Citation Nr: 21014329 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 18-24 427 DATE: March 11, 2021 ORDER Entitlement to service connection for hypertension (HTN) is granted. Entitlement to service connection for a right knee condition, to include as secondary to service-connected right ankle disability, is denied. Entitlement to an initial rating of 70 percent, but no more, for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to a compensable rating for service-connected residuals, right fifth metacarpal fracture is remanded. FINDINGS OF FACT 1. The preponderance of the evidence supports the finding that the Veteran’s HTN is aggravated by his service-connected PTSD. 2. The evidence fails to establish that the Veteran’s claimed right knee condition was caused by service or was caused or aggravated by the service-connected right ankle condition. 3. The Veteran’s reported psychiatric symptoms include suicidal ideation. CONCLUSIONS OF LAW 1. The criteria for service connection for HTN have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a right knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for an initial disability rating of 70 percent for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1997 to July 2001. This appeal comes before the Board of Veterans’ Appeals (Board) consisting of merged appeal streams, one arising from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama; the second appeal arising from a May 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, and the third appeal arising from a May 2018 rating decision issued by a VA RO. The Veteran testified at a February 2020 videoconference Board hearing before the undersigned Acting Veterans Law Judge (AVLJ); a transcript of this hearing has been associated with the claims file. The Board observes the following complicated procedural history relevant to this appeal. The RO issued a July 2013 deferred rating decision noting a provisional rating quickly followed by a July 2013 rating decision that in part denied service connection claims for HTN, PTSD, and a right knee condition, and an increased rating claim for residuals, right metacarpal fracture. In Correspondence dated in December 2013, the Veteran’s attorney noted receipt of updated VA treatment records which were not considered in the July 2013 rating decision. Another deferred rating decision was issued in August 2014. The May 2015 rating decision on appeal, among other issues, denied separate service connection claims for PTSD, HTN, and a right knee condition, and proposed a decreased disability rating for service-connected residuals, right fifth metacarpal fracture. In June 2015 correspondence, the Veteran’s attorney requested a hearing with respect to his service-connected right fifth metacarpal disability. Separately, the Veteran’s attorney submitted a Notice of Disagreement (NOD) in June 2015 and requesting a Decision Review Officer (DRO) hearing. An informal hearing was conducted in August 2015. In the September 2015 rating decision on appeal, the disability rating for the Veteran’s right fifth metacarpal disability was decreased to noncompensable. That same month, the Veteran was afforded an informal hearing regarding, in part, the PTSD, HTN, and right knee condition service connection claims. An October 2015 NOD with the September 2015 rating decision was submitted. The RO issued a deferred rating in October 2017. A Statement of the Case (SOC) regarding the Veteran’s right fifth metacarpal fracture was issued in April 2018. The Veteran filed a May 2018 VA Form 9 Formal Appeal regarding the claim for his right fifth metacarpal fracture residuals. VA also issued a SOC in May 2018 regarding the service connection claims for HTN and a right knee condition. That same day, the RO issued a rating decision granting service connection for PTSD with a 30 percent disability rating and effective date in November 2011. The Veteran submitted a May 2018 VA Form 9 formal appeal regarding the right knee condition service connection claim and requested a Board hearing. The Veteran submitted a September 2018 NOD with the May 2018 rating decision. Separate February 2019 SSOCs, one dealing with the service connection claims for HTN and right knee condition, the other addressing the disability rating for the residuals, right fifth metacarpal fracture were issued. A deferred rating dealing with the PTSD claim was also issued that same day. The Veteran filed a VA Form 9 Formal Appeal as to his service connection claim for HTN and requested a Board hearing. A SOC regarding the Veteran’s increased rating claim for PTSD was issued November 2019. The Veteran filed a January 2020 VA Form 9 Formal Appeal as to his PTSD increased rating claim. As noted above, the Veteran testified before the undersigned AVLJ in a February 2020 Videoconference hearing. Following the Board hearing, the Veteran’s attorney submitted a 60-day extension request for additional evidence to be submitted which was GRANTED by the undersigned in November 2020. That extension having ended, the matter is properly before the Board for appellate review. The Board acknowledges the United States Court of Appeals for Veterans Claims (Court) held in Rice v. Shinseki, 22 Vet. App. 447 (2009) that a claim for a total disability rating based on individual unemployability (TDIU) is part and parcel of an increased rating claim when such is raised by the record. The Veteran has not contended, and the evidence does not otherwise suggest, that his service-connected PTSD precludes him from securing and following substantially gainful employment. In fact, the Veteran testified in the February 2020 Board hearing that he has a job. Accordingly, a TDIU claim has not been raised, and no action under Rice is necessary. This case raises no further issues. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for HTN As an initial matter, the Board notes that, while service connection for HTN was treated as a reopened new and material evidence claim by the RO in the rating decision on appeal, new VA generated evidence was received within one year of the July 2013 rating decision. As such, the rating decision did not become final. The Board notes the evidence was subsequently reviewed in the May 2015 rating decision on appeal. Given the grant below, and to avoid unnecessary complication, the Board will proceed to a de novo decision on this issue. The Veteran has not asserted, nor does the record reflect, that his diagnosed HTN first manifested during service or is directly related to his active duty service. It has only been claimed that HTN is secondary to PTSD. Thus, the Board will only address whether the Veteran is entitled to service connection on a secondary basis. See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). The Board acknowledges that the Veteran is currently diagnosed with HTN. See November 2017 VA hypertension examination. The Veteran is service connected for PTSD, effective November 2011. See February 2020 rating decision. Therefore, the only questions for the Board are whether there is a nexus between the current disability and service, or in the alternative, if the Veteran’s HTN is caused or aggravated by his service-connected PTSD. The claims file includes a February 2017 VA hypertension examination. The examiner confirmed a diagnosis of HTN from August 2011. The examiner opined that the Veteran’s HTN is less likely than not (less than 50 percent probability) proximately due to or the result of his service-connected PTSD. As a rationale, the examiner noted the Veteran is currently diagnosed with an acquired psychiatric disorder to include PTSD. Further, a review of the record shows the Veteran was diagnosed with HTN in August 2011. Evidence in the record does not support causation of HTN due to an acquired psychiatric illness to include PTSD. The Veteran has been diagnosed with essential HTN, which is the most common type of HTN. The cause of essential HTN is unknown. For this examination, the Veteran had slightly increased blood pressure but was asymptomatic. Neither current medical literature nor the evidence of record support causation of essential HTN due to an acquired psychiatric illness. The claims file also includes a May 2020 private medical opinion providing a positive etiology for the Veteran’s HTN. The private treatment provider confirmed a diagnosis of HTN then opined it is as likely as not that the Veteran’s HTN is secondary to his service-connected PTSD. As a rationale, the private provider noted the Veteran’s first abnormal blood pressure reading was in 2015. The examiner noted that the Veteran has a sleep disorder associated with his PTSD and insomnia elevates blood pressure. The private provider also cited medical literature indicating an increased risk for HTN in soldiers with PTSD. Based on a review of the record, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran’s HTN is secondary to his service-connected PTSD. The Board is mindful of the negative November 2017 VA medical opinion; however, this opinion only serves to place the medical evidence in a state of relative equipoise with the affirmative May 2020 private medical opinion. Resolving all doubt in the Veteran’s favor, the Board finds that the record is in equipoise on all material elements of the claim for secondary service connection. The Board notes that the benefit of the doubt mandate is triggered when the evidence reaches a stage of equipoise. In this matter, as there is competent medical evidence both in favor of and against the claim, the Board is of the opinion that this point has been attained. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). Accordingly, service connection for HTN as secondary to service-connected PTSD is warranted. The appeal to this extent is granted. 