Citation Nr: 21022576 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 12-15 928 DATE: April 16, 2021 ORDER Service connection for a neck disability, diagnosed as cervical spine degenerative changes, is granted. Service connection for a back disability, most recently diagnosed as lumbar intervertebral disc disorder, status post laminectomy and excision of herniated nucleus pulposus, is granted. REMANDED Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability other than hallux valgus is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 6, 2017 is remanded. FINDINGS OF FACT 1. The Veteran’s neck disability, diagnosed as cervical spine degenerative changes, is related to an injury sustained in service. 2. The Veteran’s back disability, most recently diagnosed as lumbar intervertebral disc disorder, status post laminectomy and excision of herniated nucleus pulposus, is related to an injury sustained in service. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck disability, diagnosed as cervical spine degenerative changes, are met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a back disability, most recently diagnosed as lumbar intervertebral disc disorder, status post laminectomy and excision of herniated nucleus pulpous, are met. 38 U.S.C. §§ 1111, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 3, 1985, to November 19, 1985. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision, in which, among numerous other issues, the agency of original jurisdiction (AOJ) declined to reopen service connection claims for cervical spine condition, including C6, C7 degenerative changes, previously denied as arthritis, and for chronic back pain with laminectomy, herniated nucleus pulposus and sciatica, previously denied as arthritis. The AOJ also denied entitlement to TDIU. In a May 2013 rating decision, service connection was denied for hammertoes, bunions/hallux valgus, and flatfeet. In a January 2016 rating decision, service connection was granted for hallux valgus, left foot, evaluated as noncompensable effective December 14, 2009. In an August 2017 rating decision, the Veteran’s hallux valgus of the left foot was evaluated as 10 percent disabling effective July 10, 2017. Regarding hearings, the law requires that a Veterans Law Judge (VLJ) who conducted a hearing on appeal must participate in any decision made on that appeal. 38 U.S.C. § 7107(c); 38 C.F.R. § 38 C.F.R. § 20.604 (formerly§ 20.707). Furthermore, appeals can be assigned only to an individual VLJ or to a panel of not less than three members. 38 U.S.C. § 7102(a). Furthermore, a veteran is entitled to have an opportunity for a hearing before all Board members who will ultimately decide the appeal. Arneson v. Shinseki, 24 Vet. App. 379 (2011). Here, in May 2013, a hearing was held, and a transcript is of record. In a December 2014 decision and remand, the Board reopened the Veteran’s service connection claims for disabilities of the neck, back, and bilateral feet and remanded the issues along with entitlement to TDIU for further development. In May 2016, a hearing was held before a different VLJ who heard, in pertinent part, evidence on the issues of service connection for disabilities of the cervical spine; lumbar spine; right foot, including but not limited to bunions, hallux valgus, flat foot, or hammertoes; and left foot other than hallux valgus and bunions, including but not limited to flat foot, hammertoes, and residual of stress fracture. During the hearing, the Veteran waived her right to a hearing before a third VLJ who would make up a panel. A transcript is of record. In September 2020, the Board remanded for further development the issues of entitlement to service connection for disabilities of the cervical spine, lumbar spine, right foot, and left foot, as well as entitlement to TDIU, and the case has been returned for appellate consideration. As the VLJs who conducted the May 2013 and May 2016 hearings are no longer with the Board, in February 2021, the Veteran was offered the opportunity for another hearing before the VLJ who would decide her case. By letter dated in February 2021, the Veteran waived her right to an additional hearing. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Cervical Spine 2. Lumbar Spine In her December 2009 claim, the Veteran sought service connection for cervical and lumbar spine disabilities, which included arthritis throughout and disc herniations. The Board understands her contention to be that she fell during service in 1985, sustaining numerous injuries, which have resulted in her current disability. See December 1985 Application; June 2013 Transcript. In particular, she contends that the fall resulted in herniation of lumbar discs. See June 2013 Transcript. She also contends, in the alternative, that her neck and back disabilities are secondary to her service-connected hallux valgus, left foot, with degenerative changes. See May 2016 Transcript. Throughout decades of adjudication of her claims, the Veteran has