Citation Nr: 21010341 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-29 890 DATE: February 24, 2021 ORDER Entitlement to an initial rating in excess of 50 percent for bilateral pes planus is denied. Entitlement to an initial rating in excess of 30 percent for right upper extremity carpal tunnel syndrome with ulnar nerve entrapment is denied. Entitlement to an initial rating in excess of 20 percent for left upper extremity carpal tunnel syndrome with ulnar nerve entrapment is denied. Entitlement to an initial rating in excess of 10 percent for cervical spine degenerative disc disease is denied. Entitlement to higher staged initial ratings for a lumbar strain, currently rated as 10 percent for the period from September 21, 2003, through September 16, 2019, and 20 percent from September 17, 2019, is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome is remanded. FINDINGS OF FACT 1. The Veteran was assigned a 50 percent rating for bilateral pes planus for the entire appeal period, which is the maximum that may be granted under the rating schedule. The record does not reflect exceptional or unusual impairment to the extent that an extraschedular rating may be considered. 2. The most probative evidence does not reach the level of equipoise as to whether the Veteran’s right upper extremity carpal tunnel syndrome with ulnar nerve entrapment manifested functional impairment to the extent that a higher rating may be assigned. 3. The most probative evidence does not reach the level of equipoise as to whether the Veteran’s left upper extremity carpal tunnel syndrome with ulnar nerve entrapment manifested functional impairment to the extent that a higher rating may be assigned. 4. The most probative evidence does not reach the level of equipoise as to whether the Veteran’s cervical spine degenerative disc disease manifested functional impairment to the extent that a higher rating may be assigned. 5. The most probative evidence does not reach the level of equipoise as to whether the Veteran’s lumbar strain manifested functional impairment to the extent that a higher rating may be assigned. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 50 percent for bilateral pes planus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.10, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5276. 2. The criteria for entitlement to an initial rating in excess of 30 percent for right upper extremity carpal tunnel syndrome with ulnar nerve entrapment have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.124a, DC 8515. 3. The criteria for entitlement to an initial rating in excess of 20 percent for left upper extremity carpal tunnel syndrome with ulnar nerve entrapment have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.124a, DC 8616-8515. 4. The criteria for entitlement to an initial rating in excess of 10 percent for cervical spine degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.45, 4.59, 4.71a, DC 5242. 5. The criteria for entitlement to higher staged initial ratings for a lumbar strain, currently rated as 10 percent for the period from September 21, 2003, through September 16, 2019, and 20 percent from September 17, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.45, 4.59, 4.71a, DC 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1992 to May 2000. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA). These matters have an extended procedural history dating back to 2003. Most recently, in March 2018, the Board remanded increased rating claims for pes planus, left and right upper extremity carpal tunnel syndrome, left knee patellofemoral pain syndrome, cervical spine degenerative disc disease, and a lumbar strain for further development. The agency of original jurisdiction (AOJ) was asked to procure VA examinations documenting the current severity of the Veteran’s pes planus, carpal tunnel syndrome, cervical spine, and lumbar spine disorders. Regarding the left knee disorder, the Board remanded the claim for initial AOJ adjudication because additional evidence had been received since the last Supplemental Statement of the Case was issued. See BVA Decision, March 2018. The Veteran appeared for VA examinations of his cervical spine, lumbar spine, pes planus, and carpal tunnel syndrome in September 2019. The Board notes that the Veteran was unable to perform range of motion testing of the cervical and lumbar spine due to pain and an inability to stand on his own without great risk of falling. Nevertheless, the examiner was able to estimate lost range of motion during flare-ups and after repetitive use of the lumbar spine, and after repetitive use of the cervical spine (the Veteran did not report flare-ups of the cervical spine), based on his observations of the disorders and the Veteran’s reported symptoms. Thus, as the examiner made an estimate of