Citation Nr: 21073642 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 13-36 247 DATE: December 9, 2021 ORDER Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for residuals of a concussion or traumatic brain injury (TBI) is denied. Entitlement to a rating higher than 50 percent, since July 9, 2014, for a left shoulder disability is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to a compensable rating for folliculitis is remanded. Entitlement to an initial rating higher than 20 percent, from August 18, 2006, to July 8, 2014, for a left shoulder disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 23, 2021. FINDINGS OF FACT 1. The weight of the evidence is against finding that a chronic lumbar spine disability began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence indicates that the Veteran does not currently have any residuals of a concussion, TBI, or brain disease that was incurred in service. 3. Since July 9, 2014, the Veteran has been assigned the maximum rating for a minor arm shoulder prosthetic replacement. He does not have impairment of the humerus causing loss of head (flail shoulder) or nonunion (false flail shoulder). CONCLUSIONS OF LAW 1. The criteria for service connection fora lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for residuals of a concussion or a brain disease due to trauma have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Since July 9, 2014, the criteria for a rating higher than 50 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.40, 4.45, 4.71a, Diagnostic Code 5051. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1954 to November 1967. This case comes to the Board of Veterans' Appeals (Board) from February 2012, June 2013, and March 2014 rating decisions of the Department of Veteran's Affairs (VA) Regional Office. In March 2015, the Board reopened the previously denied issue of entitlement to service connection for a right knee disability, reopened and granted the issue of entitlement to service connection for a right shoulder disorder, and remanded the remaining issues for further development. In June 2019, the Board then denied all of the appealed issues. The Veteran appealed this decision to the Court of Appeals for Veterans Claims, and a Joint Motion for Remand was issued in May 2020, vacating the June 2019 Board decision due to multiple duty to assist errors, including VA's failure to obtain all relevant records. In November 2020, the Board remanded the appeal in order to obtain all of the missing records and to afford the Veteran new VA examinations. In a March 2021 rating decision, entitlement to service connection for left upper extremity peripheral neuropathy was granted. This is a full grant of the Veteran's claim for service connection for left arm nerve damage, and the issue is no longer part of the current appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Lumbar Spine Disability The Veteran has requested service connection for a lumbar spine disability. He contends that he has had chronic back pain for a long time, and that he believes that it is related to a car accident he experienced in service in 1964. Generally, service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). After reviewing all of the evidence of record, the Board finds that entitlement to service connection for a lumbar spine disability is not warranted. While the appellant has a current back disorder, there is no probative nexus evidence linking this disorder to any event or injury in his military service. VA treatment records show that the Veteran has been diagnosed with a lumbar spine disability. The earliest record of treatment for back pain is in August 2013. At a September 2013 physical therapy consultation, the Veteran reported that his intermittent back pain started about 4 to 5 years prior. X-rays showed mild arthritis change. A May 2017 MRI found mild degenerative disc disease. The Veteran's service treatment records show that in February 1963, he reported pain in the neck and head, and an X-ray was conducted to rule out spinal pathology. In February 1967, he had a fall and was knocked unconscious. He had cervical spasm, but there was no indication of any problems or symptoms associated with the lumbar spine. A cervical X-ray was normal. An October 1967 Report of Medical History shows that he denied recurrent back pain. On his October 1967 Report of Medical Examination, his spine was clinically evaluated as normal. At the February 2014 VA examination, the Veteran reported that he was in a motor vehicle accident and was not sure if he injured his lumbar area at that time. The examiner noted that service treatment records did not reflect any documentation of a significant injury to his lumbar spine sustained during his active duty, and the Veteran did not recall other serious back injury/problems during his active duty. The examiner noted that his 1967 separation examination was negative for diagnosis of any lumbar condition. The Veteran denied any serious back injury after service. The