been circumspect as to the particulars of the in service fall. See October 2017 C&P Exam. Consequently, resolving reasonable doubt in favor of the Veteran, the Board concludes that symptoms of a chronic neck and back disability, including those related to the development of arthritis of the spine, manifested during active duty service after injuries and continued until the present. In connection with complaints of vascular headaches and lower back pain, a January 1990 CT scan of the cervical spine revealed degenerative changes. See MTR, received 5/21/1991. X-rays done in May 1999 of the cervical spine revealed increased cervical lordosis; C5-6-7 degenerative joint disease with anterior spurring. See MTR, received 10/8/2010. X-rays of the lumbar spine revealed L5-S1 disc disease and degenerative joint disease. Id. November 2000 MRIs of the cervical and lumbar spines revealed consistent findings. Id. As the medical evidence establishes through imaging the presence of arthritis and other disabilities of the Veteran’s cervical and lumbar spines, the first Shedden element is met. Reading the record most sympathetically to the Veteran, the Board understands the events in service to have been consistent with there having been a fall in October 1985. Although she has stated the fall occurred on October 15, 1985, her service treatment records suggest it was ten days or so earlier. On October 4th, she was seen for a left elbow injury after having fallen, and X-rays revealed the absence of any bony abnormality. She was seen on October 7th, for left elbow pain of four days duration after having been hit with a weapon; she was found to have left elbow contusion. She was seen on October 23rd for left knee pain of three days duration; she was found to have overuse syndrome and it was ace wrapped. She was seen again on October 25th for left knee pain; a normal knee examination was noted and she was given exercises. She was seen on November 1st for left leg pain of three days duration; X-rays were negative and she was given crutches. She was discharged from service on November 19, 1985. See STRs, received 7/28/1987; December 1985 Application for Compensation; June 2013 Transcript; MTR, received 7/9/2013; May 2016 Transcript. The Veteran is competent to report those things of which she has personal knowledge, such as the events of her injuries, her symptoms, and the treatment she received. See 38 C.F.R. § 3.159(a)(1)–(2) (defining competent medical evidence and competent lay evidence); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994). Furthermore, the Board finds her reports credible, and therefore, highly probative. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (explaining that lay evidence is credible when it is internally consistent and consistent with other evidence of record). The Board finds that the evidence, lay and medical, is consistent with a scenario of the Veteran experiencing a single physically traumatic event during which she suffered multiple injuries to the left side of her body, including left foot/leg, left knee, and left elbow. Rather than report the full extent of her injuries initially, she sought treatment of the individual aspects of her injuries through October 1985. The Board finds that, taken in the whole, the treated injuries would also be consistent with events that could have also resulted in trauma to the Veteran’s neck and back. Consequently, the second Shedden element is met. The Board notes that in May 1991 the Veteran contacted VA to file an informal claim for “another injury I believe incurred in the service. Arthritis in the spine in which the medical term is degenerative changes, cervical spine.” See May 1991 Statement. In February 1996, she filed her first claim for service connection for a back injury and stated: “DJD in spine 1989 thru 1990.” See February 1996 Application. Based upon her understanding of her subsequent providers’ explanations to her, the Veteran contends that her spinal disc herniations occurred at the time of her in-service fall and that the spinal arthritis was a direct result of her in-service injuries. See June 2013 Transcript; May 2016 Transcript. The Veteran, however, is not competent to proffer an opinion as to diagnosis or etiology, as such opinions require specific medical training and are beyond the competency of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007). Accordingly, the Board turns its attention to the probative medical findings. The record establishes that in August 1997 the Veteran fell while lifting a heavy box at work. See MTR furnished by SSA, received 2/6/2012. Soon thereafter she developed severe right leg pain to the point of inability to walk and was found to have a severe lumbar spine disc herniation that required surgery. Soon thereafter the right leg symptoms returned and it was found that there was a recurrent herniation of a lumbar spine disc. In June 1999, the Veteran underwent a neurological examination by Dr. M.M.H. See MTR, received 