Citation Nr: 21077266 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 15-26 093 DATE: December 29, 2021 ORDER Service connection for osteoarthritis (OA) is denied. FINDINGS OF FACT 1. The Veteran served on active duty from October 1980 to May 1982. 2. A confirmed diagnosis of OA of the right knee, left knee, right hip, left shoulder acromioclavicular (AC) joint, right shoulder glenohumeral joint, cervical spine, lumbosacral spine, right ankle, and left elbow was not shown in service, not shown to a compensable degree within one year of service, and symptoms of OA were not continuous since service; the current diagnoses of OA are not causally or etiologically related to service. CONCLUSION OF LAW OA was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C. §§ 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSION In July 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In November 2020, the issue was denied. She appealed to the Veterans Claims Court. In July 2021, the Court Clerk granted a Joint Motion for Remand (JMR), which vacated the Board's November 2020 decision and remanded the matter to the Board for action in compliance with the JMR. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. The Veteran claims that service connection is warranted for OA of multiple joints because it is related to her diagnosis of OA in service, including an April 1982 right leg/thigh/knee injury, May 1982 finding of right knee OA, and the May 1982 separation Report of Medical History noting "arthritis of unknown etiology." She also claims that she has had symptoms of OA since service. The medical evidence reflects that the Veteran has current diagnoses of OA of the right knee, left knee, right hip, left shoulder AC joint, right shoulder glenohumeral joint, cervical spine, lumbosacral spine, right ankle, and left elbow. As such, the first element of service connection has been met. Right Knee As to in-service incurrence, an April 1982 service treatment record (STR) noted that the Veteran had trauma when she fell on her leg. Pain radiated from her right knee to her thigh and was painful when walking or moving her leg. There was tenderness when bending the knee. A note several weeks later reflected status/post trauma to the right knee one month prior. There was residual edema inferior to the patella. The Veteran complained of intermittent sharp pain to the right knee. A May 1982 physical profile Board proceedings notation identified OA of the right knee. The May 1982 discharge Report of Medical History recorded "arthritis of unknown etiology." As such, the second element of service connection has been met. Regarding a medical nexus between the in-service right knee injury/arthritis complaints/findings and her current diagnoses, the medical evidence does not support the claim. The clinician who authored the September 2020 VA addendum opinion found that it was less likely as not that the current OA was incurred in or caused by the claimed in-service injury, event, or illness. The September 2020 clinician acknowledged the Veteran's contentions (in correspondence responding to the supplemental statement of the case (SSOC) received August 18, 2020) that the chronic disease entity of OA was clearly identified in service, that the diagnosis of OA in service was not subject to a legitimate question, that there had been continuity of symptomatology, and that the Veteran exhibited subsequent manifestations (of OA) at a later date. As to the question of whether the Veteran's current right knee OA was present during service or within one year of service, the clinician opined that it was not present during that time and that the diagnosis of OA of the right knee in service was, in fact, subject to legitimate question for reasons discussed below. After a thorough review of the record, the clinician noted that the April 1982 in-service record stated that the Veteran sustained trauma to the right thigh and was experiencing tenderness when bending the right knee. The assessment was "possible psoriatic arthritis?" and it was noted that the Veteran was to be referred for a dermatology consultation to rule/out that diagnosis. However, there is no evidence in the STRs that this consultation was ever performed. The clinician emphasized that there was no evidence in any available medical records that the Veteran has ever been diagnosed with psoriatic, rheumatoid, or any other rheumatic inflammatory arthritis. The clinician also stressed that an assessment of a "possible" diagnosis does not constitute an actual diagnosis. In addition, there were no findings recorded that would be consistent with psoriatic arthritis, so it was unclear to the clinician why this was even considered as a possible diagnosis following a trauma. With regard to the STR physical profile dated in May 1982, the clinician stated that although it indicated "arthritis of the right knee," nowhere in the STRs was there documentation of physical examination findings that would support a diagnosis of OA. The May 1982 separation Report of Medical History indicated that the Veteran reported having had swollen or painful joints, cramps in legs, arthritis, rheumatism, or