examiner found little evidence of a chronic back condition until the lumbar X-ray in September 2013 which showed some minor spondylitic changes at L5-S1. The examiner opined that the back condition was less likely than not due to service as his service treatment records do not provide clear documentation of a significant lumbosacral injury during his active duty; his 1967 military separation examination did not document any diagnosis of a lumbosacral condition; there was no persuasive documentation showing chronicity of a lumbosacral condition from the time of his active duty until the present; and, abnormalities seen on his lumbar X-rays were mild in severity, non-specific in appearance, and were consistent with the degenerative spondylosis associated with the aging process. The Board finds the VA examiner's opinion to be highly probative evidence that weighs against the claim. The opinion, which was based on review of the appellant's documented and asserted medical history and an in-person examination, constitutes probative evidence on the medical nexus question. See Prejean v. West, 13 Vet. App. 444 (2000). The Board finds that this medical opinion was fully supported by the evidence of record, and the examiner provided adequate rationale for his findings. There are no contradictory medical opinions of record which came to a different conclusion regarding the appellant's back disorder. The appellant has not submitted any other medical evidence regarding the etiology of his current back disorder. While the appellant may believe that his back disorder is related to service or was aggravated by service, such lay assertions do not constitute probative medical evidence. The appellant is competent to describe his symptoms as he perceives them, but as a lay person, he is not competent to provide a medical diagnosis of his back pain or to opine on the etiology of his current back pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). To the extent that he argues he has a current back disorder that was caused by service, his assertions are outweighed by the findings of the more competent February 2014 VA examiner. The Board acknowledges that arthritis is a chronic disorder, and when such a disorder is diagnosed during active duty service, or within a year of such service, or there is a continuity of symptomatology for such a disorder since service, service connection can be granted on a presumptive basis. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1336 (Fed. Cir. 2013). In this case, however, the Veteran was not diagnosed with arthritis of the spine in service or in the years immediately following service, and he has not actually asserted that he experienced a continuity of back pain symptomatology from the time of service to the present. The Veteran has written only that he has had back pain for a long time, and in September 2013, he told his treatment provider that it started 4 to 5 years earlier. The Board therefore finds that a chronic disorder which began in service has not been established. For the foregoing reasons, the Board finds that the evidence demonstrates that the appellant's current back disability was not incurred in or related to service, nor has he been found to have a chronic disorder such as arthritis that began during or within a year of service. The claim for service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt; however, the preponderance of the evidence is against the appellant's claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Residuals of Concussion or Brain Disease The Veteran asserts that he has residuals of a concussion or brain disease due to in-service trauma. The Veteran's colleague H.D. wrote in January 2008, that he was present when the Veteran slipped on the stairs and injured his shoulder in 1959 or 1960. The service treatment records show complaints of recurrent headaches during active service. The Veteran reported having persistent headaches for the past six months in July 1958. An X-ray of the skull was essentially negative, except for a small benign osteoma attached to the frontal sinus that was thought to be entirely incidental. In February 1961, the Veteran reported that he had recurrent headaches for the past three and a half years. His medical history was discussed at length, and it was indicated that his headaches had accompanied simultaneous emotional stressors. He was diagnosed with headache, etiology unknown, related to tension and/or emotional disturbance. A February 1967 service treatment record reflects that the Veteran fell four days prior and was knocked unconscious. The October 1967 Report of Medical History reflects that the Veteran checked the "Yes" box for recurrent headaches, and the examiner indicated a history of situational maladjustment manifested by tension headaches. The October 1967 Report of Medical Examination reflects the same diagnosis. In February 1970, the Veteran underwent a VA neuropsychiatric examination, where he complained of tension headaches in the service. The Veteran