Citation Nr: 21073591 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 19-03 605 DATE: December 9, 2021 ORDER New and material evidence has been received to reopen a claim of service connection for a back disorder. New and material evidence has been received to reopen a claim of service connection for a left knee disorder. Entitlement to a rating greater than 10 percent for right knee osteoarthritis is denied. Entitlement to an initial 70 percent rating, and no more, for major depressive disorder is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for a thoracolumbar spine disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In July 2015, VA confirmed and continued the previous denials of service connection for a back condition and a left knee condition; the Veteran did not appeal this decision and new and material evidence was not received within the one-year appeal period. 2. Evidence added to the record since the July 2015 rating decision is new and raises a reasonable possibility of substantiating claims of service connection for a back disorder and a left knee disorder. 3. The Veteran's right knee osteoarthritis is not manifested by flexion limited to 30 degrees or extension limited to 15 degrees. 4. The evidence is at least in equipoise as to whether the Veteran's major depressive disorder is manifested by occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The July 2015 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received to reopen claims of service connection for a back disorder and a left knee disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for a rating greater than 10 percent for right knee osteoarthritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261. 4. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent rating, and no more, for major depressive disorder have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1999 to December 2004. In January 2021, a virtual hearing was held before the undersigned Veterans Law Judge (VLJ). At that time, the Veteran's attorney waived agency of original jurisdiction (AOJ) review of evidence added to the record since the appeal was certified. New and Material Evidence By way of history, in January 2014, VA denied service connection for a back disorder and for a left knee disorder. In January 2015, the Veteran requested to reopen his claims. In July 2015, VA reopened the claims but determined that service connection was not warranted because the conditions were not related to service or service-connected disability, nor did they manifest to a compensable degree within one-year following discharge from service. The Veteran did not appeal this decision and new and material evidence was not received within the one-year appeal period. Thus, the decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In November 2016, the Veteran requested to reopen the claims. In March 2017, VA determined that new and material evidence had been received to reopen the claims and confirmed and continued the previous denials of service connection for a back disorder and a left knee disorder. The Veteran disagreed with the decision and perfected this appeal. Regardless of the AOJ's determination, it is a jurisdictional requirement that the Board reach its own determination as to whether new and material evidence has been submitted. Barnett v. Brown, 8 Vet. App. 1 (1995). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New" evidence means existing evidence not previously submitted to agency decisionmakers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. Relevant evidence of record at the time of the final July 2015 decision included the Veteran's contentions that his back and left knee conditions were related to service-connected disabilities (bilateral ankles and right knee). The Veteran was provided VA back and knee examinations in July 2015 and the examiner provided negative opinions on secondary service connection. Evidence added to the record since the final July 2015 decision includes the Veteran's testimony at the January 2021 hearing, wherein he reported that a physician had attributed his back problems to his "foundation being not good" and this would affect things going from ankles to knees and from knees to back. He further reported that he had low back pain in service which has become worse. On review, the Board finds this evidence new. It is also material in that is relates to an unestablished fact (nexus) and raises a reasonable possibility of substantiating the claims. The Board notes that in determining whether evidence is new and material, the credibility of the new evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The claims are reopened. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Entitlement to a rating greater than 10 percent for right knee osteoarthritis In December 2018, VA continued a 10 percent rating for right knee osteoarthritis. The Veteran disagreed with the decision and perfected this appeal. He contends that the assigned rating does not adequately reflect the severity of his disability. At the hearing, he testified that he has constant pain in both knees. Degenerative arthritis established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of flexion of the leg is evaluated as follows: flexion limited to 15 degrees (30 percent); flexion limited to 30 degrees (20 percent); flexion limited to 45 degrees (10 percent); and flexion limited to 60 degrees (noncompensable). 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg is evaluated as follows: extension limited to 45 degrees (50 percent); extension limited to 30 degrees (40 percent); extension limited to 20 degrees (30 percent); extension limited to 15 degrees (20 percent); extension limited to 10 degrees (10 percent); and extension limited to 5 degrees (noncompensable). 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint if none of the symptomatology on which each rating is based is duplicative or overlapping. VAOPGCPREC 9-04; 69 Fed. Reg. 59990 (2004); 38 C.F.R. § 4.14. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The United States Court of Appeals for Veterans Claims (Court) has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." See 38 C.F.R. § 4.40. On VA examination in July 2018, the Veteran reported worsening bilateral knee pain. He takes ibuprofen and tramadol and applies ice and warm compresses. He did not have relief with conservative treatment. He denied flare-ups of the knee. Functional impairment was described as including the inability to go up and down stairs, stand for long, or walk too far. There was pain noted on range of motion testing, but the examiner was unable to provide measurements. He noted that the Veteran demonstrated almost no movement in all directions during formal range of motion testing, resisting efforts. He had more movement when formal testing was not being done. It was further noted that recent examination reported range of motion from 0 to 140 degrees bilaterally. There was pain on passive range of motion testing. There was objective evidence of tenderness to palpation of the joint line at the anterior and medial aspect as well as crepitus. Muscle strength in the right knee was 5/5 in flexion and extension and there was no muscle atrophy. There was no ankylosis. Joint stability testing was normal. The examiner noted the Veteran had a right-side meniscal tear with frequent episodes of joint locking, pain, and effusion. A September 2018 VA record indicates the Veteran was seen for bilateral knee pain. Examination of the right knee showed disuse atrophy at the vastus medialis oblique muscle. Range of motion of the right knee was from 0 to 140 degrees with mild crepitus on flexion. There was positive effusion but no redness or warmth. There was tenderness at the medial joint line without ligamentous instability. On review, there is no evidence of right knee flexion limited to 30 degrees or extension limited to 15 degrees at any time during the appeal period and a rating greater than 10 percent is not warranted. Separate ratings are also not warranted under Diagnostic Codes 5260 and 5261 as compensable limitation of flexion and/or extension is not shown. The Board acknowledges that recent examination did not provide specific range of motion findings. The examiner, however, stated that the Veteran was resisting efforts and limitations shown were not consistent with motion when testing was not being accomplished. The Veteran has a duty to cooperate with objective testing. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that the duty to assist is not a one-way street). The Board has considered the overall evidence during the appeal period and does not find adequate pathology to support a higher rating based on limitation of motion due to pain or other factors. In this regard, it is noted that the July 2018 examiner was unable to provide any statements without speculation as to additional limitation of motion based on repetitive use or during flare-ups. Considering the Veteran's failure to cooperate with objective testing, the Board does not find it necessary to remand for additional information pursuant to Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017) (examiners must offer opinions with respect to the additional limitation of motion during flare-ups based on estimates derived from information procured from relevant sources, including a veteran's lay statements). VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998). Recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when slight, a 20 percent rating when moderate, and a 30 percent rating when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The July 2018 VA examination did not show any right knee instability nor does the Veteran specifically contend as such. Thus, a rating under Diagnostic Code 5257 is not warranted. The attorney, however, argues that a 20 percent rating is warranted under Diagnostic Code 5258. Under this provision, a 20 percent rating is assigned when there is cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The July 2018 VA examination shows the Veteran has a right knee meniscal tear with frequent episodes of joint locking, joint pain, and joint effusion. The examiner, however, stated that the meniscal diagnosis was not associated with the service-connected condition. Review of the record shows that a February 2012 VA examiner stated that the Veteran's chronic bilateral ankle condition could have triggered a degenerative cascade on his right knee. In April 2012, VA granted service connection for right knee osteoarthritis. In February 2013, the Veteran underwent a right knee scope with partial meniscectomy and chondroplasty for a right knee medial meniscus tear and chondromalacia. In January 2014, VA assigned a temporary total evaluation based on this surgery. As indicated, the Veteran is service connected for right knee osteoarthritis. He is not service connected for the meniscal tear. The Board acknowledges that he was awarded a convalescence rating for a partial meniscectomy and the Board will not disturb this rating. The overall evidence, however, shows that the right knee meniscal tear is not related to the service-connected condition. Thus, a separate rating is not warranted under Diagnostic Code 5258 despite the objective findings. Finally, the Board observes that VA's schedule for rating musculoskeletal disabilities was amended during the appeal period effective February 7, 2021. See 85 Fed. Reg. 76453, 76,462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5243). The Board may not apply the amended regulation prior to the effective date of February 7, 2021. See VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the record contains no relevant evidence pertaining to the right knee dated after February 6, 2021, further discussion is not required. Entitlement to an initial rating greater than 50 percent for major depressive disorder In December 2018, VA granted service connection for major depressive disorder and assigned a 50 percent rating effective October 15, 2018. The Veteran disagreed with the rating and perfected this appeal. He contends that the assigned rating does not adequately reflect the severity of his disability and he specifically argues that a 70 percent rating is warranted. Major depressive disorder is evaluated pursuant to the General Rating Formula for Mental Disorders. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434. A 70 percent rating is assigned when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assigned if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, an evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed under the referenced diagnostic code are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Notably, the Court has held that "the language of [38 C.F.R. § 4.130] indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas." Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). The Veteran underwent a private psychological evaluation in July 2018. The examiner stated that the Veteran's chronic pain has manifested into intense anxiety, depressed mood, uncontrollable frustration, anger, and the inability to concentrate or sleep at night. He wakes up with cold sweats and has difficulty breathing. He has poor self-esteem and has experienced suicidal ideations. His relationships with others, to include his parents and children, are affected by his emotional state. During the evaluation, the Veteran was cooperative and demonstrated a willingness to follow directions. He was persistent in completing tasks and test results were felt to be a valid estimate of his current level of functioning. Projective testing and clinical interviewing techniques suggest the Veteran was an anxious and depressed person who was very frustrated with his life. Diagnoses were anxiety disorder and major depression, both due to medical conditions. The examiner stated that the Veteran's symptoms cause clinically significant distress and impairment in social and occupational areas of functioning. On VA examination in December 2018, the Veteran reported he has maintained a positive rapport with his mother and siblings. He was divorced and unemployed. He began seeing a psychologist in approximately May 2018 for psychosocial issues and depression. The Veteran reported poor sleep, daytime fatigue, low energy, anhedonia, decreased attention/concentration, irritability, and angry mood. He also has anxiety, feels on edge, and worries. He denied suicidal or homicidal ideation or feelings of hopelessness at present but did admit to suicidal thoughts with no plan or intent 2 years prior. He reported an episode of domestic violence in February 2018 wherein he lost control secondary to exacerbation of his mood and anxiety symptoms. Symptoms were listed as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran was alert and well oriented with good hygiene and grooming. Attention and concentration were fair, and mood was anxious and down with congruent affect. Thought processes were goal directed and he denied any delusions or paranoia. Insight and judgment were fair. The Veteran's level of disability was summarized as occupational and social impairment with reduced reliability and productivity. VA records show the Veteran underwent an initial psychiatric assessment in March 2019. He reported several stressors including family issues. He has been depressed with difficulty sleeping, irritability, decreased energy, and increased appetite. He denied suicidal or homicidal ideation and was not hypomanic or psychotic. He reported a good relationship with his mother and siblings and stated he was engaged. Mental status examination showed dysthymic mood. Regarding patient strengths, the examiner stated he was motivated for treatment and had good insight, judgment, and effective coping skills. He was alert and oriented and free of any altered thought process. Mood was stable and he was not experiencing suicidal or homicidal ideations. He could accomplish activities of daily living without assistance. Subsequent VA notes indicate panic attacks several times per week and major depressive disorder not improving as expected. Information in the claims folder indicates that the Veteran was incarcerated in May 2021 for a serious charge involving domestic violence. As discussed, the VA examiner summarized the Veteran's level of disability as consistent with a 50 percent rating (reduced reliability and productivity). The private examiner, however, indicated his symptoms were productive of clinically significant distress and impairment in social and occupational areas of functioning which suggests deficiencies in various areas. As set forth, the Veteran experiences numerous symptoms to include depression, anxiety, panic attacks, and sleep impairment. Evidence of record also indicates impaired impulse control with episodes of domestic violence. He has difficulty adapting to stressful circumstances due to anger and irritability. The Board acknowledges that there is some inconsistency in the records regarding the Veteran's ability to maintain effective relationships but regardless, there is no indication of meaningful relationships outside of his family. On review, the evidence is at least in equipoise as to whether the disability picture more nearly approximates occupational and social impairment with deficiencies in most areas. Resolving reasonable doubt in the Veteran's favor, an initial 70 percent rating is granted. 38 C.F.R. § 4.3. A rating greater than 70 percent is not warranted at any time during the appeal period as the disability picture does not more nearly approximate total occupational and social impairment. The Veteran is able to maintain relationships with his mother and children. He is fully oriented, there is no indication of gross impairment in thought processes or psychotic behavior, and he is independent in the activities of daily living. While the Veteran is shown to have anger issues and episodes of domestic violence, there is no indication of a persistent danger of hurting self or others. REASONS FOR REMAND Entitlement to service connection for a thoracolumbar spine disorder The Veteran contends that he has a back disorder related to service or service-connected disabilities. Service treatment records show that on enlistment examination in January 1999, the Veteran's spine was reported as normal on clinical examination. A May 1999 record indicates that thoracic curvature was detected on chest x-ray. Assessment was asymptomatic thoracic scoliosis. A February 2002 record shows the Veteran was seen with complaints of pain to the mid back which he reported beginning about 8 months prior. Assessment was scoliosis and thoracic spine pain. In October 2002, he was seen following a motor vehicle accident with complaints of muscular ligamentous back pain. A note dated four days later indicates that the back strain was resolving. A private neurosurgical evaluation dated in March 2011 indicates that the Veteran was in a motor vehicle accident in November 2010 with complaints of constant back pain. He had a previous car accident in March 2009 with a back injury and had undergone a lumbar disc decompression. The Veteran underwent VA back examinations in July 2015 and February 2017. Both examiners opined that it was less likely than not that his back condition was secondary to (proximately due to or the result of) service-connected disability. The Veteran underwent a VA back examination in January 2019 and the examiner provided a negative opinion on direct service connection finding that the current diagnoses were not incurred in or caused by the complaints of back pain during service. Congenital or developmental "defects" automatically rebut the presumption of soundness and are therefore considered to have pre-existed service. 