Citation Nr: 21014650 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 17-36 264A DATE: March 15, 2021 ORDER An increased 10 percent disability rating for instability of the left knee is granted. An increased 10 percent disability rating for instability of the right knee is granted. A separate 10 percent disability rating for limitation of flexion of the left knee is granted. A separate 10 percent disability rating for limitation of flexion of the right knee is granted. A 40 percent disability rating for a low back disability is granted. REMANDED The issue of entitlement to service connection for a right shoulder injury is remanded. The issue of entitlement to service connection for bilateral peripheral neuropathy of the lower extremities is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. VETERAN’S CONTENTIONS The Veteran contends that his left and right knee disabilities are more severe than as reflected by the ratings currently assigned. Specifically, the Veteran contends that he has limitation of motion, pain, swelling, inflammation, throbbing, and, stiffness; and instability when walking downstairs or for extended distances. The Veteran contends that his low back disability is more severe than as reflected by the rating currently assigned. Specifically, the Veteran contends that his low back disability flares up when he engages in certain physical activities, including standing and sitting for long periods of time. The Veteran further contends that his range of motion is further limited during a flare-up because of pain and stiffness. FINDINGS OF FACT 1. The Veteran’s left knee disability is productive of slight lateral instability and symptoms which approximate limitation of flexion to 45 degrees. It has not been productive of flexion limited to 30 degrees or less; extension limited to 5 degrees or more; ankylosis; dislocation of semilunar cartilage with frequent episodes of “locking”, pain, and effusion into the joint; cartilage; malunion or nonunion of the tibia and fibula; or genu recurvatum. 2. The Veteran’s right knee disability is productive of slight lateral instability and symptoms which approximate limitation of flexion to 45 degrees. It has not been productive of flexion limited to 30 degrees or less; extension limited to 5 degrees or more; ankylosis; dislocation of semilunar cartilage with frequent episodes of “locking”, pain, and effusion into the joint; cartilage; malunion or nonunion of the tibia and fibula; or genu recurvatum. 3. When considering additional functional loss due to flare-ups, the Veteran's low back disability manifested in symptoms which approximated limitation of forward flexion of the thoracolumbar spine to 30 degrees or less throughout the period on appeal. 4. Throughout the entirety of the appeal period, the Veteran's low back disability has not been productive of unfavorable ankylosis of the thoracolumbar spine or unfavorable ankylosis of the entire spine. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating of 10 percent for lateral instability of the left knee are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.14, 4.21, 4.25, 4.40, 4.71a, Diagnostic Code 5257. 2. The criteria for an increased disability rating of 10 percent for lateral instability of the right knee are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.14, 4.21, 4.25, 4.40, 4.71a, Diagnostic Code 5257. 3. The criteria for a separate disability rating of 10 percent for limitation of flexion of the left knee are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.14, 4.21, 4.25, 4.40, 4.71a, Diagnostic Code 5260. 4. The criteria for a separate disability rating of 10 percent for limitation of flexion of the right knee are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.14, 4.21, 4.25, 4.40, 4.71a, Diagnostic Code 5260. 5. The criteria for an increased disability rating of 40 percent for a low back disability are met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.10, 4.14, 4.2, 4.21, 4.25 4.40, 4.7 38 C.F.R. § 4.71a, Diagnostic Code 5237. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1979 to August 1983. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction is currently with the RO in Honolulu, Hawaii. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in November 2020 and a transcript of the hearing has been associated with the claims file. The Board notes that the Veteran previously filed a claim for entitlement to service connection for a right shoulder injury that was denied in a May 2005 rating decision. The Veteran was notified of that denial in May 2005 and, as the Veteran neither appealed nor submitted additional evidence within one year of the decision, it became final. Pursuant to 38 C.F.R. § 3.156, a claimant may reopen a finally adjudicated claim by submitting new and material evidence. The Board finds that such evidence has been received and it will reopen the pending claim for service connection. As such, the case is in a posture such that the Veteran’s claim may be addressed on its merits. The issue of entitlement to a TDIU has been raised by the evidence of record, to include as part and parcel of the increased rating claims. Thus, it is presently in appellate status before the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Rating Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes, is to be avoided. See 38 C.F.R. § 4.14. Thus, separate ratings under different diagnostic codes are only permitted if, for example, those separate ratings are assigned based on manifestations of the Veteran's disability that are separate and apart from manifestations for which the Veteran has already been rated. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. 