bursitis. The clinician indicated that this section was completed by the Veteran, who would not be considered qualified to make an actual diagnosis of OA. While the physician summary and comments section of the Report of Medical History indicated "arthritis of unknown etiology," the clinician stressed that the clinical evaluation section for the lower extremities and other musculoskeletal were all normal on the May 1982 separation examination report. The clinician therefore opined that the comment of "arthritis of unknown etiology" on the May 1982 separation Report of Medical History was based on the Veteran's report and not based on any objective findings of OA or review of any records documenting physical findings consistent with a diagnosis of OA because there were none in the STRs. The clinician noted that it is considered to be standard of care and documentation (and was in 1982, also) that a medical record should contain historical and examination findings to support the given diagnosis; however, such documentation of historical and examination findings to support a diagnosis of OA was lacking in the STR treatment notes. Therefore, the clinician concluded that there was a legitimate reason to question the OA diagnosis. The clinician further stated that reasonable clinicians would never make a diagnosis of OA based on the presence of knee pain alone. In most cases, radiographic findings of OA would be expected to confirm a diagnosis. However, the clinician indicated that there were no knee X-rays performed in service or documented within the year following service. [The clinician clarified that the terms degenerative arthritis (DJD) and osteoarthritis (OA) refer to the same disease entity.] In addition, the clinician noted that, clinically, there are circumstances where a diagnosis of OA may be made with reasonable confidence based on history and physical examination findings alone. In this regard, The American College of Rheumatology criteria for diagnosis of OA of the knee based on history and examination in the absence of imaging include pain in the knee and three of the following: over 50 years old; less than 30 minutes of morning stiffness; crepitus on active motion; bony tenderness; bony enlargement; no palpable warmth of synovium. The clinician similarly noted that the Guideline Development Group of the National Institute for Health and Care Excellence (United Kingdom) in 2008 considered the following to represent a clinician's working diagnosis of peripheral joint OA: persistent joint pain that is worse with use; and age 45 years old and over; and morning stiffness lasting no more than half an hour. The clinician noted that the Veteran was 27 years old at the time of separation and that there were no reports regarding morning stiffness in service, nor was there any documentation of knee crepitus, bony tenderness, bony enlargement or synovial warmth in the right knee joint during service or in the year after separation. Notably, clinical evaluation of the lower extremities and other musculoskeletal segments were all indicated as normal on the separation examination, and the Veteran did not specifically claim knee OA in her June 1982 claim for service connection for OA. Additionally, the initial post-service July 1982 VA examination report (conducted pursuant to the June 1982 service connection claim) did not make any mention of knee complaints in the History section. The report reflected an unremarkable examination and no objective orthopedic physical signs were found. Therefore, based on the objective evidence of record, the clinician opined that the Veteran did not meet any accepted criteria for a diagnosis of OA of the right knee during service or within one year of service. With respect to the Veteran's contentions that she had ongoing knee symptomatology since service, the clinician noted that the contemporaneous records at the time of separation and subsequently did not support this contention. The first documentation of right knee pain following service was in January 1995, 13 years after discharge. The January 1995 private medical records indicated that the right knee pain was due to a recent injury related to an assault. There was no description of chronic knee pain related to service prior to the 1995 knee injury. The first indication of knee pain in the VA medical record was in May 2006, 24 years after service separation, and at that time only occasional pain in the right knee was described and X-rays did not confirm a diagnosis of OA. Similarly, at a February 2007 orthopedic consultation, the Veteran described right knee pain and swelling for many months. It was noted that she could not recall any specific injury or trauma and no history was obtained that would indicate chronic knee pain since service. By 2008, she was clearly having symptoms of OA of the right knee and this was documented by MRI. Based on review of the evidence of record as described above, the clinician opined that any problems the Veteran had orthopedically in service were acute and transitory and left no residuals, with no indication of OA shown in service or within one year of separation. Multiple Joints The clinician