5/7/2015. She complained of severe persistent neck and back pain shooting to her right arm, right leg with weakness of the right arm and leg and numbness of the right arm, hand, leg, and foot and persistent severe headaches, dizziness, and depression. She denied any previous history of arthritis or arthralgias. It was stated: “It is my professional opinion that these injuries are a direct result of the work-related accident as related by the patient.” The Board notes that during an October 2002 neuropsychological evaluation, the Veteran reported that she herniated lumber discs in 1996 [sic] while picking up heavy boxes at work and that she herniated three discs in her neck in a 1999 car accident. See MTR, received 10/08/2010. In September 2010, Dr. S.K.K. reviewed the Veteran’s claims file in connection to her VA claim as well as to provide an opinion on the deterioration of her 1997 lumbar spine surgery. See MTR, received 10/08/2010. It was noted that the Veteran had had ongoing right arm and hand symptoms since the early 1990s consistent with her cervical spine degeneration. See MTR from SSA, received 2/6/2012. It was stated that, “[a]pparently at this point, she continues to complain of leg pain, lower back pain, neck, and arm pain which has really extended since the date of her injury which was accepted to be related to her military duty.” As to the Veteran’s lumbar spine disability, it was stated: “I believe there is a strong case to support [the Veteran’s] strong relationship of her current symptoms to her miliary service specifically in regards to the lower back injury resulting in herniated disc rupture requiring a full L5 laminectomy.” As to her neck, it was stated: “I believe her symptoms are likely directly related to the injury incurred to her neck a number of years ago.” In June 2013, Dr. J.W.E., an independent medical examiner, reviewed the Veteran’s claims file and performed a physical examination. See MTR, received 7/9/2013. The stated understanding of the Veteran’s claim was that, during basic training, “she fell and landed on her back,” immediately having “pain in her back and lateral aspect of her left foot.” The back pain became progressively worse over the next couple of days such that she developed tingling in the back of her thighs. It was stated that, when she left service, the Veteran still had back pain and difficulty with lifting, bending, and coming up from a flexed position. She reported having shooting pain into the back of her thighs. It was stated that “[b]y about the 1990s, she began having shooting pain down her right leg into the dorsal and lateral aspects of her right foot.” It was noted that she had back surgery in October 1997. Dr. J.W.E. explained that “[t]he fall was significant and strained the sacroiliac and iliolumbar ligaments and injured the discs in her lower back. It caused some tightness in her buttocks. It caused some lumbosacral plexus impingement with tingling in the back of her thighs.” Thereafter, the continued tightness in her back from the fall caused “the discs in her lower back to continue to deteriorate” with bulging and “causing right L5 and S1 spinal cord impingement” that required surgery. It was concluded that it was as likely as not that the Veteran’s cervical and lumbar spine disabilities were a consequence of the Veteran’s military service. In October 2015, the Veteran was afforded a VA examination for neck conditions, during which she was found to have a January 1990 diagnosis of cervical spine degenerative changes. The Veteran reported that she began having neck pain after her back surgery, and she was found to have a herniated disc in her neck. It was indicated that there was evidence of the presence of arthritis on imaging. In October 2015, she was also afforded an examination for back conditions, during which she was found to have lumbar intervertebral disc disorder with radiculopathy, status post laminectomy and excision of herniated nucleus pulpous in 1997. She reported having fallen in service and having had back pain since the 1980s, which continued through the 1990s when she fell at work. An MRI revealed a 10 mm herniated disc at L4-L5 causing right sciatica. It was indicated that imaging confirmed the presence of arthritis. The examiner opined that it was less likely than not that the Veteran’s neck or back conditions were related to service. As to the neck condition, it was noted that there was evidence of degenerative changes in the neck in January 1990, MRI in November 1998 revealed herniated discs, and she had an automobile accident in October 1999. It was noted that the Veteran reported neck pain starting after her back surgery in 1997. It was noted that her service treatment records were silent for any neck complaint. It was concluded that her neck condition began several years after leaving service. As to the back condition, it was stated that “medical records indicate that her back condition [] began in 1997” due to work requirements and injury carrying heavy