Citation Nr: 21006952 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 14-19 886 DATE: February 8, 2021 ORDER Entitlement to service connection for anemia is denied. Entitlement to a rating in excess of 10 percent for psoriasis of the scalp is denied. REMANDED Entitlement to a rating in excess of 10 percent for patellar tendonitis of the left knee is remanded. Entitlement to a rating in excess of 10 percent for patellar tendonitis of the right knee with arthritis is remanded. FINDINGS OF FACT 1. Iron deficient anemia resolved prior to the pendency of the claim; pernicious anemia did not manifest in service or within one year of separation from service and is not otherwise related to service or to service-connected disability, to include medications used to treat a service-connected disability. 2. The Veteran’s psoriasis of the scalp does not cover more than five percent of the entire body or exposed areas, nor has systemic therapy been required during a 12-month period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for anemia have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310 (2019). 2. The criteria for a rating in excess of 10 percent for psoriasis of the scalp have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.118, Diagnostic Code 7806 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1993 to May 1998. These matters were previously remanded by the Board of Veterans’ Appeals (Board) in September 2019. The case has since returned to the Board for appellate disposition. With respect to those claims herein decided, the Veteran was afforded examinations and updated records were obtained in compliance with the Board’s remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for anemia The Veteran seeks service connection for anemia, claimed as due to service or as secondary to service-connected gastritis. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321(2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he or she files the a claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, this list includes anemia, primary. See 38 C.F.R. § 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including primary anemia, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307. Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service treatment records include a September 1993 physical profile noting assessment of anemia January 1994 dental report noting that the Veteran was previously unable to donate blood due to anemia. No other findings or diagnosis pertinent to anemia were noted in service treatment records. A May 2003 VA treatment report reflects assessment of iron deficiency anemia. The Veteran was prescribed iron tablets. A November 2008 VA examination report reflects that the Veteran described an iron-deficiency anemia over a period of 12-13 years. She stated that the anemia cleared about 2 years prior. It was indicated that her most recent laboratory testing showed no evidence of iron deficiency. In July 2007, she was noted to have low B-12 levels and started B-12 injections. A May 2010 primary care note indicates that the Veteran’s blood count was normal with no anemia. A September 2014 VA treatment report reflects that the Veteran had a B12 deficiency of unclear etiology, possibly secondary to gastritis or idiopathic. A long-standing history of norm-cytic anemia with low ferritins as far back as 2007 was also indicated. An impression of chronic normocytic anemia, probably multifactoral, was noted. On VA stomach examination in March 2015, the examiner indicated that anemia was a sign or symptoms due to the Veteran’s gastritis. On VA stomach examination in April 2017, the examiner noted that the Veteran had a history of B12 deficiency thought related to long-term use of proton pump inhibitors. In a January 2019 statement, the Veteran reported that she had been receiving B12 injections since 2011 or 2012. She asked that her anemia be found secondary to her gastritis. She stated that she had seen a hematologist at a VA medical center—her stomach was not absorbing B12 from food and her stomach lining was destroyed due to her chronic gastritis. On VA examination in December 2019, the examiner reviewed the Veteran’s records. He noted that service treatment records revealed low hemoglobin values in 1993, but this was transitory as other recorded values were within normal limits. Following service, July 2007 VA reported noted somewhat-low b12 levels and she was placed on intramuscular B12 supplementation to treat pernicious anemia. As of February 2008, her B12 levels were within normal limits. At the time of the diagnosis of the B12 deficiency, she had not been prescribed a NSAID for daily use, nor a proton pump inhibitor antiacid. The examiner also reviewed the Veteran’s treatment records for gastritis, including VA treatment records and the VA examination reports diagnosing gastritis and finding it as likely as not due to NSAID use. However, the examiner noted that when off of all NSAIDs and prescribed daily antacid therapy, the Veteran’s gastritis had not resolved as had been anticipated by a previous VA examiner. The examiner diagnosed pernicious anemia or other vitamin B12 deficiency anemia; no other type of anemia was indicated. After examination and review of the record, the examiner opined that the Veteran’s anemia was not as least as likely as not proximately due to or the result of the service-connected gastritis. In so finding, the examiner noted that the Veteran did not currently suffer from an “anemia” if that term is strictly construed as a decrease in the total amount of red blood cells in the blood, the presence of a low hemoglobin or hematocrit. Instead, the Veteran suffered from pernicious anemia, which is a chronic autoimmune disease that can lead to a vitamin B12 deficiency resulting from a lack of intrinsic factor. While the cause of this autoimmunity is unknown, the examiner indicated that it was not due to gastritis caused by NSAID use. The examiner indicated that if the Veteran’s gastritis were due to NSAID use, endoscopic studies in 2016 and 2017 were not consistent with a pathology that would lead to a vitamin B12 deficiency. It was clear from his review that the Veteran’s B12 deficiency was noted prior to the evaluation of her NSAID-related gastric complaints, and that any gastritis that might have been caused by her NSAID use would not have affected the region of the stomach responsible for intrinsic factor/B12 integrity. Therefore, the examiner concluded that the Veteran’s pernicious anemia, without anemia on current therapy, was not incurred on active duty as is less likely than not proximately due to, the result of, or incrementally aggravated by her use of NSAIDs or gastritis. As to the Veteran’s previously-diagnosed iron-deficient anemia, the Board finds that this disability had resolved as of the time of the December 2013 claim for service connection for anemia. While the 2014 report notes chronic normocytic anemia with low ferritins, VA treatment records reflect that the condition had largely resolved by 2008 and the Veteran has not been longer on iron supplements for several years prior to the claim. In addition, the 2019 VA examiner did not diagnosis iron deficient anemia. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for iron-deficient anemia. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary. In regard to pernicious anemia, or vitamin B12 deficiency, this form of anemia was first noted in 2007, many years after discharge from service. Moreover, while anemia was indicated in service, the examiner determined that this type of anemia was transitory. Therefore, the record establishes that pernicious anemia was not "noted" during service or within one year of separation. Furthermore, the objective evidence establishes that she did not have characteristic manifestations of the disease during service. 38 C.F.R. § 3.303(b). There is no evidence otherwise linking the Veteran’s pernicious anemia to service. The VA examiner concluded that it was less likely than not incurred on active duty; there is no opinion that in fact supports the claim for service connection fr pernicious anemia on a direct basis. Therefore, service connection for pernicious anemia on a direct or presumptive basis must be denied. As to secondary service connection for pernicious anemia, the Board notes that there is some evidence in support of a secondary relationship to the service connected gastritis, with a VA examiner indicating that the Veteran’s anemia was a sign or symptom of gastritis and the 2014 report noting gastritis as a possible etiology. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board finds the December 2019 VA examiner’s opinion more probative. In this regard, the Board observes that the VA examiner reviewed the entire claims file, including the prior VA examinations and treatment records providing a potential link between the Veteran’s pernicious anemia and her service-connected gastritis. The examiner listed pertinent findings related to anemia and gastritis and provided sound medical rationale for the conclusions reached, with discussion of why he believed the previous providers’ opinions were not correct. The previous examiners/providers did not provide any rationale or basis for finding that the Veteran’s pernicious anemia is due to her gastritis. To the extent that the Veteran contends that her anemia is related to service or service-connected disability, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316. In addition, the Veteran is competent to report what her doctor told her in regard to the relationship between her gastritis and pernicious anemia. In any event, the probative value of the Veteran's assertions in this regard is outweighed by the probative evidence of record outlined above, including the specific, reasoned opinion from the VA examiner, who had the opportunity to review the prior providers’ opinions and provided sound medical rationale in refuting those opinions. Accordingly, the claim for service connection for anemia, to include as secondary to service-connected disability must be denied. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a rating in excess of 10 percent for psoriasis of the scalp The Veteran contends that her psoriasis of the scalp should be rated higher than 10 percent. Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran’s psoriasis of the scalp is rated as 10 percent disabling pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806. Effective August 13, 2018, VA amended the regulation pertaining to ratings of the skin, specifically Diagnostic Code 7806 for dermatitis or eczema. Prior to August 13, 2018, Diagnostic Code 7806 provided that a 10 percent rating is warranted for a skin disability covering at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is given for skin disabilities affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during a 12-month period. A 60 percent rating is warranted for skin disabilities affecting more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the prior 12-month period. 38 C.F.R. § 4.118 (2020). Beginning August 13, 2018, 38 C.F.R. § 4.118 lays out the General Rating Formula for the Skin, which includes Diagnostic Code 7806. The General Rating Formula for the Skin has the same criteria for characteristic lesions involving certain percentages of the body and exposed areas but further defines the term systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs. 38 C.F.R. § 4.118. The Federal Circuit Court has held that systemic therapy means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied, and that nothing in Diagnostic Code 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects "only the area to which it is applied" to count as a systemic therapy under the Code. However, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case and does not automatically mean systemic therapy because Diagnostic Code 7806 distinguishes between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. The Board must thus consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the pre-August 13, 2018 version of Diagnostic Code 7806: a) Whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition; and b) Whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic. In a November 2011 statement, the Veteran expressed that her scalp condition had worsened and was affecting other parts of the body. On VA examination in January 2012, the Veteran reported that she had been using ketoconazole 2 percent shampoo and fluocinonide .05 percent ointment for many years, which was moderately successful in controlling her symptoms. She had also tried selenium sulfide 2.5 percent lotion in the past. The psoriasis was originally localized to her scalp, but had progressively spread to her forehead, cheeks, and buttocks over the last year. She reported intermittent patchy areas and flaking of the skin over her face, with no apparent triggers, such as changes in the weather. She had not been seen at the VA dermatology clinic since 2001. The examiner indicated that the skin condition did not cause scarring or disfigurement of the head, face or neck, and there were no systemic manifestations due to any skin disease. The Veteran had been treated with topical corticosteroids on a constant or near-constant basis in the last 12 months. She had not had any other