Citation Nr: 21022202 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 16-56 443 DATE: April 15, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an initial disability rating in excess of 20 percent for a service-connected lumbosacral strain is denied. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a bilateral foot disability, claimed as bilateral plantar fasciitis, is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for migraine headaches is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had, at any time during the pendency of the claim, a current diagnosis of bilateral hearing loss for VA purposes. 2. The preponderance of the evidence of record is against finding that the Veteran’s tinnitus is etiologically related to his period of active service or a service-connected disability. 3. For the entire period on appeal, the Veteran’s lumbosacral strain has been productive of, at most, forward flexion greater than 30 degrees, but not greater than 60 degrees, without ankylosis or intervertebral disc syndrome requiring physician prescribed bed rest. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.385. 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310. 3. The criteria for an initial disability rating in excess of 20 percent for a service-connected lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5237. (CONTINUED ON NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1982 to June 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in January 2016, September 2016, and March 2017 of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in March 2019 when the issues of entitlement to service connection for bilateral hearing loss, tinnitus, and migraine headaches and entitlement to an increased rating for lumbosacral strain were remanded. The remaining issues of entitlement to service connection for a left knee disability, right knee disability, cervical spine disability, and bilateral plantar fasciitis were denied. The Veteran appealed the March 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2020 Memorandum Decision, the Court set aside the Board decision with respect to the denied issues and remanded them for additional action. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, such as sensorineural hearing loss and tinnitus (as organic diseases of the nervous system), are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown if “the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology.” Savage v. Gober, 10 Vet. App. 488, 498 (1997). 1. Entitlement to service connection for bilateral hearing loss The Veteran asserts that he is entitled to service connection for bilateral hearing loss related to hazardous noise exposure during his period of active service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as least as likely as not related to an in-service injury, event, or disease.  The Board concludes that the Veteran does not have a current diagnosis of bilateral hearing loss, for VA purposes, and has not had one at any time during the pendency of the claim or recent filing of the claim.  38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d).  For the purposes of applying the laws administered by VA, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent.  38 C.F.R. § 3.385.  The Veteran’s service treatment records are absent of a diagnosis or complaints of hearing loss.  However, the Veteran stated that he was exposed to hazardous noise in the boiler room. Additionally, he said he was exposed to hazardous noise from helicopters and as part of a repair team. The Board finds that hazardous noise exposure is conceded based on the Veteran’s military occupational specialty as a boiler technician. Further, the Veteran’s post-service treatment records reflect that he was issued hearing aids in 2017. However, at that time, the audiologist indicated that the Veteran’s hearing was within normal limits from 250 Hertz to 4000 Hertz with excellent speech recognition scores bilaterally. The Veteran was afforded a VA audiology examination in January 2016.  The examination report reveals the following auditory thresholds, in decibels (dB):  Hertz (Hz)  500 Hz  1000 Hz  2000 Hz  3000 Hz  4000 Hz  Right  15 dB  10 dB  15 dB  10 dB  15 dB  Left  20 dB  15 dB  10 dB  15 dB  10 dB  The speech discrimination scores, using the Maryland CNC word list, were 98 percent bilaterally.  The audiologist diagnosed the Veteran with sensorineural hearing loss bilaterally.  The Veteran was afforded an additional VA audiology examination in October 2019. The Veteran indicated that he had difficulty hearing conversations. The examination report reveals the following auditory thresholds, in decibels (dB):  Hertz (Hz)  500 Hz  1000 Hz  2000 Hz  3000 Hz  4000 Hz  Right  20 dB  10 dB  10 dB  20 dB  30 dB  Left  15 dB  15 dB  15 dB  20 dB  25 dB    The speech discrimination scores, using the Maryland CNC word list, were 94 percent bilaterally.  The audiologist diagnosed the Veteran with bilateral sensorineural hearing loss.   Notwithstanding the examiners’ diagnoses, the Veteran’s auditory thresholds do not meet the definition of hearing loss for VA compensation purposes during either examination.  The Veteran’s post-service treatment records similarly do not reflect auditory thresholds or a diagnosis that conforms to VA’s definition of hearing loss.  See 38 C.F.R. § 3.385.  While the Veteran believes he has a current diagnosis of bilateral hearing loss, he is not competent to provide a diagnosis, based on audiometric data, in this case.  The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence of record. The Board has also considered article submitted by the Veteran’s attorney regarding early noise exposure accelerating age-related hearing loss. However, the existence of a current disability is the cornerstone of a claim for VA disability compensation.  38 U.S.C. § 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary).  