also opined that it was less likely than not that the OA of multiple joints was incurred in or caused by the claimed in-service injury, event or illness. The clinician noted that per review of VA treatment records and May 2015 VA examination report, the Veteran had documentation of current diagnoses of OA of the left knee, right hip, left shoulder AC joint, right shoulder glenohumeral joint, cervical spine, lumbosacral spine, right ankle, and left elbow in addition to the right knee OA that was addressed above. The clinician also indicated that the Veteran has been diagnosed with osteoporosis, which was noted to be a condition of decreased bone density and calcium, and was not considered to be chronic inflammation of the bones and joints as contended in Veteran's August 2014 correspondence. The clinician acknowledged the Veteran's contentions that the chronic disease entity of OA was clearly identified in service and that the diagnosis of OA in service was not subject to legitimate question, that there has been continuity of symptomatology, and that the Veteran exhibited subsequent manifestations (of OA) at a later date. As to the question of whether the current OA/DJD of multiple joints was present during service or within one year of service, the clinician opined that it was not present during that time and that a diagnosis of OA of multiple joints in service was subject to legitimate question for reasons discussed above and additional reasons/discussion below. The clinician noted that nowhere in the STR was there any documentation of physical examination findings that would support a diagnosis of OA of any joint. Further, the STR regarding the right knee cited above did not indicate anything specifically regarding "arthritis" of other joints or symptoms involving other joints. There is also no indication of any profile for joint problems other than the right knee. Similar to the right knee, the clinician stated that reasonable clinicians would never make a diagnosis of DJD/OA based on the presence of joint pain alone; in most cases, radiographic findings of OA would be expected to confirm a diagnosis. The clinician noted that there were no joint X-rays performed in service and X-rays of the right hip and left ankle in August 1982, several months after service separation, were normal. It was noted that although there were circumstances where a diagnosis of OA may be made with reasonable confidence based on history and physical examination findings alone, there were no generally accepted guidelines that would indicate a likely diagnosis of DJD/OA in a joint other than the knee in individuals under the age of 45 in the absence of radiographic evidence. In this regard, The American College of Rheumatology criteria for diagnosis of OA of the hip based on history and exam only are: pain in the hip AND internal rotation less than or equal to degrees AND hip flexion less than or equal to 115 degrees, OR internal rotation greater than or equal to 15 degrees AND pain associated with internal hip AND morning stiffness of the hip for less than or equal to 60 minutes AND over 50 years of age. The clinician indicated that the Guideline Development Group of the National Institute for Health and Care Excellence (United Kingdom) in 2008 considered the following to represent a clinician's working diagnosis of peripheral joint OA (these criteria would apply to any peripheral joint): persistent joint pain that is worse with use and age 45 years old and over and morning stiffness lasting no more than half an hour. If other physical findings are also present such as tenderness, limitation of motion, bony swelling, joint deformity or instability the diagnosis of OA would be more confident even in the absence of any imaging studies. The clinician also indicated that because spinal pain due to degenerative disc disease (DDD)/DJD had no specific examination findings that would distinguish it from pain of soft tissue etiology, there were no guidelines for diagnosing spinal OA in the absence of imaging. The clinician opined that reasonable clinicians would not make that diagnosis without imaging confirmation. The clinician pointed out that the Veteran was 27 years old at the time of separation and there are no reports regarding morning stiffness and no documentation of crepitus, chronic bony tenderness, bony enlargement or chronic synovial warmth in the peripheral joints during service or in the year after separation. A November 1980 STR reflected swollen ankles for several weeks associated with prolonged marching and walking. There was some evidence of tenderness bilaterally, but subsequent STR notes and separation examination did not show any evidence of chronic ankle and foot tenderness or swelling consistent with a diagnosis of DJD/OA. Further, according to the May 1982 separation examination, the clinical evaluation for the lower extremities and other musculoskeletal areas were all normal. Finally, the May 1982 Report of Medical History showed that the Veteran specifically indicated "no" to having painful shoulder, trick elbow or recurrent back pain. There is also no indication of any neck/cervical spine pain. It was noted that the