Citation Nr: 21015013 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 17-31 706 DATE: March 16, 2021 ORDER Entitlement to an initial rating higher than 10 percent for right knee degenerative joint disease is denied. Entitlement to an initial rating higher than 10 percent for a left knee degenerative joint disease is denied. Entitlement to an initial compensable rating for closed fracture, right calcaneus, (claimed as a right foot disability), is denied. Entitlement to an initial compensable rating for closed fracture, left heel, (claimed as a left foot disability), is denied. REMANDED Entitlement to service connection for a back disability, to include as secondary to service-connected disabilities, is remanded. FINDINGS OF FACT 1. During the pendency of the appeal, the Veteran’s right and left knee disabilities have been manifested by arthritis with range of motion limited to no worse than 120 degrees flexion, and normal extension with pain. 2. During the pendency of the appeal, the service-connected closed fracture of the right and left heels are essentially healed; symptoms do not more nearly approximate a moderate foot injury in either foot. 3. The Veteran’s foot pain is a symptom of his non service-connected bilateral plantar fasciitis, which is medically shown to not be a related to the prior heel fractures. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 10 percent for a right knee disability are not met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.59, 4.7, 4.71a, DC 5003-5261 (2019). 2. The criteria for an initial rating higher than 10 percent for a left knee disability are not met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.59, 4.7, 4.71a, DC 5003-5261 (2019). 3. The criteria for an initial compensable rating for a right heel disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5284 (2019). 4. The criteria for an initial compensable rating for a left heel disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5284 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2005 to November 2013, to include service in Southwest Asia. The Veteran and his spouse testified at a May 2019 Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the claims file and has been reviewed. In December 2019, the Board remanded the initial rating claims on appeal for further development and the service connection back claim for the issuance of a statement of the case (SOC). The RO adjudicated the back disability in a supplemental statement of the case (SSOC), and despite the Veteran’s failure to submit a substantive appeal (VA Form 9), the Board would consider the December 2020 argument regarding the back disability as a valid substantive appeal. Increased Rating – Applicable Laws and Regulations Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Right and Left Knees – Rating Criteria DC 5003 provides that when limitation of motion is noncompensable under the appropriate code or codes, a rating of 10 percent may be applied to each major joint or group of minor joints affected by limitation of motion. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. If there is no limitation of motion, a 10 percent rating will be assigned where there is x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent rating will be assigned where there is such involvement along with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. The lumbar vertebrae are considered a group of minor joints, ratable on a parity with major joints for these purposes. See 38 C.F.R. § 4.45(f). Knee disabilities can be rated under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, and 5263. 38 C.F.R. § 4.71a. DC 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words “slight,” “moderate” and “severe” as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6; Spellers v. Wilkie, 30 Vet. App. 157 (2018). DC 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. DC 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a. DC 5260 provides for the evaluation of limitation of flexion of the knee. A non-compensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a. Under DC 5263, genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. 38 C.F.R. § 4.71a. Genu recurvatum is hyperextension of the knee. See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY (30th Ed. 2003) at 765. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Where arthritis results in painful motion of the joint, the rating criteria allow for at least the minimum compensable evaluation for the joint. 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Id. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). On February 7, 2021, amendments to the schedule for rating disabilities of the musculoskeletal system, including DC 5257, which separated the rating into two categories: recurrent subluxation or instability, and patellar instability. However as will be discussed below, this has no impact in the current appeal. Right and Left Knees – Rating Analysis For the entire rating period on appeal, the Veteran is in receipt of separate 10 percent ratings for right and left knee disabilities pursuant to DC 5257-5003. For the reasons expressed below, the Board finds that a rating higher than 10 percent is not warranted for the right and left knee disabilities. According to VA treatment records dated from 2013 to 2014, the Veteran complained of bilateral knee pain. X-rays of the knees in January 2014 revealed evidence of mild degenerative changes, bilaterally. At the time of this visit, the Veteran denied any “giving out” or locking of the knees. Range of knee motion was full (flexion to 140 degrees) and extension to 0 degrees, bilaterally. There was no tenderness. In January 2015, the Veteran had good flexion of the knees. In June 2015, the Veteran underwent a VA compensation examination of the knees, at which time the examiner confirmed a diagnosis of bilateral degenerative arthritis. The Veteran reported knee pain and noted that he sometimes had swelling and locking when he tried