reported that during service, he was under extreme financial and personal stress and developed tremendous headaches which were called nervous tension. The Veteran reported only "normal" headaches but no other symptoms. No neuropsychiatric disorder was found. A May 2013 VA TBI examination reflects a diagnosis of remote mild TBI without residuals. The Veteran reported that he fell backward on ice in 1967 and was knocked out for a while. He also reinjured his right shoulder due to the fall. The Veteran reported that he had mild memory loss and chronic headaches. The examiner did not, however, find that the Veteran currently had residuals of a TBI. The examiner stated that while the Veteran suffered a TBI in February 1967, it left no residuals. A May 2013 VA mental disorder examination reflects the examiner's opinion that the Veteran has no diagnosis as the result of a motor vehicle accident or a fall in service. There were no residuals of any accident resulting in loss of memory or forgetfulness. The Veteran reported a reduction in memory and stress at work with depressive symptoms in 2003 and was seen starting in 2005. Neuropsychological testing and an MRI were negative for a TBI. The Veteran reported his doctor's belief that he may have suffered mild strokes. The examiner noted age-related word finding issues, and the Veteran denied any mental health issues such as depression or anxiety which could impact cognitive functioning. He had a history of adjustment disorder related to family stress, but he denied any issues at the time of the examination. The Veteran was able to socialize and function cognitively, he could process information and make decisions with good results, and his judgment was not impaired. The examiner found no mental health diagnosis. The examiner commented that the Veteran had word finding issues and could struggle to recall names, but he did not appear to have dementia. The examiner found that the Veteran had no diagnosed condition of a TBI and no residuals of a TBI. The Veteran's private treatment records show that he has been diagnosed with prior strokes, but with no current residuals, and they have not been related to any TBI or head injury. In March 2005, the Veteran reported having vertigo and clumsiness, but a brain MRI found no acute findings, other than a few nonspecific chronic lesions in the white matter. A July 2015 brain MRI found mild chronic microvascular ischemic changes in the periventricular regions, which suggested an internal carotid artery aneurysm. The Veteran was diagnosed with a stroke. In February 2016, it was noted that he had 3 prior strokes, and the last one was in July 2015. The Veteran had a brain CT scan because he was experiencing dizziness. There was no intracranial mass, hemorrhage, midline shift, or fluid collection. A May 2017 brain scan found no intracranial hemorrhage, although there were white matter hypodensities which could represent small vessel disease. A left frontal periventricular white matter old lacunar infarct was present. The Veteran's private records also show that on several occasions he has reported feeling dizzy. In March 2016, he was diagnosed with chronic vertigo, which was found to be multifactorial and likely to do with dehydration, complex migraines, and urinary retention. In January 2020, a VA physician found that the Veteran had dizziness which was due to illness and decreased food intake, and a separate evaluation found that it was multifactorial, and due to elevated blood pressure, pain, and orthostasis. In March 2021, the Veteran's VA treatment provider wrote that the Veteran had dizziness, which was suspected to be multifactorial, possibly from pain and orthostasis. After reviewing all of the evidence of record, the Board concludes that while the Veteran sustained a TBI during active service, he does not have a current diagnosis of residuals of the in-service TBI, and no residuals have been shown at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). While the Veteran did injure his head in service, there is no indication that he incurred any continuing symptoms from that injury. The Veteran was treated for headaches on multiple occasions, but his headaches preceded his head injury, and were attributed to other causes, such as emotional stress. The Veteran underwent an evaluation in February 1970, just a few years after his separation from service, and a psychiatric disability was not diagnosed and any TBI residuals were not discussed or detailed or diagnosed. The May 2013 VA examiners evaluated the Veteran and determined that while he sustained an in-service TBI, no TBI residuals were shown. Moreover, treatment records on file do not reflect residuals of a TBI. The Veteran has reported having symptoms of headaches, dizziness, and memory loss, but at no time has any examiner attributed these symptoms to a TBI incurred in service. The Veteran has, however, been found to have had a stroke or brain aneurysm in July 2015, with possible other "mini-strokes," but this is a separate