The Veteran does not have bilateral hearing loss as defined by 38 C.F.R. § 3.385, and service connection cannot be granted as a matter of law.  Accordingly, the preponderance of the evidence is against the Veteran’s claim for service connection for bilateral hearing loss and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for tinnitus The Veteran asserts that he has tinnitus that is related to his period of active service. Alternatively, the Veteran seeks service connection for tinnitus as secondary to his bilateral hearing loss. As noted above, hazardous noise exposure in service has been conceded. Additionally, the Veteran is found competent and credible to report ringing in his ears. Accordingly, the question before the Board is whether the Veteran’s current tinnitus is caused by or otherwise related to his period of active service or a service-connected disability. After reviewing the record, the Board finds the criteria for service connection for tinnitus have not been met. 38 C.F.R. §§ 3.303, 3.310. The Veteran was afforded a VA examination in January 2016. At that time, the Veteran reported bilateral tinnitus for the previous 2 to 5 years. The Veteran was afforded an additional VA examination in October 2019. At that time, he reported the onset of his tinnitus was 6 or 7 years ago and has worsened since that time. The examiner found that the Veteran has a diagnosis of clinical hearing loss and his tinnitus is at least as likely as not a symptom associated with that hearing loss. The examiner further indicated that it was less likely than not that the Veteran’s tinnitus was caused by or a result of military noise exposure. The rationale was that the Veteran’s in-service treatment records reveal no permanent auditory threshold shift from enlistment to separation in either ear. Additionally, current science indicates that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely. Rather, the most pronounced effects of a given noise exposure on pure-tone thresholds are measurable immediately following the exposure. Since there is no evidence of permanent auditory threshold shifts during military service, the examiner found it unlikely that hearing loss is related to military service. After carefully reviewing the entire record, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for tinnitus. Notably, the only positive evidence indicating that service connection is warranted for his current tinnitus is his general lay statements and an article noting the link between tinnitus and hearing loss. To that end, the Board acknowledges that the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by an examiner. Layno, 6 Vet. App. at 469-70; Jandreau, 492 F.3d at 1377. However, there is no indication that the Veteran’s tinnitus had its onset in service or within 1 year of discharge and has continued since that time. Indeed, the Veteran reported the onset of his tinnitus was at least 2 decades after service discharge during both examinations. Moreover, the opinion of the medical expert is that the Veteran’s tinnitus is at least as likely as not due to his hearing loss and less likely due to his service. There is no evidence refuting this opinion. As the Veteran’s hearing loss is not found to be service-connected, secondary service connection is not warranted for the Veteran’s tinnitus. Accordingly, the preponderance of the evidence is against the Veteran’s claim for service connection for tinnitus and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990). Increased Ratings A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 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 rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to an initial disability rating in excess of 20 percent for a service-connected lumbosacral strain The Veteran asserts that a disability rating in excess of 20 percent is warranted for his service-connected lumbosacral strain. His lumbosacral strain is currently rated pursuant to diagnostic code 5237. This diagnostic code indicates that the disability be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula, a 20 percent rating 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 not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (holding that it is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing for pain on both active and passive motion and in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded a VA examination in January 2016. However, as noted by the Board in March 2019, the examiner failed to provide information necessary to assess the functional impairment resulting from the Veteran’s lumbosacral strain. Accordingly, the Board will not discuss the results of this examination. The Veteran submitted private treatment records from his chiropractor dated in February 2017 noting that the Veteran’s back pain was aggravated by activities involving bending and that some relief was obtained when ice was applied. The Veteran was afforded a VA examination in May 2017. At that time, the Veteran reported excruciating and constant back pain that spreads towards his legs. He used hydrocodone, gabapentin, epidural blocks, acupuncture, and a chiropractor to treat his pain. The Veteran denied flare-ups of pain and any functional impairment of the back. Range of motion testing was normal, and no pain was noted on the examination. No objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the spine was indicated. There was also no evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing with at least 3 repetitions and without any additional loss in range of motion. The examiner noted that the Veteran did not have guarding or muscle spasm of the spine. Muscle strength testing was normal as were reflex and sensory examinations. No ankylosis of the spine was indicated and there were no neurologic abnormalities found. The Veteran did not have intervertebral disc syndrome. There was no objective evidence of pain