treatment or procedures. On physical examination, the examiner observed that the Veteran’s psoriasis affected less than 5 percent of the total body area and less than 5 percent of exposed body areas. The examiner diagnosed psoriasis and indicated that the disability did not impact the Veteran’s ability to work. In a May 2014 statement, the Veteran expressed her belief that she is entitled to a 60 percent under Diagnostic Code 7806. She noted that she had been prescribed fluocinonide cream, which is a corticosteroid, and had been on this medical for over 10 years. The condition had also spread to other parts of her body, including additional exposed areas—such as the buttocks, arms, legs, inside of the ears, and face. A June 2016 VA dermatology note reflects that the Veteran reported that her sebo-psoriasis was well-controlled on her current regiment. No flaking or scales was seen on the scalp. She was assessed with sebo-psoriasis, and it was recommended that she continue with her regiment of ketoconazole shampoo 2-3 times per week, and fluocinonide as needed. On VA examination in December 2019, the examiner noted that the Veteran’s scalp care regimen consisted of an antifungal shampoo (ketoconazole 2 percent) used every other day with a topical steroid (fluocinonide .05 percent cream or solution) applied to scaly or waxy areas daily, as need. The Veteran reported some hair loss at the forehead and temple, but the examiner indicated that this was attributable to traction alopecia from her hairstyle, rather than from her service-connected skin condition. Fluocinonide 0.05 percent cream was indicated to be topical corticosteroid that was used of a duration of 6 weeks or more, but not constantly, during the last 12 months. Ketoconazole 2 percent was noted to be topical and used on a near-constant basis over the last 12 months. No other treatment or medication was provided. The examiner indicated that the Veteran’s skin disability affected less than 5 percent of total body area, and less than 5 percent of exposed body areas. In describing the condition, the examiner noted sebo-psoriasis with mild flaking of the scalp and some waxiness at the temple brow line, but no erythematous lesion or spotting alopecia and no involvement of the brows or skin of the ears. The examiner diagnosed seborrheic psoriasis. Here, the Veteran's disability is not shown to involve 20 to 40 percent of exposed body area or total body area. While the Veteran has reported that the condition has spread to other areas, those statements are outweighed by the objective findings on VA examination, both of which found that the service-connected psoriasis affects less than 5 percent of total and exposed body area. As to whether the Veteran’s use of ketoconazole and fluocinonide constitutes systemic therapy topical, the record reflects that these treatments applied directly to the affected areas with use of topical shampoo and creams/lotions. As the Veteran’s skin condition covers less than 5 percent of her body, application of this topical treatment would not be on such a large scale as to be considered systemic. The Board acknowledges corticosteroid use, as the Veteran reports; however, use of these medications on a systemic basis is not shown. Accordingly, based on the relevant medical and lay evidence of record, the Board finds that the criteria for a rating in excess of 10 percent for psoriasis of the scalp have not been met. See 38 C.F.R. § 4.118, Diagnostic Code 7806. In reaching its conclusions, the Board acknowledges the Veteran's belief that her psoriasis is more severe than the current rating reflects. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Boehlert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds the medical evidence in which professionals with medical expertise examined the Veteran's scalp and skin, acknowledged her reported symptoms and treatment, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her own reports regarding the severity of such conditions. The Veteran has not raised any other issues on appeal nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (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 Accordingly, the Board finds that a rating in excess of 10 percent for psoriasis of the scalp is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND Upon review of the claims file, the Board believes that additional development on the remaining claims on appeal is warranted. 3. & 4. Entitlement to ratings in excess of 10 percent for patellar tendonitis of the right and left knees Pursuant to the Board’s remand, the Veteran underwent a VA Knee and Lower Leg Conditions examination in December 2019. The Board finds that the December 2019 examination does not fully comply with Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the United States Court of Appeals for Veterans Claims (Court) determined that the final sentence of 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Id. Although the examiner noted pain on passive motion and on weight-bearing for the Veteran's right and left knees, estimates in the form of degrees of range of motion lost in these circumstances were not provided. The Veteran also expressed in a June 2020 correspondence that she did not believe the examination was adequate and that the examiner failed to note her prior diagnosis of arthritis. Accordingly, the Veteran should be afforded a new examination to determine the nature and severity of her service-connected right and left knee disabilities, to include consideration of the range of motion testing requirements of Correia. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination). The matters are REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records, to include updated VA treatment records. 2. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of the Veteran's service-connected right and left knee disability. The claims file should be made available to the examiner for review in connection with the examination. In particular, the examiner should be directed to perform range of motion testing to determine the extent of limitation of motion. Additionally, the examiner must include range of motion testing in the following areas: Active motion; Passive motion; Weight-bearing; and Nonweight-bearing. The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the right and left knee is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES' SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also comment on the impact of the Veteran's knee disabilities on her ability to work. The examiner must provide a complete rationale for all the findings and opinions. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.