lost range of motion based on direct observation of the Veteran’s disorder, and using such estimates would encompass the functional loss of the disorders at their highest level of severity with flare-ups and repeated use, the Board finds that the examinations are substantially compliant with the Board’s remand directives. See 38 U.S.C. § 5103A(d). The Board notes that, while this appeal was pending, the AOJ granted higher staged ratings for the lumbar spine, bilateral pes planus, and right and left upper extremity carpal tunnel syndrome. See Notification Letter, January 2020; Rating Decision – Narrative, October 2020. As these are considered partial grants of the claims at issue, the matters remain within the Board’s jurisdiction. See AB v. Brown, 6 Vet. App. 35 (1993). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). Legal Criteria – Rating Disabilities Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). 1. Entitlement to an initial rating in excess of 50 percent for bilateral pes planus The Board finds that the most probative evidence does not support an initial rating in excess of 50 percent for the Veteran’s bilateral pes planus. Therefore, the claim must be denied. Pes planus is rated under 38 C.F.R. § 4.71a, DC 5276, which provides a 30 percent evaluation for severe bilateral pes planus; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 50 percent rating, the maximum, is assigned when there is evidence of pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of tendo achilles on manipulation, not improved by orthopedic shoes or appliances. The Veteran has been assigned a 50 percent rating for his pes planus for the entire appeal period. See Rating Decision – Codesheet, January 2021. As the Veteran has received the maximum rating allowed for pes planus for the entirety of the appeal period, there is no basis for the Board to assign a higher rating under the rating schedule. 38 C.F.R. § 4.71a, DC 5276. Moreover, the record does not reflect, and the Veteran has not asserted, that his pes planus manifests exceptional or unusual impairment not contemplated by the rating schedule to the extent that a referral for extraschedular consideration would be appropriate. See 38 C.F.R. § 3.321(b). In sum, the record does not support that an initial rating in excess of 50 percent may be assigned for bilateral pes planus. See 38 U.S.C. § 5107(a) (“[A] claimant has the responsibility to present and support a claim for benefits....”); Fagan v. Shinseki, 573 F.3d 1282, 1286 (Fed. Cir. 2009) (stating that the claimant has the burden to “present and support a claim for benefits” and noting that the benefit of the doubt standard in section 5107(b) is not applicable based on pure speculation or remote possibility). 2. Entitlement to an initial rating in excess of 30 percent for right upper extremity carpal tunnel syndrome with ulnar nerve entrapment 3. Entitlement to an initial rating in excess of 20 percent for left upper extremity carpal tunnel syndrome with ulnar nerve entrapment The Board finds that the most probative evidence does not reach the level of equipoise in the claims of entitlement to higher staged ratings for left and right upper extremity carpal tunnel syndrome. Therefore, the claims must be denied. The Veteran’s bilateral upper extremity carpal tunnel syndrome is rated under 38 C.F.R. § 4.124a, DC 8515. Although the left upper extremity has been assigned a hyphenated diagnostic code at DC 8616-8515, the disorder is nevertheless rated under DC 8515. See Rating Decision – Codesheet, January 2021. Under DC 8515, ratings are assigned for paralysis of the median nerve, with complete paralysis rated as 70 percent disabling (60 percent if in the minor (non-dominant) extremity); severe incomplete paralysis, rated as 50 percent disabling (40 percent if in the minor extremity); moderate incomplete paralysis, rated as 30 percent disabling (20 percent if in the minor extremity); and mild incomplete paralysis rated as 10 percent disabling in either extremity. Turning to the evidence of record, the Veteran underwent a VA examination in June 2010. He reported a chronic gradual onset of tingling in the upper extremities. A physical examination showed upper extremity motor testing 4/5 proximal and 5/5 distal strength. Sensory testing of the peripheral nerves revealed hyperactive reflexes in the left biceps, triceps, brachioradialis, and finger jerk, but normal in the right upper extremity. Extension and flexion of the bilateral elbows and wrists was active movement against some resistance, as was bilateral finger flexion, abduction, and thumb opposition. The examiner found that the disorder would cause decreased manual dexterity and strength, lack of stamina, weakness, and fatigue, and problems with lifting and carrying. In August 2017, the Veteran underwent a VA examination. He