2. Entitlement to service connection for a right knee condition The Veteran also asserts entitlement to service connection for a right knee condition as secondary to his service-connected right ankle condition. See July 2012 Statement in Support of Claim. By way of background the Board notes that service connection for a right knee condition based on a theory of direct connection was denied in a July 2009 rating decision; the Veteran did not initiate an appeal, and the decision became final. Service connection for a right ankle condition was subsequently granted with an effective date in March 2012. The service connection claim for a right knee condition was considered reopened and denied again in a July 2013 rating decision. As noted above, new VA generated evidence was received within one year of the July 2013 rating decision that denied service connection. As such, the rating decision did not become final. The Board notes the evidence was subsequently reviewed in the May 2015 rating decision on appeal. The Veteran’s service treatment records (STRs) include numerous treatment records for a right ankle condition, and a single treatment record for left knee pain, however they are silent for any complaints, treatment, or diagnosis of a right knee condition. Post service treatment records include a September 2015 primary care record that noted complaints about right knee pain; the Veteran indicated his knee locks up and gives out on him while walking. The record also noted range of motion (ROM) was intact: no laxity, swelling or erythema was noted; crepitus was noted. An October 2015 kinesiotherapy initial consultation record noted the Veteran needs a knee brace for his right knee. The claims file includes a November 2017 VA knee and lower leg examination wherein the examiner confirmed a diagnosis of right knee pain. The examiner noted the Veteran’s report of injuring his knee during active service. The examiner also noted that the Veteran believes his right knee condition is related to his right ankle condition. The only treatment indicated for his right knee was the prescribed brace. The examiner noted no functional impact. The examiner opined the claimed right knee condition is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected acquired psychiatric disorder and PTSD and provided a supporting rationale. The requested medical opinion was incorrect, as noted in a February 2018 deferred rating decision as it addressed the knee being secondary to PTSD. VA requested a new medical opinion for the right knee condition as secondary to the service-connected right ankle sprain. The same examiner opined in an April 2018 VA medical opinion that the Veteran’s right knee condition is not caused by the Veteran’s right ankle sprain. As a rationale, the examiner noted a review of the record shows the Veteran is service-connected for a right ankle condition. STRs are silent for a right knee condition during active service. The Veteran’s June 2001 separation examination shows no diagnosis of a right knee condition. A further review of the STRs show the Veteran had a body mass index (BMI) of 34 at the time of his separation examination. Post-service treatment records are silent for right knee until October 2015 when the Veteran was diagnosed with right knee pain by his VA primary care provider. At that time, the Veteran’s BMI was noted at 44. The December 2017 VA knee and lower leg examination noted the Veteran recalled injuring his knee during service and believed his knee and ankle conditions were related. Physical examination during the examination revealed slightly decreased active range of motion of the right knee. Scrutiny of the records supports no process by which a remotely sprained right ankle during service in 2000 and another right ankle sprain post-service in 2007 would cause right knee pain. Recent right knee X-rays showed no evidence of a right knee condition. In short, the examiner noted that evidence in the STRs and current medical records does not support a nexus between right knee pain and service-connected right ankle condition. Current imaging studies support no radiographic evidence of a right knee condition. The Board observes no other medical opinions regarding the right knee disability in the Veteran’s claims file. The Veteran testified at the February 2020 hearing and his attorney reiterated service connection is entitled based on a secondary theory. The Board also reviewed and considered the Veteran’s lay statements in support of him claim. The Board notes that the Veteran is competent to report the symptoms he experienced, including knee pain. That having been said, the record does not establish that the Veteran has the training or credentials needed to competently diagnose a right knee disorder or opine as to its etiology. His lay contentions as to etiology of his right knee pain are thus of markedly lower probative value than the VA examiner’s opinion. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran’s right knee condition was caused by service, or in the alternative was caused by or aggravated by his service-connected right ankle sprain. In the absence of competent evidence supporting the Veteran's claim for service connection for a right knee disorder, secondary to the service-connected right ankle condition, the Board finds that service connection is not warranted. There is no reasonable doubt to be resolved, and the claim of entitlement to service connection for a right knee disability must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. Peyton v. Derwinski, 1 Vet. App. 282 (1991). Any doubt regarding the extent of the disability is resolved in the Veteran’s favor. 