condition from the Veteran's TBI in service, and has at no time been attributed to traumatic injury to the head or brain. The preponderance of the probative medical evidence indicates that the Veteran does not have any current symptoms or residuals which are related to an in-service TBI. While the Veteran believes he has residuals of a TBI, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran is competent to report on his own symptoms as he experiences them, such as feeling dizzy or having headaches, but he is not competent to opine on their etiology, and the Board gives more probative weight to the competent VA medical opinions which did not find that these reported symptoms were due to a TBI. In sum, the preponderance of the evidence indicates that the Veteran does not have any current residuals of a TBI incurred in service, and the claim is denied. The Board has again considered the doctrine of reasonable doubt, but the preponderance of the evidence is against the claim. See Gilbert, 1 Vet. App. 49. Left Shoulder Disability since July 9, 2014 The Veteran has requested higher initial ratings for his service-connected left shoulder disability. He has been assigned ratings of 20 percent from August 18, 2006 to July 8, 2014, and 50 percent since July 9, 2014. The issue of entitlement to a rating higher than 20 percent for the period from August 18, 2006, to July 8, 2014, is addressed in the remand below. For the period since July 9, 2014, the Veteran has been assigned the maximum rating, and a higher rating is not warranted. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The Veteran's left shoulder prosthetic replacement is rated under Diagnostic Code 5051, for shoulder replacement (prosthesis). A 100 percent rating is awarded for the first year following implantation of prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5051. At the June 2008 VA examination, the Veteran reported that his right hand was his dominant hand, so his left arm is his "minor" arm. The minimum rating is 20 percent. With intermediate degrees of residual weakness, pain, or limitation of motion, the arm is rated by analogy to Diagnostic Codes 5200 (scapulohumeral articulation) and 5203 (impairment of clavicle or scapula). A 50 percent rating is assigned when there are chronic residuals consisting of severe, painful motion or weakness in the affected extremity. Id. The only rating criteria that allow for a higher rating for the minor shoulder is under Diagnostic Code 5202, for other impairment of the humerus. Nonunion (false flail joint) is assigned a 50 percent rating, and loss of the head (flail shoulder) is assigned a 70 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5202. The rating criteria for musculoskeletal disorders under 38 C.F.R. § 4.71a were amended, effective February 7, 2021 [Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453-69 (November 30, 2020)]. The amendments did not substantially alter the rating criteria which are relevant in this case. The Veteran has therefore already been assigned the maximum rating for his left shoulder prosthetic replacement. 50 percent is the highest rating under Diagnostic Code 5051, and even if Diagnostic Codes 5200 or 5203 were applied, they only allow for maximum ratings of 20 or 40 percent, and therefore would provide no greater benefit for the Veteran. The VA examinations show that the Veteran does indeed have severe painful motion and weakness in his left shoulder, and the 50 percent rating is appropriate. At a March 2021 VA examination, the Veteran reported that he had difficulty doing tasks and lifting his arm above his head. Range of motion testing found flexion, abduction, internal rotation and external rotation to 90 degrees. With flare ups, flexion and abduction would be reduced to 70 percent. There was no ankylosis and no loss of head (flail shoulder) or nonunion (false flail shoulder). While the March 2021 VA examiner did not test the right shoulder, the Board finds that this error is harmless, and there is no possibility that such testing would change the outcome for this issue. A May 2021 addendum stated that the Veteran had chronic residuals consisting of severe painful motion or weakness. The Veteran also attended VA examinations in July 2014, July 2016, January 2018, where his range of motion testing was found to be equal to, or better than, the results at the March 2021 VA examination, with the exception of a finding of external and internal rotation to 60 degrees with repeated use over time and 50 degrees with flare ups at the July 2016 VA examination. At the July 2014 VA examination, specific findings in degrees for range of motion impairment during flare ups was not given, but the Veteran did report that his restriction by 75 percent during flare ups. Even taking this into account, the Veteran's flexion of 160 degrees would be reduced to 40 degrees, and his abduction of 150 degrees would be reduced to 37.5 degrees. This indicates severe limitation of motion, but still does not indicate that any