38 C.F.R. §§ 3.303(c), 4.9. Service connection is not available for congenital defects, but service connection may be awarded for disease or injury that is superimposed upon the congenital defect during service. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009); Monroe v. Brown, 4 Vet. App. 513, 515 (1993); VAOPGCPREC 82-90. On review, the Board finds that additional opinion is needed to address whether the thoracic scoliosis is a congenital defect and if so, whether there is evidence of superimposed disease or injury. In April 2020, the attorney noted that a VA opinion was not provided regarding whether the Veteran's back condition was aggravated by the service-connected conditions. The attorney argued that at a minimum, remand was appropriate for the purpose of obtaining an additional opinion. The Board has reviewed the July 2015 and February 2017 opinions and agrees that additional opinion is warranted on secondary service connection. In this regard, it is noted that a medical opinion which focuses solely on causation is inadequate to address whether a service-connected disability aggravated another condition. When causation and aggravation are at issue, the Board must ensure that the opinion addresses each. El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Entitlement to service connection for a left knee disorder The Veteran contends he has a left knee disorder related to service-connected disabilities. The Veteran underwent VA knee examinations in July 2015 and February 2017. Both examiners opined that it was less likely than not that his left knee condition was secondary to (proximately due to or the result of) service-connected disability. In April 2020, the attorney noted that a VA opinion was not provided regarding whether the Veteran's left knee condition was aggravated by the service-connected conditions. He argued that at a minimum, remand was appropriate for the purpose of obtaining an additional opinion. The Board has reviewed the July 2015 and February 2017 opinions and agrees that secondary aggravation was not addressed. Accordingly, additional opinion is warranted. See El Amin. Entitlement to TDIU In December 2018, VA denied entitlement to TDIU. The Veteran disagreed with the decision and perfected this appeal. In his June 2018 VA Form 21-8940, the Veteran reported that he last worked full-time in April 2017. Information from his prior employer dated in November 2018, indicates that he was still employed, although the date of his last payment was in April 2017. At the hearing, the Veteran testified that he returned to the workforce as a truck driver at the end of December 2019. He indicated that his position is full-time, but he was always taking days off due to issues with service-connected disabilities. He does not get paid for those days and thus, was not getting paid at the full-time rate. He noted that it is hard to operate the clutch because of his lower extremity problems and that his sleep apnea also interferes with his ability to work. On review, the Veteran meets the schedular criteria for TDIU throughout the appeal period. See 38 C.F.R. § 4.16(a). It is unclear, however, what dates he was employed during the appeal period and whether this employment was more than marginal. Accordingly, a remand is necessary to obtain additional information concerning any employment since April 2017. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of any thoracolumbar spine disorder(s). The examiner is asked to review the claims folder and respond to the following questions: (a) Is it at least as likely as not that the Veteran has a thoracolumbar spine disorder that is related to active service or events therein, to include his complaints of back pain during service? In making this determination, please indicate whether the thoracic scoliosis noted during service is a congenital defect and if so, is there evidence of any superimposed disease or injury during service resulting in additional disability? (b) Is it at least as likely as not that the Veteran has a back disorder that is aggravated, i.e., worsened beyond its natural progression, by service-connected right knee and bilateral ankle disorders? In making this determination, the examiner is requested to consider the April 2016 VA medical record which indicates a change in gait related to the bilateral ankle injuries which affected his lower back. As concerns both questions, the examiner should consider the impact, if any, of the Veteran's post-service motor vehicle accidents and back injuries. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required), or the examiner (does not have the needed knowledge or training). 2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's left knee disorder. The examiner is asked to review the claims folder and state whether any left knee disorder is at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected right knee and bilateral ankle disorders? (Continued on the next page) A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required), or the examiner (does not have the needed knowledge or training). 3. Contact the Veteran and ask him to identify any employment since April 2017. The AOJ should then ask any identified employer to complete a VA Form 21-4192, Request for Employment Information in Connection with a Claim for Disability Benefits. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Carsten, 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.