to stand from a sitting position. He further reported that his right knee gave out without warning and sometimes the left knee would also give out. The Veteran denied having flare-ups or functional loss/impairment. Range of motion of both knees was normal with flexion to 140 degrees and extension to 0 degrees. No pain was noted on examination and there was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation and no evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, which did not result in additional functional loss or range of motion. The examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time and/or during flare-ups. Muscle strength testing was normal, bilaterally with no evidence of reduction in muscle strength or atrophy. There was no ankylosis or history of recurrent subluxation/effusion. Joint stability testing was normal with no evidence of joint instability, bilaterally. There were left leg shin splints that did not impact range of motion of the knee or ankle. The Veteran never had a meniscus condition. The Veteran used no assistive devices and the examiner noted that the bilateral knee disability had no impact on the Veteran’s ability to work. According to January 2019 VA treatment records, MRI of the knees showed no acute or concerning abnormality of the right knee and no internal derangement of the left knee. During the May 2019 Board hearing, the Veteran testified that the symptoms in both knees were the same. He challenged the adequacy of the 2015 examination report, indicating that he had pain during the examination and made the examiner aware of such despite the notation in the examination report of no pain. He testified that functional loss was an inability to squat for too long, lack of strength to “pull up,” constant popping, and inability to walk and stand for long periods. Lastly, he noted that at times he had flare-ups after prolonged standing. In October 2020, the Veteran underwent an additional VA compensation examination of the knees. He reported constant bilateral knee pain along and below the patella with moderate to severe functional loss after repetitive use over time due to pain. He took Ibuprofen three times a day and applied heat and ice as needed. Flare-ups were described as occurring twice a week for a few hours where pain would be moderate to severe. Functional loss/impairment was present as the disabilities affected his life and made him unable to do much of anything in the evening. Upon physical examination, range of motion of both knees was normal with flexion to 140 degrees and extension to 0 degrees. Pain was noted on examination but did not result in/cause functional loss. There was objective evidence of moderate localized tenderness and pain with weight bearing, but no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, which did not result in additional functional loss or range of motion. The examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and/or during flare-ups. Pain significantly limited functional ability with repeated use over a period of time and/or during flare-ups and the examiner estimated that under those conditions range of motion would decrease flexion to 120 degrees, bilaterally. Other factors contributing to the disability included disturbance of locomotion and pain with walking, heel/toe walking, and squatting. Muscle strength testing of the lower extremities was normal throughout with no reduction in muscle strength and no evidence of muscle atrophy. There was no ankylosis, history of recurrent subluxation, or history of lateral instability. Joint stability testing was normal, bilaterally. There was no evidence of any other conditions, to include a meniscus condition. The Veteran used no assistive devices. Upon review of all the evidence, lay and medical, the Board finds that the criteria for a rating higher than 10 percent are not met for the right and left knee disabilities. A higher rating under DC 5003 is not warranted for either knee because the Veteran has not exhibited degenerative arthritis of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Here, just one major joint is involved when evaluating the knees separately. A higher rating under DC 5261 based on limitation of extension is also not warranted. Extension has been regarded as normal (0 degrees) throughout the pendency of the appeal, and as such, the criteria for even a noncompensable (zero) rating under DC 5261 are not met.. Similarly, a higher rating under DC 5260 is not warranted for either knee. Specifically, range of bilateral knee motion was normal during testing. While acknowledging that the Veteran reported flareups of knee pain, the examiner estimated a 20-degree reduction of flexion, i.e., so to 120 degrees. Even accepting the Veteran’s statement of flareups and functional loss, the severity and frequency of these flare-ups, do not more nearly approximate the criteria for even a compensable rating under DC 5260 and/or 5261. As indicated, a compensable rating requires evidence of limitation of flexion to 60 degrees or limitation of extension to 10 degrees, and neither of which is more nearly approximated during the pendency of the appeal, to include during flare-ups and/or after repeated use over time. The Board concludes that the separate 10 percent ratings already compensate the Veteran for any functional loss he experiences in each knee. The Board also considered the applicability of other potential diagnostic codes during this period on appeal. As the evidence of record fails to demonstrate ankylosis; instability; cartilage removal; meniscus impairment; impairment of the tibia or fibula; or genu recurvatum, the Veteran is not entitled to a higher or separate rating under DCs 5256, 5257, 5258, 5259, 5262, or 5263 respectively. Regarding instability, the Board considered the holding in English v. Wilkie, 30 Vet. App. 347, 349 (2018), namely, that DC 5257 does not require medical evidence of lateral instability for a rating to be assigned. However, a careful review