higher or separate rating could be assigned, as 50 percent is the maximum rating for limitation of motion in a shoulder with prosthetic replacement. At no time was the Veteran ever found to have ankylosis, flail shoulder, or false flail joint. The Veteran's VA and private records are largely consistent with these findings and do not indicate that any higher or alternate rating would be appropriate. In March 2018, the Veteran reported having acute left shoulder pain for the past 5 days. Physical examination found forward flexion to 120 degrees, and abduction to 80 degrees. Strength was 4/5. The Board acknowledges that the Veteran attended a VA examination in September 2021 which included evaluation of his left shoulder, and that this evidence has not yet been reviewed by the Agency of Original Jurisdiction (AOJ) in a Supplemental Statement of the Case. The Board finds that this procedural error is harmless, however, as the evidence obtained at this examination does not indicate that any higher or different rating should be applied. At the September 2021 VA examination, the Veteran had left shoulder flexion and abduction of 90 degrees, and internal and external rotation of 60 degrees. This was limited to flexion and abduction of 60 degrees, and internal and external rotation of 50 degrees with repeated use over time, and flexion and abduction of 55 degrees, and internal and external rotation of 45 degrees with flare ups. There was no ankylosis and no loss of head (flail shoulder) or nonunion (false flail shoulder). These findings are not indicative that any higher or different rating should be applied, so they are substantively duplicative of the evidence already reviewed by the AOJ. The Board therefore finds that the Veteran has already been assigned the maximum rating for a minor arm left shoulder prosthetic replacement, and there are no other rating criteria which could be applied which would allow for a higher rating. Entitlement to a rating higher than 50 percent from July 9, 2014 for a left shoulder disability is denied. The Board has again considered the doctrine of reasonable doubt, but the preponderance of the evidence is against the claim. See Gilbert, 1 Vet. App. 49. REASONS FOR REMAND Right Knee Disability The Veteran has also requested service connection for a right knee disability. He wrote in August 2013 that he injured his right knee in November 1965, and that this led to his current knee pain. The May 2020 Joint Motion for Remand found that the Board and the February 2014 VA examination had failed to adequately consider the Veteran's reports of having continuous knee symptoms since service and the medical evidence which also indicated a continuity of symptomatology. It noted that the Veteran's separation examination said that his health was good except for his right knee, he filed a claim for service connection for the right knee just a few months after separation in 1968, and he reported pain and swelling in his knee at the 1970 VA examination. The Board then remanded this issue in order to obtain a new VA examination and opinion. A nurse practitioner provided an opinion in March 2021 that found that the condition was less likely than not related to service, and as rationale, he wrote that despite the in-service knee injury, a right knee disability was not diagnosed in the years following separation from service, and that it was only diagnosed in 2008. The Board unfortunately finds that the March 2021 VA examination is not adequate, as this examiner also failed to consider the Veteran's reports of continuous knee pain since service, and the fact that these assertions are supported by the medical evidence. The Veteran did indeed write that his health was good except for his right knee on his October 1967 Report of Medical History, and at a February 1970 VA examination, the Veteran reported that his knee would catch and pop at times, and that it ached with prolonged standing and walking. This issue is therefore remanded so that these records and the Veteran's lay assertions can be appropriately considered in a VA medical opinion. Folliculitis The Veteran contends that a compensable rating is warranted for his folliculitis. He has written that he has to use a medicated cream, and that the affected area of his face is discolored and scaly. The May 2020 Joint Motion for Remand found that the Board had previously erred by denying a higher rating without considering the holding in Burton v. Wilkie, 30 Vet. App. 286 (2018). In Burton, the Court held that situations where topical skin treatment could constitute systemic therapy under 38 C.F.R. § 4.118, Diagnostic Code 7806 were not limited to situations involving large scale topical application, but also included the method by which a treatment worked, for instance a limited topical treatment could still affect the body as a whole if it circulated throughout the body via the bloodstream. Burton, 30 Vet. App. at 290-95. VA must therefore determine whether a topical treatment operates by affecting the body