1. Entitlement to a compensable disability rating for a left knee disability 2. Entitlement to a compensable disability rating for a right knee disability The Veteran is currently in receipt of noncompensable ratings under diagnostic code 5257 for both the left and right knee throughout the period on appeal. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, a 10 percent rating is warranted where there is slight recurrent subluxation or lateral instability, a 20 percent rating is warranted where there is moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted where there is severe recurrent subluxation or lateral instability. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. Normal range of motion for the knee is 0 degrees in extension and 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. After a review of the evidence of record, the Board finds that throughout the period on appeal, the Veteran’s left and right knee disabilities were productive of slight lateral instability, entitling him to increased disability ratings of 10 percent; and symptoms which approximated limitation of flexion to 45 degrees, entitling him to separate disability ratings of 10 percent. In this regard, during a November 2016 VA knee and lower leg conditions examination, the Veteran complained of chronic knee pain and reported needing a brace when participating in sports. Upon examination, the Veteran demonstrated flexion to 130 degrees and extension to 0 degrees for both the left and right knees. The examiner documented mild tenderness on palpation of the patella and the bilateral joint lines, but no noted no pain on examination. The examiner also noted no muscle atrophy; ankylosis; joint instability; recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment; or meniscus (semilunar cartilage) condition. The examiner documented that the Veteran did not report flare-ups of knee and/or lower leg. In a July 2017 VA Form 9, the Veteran reported limitation of motion of the bilateral knees. The Veteran testified during the November 2020 Board hearing that his symptoms included pain, swelling, inflammation, throbbing, and stiffness. He further testified that he wears a brace, hears a “snapping noise when going downhill”, and that his knees give way whenever he has to walk extensive or extended distances or when going downstairs. He denied experiencing symptoms of locking and undergoing fluid draining. Based on the foregoing evidence, and resolving all doubt in favor of the Veteran, the Board finds that increased 10 percent ratings are warranted for slight lateral instability throughout the period on appeal. The Veteran testified during the November 2020 Board hearing that his knees give way whenever he has to walk extensive or extended distances, or when going downstairs. A rating in excess of 10 percent is not warranted as there was no objective evidence of instability, such that the severity of his instability cannot be found to more closely approximate moderate instability. Next, after resolving all doubt in favor of the Veteran, the Board finds that separate 10 percent ratings are warranted based on signs and symptoms that approximate limitation of flexion to 45 degrees throughout the period on appeal. In a July 2017 VA Form 9, the Veteran reported limitation of motion of the bilateral knees. During the November 2016 VA knee and lower leg conditions examination the Veteran reported chronic knee pain and needing a knee brace when participating in sports. The Veteran testified during the November 2020 Board hearing that his symptoms included pain, swelling, inflammation, throbbing, and stiffness. While there is no indication of objective evidence of knee flexion limited to 45 degrees, the Board finds that the Veteran is entitled to ratings of 10 percent for limitation of flexion of the left and right knees under the DeLuca factors and 38 C.F.R. § 4.59. Ratings in excess of 10 percent are not warranted as there was no objective evidence of limitation of flexion, including limitation of flexion to 30 degrees or less. The Board acknowledges that the November 2016 VA examiner did not indicate that the Veteran had instability or pain upon examination. However, the Veteran competently and credibly reported that he has experienced left and right knee instability, pain, and limitation of motion. Therefore, at the very least, the Board finds that the evidence is approximately evenly balanced as to whether the Veteran has left and right knee instability and symptoms which approximate limitation of motion to 45 degrees. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to 10 percent ratings under Diagnostic Code 5257 for slight lateral instability and 10 percent ratings under Diagnostic Code 5260 for limitation of flexion to 45 degrees are warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Next the Board considered whether the Veteran's left and right knee disabilities present any additional manifestations that would warrant the assignment of additional separate ratings. The record is negative for evidence of ankylosis; cartilage, semilunar, dislocated, with frequent episodes of “locking”, pain, and effusion into the joint; cartilage, semilunar, removal of, symptomatic; limitation of extension to 5 degrees or more; impairment of tibia and fibula; and genu recurvatum; therefore the Board finds that the following diagnostic codes are not applicable in the present case: 5256 (ankylosis of the knee); 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking”, pain, and effusion into the joint); 5259 (symptomatic removal of semilunar cartilage); 5261 (limitation of extension); 5262 (impairment of tibia and fibula); and 5263 (genu recurvatum). Lastly, the Board notes that during the pendency of the appeal, Diagnostic Code 5257 was amended, effective February 7, 2021. See 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Where, as here, a diagnostic code is amended while a claim is pending, VA is required to consider both versions of the code and apply the version most favorable to the Veteran. The amended version of the Diagnostic Code rates knee instability based on the existence of ligament tears. As there is no evidence of a ligament tear in the record, the Board finds the prior version of the Diagnostic Code more favorable to the Veteran and thus rates instability in this case accordingly. In short, increased disability ratings of 10 percent for slight instability and separate 10 percent disability ratings for limitation of flexion to 45 degrees are warranted. 