boxes. The examiner stated that “service treatment records do not indicate a fall in service as the source of her elbow pain, left foot pain, and back pain.” In detailed medical opinions, a VA examiner opined in November 2020 that it was less likely than not that the Veteran’s neck and back disabilities were proximately caused by or aggravated by her service-connected hallux valgus of the left foot. As to the neck, it was explained that hallux valgus does not cause or contribute to degenerative changes in the cervical spine. It was stated that “[t]here is a lack of significant anatomical and physiological relationship of the foot to the neck.” It was stated that risk factors for the Veteran for developing cervical spine degenerative changes were being a smoker, overweight, “and also having a car accident in 1999.” Based upon a June 1987 VA examination, it was stated, furthermore, that that was “a lack of evidence of significant functional disability from the left foot hallux valgus with degenerative changes.” In support of there not being any aggravation of the Veteran’s neck disability by her service-connected left foot disability, it was stated that, during the 1987 examination, she “had a normal gait while wearing high heels which could not be done with any functional foot disability.” As to the back, it was explained that hallux valgus does not cause a herniated nucleus pulposus resulting in lumbar intervertebral disc disorder. It was opined that the Veteran’s lumbar spine disability was the result of the August 1997 work injury. It was opined that the Veteran’s back disability was not aggravated beyond its natural progression by the Veteran’s service-connected hallux valgus because, essentially, during a June 1987 VA examination the Veteran was able to wear high heels and maintain a normal gait. As factfinder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). As stated above, the Board finds the Veteran credible as to the issues of her neck and back disabilities notwithstanding her reports to Dr. M.M.H. in June 1999 during an examination for the purpose of work-related disability. The medical evidence of record that she had pre-existing complaints related to her neck and back establishes that she was not forthcoming with Dr. M.M.H. when she denied having a prior medical history as to her neck and back. In terms of her VA claim, the Board notes that there is sufficient independent evidence to support her factual assertions supporting her prior history in relationship to her neck and back disabilities. Indeed, the Veteran filed an informal service connection claim for her neck in 1991 and a formal claim for service connection for her back in 1996, and consequently, the Board finds her credible. The Board’s responsibility also includes the weighing of conflicting medical opinions, and the Board may place greater weight on one physician’s opinion over another depending upon factors such as reasoning employed by the physicians and the extent to which they reviewed prior clinical records and other evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300–04 (2008); Prejean v. West, 13 Vet. App. 444, 448–49 (2000) (stating that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Here, the Board finds the older medical evidence and Veteran’s statements more probative because they are more contemporaneous to the events and symptoms being reported. The later medical opinions focus on an intervening car accident and work injury while failing to acknowledge the prior evidence establishing that the complained of conditions pre-existed those events. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). Furthermore, in rendering their negative nexus opinions, both the October 2015 and November 2020 VA examiners primarily relied upon the lack of evidence of complaint of neck or back problems in the Veteran’s service treatment records, which reduces them to having little probative value. See Nieves-Rodriguez, 22 Vet. App. at 301; see e.g., Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993) (addressing service connection for hearing loss). In other words, the mere absence of evidence does not necessarily equate to unfavorable evidence. See e.g., Horn v. Shinseki, 25 Vet. App. 231, 239 (2012); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc). The Board also notes that the evidence of record fails to support the November 2020 examiner’s reference to the Veteran having a significant smoking history. The Board points out that the Veteran’s in-service fall occurred in early- or mid-October 1985 and she was discharged from service on November 19, 1985. The evidence establishes that in that period she incrementally reported her injuries to the left side of her body, such that she either chose not to report injuries to her neck or back. Equally possible is that she did report neck and back pain but it was not recorded due to a more pressing complaint during her multiple visits to sick call between October 4 and November 1, 1985. The Board