as a whole. Id. at 292; see also Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017); Warren v. McDonald, 28 Vet. App. 194 (2016) (holding that Diagnostic Code 7806 includes treatments that are "like corticosteroids or other immunosuppressive drugs"). The Veteran attended a VA examination in March 2021. When asked whether the Veteran's topical treatment constituted systemic therapy or was similar to corticosteroids or other immunosuppressive drugs, the examiner only wrote "Similar to corticosteroids." When asked to provide his rationale, he repeated "Similar to corticosteroids." Unfortunately, the Board does not find that this response is sufficient to determine whether the Veteran's topical treatment affects the body as a whole by circulating through the blood stream and acting as a corticosteroid or other immunosuppressive drug. The Board also notes that the Veteran attended a new VA examination in September 2021, at which he reported that he was no longer bothered by severe episodes, and no current diagnosis was found. This examination is greatly inconsistent with the Veteran's prior lay statements, and the Board finds that an opinion is therefore still needed regarding the Veteran's skin medication. This issue is again remanded in order to obtain an adequate addendum medical opinion. Left Shoulder Disability from August 18, 2006 to July 8, 2014 In October 2011, the Veteran submitted a request for a higher rating for his service-connected left shoulder disorder had been rated as 20 percent disabling since December 20, 2007. In a November 2013 rating decision, a clear and unmistakable error was found in the effective date that had been assigned for service connection for prosthetic replacement of the left shoulder from degenerative arthritis, and a retroactive evaluation of 20 percent from August 18, 2006 was assigned. In a September 2014 rating decision, the Veteran's evaluation was increased to 50 percent, effective July 9, 2014. The current period on appeal therefore extends back to August 18, 2006. The May 2020 Joint Motion for Remand found that the Board had failed to explain why, because the Veteran had failed to report for a December 2011 VA examination, a medical opinion could not have instead been obtained to address the Veteran's functional impairment during flare ups. See Turk v. Peake, 21 Vet. App. 565, 569 (2008) (explaining that when a claimant fails to report to a scheduled VA examination, the Board is to consider "(1) whether the examination was necessary to establish entitlement to the benefit sought, and (2 whether the veteran lacked good cause to miss the scheduled examination"). In November 2020, the Board then remanded this issue and requested that the examiner provide a retrospective opinion on the functional limitations caused by pain and any other associated symptoms, to include the frequency and severity of flare-ups of these symptoms, and the effect of pain on range of motion for the period prior to July 9, 2014. The examiner was also asked to provide a retrospective estimate regarding additional loss of function during such flare-ups and to express such additional loss in degrees of motion. A VA medical opinion was obtained in March 2021, but regarding the retrospective opinion, the examiner just wrote that it was impossible to do so as it would be mere speculation, because the examiner did not see the Veteran in 2014 or before that, and therefore could not accurately obtain subjective and objective information to determine what functional limitations, if any, would be present during this time. Unfortunately, this is not an adequate response to the Board's question, and it is a failure to substantially comply with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding veterans are entitled to compliance with Board remand instructions). If an examiner states that he cannot give an opinion without resort to speculation, it must be clear that the examiner has considered all procurable and assembled data, and he/she must explain the basis for his or her conclusion that an opinion cannot be offered, such as explaining whether it is a limitation of the individual examiner, whether based on lack of expertise, insufficient information, or unprocured testing. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Here, it appears that the examiner was simply unwilling to provide such an opinion. The very purpose of a retrospective opinion is to provide one based on review of the medical evidence and the statements of the Veteran, as it is obvious that the examiner was not expected to travel back in time to examine the Veteran. This issue is therefore remanded so that a new VA medical opinion can be obtained which addresses the severity of the Veteran's left shoulder disability during the period from August 18, 2006 to July 8, 2014. TDIU prior to August 23, 2021 The Veteran has also asserted that he has been unable to maintain employment because of his service-connected disabilities, including his left shoulder disorder. This issue is