Veteran did file a claim for non-specified OA in June 1982 and the July 1982 VA examination report related a history of "arthritis" pains in the right thigh and giving way of the left ankle. There were no other specific joint or spine pains noted, and no objective orthopedic physical signs were found. On examination, flexion of the right hip was 125 degrees and internal rotation was 40 degrees. The clinician stated that these findings would not meet the above listed clinical criteria for OA. The July 1982 examination report indicated that other ranges of motion, including left ankle, were normal. There was also no crepitation or spasms. August 1982 X-ray studies of the right hip did not demonstrate OA and X-rays studies of the left ankle were normal. Therefore, based on the objective evidence of record, the clinician opined that the Veteran did not meet any accepted criteria for a diagnosis of OA of any joint during service or within one year of service. Although the Veteran has contended continuity of symptomatology, the clinician opined that the contemporaneous records at the time of separation and subsequently do not support this contention. The first documentation of cervical spine pain and DDD/DJD was December 1995, 13 years after service separation. As noted above, the Veteran did not complain of recurrent neck pain, back pain, or shoulder pain at separation or at her subsequent initial VA examination in July 1982 and the initial VA Primary Care exam in September 2005 indicated that she denied any physical complaints. She did not indicate any concern regarding chronic joint pains dating back to service. At a May 2007 Primary Care Comprehensive visit, about 24 years after service separation, right knee pain was noted but review of systems indicated that she otherwise denied swelling or pain in her joints. On examination, there was no decreased range of motion. The first indication of shoulder pain was an August 2007 Rheumatology Consultation, at which time right shoulder pain was noted but not further evaluated. Back pain first appeared in the VA record in a telephone note dated in March 2007. At that time, she reported longstanding back pain from a motor vehicle accident (MVA). The clinician noted that there was no evidence that the Veteran was in a MVA during service. Further, a June 2014 left shoulder X-ray showed only mild AC joint DJD and a January 2008 MRI showed mild glenohumeral joint OA of the right shoulder. Similarly, an October 2009 lumbar spine X-ray revealed mild osteophytosis, which was consistent with only a mild level of DJD of the spine. A December 2009 cervical spine X-ray showed significant DDD/DJD changes, but this was 27 years following service. A September 2010 right ankle X-ray reflected mild degenerative changes and a March 2008 MRI of the right hip reflected subtle thinning of the right hip articular cartilage compatible with very early OA. No clearly identified intra-articular loose bodies were seen. The clinician opined that the above noted imaging findings were entirely consistent with age related DJD/OA changes or the expected natural progression of age related DDD/DJD. Also noted was that autopsy studies have shown that up to 90 percent of individuals over 40 years old have evidence of degenerative changes in the weight bearing joints, most without symptoms. Based on review of the evidence of record as described above, the clinician concluded that any problems the Veteran had orthopedically in service were acute and transitory and left no residuals, with no indication of OA shown in service or within one year of separation. There is no medical opinion in favor of the claim. Therefore, the medical evidence does not support service connection on a direct basis. As to presumptive service connection, for the reasons described extensively above in the September 2020 VA opinion report, OA was not shown in service. Regardless of the clinician's opinion that it was not standard practice to diagnose OA without X-rays, the medical evidence in service and ever since undermines a conclusion that the Veteran ever had a firm diagnosis of OA in service. In this regard, although there was evidence of a fall and thigh pain, the initial consultation indicated that there might be psoriatic arthritis. A review of the record reflects that the Veteran was not at that time or since, diagnosed with psoriatic arthritis of any joint. As such, psoriatic arthritis was not present in service. Moreover, while there is evidence of "trauma" in terms of a fall and pain to the right thigh as well as a finding of "arthritis of unknown etiology" at the time of service separation, the STRs do not reflect any physical examination findings supportive of such a diagnosis. Additional evidence weighing against the presence of right knee OA in service is the fact that the Veteran filed claims for service connection one month after service separation but did not specifically claim anything about the right knee, the Veteran was examined and reported right thigh pain at the 1982 VA examination, but there were no physical examination findings indicative of OA of the right knee or any other body part at that time, and she