also notes that she was not afforded a physical examination upon separation. The Board also notes the Veteran’s report that during the October 2015 VA examinations the examiner did not have access to the Veteran’s claims file. See May 2016 Transcript. She stated that she was told that “it was locked up and he couldn’t get in [her] C file.” On each of the DBQs (disability benefits questionnaires) for her October 2015 VA examinations, it was indicated that both the VBMS e-file and Virtual VA electronic files were reviewed. The Board also notes that the reports were not finalized until a month after the actual examination such that it appears the examiner did subsequently have the opportunity to fully review the Veteran’s claims file. The Board finds that Dr. J.W.E.’s June 2013 analysis to be the most consistent with the evidence of record and the most informative. The Veteran’s fall in service was described as significant, and when she fell, she landed on her back. As the spine is a continuous structure, this also implies involvement of the neck. The anatomic basis for immediate pain as well as the long-term development of spinal deterioration and bulging discs of the lumbar spine that required surgery. It was concluded that it was as likely as not that the Veteran’s cervical and lumbar spine disabilities were the consequence of her service. This opinion builds upon that of Dr. S.K.K. from September 2010. As to the neck disability, there was evidence of arthritis on imaging in January 1990, which was merely four years after service and when the Veteran was only 37 years old. Dr. S.K.K. pointed out that this was consistent with her symptoms in the early 1990s of ongoing right arm and hand symptoms and opined that this was directly related to her in-service injury. As to the back disability, in January 1990, the Veteran reported lower back pain when she was treated for vascular headaches, and subsequently, the presence of herniated lumber discs was revealed. Dr. S.K.K. opined that there was a strong relationship between the Veteran’s in-service fall and back injury and the later discovered herniated lumbar discs. Much has been made of the Veteran’s work-related back injury in 1997 and her 1999 car accident. Indeed, in 2002, she reported during a neuropsychological evaluation that the herniated discs in her neck were the result of the car accident and the herniated lumbar discs were the result of the work accident. Be that as it may, the evidence establishes that the Veteran had symptoms in her neck with symptomatology to her right arm and hand years before her car accident even if the car accident did cause the cervical disc herniations. As to her back disability, all that can be said is that the herniated lumbar discs were imaged for the first time after her work-related accident. There is no evidence that there was not an underlying residual condition from an in-service injury that predisposed her to have such a severe herniation in the lumbar spine in 1997. As noted by Drs. S.K.K. and J.W.E., the Veteran’s pain pattern since the time of service was consistent with the presence of lumbar disc herniation. Stated differently, the date of imaging does not constitute the date of coming into existence of herniated discs, and the intervening event prompting the ordering of imaging does not negate evidence of prior existence of a disability. Furthermore, it is commonly known that the development of arthritis is a slow process, and, here, the Veteran was found to have arthritis in her neck within four years of an in-service fall that has been accepted as having included injury to the neck. Consequently, resolving reasonable doubt in favor of the Veteran, the Board finds that the probative evidence, lay and medical, is in relative equipoise as to whether the Veteran’s cervical and lumbar spine disabilities began in service. Accordingly, the third Shedden element is met, and service connection for a neck disability, diagnosed as cervical spine degenerative changes, and for a back disability, most recently diagnosed as lumbar intervertebral disc disorder with radiculopathy, status post laminectomy and excision of herniated nucleus pulpous, is warranted. REASONS FOR REMAND 1. Right Foot Disability 2. Left Foot Disability other than Hallux Valgus 3. TDIU prior to August 6, 2017 The Veteran seeks service connection for disabilities of her right and left feet for which there have been diagnoses of flatfoot (pes planus), bunion/hallux valgus, hammertoes, degenerative changes to interphalangeal joints, and metatarsalgia. As stated above, the Veteran is service-connected for hallux valgus, left foot, evaluated as 10 percent disabling. One of the many issues in this case is whether the Veteran has hammertoes. Medical evidence prior to an October 2015 VA examination referenced the presence of hammertoes on the left foot. See MTR, received 8/25/2010; MTR, received 7/9/2013. The VA examiner, however, stated that the presence of hammertoes was not observed. See C&P Exam, DBQ & separate medical opinion, received 11/24/2015. In May 2017, X-rays of the left foot revealed degenerative changes involving the first metatarsophalangeal joint and multiple interphalangeal joints. See MTR, received 6/7/2017. In June 2017, Dr. W.W.L. noted the presence of bilateral hammertoes. See VA Examination, received 7/15/2017. In November 2020, the VA examiner provided a new medical opinion without the benefit of re-examining the Veteran and restated that the presence of hammertoes had not been observed. See C&P Exam, received 11/06/2020. The Board finds the VA medical opinions problematic because probative evidence was added to the claims file after the examiner examined the Veteran. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate or incomplete factual premise is not probative). Consequently, a remand is required to afford the Veteran an in-person examination to determine the presence of hammertoes and the nature and etiology of her bilateral foot disabilities, excluding hallux valgus of the left foot. On remand, a VA examination is required to determine the nature and etiology of the Veteran’s right and left foot disabilities, excluding hallux valgus of the left foot, taking into account the record evidence and accepted medical principles. 38 C.F.R. § 3.159(c)(4). The service-connection claims remanded herein are inextricably intertwined with the TDIU claim, which is also remanded. These matters are REMANDED for the following actions: 1. Schedule the Veteran for an appropriate examination performed by an examiner versed in podiatry, if available, and who has not previously reviewed this case, to determine the nature and etiology of the Veteran’s right and left foot disabilities, excluding hallux valgus of the left foot. All studies, tests, and evaluations deemed necessary by the examiner should be performed. In addition to access to the claims file, provide the examiner with a copy of this Remand. The examiner must obtain a full history from the Veteran. After reviewing the claims file and examining the Veteran, the examiner is asked to: (a) Excluding the Veteran’s service-connected hallux valgus of the left foot, identify all right and left foot disorders present since the date of claim, October 2010, including but not limited to bilateral pes planus, hallux valgus of the right foot, degenerative changes to interphalangeal joints, and metatarsalgia. When identifying the foot disorders present during the period on appeal, the examiner is asked to reconcile the differences of medical opinion as to whether the Veteran has hammertoes. The examiner is also asked to explain the relationship, if any, between hammertoes, metatarsalgia, and degenerative changes of interphalangeal joints. The examiner’s attention is directed to the following evidence: * August 2010 X-rays of the left foot showing hammering of digits 2-4 and the examination report by Dr. A.S.; see MTR, received 8/25/2010. * July 2013 report by Dr. J.W.E. noting the presence of bilateral hammertoes of the great toes; see MTR, received 7/9/2013. * October 2015 VA examination report finding no evidence of the presence of hammertoes; see C&P Exam, DBQ & separate medical opinion, received 11/24/2015. * May 2017 X-rays of the left foot showing degenerative changes of the first metatarsophalangeal joint and multiple interphalangeal joints; see MTR, received 6/7/2017. * June 2017 report by Dr. W.W.L. noting the presence of bilateral hammertoes; see VA Examination, received 7/15/2017. (b) For each identified foot disorder, opine whether it is at least as likely as not that it (1) is proximately due to or (2) aggravated by the Veteran’s service-connected hallux valgus of the left foot. The examiner must provide separate findings and rationales relating to causation and aggravation. Also, aggravation need not be permanent. (c) For each identified right and left foot disorder, excluding hallux valgus of the left foot, opine whether it is at least as likely as not that it (1) had its onset during active service, or (2) is otherwise related medically to the Veteran’s service. In rendering this opinion, the examiner is advised that the Veteran is competent to report her symptoms and history as contained in separate statements as far back as the 1980s and as part of treatment providers’ medical records found in the evidence of record. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, an explanation for the rejection must be provided. All opinions must be supported by a clear rationale and a discussion of the facts and scientific/medical principles involved, such that there is a reasoned medical explanation connecting the conclusion and the data. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that the limits of current medical knowledge have been exhausted in providing an answer. (Continued on the next page)   2. Readjudicate the claims. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Leanne M. Innet, 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.