therefore part of the current appeal for an increased rating for a left shoulder disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a November 23, 2021 rating decision, entitlement to a TDIU was granted, effective August 23, 2021. The appeal period for the Veteran's left shoulder disability extends back to 2006, however, and the Veteran has indicated that he last worked full-time in August 2007, and that he became too disabled to work in 2009. The issue of entitlement to a TDIU prior to August 23, 2021 therefore remains on appeal. This issue is intertwined with the issues currently being remanded, and therefore is remanded as well. Additionally, as a retrospective opinion is being requested regarding the severity of the Veteran's left shoulder disability, the examiner is also asked to discuss the impact of the Veteran's left shoulder disability and other service-connected disabilities on his ability to work prior to August 23, 2021. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since August 2021. 2. Obtain an addendum medical opinion addressing the etiology of the Veteran's right knee disability. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner should then address: Whether it is at least as likely as not (50 percent probability or more) that the Veteran's right knee disability was incurred in or is related to any event or injury in service. The examiner is asked to specifically address the following evidence: the Veteran's lay assertions that he has had continuous knee pain since his injury in service; the November 1961 X-ray for a hurt right knee; the November 1965 service treatment record showing that the Veteran sprained his right lateral collateral ligament while playing football; the October 1967 Report of Medical History at which the Veteran wrote that his health was good except for his right knee; and the February 1970 VA examination at which the Veteran reported that his knee would pop and catch, and that it had pain and swelling with prolonged walking and standing. If the examiner finds that the Veteran's lay assertions are not credible, he/she must explain why and discuss what evidence supports this finding. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. Obtain an addendum medical opinion addressing the nature of the Veteran's treatment for folliculitis. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the examiner. The examiner should then discuss all of the medications that the Veteran has taken for treatment of his folliculitis, including hydrocortisone cream, and state whether any of these topical treatments a) operate by affecting the body as a whole in treating his skin condition by entering the bloodstream, and b) are, or are "like," a corticosteroid or other immunosuppressive drug. Please also discuss whether the Veteran uses these medications on a large enough scale that the use of this treatment could be considered "systemic." The examiner must provide a thorough explanation for this finding. If the medication is found to be "like" a corticosteroid or other immunosuppressive drug, the examiner must explain why, scientifically, this is the case. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. 4. Obtain an addendum medical opinion addressing the severity of the Veteran's left shoulder disability from August 18, 2006 to July 8, 2014. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner should provide a retrospective opinion on the functional limitations of the Veteran's left shoulder disability caused by pain and any other associated symptoms on range of motion, for the period from August 18, 2006 to July 8, 2014. The examiner should attempt to provide a retrospective estimate regarding additional loss of function during such flare-ups, and the additional loss should be expressed in degrees of motion. The examiner should base this opinion on the medical evidence of record and the lay statements of the Veteran, such as his July 9, 2014 statement that during flare ups, his function was restricted by 75 percent. The examiner is also asked to specifically address whether, during this period, the Veteran's left shoulder symptoms consisted of "severe, painful motion or weakness in the affected extremity." If possible, please attempt to identify the date at which his left shoulder symptoms became "severe." The examiner should also discuss what the functional impact of the Veteran's service-connected disabilities, including his right and left shoulder disorders and left arm peripheral neuropathy, on his ability to maintain employment, and whether it is ascertainable, from the medical evidence, at what point he became too disabled to work. The examiner must provide a thorough explanation for his findings. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why, including whether he/she has considered all procurable and assembled data, and whether it is due to the limitations of the examiner, such as a lack of expertise, insufficient information, or unprocured testing. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.