of the evidence shows no evidence of recurrent subluxation or lateral instability. There is evidence of only one isolated notation of “giving out” of the right knee (during the June 2015 examination); otherwise, the Veteran has denied any instability of the knees on examination. Moreover, the Board notes that the Veteran has not used any assistive devices, such as a knee brace, throughout the pendency of the appeal. As such, the evidence as a whole does not warrant the assignment of a separate or higher rating under DC 5257 as not even slight recurrent instability or subluxation is shown. Bilateral Heel Fractures For the entire rating period on appeal, the RO separately rated the Veteran’s closed fractures of the right and left heel as noncompensably disabling, pursuant to DC 5284. See 38 C.F.R. § 4.71a. The Veteran seeks a higher rating. DC 5284 provides the rating criteria for evaluation of foot injuries. Under DC 5284, a 10 percent rating is assigned for moderate foot injury. A moderately severe foot injury warrants a 20 percent rating. A severe foot injury warrants a 30 percent rating. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. See 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2019). In June 2015, the Veteran underwent a VA foot conditions compensation examination, at which time the examiner rendered a diagnosis of stress-related changes involving the calcanei, bilaterally, right greater than left. The Veteran reported that he sometimes had an ache in the right heel that did not put him out of commission. He denied having foot pain at the time of the examination, flare-ups, or functional loss/impairment. The examiner noted a previous right calcaneus fracture. The foot condition did not compromise weight bearing and did not require arch support, custom orthotic inserts, or shoe modifications. There was no pain on physical examination. The examiner explained that the Veteran noted occasional aches in the right heel that did not compromise his activities. There was no pain reported regarding the left foot. There was no pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. There was no other functional loss under these conditions. Inspection and palpation of the right foot revealed no abnormality on examination. The Veteran walked on tiptoe and heels without difficulty or discomfort, bilaterally. In July 2015, the Veteran underwent an additional VA foot compensation examination, at which time the examiner rendered a diagnosis of bilateral closed-heel fractures. This examination was focused on the Veteran’s ankles, which are rated separately. The Veteran reported bilateral foot pain by the end of the day and that he refrained from climbing. VA treatment records dated from 2015 to 2020 showed one isolated complaint of foot pain. During the May 2019 Board hearing, the Veteran testified that prolonged walking caused unbearable pain at times in the heel and arch of the foot. In October 2020, the Veteran underwent an additional foot examination, at which time the examiner rendered a diagnosis of bilateral plantar fasciitis. The Veteran reported having pain in the bottom of both heels when on his feet for a long time. The pain was described as “shooting and sharp.” He further reported having flare-ups that were described as “just a stronger pain.” Functional loss/impairment was described as inability to exercise and play with the kids. There was accentuated pain on use and accentuated pain on manipulation of the feet. There was no indication of swelling on use and the Veteran had no characteristic calluses. The Veteran used no arch supports, built-up shoes, or orthotics. There was no extreme tenderness of the plantar surfaces of either foot. There was no decreased longitudinal arch height, marked deformity, or marked pronation of either foot. The weight bearing line did not fall over the medial or the great toe of either foot. No lower extremity deformity caused alteration of the weight bearing line. There was no “inward” bowing or marked inward displacement and severe spasm of the Achilles’ tendon. The examiner concluded that the bilateral foot disability impacted standing, walking, negotiating stairs, climbing, squatting, kneeling, pushing, and pulling. The Veteran used no assistive devices and x-rays of the feet were negative for abnormality. In December 2020 correspondence, the Veteran’s attorney argued that it was “time to finally grant” a 10 percent for moderate foot injury pursuant to DC 5284. Specifically, the attorney indicated that the Veteran has severe pain that prevents him from standing in the early afternoon. The attorney added that the 2020 examiner indicated that this “severe” pain is from plantar fasciitis after years of abnormal walking, coupled with weight gain. On review, the Board finds that the criteria for a compensable rating for right and left heel fractures are not met or more nearly approximated. As indicated, the Veteran’s foot disabilities are rated as noncompensable under DC 5284, and to support a compensable 10 percent rating under such code, a moderate foot injury must be demonstrated, and such is not shown. The Veteran’s primary complaint appears to be foot pain, which he is competent to report; however, the dispositive issue here is whether the pain is a manifestation of the service-connected closed heel fractures on appeal. Ultimately, the 2020 VA examiner attributed no foot symptoms to the service-connected closed fractures. The examiner stated that it is apparent from the imaging studies that the Veteran’s closed fracture most likely healed and no longer present as x-rays of the feet taken in 2020 showed no evidence of acute fracture or dislocation. The 2020 VA examiner did diagnose the Veteran with plantar fasciitis but explained that such diagnosis is not related to the heel fractures, but rather caused by activities (such as long distance running, abnormal pattern of walking from flat feet, obesity, and occupations that required prolonged standing and/or walking) that place