Citation Nr: 21074748 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 16-17 367 DATE: December 16, 2021 ORDER A rating in excess of 30 percent prior to February 28, 2019 and in excess of 50 percent thereafter for posttraumatic stress disorder (PTSD) with alcohol use disorder is denied. A total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for a right knee disability, to include a knee strain, is remanded. Entitlement to service connection for a left knee disability, to include a meniscal tear and knee strain, is remanded. FINDINGS OF FACT 1. Prior to February 28, 2019, the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. Since February 28, 2019, the Veteran's PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas, or worse. 3. The evidence is insufficient to show that the Veteran has been unable to obtain and maintain substantially gainful employment due to his service-connected disabilities as he is still employed. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent prior to February 28, 2019 and in excess of 50 percent thereafter for PTSD with alcohol use disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1988 to October 1988 and August 1989 to September 1992. The issue of service connection for a bilateral knee disability was remanded by the Board in September 2018 and March 2021, and has been returned to the Board for appellate review. The issue of entitlement to a rating in excess of 30 percent for PTSD and for TDIU was remanded by the Board in January 2019 and March 2021 for further development. The Board is satisfied that there has been at least substantial compliance with the remand directives for these issues on appeal discussed below on the merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Veteran was provided notification of how claims for a TDIU may be substantiated in a September 2019 letter. The Veteran submitted a VA Form 21-8940 in February 2019. Outstanding VA treatment records were obtained and associated with the record in March 2021, April 2021, and July 2021. The Veteran was provided a VA Disability Benefits Questionnaire (DBQ) examination for PTSD in June 2021 and VA Individual Unemployability statement for TDIU in June 2021, and both are adequate as they were based on a review of the history, examination, and sufficient information was provided to allow the Board to render an informed determination. These issues were also readjudicated in August 2020 and July 2021 supplemental statements of the case (SSOCs). The requirements of 38 U.S.C. §§ 5103 and 5103A have been met regarding the issues on appeal discussed below on the merits. VA's duty to notify was satisfied by December 2014 letter, April 2016 statement of the case (SOC), and September 2019 letters. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020). VA also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate these claims to include where warranted by law, and affording the claimant VA examinations, VA medical opinions, and a hearing before the Board. 38 U.S.C. §§ 5103, 5103A. There is no objective or subjective evidence indicating that there has been a material change in the severity of the Veteran's service-connected PTSD since he was last examined in June 2021. 38 C.F.R. § 3.327(a) (2020). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95; 60 Fed. Reg. 43186 (1995). There is no evidence that additional records have yet to be requested. In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Lastly, a notice letter was sent to the Veteran in September 2021 affording him the opportunity to clarify some discrepancy regarding who actually represents him before VA. In an October 2021 VA Form 27-0820 (Report of General Information), the Veteran called to inform VA that he is representing himself. 1. Entitlement to a rating in excess of 30 percent prior to February 28, 2019 and in excess of 50 percent thereafter for PTSD with alcohol use disorder In a May 2013 VA rating decision, service connection for PTSD was granted and assigned at 30 percent disabling effective for the entire rating period from July 24, 2011. See 38 C.F.R. § 4.130, Diagnostic Code 9411. On August 7, 2014, the Veteran's request for a higher rating for the issue on appeal was obtained and associated with the record. A July 2021 rating decision increased the disability rating to 50 percent effective from February 28, 2019. Since the 30 and 50 percent disability ratings are not the maximum ratings available prior to February 28, 2019 or thereafter, the issue has been characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). At issue is whether the Veteran is entitled to a rating in excess of 30 percent prior to February 28, 2019 and a rating in excess of 50 percent thereafter. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). 38 C.F.R. § 4.130. A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. Id. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Id. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. Id. Lay and Medical Evidence In November 2014, the Veteran was afforded a VA examination at which he was diagnosed with PTSD and Alcohol Use Disorder (by history). The Veteran reported that he currently lived with his fiancée and four of her grandchildren. The Veteran reported that he had a great relationship with his fiancée's grandchildren and that he maintains contact with one of his younger brothers on a regular basis. The Veteran reported that his relationships with his children is strained. The Veteran indicated he was employed, for nearly two years, at Jacobson Warehouse where he worked as a "Lead Person" (supervisor) at the facility. The Veteran indicated that he was not currently receiving psychiatric treatment or taking psychiatric medications. He reported symptoms of anxiety and chronic sleep impairment. The Veteran denied suicidal and homicidal ideations, hallucinations, and delusions. The examiner observed that the Veteran was casually and appropriately dressed and that his affect was somewhat dysphoric and irritable at times. The examiner opined that the Veteran's PTSD symptoms caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. A private medical opinion was received in August 2015 from Dr. H.-G. Dr. H.-G. indicated that the Veteran endorsed symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; persistent delusions or hallucinations. Dr. H.-G. indicated that the Veteran's claims file, VA records, and Mental Status examination, however, she noted that the Veteran denied a history of substance use with no mention that the Veteran is service connected for PTSD with Alcohol Use Disorder, the Veteran's alcohol use disorder treatment during service, and prior diagnosis at a November 2014 VA examination. This calls into question whether a thorough review of the Veteran's claims file was completed to provide a complete medical opinion. The Veteran was afforded an additional VA examination in October 2018 at which the diagnosis of PTSD was confirmed. He indicated that he continues to be in a long-term relationship and lives with just his partner. The Veteran indicated that school has been a struggle because he dislikes being around people and that it is stressful when others in the classroom do not stay still. He indicated that his professors have been accommodating and reported doing well academically and enjoying learning. The Veteran indicated that he was let go from his job at Jacobsen Warehouse due to a conflict with a coworker. He reported starting school in the summer of 2015 and that he graduated with his associate degree in Applied Science (HVAC) in the Spring of 2017. The Veteran reported he will finish his bachelor's degree in May 2019 and is thinking about going to get a master's degree, but indicated that he feels it would have to be online. The Veteran endorsed symptoms of anxiety, suspiciousness, and chronic sleep impairment. The examiner observed that the Veteran was appropriately dressed, nicely groomed and that his affect was alert and anxious. He indicated the Veteran was oriented to person, place, time, and situation and that his memory was within normal limits. The Veteran denied suicidal or homicidal ideations. The examiner opined that the Veteran's PTSD symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. In June 2021, the Veteran was afforded a VA examination. The Veteran reports that since October 2018 he has not been going anywhere and staying in his room. He has two children who are living with him and attending college and he reports some conflicts with these children since he can be abrasive. The Veteran indicated that he has been doing maintenance in apartments as a temporary employee since 2014 and worked for VA for 8 months and then went back to his maintenance job. The Veteran indicated that he completed a master's degree in Public Administration in 2021 and wants to create a non-profit to help homeless Veterans. The Veteran endorsed symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work life setting. The examiner observed that the Veteran was casually dressed, adequately groomed and that the Veteran was slow to warm but talkative and friendly after a while and that his mood was agitated, tense and anxious with one leg shaking. The Veteran denied suicidal or homicidal ideations as well as auditory and visual hallucinations. The examiner indicated that the Veteran's eye-contact, gait and speech were normal. The examiner opined that the Veteran's PTSD symptoms cause occupational and social impairment with reduced reliability and productivity. A review of VA treatment records dated throughout the entire appeal period do not show symptoms more severe than the VA examinations during the same period. For example, the Veteran consistently denied suicidal and homicidal ideations throughout the appeal period. Additionally, the Veteran has denied hallucinations in VA treatment records. For example, in a January 2015 VA treatment note, the Veteran reported that his primary concern is continued anxiety and that he cannot tolerate people being behind him, crowds of people, and reports having a short fuse. The Veteran additionally reported recently losing his job because he "lost it" when another coworker grabbed his arm in an aggressive manner. He denied symptoms of depression, suicidal ideations, or homicidal ideations. A February 2020 letter indicates that the Veteran successfully completed the Vocational Rehabilitation and Employment (VR&E) program. Prior to February 28, 2019 Review of the evidentiary record from August 7, 2013 (one year prior to the date of claim) to February 27, 2019 does not support a rating in excess of 30 percent. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 50 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating. During the appeal period, the records do not reflect almost any of the symptoms contemplated by the 50 percent rating, such 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 or impaired abstract thinking. The records consistently show that the Veteran continued to maintain good relationships with his live-in partner and some of his children, was competent to manage his affairs, and maintained employment and successfully completed a master's degree. While he exhibited the symptoms of depressed mood, anxiety, irritability, and chronic sleep impairment with some evidence of difficulty in adapting to stressful circumstances particularly at work (though no VA examination endorsed this symptom explicitly), the records consistently show during this period that he did not exhibit any further symptoms contemplated by the 50 percent rating criteria. The August 2015 private medical opinion of record from Dr. H.-G. noted symptoms of: near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, mild memory loss, such as forgetting names, directions, or recent events, flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; persistent delusions or hallucinations. While the Board has considered this opinion, it ultimately has given it less weight than the VA examinations given that the majority of symptoms indicated in this private opinion are not noted anywhere else in the Veteran's treatment records. Additionally, as noted above, the lack of mention of the Veteran's prior substance abuse history calls into question the veracity of the claim that the full file was reviewed. As such, a rating in excess of 30 percent for PTSD during the appeal period prior to February 28, 2019 is denied. From February 28, 2019 Review of the evidentiary record since February 28, 2019 does not support a rating in excess of 50 percent. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher. The Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. VA and private treatment records, the June 2021 VA examination, and the Veteran's lay statements show that the Veteran's PTSD was manifested by one symptom associated with a 50 percent rating (difficulty in establishing and maintaining effective work and social relationships), and one symptom associated with a 70 percent rating (difficulty in adapting to stressful circumstances, including work or a work life setting). The Board finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 50 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity. While the Veteran did experience a symptom contemplated by a 70 percent rating difficulty in adapting to stressful circumstances, including work or a work life setting the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Further, while the June 2021 VA examination show the Veteran reported perceived occupational impairment, including missing work due to his mental health, prior and subsequent treatment records contain reports that the Veteran was generally performing well in an educational setting. For example, the Veteran completed VR&E in February 2020 and completed his master's degree in 2021. As such, a rating in excess of 50 percent for PTSD during the appeal period from February 28, 2019 is denied. 2. TDIU The Veteran seeks a TDIU. He reports having significant difficulty functioning around other people, has difficulty function as a team member, and feels uncomfortable around others. The Veteran reports missing four to five days per month and dreading going to work. He indicates that he has not had a full paycheck in quite a while. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. "[U]nable to secure and follow substantially gainful employment" in 38 C.F.R. § 4.16 (a) comprises both economic and noneconomic components, which required consideration of a wide range of factors and one is a veteran's ability to perform sedentary activities. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019) (also holding that Social Security Administration (SSA) regulations defining "sedentary" are not binding on VA). Withers v. Wilkie, 30 Vet. App. 139, 148 (2018) held that while 38 C.F.R. § 4.16 "does not make the concept of sedentary work an explicit TDIU factor" if TDIU is denied because "a veteran is capable of sedentary work" this must be explained in the context of that case." Thus, while not a legally governing consideration, the ability to perform sedentary work can be a relevant factor and a finding that sedentary employment is possible can be determinative when explained in relation to past education and occupational history. See id. However, neither VA nor the Court has explicitly defined the term "sedentary employment." Withers, 30 Vet. App. at 148. The Board finds that sedentary employment is the common meaning in society of non-physical, white collar, office-type work. The Board envisions potential non-physical employment to encompass administrative, managerial or other forms of employment that would not require the Veteran to spend a significant amount of time standing, ambulating or physical activity requiring lifting, bending, walking, or standing for long periods of time, and would permit the Veteran to take periodic breaks. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Substantially gainful employment" is that employment that "is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment will not be considered substantially gainful employment." 