38 C.F.R. § 4.3. 3. Entitlement to an increased initial rating of 70 percent, but no more, for PTSD Evaluations under 38 C.F.R. § 4.130 are “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed in DC 9411 are not intended to constitute an exhaustive list, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas”-i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’“ Vazquez-Claudio, 713 F.3d at 117-18 ; 38 C.F.R. § 4.130, DC 9411. The Veteran contends that his service-connected PTSD is worse than contemplated by the initially assigned 30 percent disability rating. See November 2014 NOD. Based on a review of the claims file, the Board finds the Veteran’s psychiatric symptoms warrant an increased initial 70 percent rating, but no more, for the entire period on appeal. The Veteran’s PTSD is rated under the General Rating Formula for mental disorders. 38 C.F.R. § 4.130. A 30 percent rating is assigned when the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is assigned when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating applies when occupational and social impairment reflects deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and an inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned when there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The claims file includes a November 2017 VA initial PTSD examination wherein the examiner confirmed diagnoses of PTSD. Occupational and social impairment was noted with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner discussed the Veteran’s mental health history in detail, observing the Veteran participated in individual psychotherapy in 2011-2012 and some group therapy to include anger management in 2015. Since 2011 he had also been seeing psychiatry and was currently taking prescription medication. Symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The examiner opined the Veteran meets the criteria for PTSD related to combat experiences. As a rationale for this opinion, the examiner noted the Veteran reported some degree of difficulty with short-term memory, feeling rather forgetful for various things. While no panic attacks, obsessive compulsive disorder (OCD), delusions or hallucinations were reported, the Veteran reported that years ago he heard voices, but that has not happened for a while. The Veteran reported that one of the voices was female, whispering, and he could not make it out. A second voice was a male being critical, inducing guilt from past trauma, and urging him to do something about it in his current life. A third voice was a child crying. The Veteran reported mood fluctuations. Recent treatment notes suggest that his mood has stabilized. The Veteran also reported prescription medication and coping skills he has learned in therapy to help mood, but he continues to experience depressive feelings including guilt and sadness at reminders of trauma. He reported he feels nervous and anxious all the time. He was watchful, on guard, and feels uncomfortable in crowds. The Veteran reported driving also makes him anxious; the Veteran attributed that to his history in the military of having a commanding officer put a live landmine behind his seat as he was driving to dispose of after returning to base. Regarding other PTSD symptoms, he reported much fewer nightmares with treatment, though he reports they still occur about once a week. Staying busy helps with upsetting intrusive trauma memories, but sometimes if he is not busy, such memories intrude and upset him. War news, driving, certain children, gunshot/explosion sounds, and children crying all trigger negative upsetting memories. He avoided the news and talking about trauma. He reported emotional numbing and appeared to have significant feelings of guilt, apparently related to witnessing another soldier injure a child. He described hyper-startle response and irritability. Finally, the examiner noted the Veteran reported his sleep improved with medication, yet he continues to report he only gets about four hours. Post service treatment records include a May 2018 report of psychiatric hospitalization with admission in late April 2018 and discharge in early May 2018. A November 2012 VA mental health consultation record noted current suicidal ideation. An August 2013 primary care admission record noted a positive suicide screen. A separate August 2013 record noted the Veteran was experiencing increased anxiety and depression. Additionally, the Veteran endorsed suicidal ideation, denied a current plan, and acknowledged not taking any medication. A September 2013 mental health consultation record noted the Veteran endorsed thoughts of suicide during the previous two weeks but denied any planning or intent. The claims file includes a positive suicide screen in April 2018. However, the Board also notes a January 2019 mental health record that noted the ‘high risk flag’ for suicide was inactivated. Separate July 2019 records noted