did not report any ongoing right knee pain since service and she did not seek treatment for such for years after service. In addition, when the Veteran initially sought treatment for right knee pain after service in 1995 it was specifically noted to be the result of being kicked in the knee. She did not mention ongoing right knee pain since service. The follow-up medical appointment note indicated that she was a no show for the appointment. Further, when she was first diagnosed with right knee OA in 2008, it was noted to be mild and then only moderate four years later on X-ray in 2012. These findings weigh against a finding of OA in service. Therefore, regardless of the fact that the notation of OA in service was not based on X-ray studies, the totality of the medical evidence of record does not support presumptive service connection based on a chronic disease or injury shown in service. With regard to other joints, X-ray studies of the hip and ankle in August 1982, which was within the first post-service year, were negative for OA. Moreover, the OA of multiple joints documented in the record was diagnosed as mild according to imaging studies dated decades after discharge from service. The fact that multiple joint OA was only mild more than a decade after service separation is another factor which weighs against a finding that OA was present in service. As to presumptive service connection based on continuity of symptomatology, the contemporaneous post-service medical evidence does not support this theory of entitlement. Importantly, the Veteran did not report knee pain at the July 1982 VA examination in conjunction with her 1982 service connection claim for non-specific OA and no OA was found on August 1982 X-ray studies. This weighs heavily against any finding of continuity of symptomatology. If she felt that she had right knee OA which stemmed from trauma in service just months earlier, and because she filed claims for other disabilities at that time, it stands to reason that she would have filed a claim at that time. The next documentation of any joint complaints was in 1995 when the Veteran reported knee pain and neck/back pain. This was approximately 13 years after service and importantly, these medical records did not reflect any ongoing complaints since service. Instead, the January 1995 treatment record noting knee pain related it to a recent assault as she was kicked in the right knee. This evidence supports a finding that right knee pain was not ongoing since 1982 but was rather related to an acute injury sustained over a decade after service discharge. Similarly, VA treatment records noted back pain due to a 2007 MVA, an April 2015 VA treatment record reflected back pain related to wearing heels, and a September 2018 VA treatment record reflected acute back pain for one month. Again, this evidence supports a finding that joint pain was not ongoing since service and was instead related to acute post-service injuries or incidents. Further, none of the post-service records reflect any complaints of ongoing symptoms dating back to service. Therefore, despite the Veteran's contentions, the post-service medical evidence reflects that she did not report any knee pain just months after service at a VA examination conducted pursuant to a claim for service connection for OA. She also did not report any ongoing knee or other joint symptoms since service in the initial post-service medical visits documenting joint complaints, and in some instances, she reported joint pain due to intervening post-service incidents. This evidence weighs against the Veteran's credibility as to ongoing symptoms since service. As such, the medical evidence, which does not support service connection based on continuity of symptomatology, outweighs the Veteran's contentions in this regard. Further, OA did not manifest itself to a degree of 10 percent or more within one year from the date of separation from service. As noted above, the totality of the medical evidence shows that OA was not actually present in service. In addition to the above listed reasons, there were no clinical findings supporting the bare bones hand written notation of "arthritis of unknown etiology" in service. Importantly, X-ray studies of the hip and ankle from August 1982, which was within the first post-service year, were negative for OA. Moreover, OA of multiple joints documented in the record was only diagnosed as being mild according to imaging studies dated decades after discharge from service. Therefore, the medical evidence does not support presumptive service connection on any basis. Based on the above, the medical evidence does not support the claim for OA. As noted, the STRs contain notations regarding OA of the right knee of unknown etiology; however, for the reasons discussed in detail above, the notation of OA in the STRs is not accepted as documentation of a chronic disease/disability because it is not based upon any medical/physical examination findings and it is outweighed by the other evidence of record. The fact that the in service notation of OA was not supported by any X-ray studies is not determinative. In this regard, the September 2020 