38 C.F.R. § 4.16 (a). The Veteran has the following disabilities that are service connected: sleep apnea associated with PTSD with Alcohol Use Disorder (noncompensable from July 24, 2011, 50 percent from May 28, 2014); PTSD with Alcohol Use Disorder (30 percent from July 24, 2011; 50 percent from February 28, 2019); hypertension associated with PTSD with Alcohol Use Disorder (20 percent from August 7, 2014; 40 percent from December 4, 2019); tinnitus (10 percent from August 7, 2014). Based on the forgoing, the Veteran has at least one disability rated at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more during the pendency of the claim. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). The evidence of record indicates that during the appeal period, the Veteran has had the capability to obtain and maintain substantial gainful employment. After military service, the Veteran obtained his associate degree in Applied Science (HVAC) in Spring 2017, a bachelor's degree in May 2019, and a master's degree in Public Administration in 2021. The Veteran successfully completed VA's VR&E program in February 2020. The record indicates that the Veteran has maintained employment for a majority of the period on appeal. In connection with his claim for benefits, the Veteran completed VA Forms 21-4138 and 21-8940. The Veteran reported full-time (40-hour per week) employment at LSC Communication from May 2017 to June 2017. Additionally, the Veteran indicated that he has been enrolled in higher education since May 2015. On his VA 21-8940, the Veteran reports his last day worked was August 1, 2017. However, on a more recent VA 21-4138 submitted in April 2021, the Veteran reported being currently employed for three years and five months as a full time Maintenance Tech. He reported that he has had to call out or leave early three times in the previous month because of his mental health condition. The Veteran reports that he has lost days from work and has not received a full paycheck in some time. While, the Veteran may have missed time at work as a result of his service-connected disabilities and does report discipline for attendance issues, it is noted that the Veteran receives a 90 percent rating in anticipation of some significant impairment with employment. Based on the foregoing, the preponderance of the evidence shows that the Veteran was employed and participated in VR&E and completed his master's degree during the appeals period. While the record indicates the Veteran has lost past employment due to an exacerbation of his service-connected PTSD, he was able to obtain and maintain continuous work for the past three years. Although, the Veteran has experienced some more recent occupational impairment requiring him to take sick or vacations days, such leave has not been shown to be excessive or cause the Veteran to lose his current employment. Accordingly, entitlement to a TDIU is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability, to include a knee strain 2. Entitlement to service connection for a left knee disability, to include a meniscal tear and knee strain While the Board regrets the further delay, a remand is required for the Veteran's right and left knee disabilities. At a May 2021 VA examination, the Veteran was diagnosed with a right knee strain, a left knee strain, and a left meniscal tear. The examiner indicated that all three of these conditions were less likely than not incurred in or caused by his military service. The Board finds that the May 2021 VA examination and opinion acquired by the RO, is inadequate, because the opinion failed to provide any consideration regarding the Veteran's in-service complaints of left knee pain. The Veteran's service treatment records (STRs) from December 1988 indicate that the Veteran reported pain in his back and left knee for two days but did not recall any trauma. Additionally, the May 2021 examiner noted that the Veteran's bilateral knee strains are unrelated to his left medial meniscal tear. Despite this apparent distinction between the conditions in the Veteran's knees, the examiner did not adequately provide a detailed rationale for why all of these three conditions were not related to his military service nor provide a clear explanation for this statement. As such, an addendum opinion is required before the Board can adequately adjudicate these claims. The matters are REMANDED for the following actions: 1. Return the Veteran's claims file to the examiner who conducted the May 2021 VA examination and medical opinion for knee and lower leg conditions so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination (physical or telehealth) is only required if deemed necessary by the examiner. The examiner should address each of the following questions separately: 2. Is it at least as likely as not that the Veteran's right knee disability was related to service, including his reported extensive physical training and walks carrying a 30lb ruck sack? 3. Is it at least as likely as not that the Veteran's left knee disability, including a left knee strain and left meniscal tear, was related to service, including his reported extensive physical training and walks carrying a 30lb ruck sack? In so addressing, the examiner should consider the Veteran's complaints of left knee pain in service in December 1988. In providing the requested opinion, consider the Veteran's description of his/her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his/her current disability, this should be noted. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the agency of original jurisdiction (AOJ) must implement corrective procedures. 5. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jennifer M. Narvaez, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.