a negative suicide screening and a denial of any recent psychiatric hospitalization or suicide attempt. The Veteran’s attorney submitted an April 2020 private PTSD disability benefits questionnaire wherein a licensed psychologist confirmed a diagnosis of PTSD to include major depressive disorder, hallucinations, anxiety and suicidal ideation. The examiner noted there are no other mental diagnoses. Occupational and social impairment is noted with deficiencies in most areas, such as work, school, family relations, judgement, thinking, and/or mood. The Veteran reported prescription medication to treat symptoms including hallucinations and delusions. Symptoms include depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, flattened affect, motivation and mood disturbances, difficulty adapting to stressful circumstances, including work or a work-like setting, inability to establish and maintain effect relationships, suicidal ideation, impaired impulse control such as unprovoked irritability with periods of violence, persistent delusions or hallucinations, persistent danger of hurting self or others. The claims file also includes multiple statements in support of claim, including one received by VA in July 2013 wherein the Veteran reported constant fear for his life during active service caused by repeated patrols through mine fields. In a separate July 2013 statement in support of claim, the Veteran asserted witnessing the beating of a child. During his February 2020 Board hearing, the Veteran testified that his PTSD had interfered with work and personal relationships, specifically, he is separated from his wife. The Veteran also testified to long term and short-term memory issues, irritability, and lack of impulse control. Finally, the Veteran acknowledged a belief that he poses a general threat to himself or others. The Board notes that while the Veteran does not have the training or credentials to determine the proper disability evaluation concerning his PTSD symptoms, he is competent to observe lay symptoms including suicidal ideation. See Jandreau, 492 F.3d at 1377. The Board finds a combination of the medical records noting suicidal ideology and the Veteran’s February 2020 testimony regarding posing a general threat to himself or others is sufficient to support a 70 percent evaluation throughout the entire period on appeal. The Board finds the Veteran’s symptomatology to be consistent with a 70 percent evaluation and thus finds that such evaluation, but no more, is warranted. In the absence of a finding of total occupational and social impairment, however, the Board finds no basis for a 100 percent rating. Overall, the evidence supports an initial 70 percent disability rating, but no more, throughout the entire period on appeal. The appeal to this extent is granted. REASONS FOR REMAND The Veteran’s last VA examination for his service-connected right fifth metacarpal fracture was over a year ago. See December 2017 VA examination. The Veteran testified in the February 2020 Board hearing that the symptoms associated with his disability have worsened since his last VA examination. Where the Veteran asserts that a disability has worsened since his last VA examination, a new examination is required. See 38 C.F.R. § 3.159(c)(4); see also Snuffer v. Gober, 10 Vet. App. 400, 403-04. On remand, the Veteran should be afforded a new examination to determine the current severity of his service-connected right fifth metacarpal fracture and any identified residuals. The matters are REMANDED for the following action: Schedule the Veteran for the appropriate VA examination to determine the current nature and severity of his service-connected right fifth metacarpal fracture and any identified residuals. The examination should use the most recent Disability Benefits Questionnaire (DBQ) and include all studies, tests, and evaluations deemed necessary by examiner. The claims file and copy of this remand must be made available to and reviewed by the examiner. The examiner should assess the current functioning of the Veteran’s right hand and identify and discuss limitation of motion in all fingers to include the right fifth metacarpal. The examiner should determine whether any lack of grip strength or any other joint (to include arthritis of the thumb and other fingers), muscle, or neurological abnormality of the right hand is etiologically related to, or a residual of, his right fifth metacarpal disability. The examiner should also provide an opinion as to the limitations caused by the Veteran’s right fifth metacarpal disability, and any residuals, on his occupational functioning. The examiner must provide a complete rationale for any opinion expressed. The Board is aware of the complications with scheduling examinations due to COVID-19 and encourages the medical facility to consider a telephone interview, or other telehealth means, if scheduling an examination is impracticable or would lead to significant delay or burden to the Veteran. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Banks, 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.