA direct service connection etiology opinion lacks sufficient rationale, and the negative March 2021 VA secondary service connection etiology opinion does not comport with the holding in Ward v. Wilkie, 31 Vet. App. 233 (2019). See October 2020 VA etiology opinion; March 2021 VA etiology opinion. In any event, here, the Veteran's August 1978 enlistment examination does not reflect a diagnosis of left foot pes planus, or any left foot issue, at the time the Veteran was accepted into service. The Veteran specifically denied having fallen arches and denied having any painful or trick joint. As such, the Veteran is presumed to have been sound upon entry. 38 U.S.C. §§ 1111, 1132, 1137. The Veteran's subsequent service treatment records note mild callus formation. See August 1982 Service Treatment Record. The Veteran was formally diagnosed with pes planus in the left foot in 1999, years after she separated from service. See May 1999 private medical record (noting pes planus deformity in both feet). In the May 2004 VA Form 9, the Veteran stated that her condition of flat foot should have been discovered upon her entry into the military. She further stated that her foot condition was greatly aggravated by her military duties of marching, running, and prolonged standing in heavy boots and shoes that were not designed for optimum comfort. She also stated that, alternatively, her present foot disability is a direct result of her military lifestyle. Based on the foregoing, the Board finds that remand is warranted for adequate, appropriate, etiology opinions. 2. Entitlement to service connection for a right ankle disability, to include as secondary to a service-connected disability, is remanded. In October 2019, the Board remanded the claim for direct and secondary etiology opinions. A negative VA secondary etiology opinion was obtained in March 2021. However, the opinion does not comport with the holding in Ward v. Wilkie, 31 Vet. App. 233 (2019). Therefore, upon remand, new etiology opinions that comport with the holding in Ward must be obtained. 3. Entitlement to a total disability rating for individual unemployability (TDIU) is remanded. Next, the Board finds the issue of entitlement to TDIU is inextricably intertwined with the increased rating claim for the back disability, as the criteria for TDIU are dependent, in part, on the Veteran's service-connected disability ratings. Thus, the Board remands the TDIU claim as well. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's left foot disability. The examiner should answer the following: FOR THE VETERAN'S LEFT FOOT PES PLANUS a) Did the Veteran's pes planus clearly and unmistakably (obviously, manifestly or undebatably) pre-exist her period of service? Attention is invited to the Veteran's August 1978 enlistment examination which noted no foot abnormalities, and that the Veteran was formally diagnosed with pes planus in the left foot in 1999, and that the Veteran had stated that her left foot pes planus should have been discovered upon her entry into the military. See August 1982 Service Treatment Record; May 1999 private medical record (noting pes planus deformity in both feet); May 2004 VA Form 9. b) If yes, was the Veteran's pes planus clearly an unmistakably NOT aggravated (i.e., permanently increased in severity) by her service? Is it clearly and unmistakably due to the natural progression of the disease. Attention is invited to the Veteran's statements that her foot condition was greatly aggravated by her military duties of marching, running, and prolonged standing in heavy boots and shoes that were not designed for optimum comfort. See May 2004 VA Form 9. Clear and unmistakable evidence means evidence that cannot be misinterpreted and misunderstood, i.e., it is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered aggravation in service. c) If the answer to (a) or (b) is no, is it at least as likely as not (a fifty percent probability or greater) that the Veteran's left foot pes planus is related to her active service? Attention is invited to the Veteran's statements that her foot condition was caused by her military duties of marching, running, and prolonged standing in heavy boots and shoes that were not designed for optimum comfort. See May 2004 Form 9. Moreover, her subsequent service treatment records note mild callus formation. See August 1982 Service Treatment Record. FOR THE VETERAN'S LEFT FOOT DISABILITY (OTHER THAN PES PLANUS) d) Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's left foot disability (other than pes planus) is related to her active service? Attention is invited to the Veteran's statements that her foot condition was caused by her military duties of marching, running, and prolonged standing in heavy boots and shoes that were not designed for optimum comfort. See May 2004 Form 9. Moreover, her subsequent service treatment records note mild callus formation. See August 1982 Service Treatment Record. A detailed rationale for the opinion must be provided. 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. 2. Obtain a new etiology opinion from a new examiner to assess the etiology of the Veteran's right ankle disability. Regardless of who offers the opinion, if the examiner determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination. After reviewing the claims folder and examining the Veteran, for the Veteran's right ankle disability, the examiner is specifically instructed to provide the following information: (a) Is it "at least as likely as not (50 percent probability or greater)" that the Veteran's right ankle disability BEGAN IN or is related to her time in the service, yes or no? (b) Is it "at least as likely as not (50 percent probability or greater)" that the Veteran's right ankle disability was: (i) CAUSED BY HER SERVICE-CONNECTED right foot disability, (ii) any other service-connected disability, or (iii) medicine taken for her other service-connected disabilities, yes or no? (c) Is it "at least as likely as not (50 percent probability or greater)" that the Veteran's right ankle disability underwent any incremental increase in disability, regardless of its permanence, due to: (i) the service-connected right foot disability, (ii) any other service-connected disability, (iii) medicine taken for her other service-connected disability, yes or no? The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. THE EXAMINER SHOULD ALSO BE AWARE THAT IN RENDERING AN OPINION, IT MUST "CONTAIN NOT ONLY CLEAR CONCLUSIONS WITH SUPPORTING DATA, BUT ALSO A REASONED MEDICAL EXPLANATION CONNECTING THE TWO." SEE NIEVES-RODRIGUEZ V. PEAKE, 22 Vet. App. 295, 301 (2008). Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010) (The Agency of Original Jurisdiction (AOJ) should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 3. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655. 4. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. (Continued on the next page) IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. J. Cho, 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.