did not report having any symptoms of pain, paresthesias or dysesthesias, or numbness in the upper extremities. Muscle strength, reflexes, and sensory testing were all normal in the upper extremities. Nerve testing showed normal function of all upper extremity nerves. The Veteran underwent another VA examination in September 2019. He endorsed mild constant pain, moderate intermittent pain, moderate paresthesias and dysesthesias, and moderate numbness in both upper extremities. Muscle strength testing showed active movement against some resistance in the upper extremities, and reflexes were hypoactive in the bilateral triceps, biceps, and brachioradialis. Sensory testing showed absent sensation to light touch. Nerve testing showed mild incomplete paralysis of the bilateral median nerve, mild incomplete paralysis of the right ulnar nerve, severe incomplete paralysis of the musculocutaneous nerve, severe incomplete paralysis of the long thoracic nerve, and moderate incomplete paralysis of the upper and middle radicular group. The examiner provided a clarification opinion in January 2020. He explained that only the medial and ulnar nerves are related to carpal tunnel syndrome and that the other nerve abnormalities are due to the Veteran’s multiple sclerosis, which is not an issue on appeal. The Board has reviewed the Veteran’s VA and private medical records. However, such records do not show that his carpal tunnel syndrome manifested functional impairment to the extent that higher ratings may be assigned. 38 C.F.R. § 4.2. After careful review of the record, the Board finds that the most probative evidence does not support entitlement to higher staged ratings for bilateral upper extremity carpal tunnel syndrome with ulnar nerve entrapment. The Veteran has been granted a 30 percent rating for his right (dominant) upper extremity, and a 20 percent rating for his left extremity, based on mild incomplete paralysis in the ulnar and median nerve. Such a level of functional impairment is consistent with the current assigned ratings. See 38 C.F.R. § 4.124a, DC 8515. The Board has considered whether higher staged ratings may be assigned. However, the record does not reflect a level of functional impairment equivalent to severe incomplete paralysis of the bilateral median or ulnar nerves to the extent it would be appropriate to assign higher ratings. 38 C.F.R. § 4.7. The Veteran’s lay reports have been considered. However, disability ratings are assigned by application of the rating schedule, which does not support entitlement to higher ratings in this case. 38 C.F.R. § 4.2. The Board has also considered the question of separate ratings for the ulnar and median nerves. However, the AOJ’s decision to compensate for both nerves under DC 8515 results in a higher rating for the Veteran’s dominant extremity than would result if separate ratings were assigned for mild incomplete paralysis of the ulnar and median nerves under DC 8515 and DC 8516. As such, the Board will not disturb the ratings herein. In sum, the most probative evidence does not reach the level of equipoise as to whether a rating in excess of 30 percent for right upper extremity carpal tunnel syndrome or a 20 percent rating for left upper extremity carpal tunnel syndrome may be assigned. See 38 U.S.C. § 5107(a). 4. Entitlement to an initial rating in excess of 10 percent for cervical spine degenerative disc disease The Board finds that the most probative evidence does not reach the level of equipoise in the claim for higher staged ratings for cervical spine degenerative disc disease. Therefore, the claim may not be granted. Disabilities of the cervical spine are evaluated under the General Rating Formula at 38 C.F.R. § 4.71a. Therein, a 20 percent rating is assigned when there is forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine does not exceed 170 degrees, or there is muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 degree rating is assigned for forward flexion of the cervical spine 15 degrees or less or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS), a 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. Turning to the evidence, the Veteran appeared for a VA examination in June 2010. Examination of the cervical spine revealed normal posture and no abnormal spinal curvature. Objective symptoms of the cervical sacrospinalis included bilateral pain with motion and tenderness. Range of motion of the cervical spine was forward flexion 0 to 45 degrees, extension 0 to 45 degrees, right lateral flexion 0 to 45 degrees, left lateral flexion 0 to 45 degrees, right lateral rotation 0 to 45 degrees, and left lateral rotation 0 to 45 degrees. The Veteran performed repetitive use testing without additional functional loss. X-ray testing showed narrowing of the bilateral C5-6 neural foramen, left greater