a great deal of stress on the heels and attached tissue. In other words, the examiner made it clear that the Veteran’s plantar fasciitis is not related to the previous heel fractures that are now healed. The Board finds that the attorney’s determination that the previous heel fractures caused the plantar fasciitis is not considered competent evidence, as the attorney is not shown to possess the necessary knowledge or expertise to render a medical opinion. Likewise, the Veteran himself, although competent to report having pain in his feet, is not competent to relate the pain to his service-connected heel fractures because he also is not shown to possess the requisite medical expertise to do so. To the contrary, the Board finds the October 2020 VA examination and opinions highly probative in this case. The examiner, a medical doctor, reviewed the record, examined the Veteran, and explained that the service-connected closed heel fractures resolved without any residuals. The examiner further addressed all reported symptoms and explained why those were not associated with the service-connected disability. The examiner explained the reasons for the conclusions rendered based on an accurate characterization of the evidence of record, and therefore the opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Assuming arguendo, that the reported pain is associated with the service-connected heel fractures, the Board finds that even those symptoms do not meet or more nearly approximate a moderate foot injury in either foot. Prior to the 2020 examination, the Veteran only reported occasional foot pain that increased in severity after prolonged standing at work for a whole day. In fact, during the 2015 VA examination, he did not report any pain in the left foot and only an occasional ache in the right foot. Moreover, he uses no assistive devices to help with the foot pain and has not sought treatment for the pain. In addition, the pain in the Veteran ankles is already compensated for in the separate 10 percent ratings already assigned for right and left ankle disabilities. The Board notes further that the attorney’s reference to severe foot pain in the 2020 examination report is not accurate. The Board’s review of the examination report shows no reference by the examiner to the Veteran having had “severe” pain. In fact, the report notes that the Veteran only reported pain in the bottom of the heels only after being on his feet for a long time. The Board considered the potential application of any other diagnostic code, but in this case, the medical evidence shows no current pathology or residual disability related to the heel fractures. See Copeland v. McDonald, 27 Vet. App. 333, 2015 (2015) (holding that when a diagnosed condition is specifically listed in the Rating Schedule, rating by analogy is inappropriate); see also Suttmann v. Brown, 5 Vet. App. 127, 134 (1993). For the foregoing reasons, a compensable rating is not warranted for the service-connected right and left heel fractures. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 C.F.R. § 4.3. Finally, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). REASONS FOR REMAND A remand is necessary to provide the Veteran with a new VA examination to determine the nature and likely etiology of the claimed back disability. During a 2015 VA back examination, range of motion of the Veteran’s spine was normal, there was no evidence of pain, and the examiner rendered no diagnosis; however, the examiner did not explain address the likely pathology that accounts for the Veteran’s complaints. Additionally, in Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018), the Federal Circuit found that “pain alone can serve as a functional impairment and therefore qualify as a disability.” Therefore, the absence of a diagnosis during that examination is not necessarily detrimental to the claim. On remand, the Veteran’s back complaints should be addressed in an effort to ascertain the likely nature of any current back disability. Moreover, in December 2020 correspondence, the Veteran’s attorney asserted that the lack of a back diagnosis suggests that the Veteran has an undiagnosed illness or a medically unexplained multisystem illness, with the inference being that any current symptoms are related to the Veteran’s service in Southwest Asia. Further, in subsequent correspondence, the attorney stated that the Veteran’s back problem is secondary to obesity that is caused by the service-connected disabilities; these arguments have not yet been considered by a medical professional. The matter is REMANDED for the following action: 1. Provide the Veteran with a VA examination to determine the nature and etiology of the claimed back disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed back disabilities. (b) Elicit from the Veteran the history of all signs and symptoms of the claimed back disability. (c) If a disability is not diagnosed: a. Address whether the Veteran’s competent reports of back pain result in functional impairment of earning capacity. b. Determine whether the reported symptoms are considered an “undiagnosed illness” or a medically unexplained chronic multi-symptom illness related to service in Southwest Asia. (d) For each currently diagnosed disability and/or symptoms resulting in functional impairment of earning capacity, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability), had its onset during service or is otherwise etiologically related to it. (e) For each currently diagnosed disability and/or symptoms resulting in functional impairment of earning capacity, provide an opinion as to whether it, at least as likely as not (50 percent or greater probability), related to a service-connected disability, to include weight gain resulting from limitations caused by service-connected disabilities. A complete rationale should be provided for all opinions. 2. Thereafter, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, 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.