clinician set forth the standard of care for diagnosis and documentation of OA, none of which the Veteran met in service. The clinician provided a sound medical opinion stating that there was no X-ray evidence or clinical documentation of symptomatology which could possibly support an actual finding of OA in the STRs. The totality of the evidence discussed above, without regard to the lack of X-ray studies in service, leads to the conclusion that there was no actual OA in service. The Veteran argued that the physician who noted "arthritis of unknown etiology" in the separation Report of Medical History was the same physician who evaluated her knee/leg/thigh injury in April 1982 and therefore, the notation at separation was, in fact, based upon objective evidence. However, the fact remains that at no point in the STRs, whether it be the documentation of the initial April 1982 injury, the May 1982 profile, the separation examination report, or the separation Report of Medical History, was there any notation of any reported symptoms or clinical/examination findings which would serve to support a proper diagnosis of OA according to medical literature. Moreover, imaging studies at the 1982 VA examination were negative for OA and the Veteran failed to report any right knee pain or other symptoms whatsoever at the 1982 VA examination. Therefore, based upon the recent thorough review of the evidence by a clinician, even though the physician who wrote "arthritis of unknown etiology" examined the Veteran, the physician did not document any current or historical findings which could have supported the statement in the Report of Medical History or May 1982 profile, and as such, an actual in-service diagnosis of OA is not supported by the record. The Board has considered the Veteran's lay statements that OA was present in service and has been ongoing ever since or is otherwise related to joint complaints during service. She is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. However, she is not competent to offer an opinion as to the etiology of her current OA of multiple joints due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations and opinions obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to her statements. Specifically, the Board finds the September 2020 VA opinion to be highly probative and more credible than the lay statements of record. The clinician noted the Veteran's in-service complaints and the OA notations in the STRs, including the separation examination report and report of medical history. The clinician described the clinical standards for diagnosing OA extensively reviewed and discussed the STRs and post service medical evidence, all of which supported the clinician's opinion that the notation of OA in service is not based upon any relevant medical/clinical findings. The clinician addressed the Veteran's contentions regarding ongoing symptoms since service and showed that these contentions are undermined by the contemporaneous post-service treatment records. The clinician also cited to the current imaging studies as well as medical literature, and ultimately concluded that the current OA of multiple joints was not causally or etiologically related to any in-service incident, but was more likely related to age. The Board finds the September 2020 VA opinion is of high probative value and is entitled to significant weight and weighs against the claim. Moreover, none of the VA and private treatment records associated with the claims file suggests any potential relationship between the Veteran's current OA and service. The Board underscores the September 2020 clinician's statement that the July 1982 VA examination report only noted hip and ankle pain (with no abnormal physical or X-ray findings), and after that, no post-service medical evidence reflected any joint complaints or pain for 13 years after service. The first notation of knee and spine complaints was 13 years after service, and the knee pain at that time was, in the Veteran's own words, related to a post-service assault. This evidence weighs against the claim under every theory of entitlement. The Board has conceded an in-service event and acknowledges the Veteran's reports of right thigh/knee pain, ankle pain, and joint complaints in-service. However, there is no indication that OA actually manifested in service, as the separation examination of the musculoskeletal system was normal and the August 1982 X-ray studies reflected no OA a few months after service and no evidence of medical treatment or complaints for over 13 years after service. Similarly, the medical evidence does not show that OA manifested within one year of separation. As such the Board finds that OA did not manifest during service or within the one-year period after service. In addition, in weighing the evidence of record the competent and credible evidence of record is against finding continuity of symptomatology. The Board finds that the medical evidence contradicts the Veteran's report of continuity of symptomatology and her reports are not credible. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Redman, 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.