than right secondary to large facet spur. The Veteran underwent another VA examination in September 2019. He complained of neck pain that has progressed constantly over time and is now interfering with his daily life function. He did not report flare-ups of the neck or cervical spine. The examiner estimated that the Veteran would not be additionally limited by pain, fatigue, weakness, or incoordination after repeated use over time, and indicated that his estimated range of motion during such periods would be forward flexion 0 to 45 degrees, extension 0 to 45 degrees, right lateral flexion 0 to 45 degrees, left lateral flexion 0 to 45 degrees, right lateral rotation 0 to 80 degrees, and left lateral rotation 0 to 80 degrees. There was no evidence of guarding or muscle spasm of the cervical spine, cervical radiculopathy, ankylosis, or IVDS. The Board has reviewed the Veteran’s VA and private medical records. However, such records do not show that the cervical spine disorder manifested functional impairment to the extent that higher staged ratings may be assigned. After careful review of the record, the Board finds that the most probative evidence does not support entitlement to higher staged ratings for degenerative disc disease of the cervical spine. The disorder has manifested functional impairment, at its most severe, equivalent to painful but not separately compensable range of motion. Such a level of functional impairment is contemplated by a 10 percent rating. See 38 C.F.R. § 4.59, Burton, 25 Vet. App. at 5. The record does not reflect evidence of limited flexion of the cervical spine to greater than 15 degrees but not greater than 30 degrees, combined cervical range of motion not greater than 170 degrees, muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, or any ankylosis or IVDS of the spine to the extent that a higher rating may be assigned. 38 C.F.R. § 4.7. The Board has considered whether a higher rating may be assigned based on periods of flare-ups or after repeated use over time. However, the Veteran has not reported flare-ups of the cervical spine. As to repetitive use, the VA examiner found, after evaluating the Veteran’s cervical spine and symptomatic reports, that his range of motion would not be significantly limited after repeated use over time. Accordingly, a higher rating is not appropriate on that basis. The Board has further considered the Veteran’s lay statements, but observes that ratings are determined by application of the rating schedule, which does not support a higher rating under the facts of this case. 38 C.F.R. § 4.2. In sum, the claim for higher staged ratings for the cervical spine disorder may not be granted. 5. Entitlement to higher staged initial ratings for a lumbar strain, currently rated as 10 percent for the period from September 21, 2003, through September 16, 2019, and 20 percent from September 17, 2019. The Board finds that the most probative evidence does not reach the level of equipoise in the claim of entitlement to higher staged ratings for a lumbar strain. Therefore, the claim may not be granted. Disabilities of the lumbar spine are evaluated under the General Rating Formula at 38 C.F.R. § 4.71a. Therein, a 20 percent rating is assigned when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. In November 2006, the Veteran appeared for a VA examination. He complained of having back pain for six years, including stiffness, tightness, swelling, and weakness. He claimed that his pain occurred every day and was a 10 out of 10 in severity. Range of motion testing of the spine was normal. The examiner found no evidence of radiating pain on movement, muscle spasm, or tenderness. He found that the joint function of the lumbar spine would not be additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repeated use. He found no signs of IVDS and documented no ankylosis. The examiner found that there was no pathology to diagnose a low back disorder. The Veteran underwent a VA examination in June 2010. Examination of the spine showed normal posture, and no abnormal curvature. Objective symptoms included bilateral spasm, pain with motion, tenderness, and weakness. Range of motion of the thoracolumbar spine was forward flexion 0 to 70 degrees, extension 0 to 10 degrees, right lateral flexion 0 to 30 degrees, left lateral flexion 0 to 30 degrees, right lateral rotation 0 to 30 degrees, and left lateral rotation 0 to 30 degrees. The Veteran performed repetitive use testing without additional functional loss. X-ray testing showed a “normal radiographic appearance” of the lumbar spine. The Veteran underwent a VA examination in September 2019. He reported that his condition had progressed to constant pain, with incapacitating flare-ups, and that he must use a wheelchair and at times cannot move. The examiner noted that he was unable