when the back was used in non-weight bearing and the passive range of motion testing was the same as active range of motion testing, or normal, without evidence of pain. The Veteran was afforded an additional VA examination in December 2019. At that time, the Veteran reported chronic low back pain present daily and ranging from moderately severe to severe throughout the day. The Veteran denied specific flare-ups beyond that baseline severity and there was no loss of range of motion with repeated use over time. The Veteran was treated with epidurals in the lower back. The Veteran reported that he was unable to frequently bend, lift and carry more than 40 pounds, or frequently lift and carry any weight. Range of motion testing revealed forward flexion to 40 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Pain was noted on the examination for all ranges of motion but it did not result in functional loss. There was also pain to palpation of the paralumbar and evidence of pain with weight bearing. The Veteran was able to perform repetitive-use testing with at least 3 repetitions and without additional loss of function or range of motion. The examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and incoordination were not found to significantly limit functional ability with repeated use over a period of time. The Veteran reported guarding or muscle spasm of the thoracolumbar spine, but such did not result in abnormal gait or abnormal spinal contour. Muscle strength testing showed active movement against some resistance on the right-side hip flexion and great toe extension but was normal otherwise. Reflex and sensory examinations were normal. The Veteran did not have ankylosis of the spine or any neurologic abnormalities related to a thoracolumbar spine condition. Additionally, the Veteran was not found to have intervertebral disc syndrome. The examiner noted that there was objective evidence of pain when the back was used in non-weight bearing and that passive range of motion testing could not be performed or was not medically appropriate. VA treatment records throughout the appeal period note the Veteran’s complaints of chronic back pain. After a review of the above, the Board finds that an initial disability rating in excess of 20 percent is not warranted at any time during the appeal period because forward flexion has not been limited to 30 degrees or less and the Veteran did not experience ankylosis. Even considering the Veteran’s reports of pain, the examiner did not find functional impairment beyond flexion to 40 degrees and extension to 10 degrees. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca, Correia, and Sharp, but finds that a rating in excess of 20 percent is not warranted under these criteria. At no time has the Veteran’s forward flexion has not been limited to 30 degrees or less and the Veteran did not experience favorable ankylosis; and he does not exhibit functional loss due to pain or weakness supported by pathology which is consistent with a rating in excess of 40 percent. The Veteran’s symptoms do not, when viewed in conjunction with the medical evidence, tend to establish disability which more closely approximates unfavorable ankylosis. While the Board notes that the Veteran reported that the functional impairment of his back rendered him unable to frequently bend, lift, and carry weight, the 20 percent criteria contemplates these mild to moderate impairments in performing activities of employment, to include the Veteran’s pain and reduced range of motion. Thus, to increase the Veteran’s rating based on an impairment in performing occupational activities is not warranted. The Veteran further denied flare-ups of lumbar spine pain and there is no objective evidence of loss of range of motion on repetition, in passive range of motion, or with weight bearing. Finally, the Board has considered whether a higher rating would be warranted under Diagnostic Code 5243. However, the Veteran has neither been diagnosed with intervertebral disc syndrome nor did he experience any incapacitating episodes, defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. As a result, a rating in excess of 20 percent for the Veteran’s low back disability is not warranted on any basis. Furthermore, there is no indication, nor is it contended, that the Veteran has any neurologic abnormalities or findings related to a low back disability. Accordingly, the preponderance of the evidence is against the Veteran’s claim for a disability rating in excess of 20 percent for the Veteran’s service-connected lumbosacral strain and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) REASONS FOR REMAND 3. Entitlement to service connection for a left knee disability is remanded. In the July 2020 Memorandum Decision, the Court indicated that the January 2017 medical opinion was inadequate to adjudicate the claim for entitlement to service connection for a left knee disability. Specifically, the examiner inconsistently identified which knee the opinion referred to, rendering it unclear. Additionally, the examiner employed the incorrect standard regarding aggravation, opining on “permanent aggravation” rather than any incremental increase. On remand, an additional opinion should be obtained regarding the nature and etiology of the Veteran’s claimed right knee disability. 4. Entitlement to service connection for a bilateral foot disability, claimed as plantar fasciitis, is remanded. As noted in the July 2020 Memorandum Decision, no opinion was obtained regarding the Veteran’s bilateral plantar fasciitis. However, the Veteran has competently reported current foot pain and submitted treatment records documenting tenderness to palpation of the plantar surfaces. Additionally, he credibly reported foot pain in service related to wearing steel-toed boots for 18 hours at a time without sitting. On remand, a VA opinion should be obtained regarding the nature and etiology of his claimed bilateral foot disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for a cervical spine disability is remanded. 