3. Entitlement to a disability rating in excess of 20 percent for a low back disability The criteria for rating all disabilities of the spine are set forth in 38 C.F.R. § 4.71a, which provides that spine disabilities are to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the IVDS Formula, a spine disability is rated based on the presence of incapacitating episodes, which are periods of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, IVDS Formula. The General Formula for rating a disability of the spine provides in pertinent part: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, 10 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height; a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is 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 evaluation is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine; a 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Formula. Under the General Formula, associated neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately under the appropriate diagnostic codes. Id. at Note (1). Here, after reviewing all of the clinical evidence and subjective complaints, the Board finds that the record is absent evidence of incapacitating episodes, and thus, the Veteran's low back disability must be evaluated under the General Rating Formula. Turning to the General Rating Formula, the Veteran's low back disability is currently rated 20 percent disabling under 38 C.F.R. § 4.71a Diagnostic Code 5237 throughout the period on appeal. After a review of the evidence of record, the Board finds that throughout the period on appeal, the signs and symptoms associated with the Veteran’s low back disability best approximated forward flexion of the thoracolumbar spine to 30 degrees or less, entitling him to a disability rating of 40 percent. In this regard, the Veteran testified during the November 2020 Board hearing that his low back disability flares up when he engages in certain physical activities, including standing and sitting for long periods of time. The Veteran further testified that his range of motion is further limited during a flare-up because of pain and stiffness. During a November 2016 VA spine examination, the Veteran demonstrated forward flexion 0 to 45 degrees and extension 0 to 15 degrees. The Veteran reported flare-ups resulting in sharp shooting severe pain. The examiner indicated that pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. Described in terms of range of motion, the examiner indicated that forward flexion would be limited 0 to 45 degrees and extension 0 to 15 degrees. The examiner also indicated that the Veteran did not have ankylosis. Based on the foregoing evidence, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran's low back disability was productive of forward flexion limited to 30 degrees or less throughout the period on appeal. See 38 C.F.R. § 3.102. The Veteran testified during the November 2020 Board hearing that his low back disability flares up when he engages in certain physical activities, including standing and sitting for long periods of time. The Veteran further testified that his range of motion is further limited during a flare-up because of pain and stiffness. The Board acknowledges that the November 2016 VA examiner indicated that described in terms of range of motion the Veteran’s forward flexion was limited to 0 to 45 degrees both during and not during a flare-up. However, the Board notes that the November 2016 VA examiner also indicated that that pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. The Board therefore finds that the Veteran’s lay statements and testimony indicate that his low back disability is more severe than the VA examination findings alone suggest. Accordingly, an increased disability rating of 40 percent is warranted throughout the period on appeal. A rating in excess of 40 percent is not warranted. In order to warrant a rating higher than 40 percent for the orthopedic manifestations of the Veteran's low back disability under the General Rating Formula, the evidence must show unfavorable ankylosis of the entire thoracolumbar spine, or unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Here, there is no objective medical evidence of ankylosis in the claims file. The Veteran's VA treatment records do not indicate that the Veteran was diagnosed with ankylosis or that his spine was fixed in an unfavorable position. During the November 2016 VA examination, the examiner indicated that the Veteran did not have ankylosis. Significantly, the Veteran has not raised any assertion that his low back disability is manifested by ankylosis. In short, the evidence of record does not reflect a diagnosis of ankylosis or that the Veteran's spine was fixed in an unfavorable position. As entitlement to a higher disability rating turns on a showing of unfavorable ankylosis of the thoracolumbar spine, or unfavorable ankylosis of the entire spine, a higher rating for the orthopedic manifestations of the Veteran's low back disability is simply not warranted. In making the above determinations, the Board considered Correia v. McDonald, 28 Vet. App. 158 (2016). However, a 40 percent rating is the maximum schedular rating available for limitation of motion of the thoracolumbar spine under the General Rating Formula, to include the functional equivalent of limitation of motion. Therefore, the Board finds that Correia is inapplicable. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder injury is remanded. VA must obtain an opinion when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Lay testimony as to continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. Id. at 83. The Veteran contends that he has a right shoulder injury related to service. Specifically, he asserts that he developed right shoulder pain in service as a result of heavy lifting related to his military occupational specialty (MOS) as an Administration Specialist, and that this pain persisted thereafter. In this regard, the Veteran testified during the November 2020 Board hearing that his current symptoms include right shoulder limitation of motion and inability to lift heavy items. The Veteran testified that he did not seek formal treatment for his right shoulder and instead just thought he could tough it out. The Veteran further testified that he first experienced right shoulder pain in service as a result of his duties related to his MOS, which included lifting heavy bundles of mail, and that such pain continued thereafter. In light of the foregoing evidence that the Veteran may have a right shoulder injury related to his service, the Board finds that the low threshold of the McLendon standard has been met, and that the Veteran should be afforded an initial VA opinion prior to the adjudication of the claim. See also Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (a formal diagnosis is not needed to establish a current disability if there is pain and functional impairment of earning capacity). 2. Entitlement to service connection for bilateral peripheral neuropathy of the lower extremities is remanded. The evidence of record includes a November 2016 VA spine examination report in which the examiner indicated that the Veteran did not have radicular pain or any other signs and symptoms due to radiculopathy. However, the Veteran testified during the November 2020 Board hearing that he experiences back pain and numbness in his legs radiating all the way to the calves and heels. VA's duty to assist a veteran includes providing a thorough and contemporaneous examination when the record does not adequately reveal the current state of the Veteran's disability. Hart v. Mansfield, 21 Vet. App. 505, 508 (2007) (citing, inter alia, Green v. Derwinski, 1 Vet. App. 121, 124). Therefore, the Board finds that the Veteran should be afforded a VA peripheral neuropathy examination on remand to assess the current nature and severity of any bilateral peripheral neuropathy of the lower extremities. 3. Entitlement to a total disability rating based on individual unemployability is remanded. The claim for entitlement to a TDIU is inextricably intertwined with the claims for service connection and increase that are remanded herein. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). As such, consideration of the Veteran's TDIU claim must be deferred pending the outcome of such claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Ensure that the Veteran's complete military personnel records are associated with the claims file. 3. Send the Veteran a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for completion. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his right shoulder injury. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran has a right shoulder injury, or right shoulder pain that causes functional impairment that had its onset during active service or within one year of the Veteran's separation from active service, or is otherwise related to service? The examiner is asked to discuss the Veteran’s contention that he has right shoulder pain which started in service and continued thereafter as a result of heavy lifting (bundles of mail) related to his military occupational specialty (MOS) as Administration Specialist. The Veteran testified during the November 2020 Board hearing regarding current symptoms including right shoulder limitation of motion and inability to lift heavy items. The Veteran also testified that he did not seek formal treatment for his right shoulder because he thought he could tough it out. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 5. Schedule the Veteran for a VA examination to assess the current nature and severity of his bilateral peripheral neuropathy of the lower extremities. The claims file (including any additional medical evidence obtained as a result of this Remand) should be made available to the examiner for review. The examiner should consider the full history of peripheral neuropathy, including the Veteran's competent account of his symptoms. After noting all relevant findings, the examiner should address the following: (a.) Does the Veteran have bilateral peripheral neuropathy of the lower extremities related to his service-connected lumbosacral strain? (b.) If so, provide an opinion, including a retrospective opinion, regarding the current nature and severity of the Veteran's peripheral neuropathy of the bilateral lower extremities throughout the period on appeal (from September 10, 2016 onward). The Veteran testified during the November 2020 Board hearing that he experiences numbness in his legs all the way to the calves and heels. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith-Jennings, 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.