to test the Veteran’s range of motion because of an inability to stand without great risk of falling. However, he was able to estimate that the Veteran’s range of motion after repeated use over time and during flare-ups would be equivalent to forward flexion 0 to 50 degrees, extension, 0 to 20 degrees, right lateral flexion 0 to 20 degrees, left lateral flexion 0 to 20 degrees, right lateral rotation 0 to 20 degrees, and left lateral rotation 0 to 20 degrees. Muscle strength testing showed active movement against some resistance in all extremities. There was no evidence of ankylosis or IVDS. The Board has reviewed the Veteran’s VA and private medical records. However, such records do not show that the lumbar spine disorder manifested functional impairment to the extent that higher staged ratings may be assigned. After careful review of the record, the Board finds that the most probative evidence does not support entitlement to higher staged ratings for the lumbar spine disorder. Prior to September 17, 2019, the Veteran’s lumbar strain manifested functional impairment equivalent to painful, but not otherwise compensable, range of motion. Such a level of functional loss is contemplated by a 10 percent rating. See 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 5. The record does not show functional impairment equivalent to forward flexion limited to between 30 and 60 degrees or combined range of motion of the thoracolumbar spine not greater than 120 degrees to the extent that a higher rating may be assigned. From September 17, 2019, the Veteran’s lumbar strain manifested functional impairment equivalent to forward flexion limited to between 30 and 60 degrees. Such a level of functional impairment is consistent with a 20 percent rating. See 38 C.F.R. § 4.71a, DC 5237. The record does not show evidence of functional impairment such as forward flexion limited to 30 degrees or less or ankylosis of the thoracolumbar spine to the extent that higher ratings may be assigned. The Veteran’s lay statements and reports of flare-ups have been considered. However, the Board notes that the September 2019 VA examiner’s estimate of functional loss during flare-ups and after repeated use over time served as the basis for the grant of a 20 percent rating effective September 17, 2019. See Rating Decision – Narrative, January 2020. There is no basis in the record to support that the Veteran’s flare-ups resulted in functional impairment to the extent that higher ratings may be assigned. The Board has considered the Veteran’s lay statements, but observes that disability ratings are determined by the application of the rating schedule, which does not support a higher rating in this case. 38 C.F.R. § 4.2. In sum, the most probative evidence does not reach the level of equipoise in the claim of entitlement to higher staged ratings for a lumbar spine disorder. REASONS FOR REMAND 6. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome The above claim must be remanded for a VA examination compliant with the holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017). During VA examinations in 2010 and 2017, the Veteran reported flare-ups of left knee pain. However, neither of the VA examiners provided an estimate of the Veteran’s functional loss during such periods. Accordingly, a new VA examination is required to estimate the functional loss experienced by the Veteran during periods of flare-up and after repeated use over time. The matter is REMANDED for the following actions: 1. Please secure for the record copies of complete updated clinical records of all VA and non-VA treatment the Veteran has received for the disorder on appeal. 2. Thereafter, schedule the Veteran for a VA examination to determine the current severity of the left knee disorder. The examiner should describe the disorder in detail, and provide the range of motion in degrees for the Veteran’s left knee, and in doing so, should test for pain and range of motion in active motion, passive motion, weight-bearing, and non-weightbearing. If the examiner is unable to conduct the required testing or concludes that such testing is not necessary in this case, he or she should clearly explain so in the report. The examiner is asked to elicit information on the characteristics, severity, frequency, and duration of any flare-ups, and then estimate the extent of any additional functional loss. If such an estimate cannot be provided, the examiner must indicate that he or she has considered all procurable and assembled data, and that the inability to provide an estimate results from limitations in the knowledge of the medical community at large, and not limitations of the examiner’s personal knowledge. ANTHONY C. SCIRÉ, JR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Reed, 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.