6. Entitlement to service connection for a right knee disability is remanded. As noted in the July 2020 Memorandum Decision, VA opinions regarding the nature and etiology of the Veteran’s claimed cervical spine disability and right knee disability were obtained in September 2016. During the examinations, the examiner noted that the Veteran had in-service treatment for disabilities of the cervical spine and right knee. However, the examiner seemingly relied on an absence of medical evidence of treatment for either condition until long after service-discharge in forming negative nexus opinions. As such, the examiner failed to consider whether the Veteran’s lay statements of continued symptomatology since discharge from service presented sufficient evidence of the etiology of the disabilities such that service connection could be proved. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). On remand, an opinion should be obtained regarding the nature and etiology of the Veteran’s claimed cervical spine and right knee disabilities that considers his reported history of ongoing symptomatology of each since his period of active service. 7. Entitlement to service connection for migraine headaches is remanded. The Veteran was afforded a VA examination to address his migraine headaches in November 2019. The examiner stated that the Veteran’s treatment records reflect that the onset of his migraine headaches was in 2004. At that time, they were deemed secondary to a congenital brain malformation and he was treated with a shunt by neurosurgery with immediate resolution of symptoms. Despite the shunt, migraines returned. The Board finds no evidence that the Veteran has a shunt in his brain or a congenital brain malformation. Accordingly, on remand, an opinion should be obtained regarding the nature and etiology of the Veteran’s claimed migraine headache disability. The matters are REMANDED for the following action: 1. Obtain opinions regarding the nature and etiology of the Veteran’s left knee, bilateral foot, cervical spine, right knee, and migraine headache disabilities. If an additional VA examination is deemed warranted, one should be arranged. All indicated tests and studies should be performed. The claims file should be available to and reviewed by the medical professional. Thereafter, the medical professional should respond to the following: (a.) For any disabilities of the left knee (to include consideration of pain resulting in functional impairment), is it at least as likely as not (50 percent or greater probability) that the disability is caused by or otherwise etiologically related to the Veteran’s period of active service? (b.) For any disabilities of the left knee (to include consideration of pain resulting in functional impairment), is it at least as likely as not (50 percent or greater probability) that the disability is caused by OR aggravated beyond its natural progression by a service-connected disability? Separate opinions for causation and aggravation are required. (c.) For any disabilities of the feet (to include consideration of pain resulting in functional impairment), is it at least as likely as not (50 percent or greater probability) caused by or otherwise etiologically related to the Veteran’s period of active service? The examiner should note the Veteran’s reports of in-service foot pain related to his steel-toed boots. (d.) For any disabilities of the cervical spine (to include consideration of pain resulting in functional impairment), is it at least as likely as not (50 percent or greater probability) that the disability is caused by or otherwise etiologically related to the Veteran’s period of active service? The examiner should note the Veteran’s in-service neck injury in April 1983 and reports of ongoing symptomatology since his period of active service. (e.) For any disabilities of the right knee (to include consideration of pain resulting in functional impairment), is it at least as likely as not (50 percent or greater probability) that the disability is caused by or otherwise etiologically related to the Veteran’s period of active service? The examiner should note the Veteran’s in-service right knee injury in April 1984 and reports of ongoing symptomatology since his period of active service. (f.) Is the Veteran’s diagnosed migraine headache disability at least as likely as not (50 percent or greater probability) caused by or otherwise etiologically related to the Veteran’s period of active service? (g.) Was the Veteran’s diagnosed migraine headache disability at least as likely as not (50 percent or greater probability) caused by OR aggravated beyond its natural progression by a service-connected disability? The examiner should note the article submitted by the Veteran regarding a link between posttraumatic stress disorder and migraine headaches. Separate opinions for causation and aggravation are required. The examiner is advised that the Veteran is competent to report his symptoms and history and that such reports must be acknowledged and considered in formulating any opinion. A complete rationale must be provided for all opinions expressed. A clear explanation for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide an opinion without resorting to speculation, he/she must provide an explanation as to why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he/she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. The agency of original jurisdiction must review the requested opinions to ensure they are adequate and comply with the Board’s specific reman directives herein. If deficient in any manner, corrective action must be taken at once. J. O’CONNELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Connor, Lindsey 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.