Citation Nr: 21025727 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-46 706 DATE: April 28, 2021 ORDER Entitlement to a disability rating higher than 20 percent for ankylosing spondylitis with low back pain is denied. Entitlement to a disability rating higher than 10 percent for right hip arthritis is denied. Entitlement to a compensable rating for costochondritis is denied. REMANDED The issue of entitlement to service connection for a right knee disorder is remanded. The issue of entitlement to a total disability rating for compensation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACTS 1. The Veteran’s back disability is not manifested by forward flexion limited to 30 degrees or less, or by favorable ankylosis of the entire thoracolumbar spine. 2. The Veteran’s right hip disability is not manifested by limitation of motion that is compensable. 3. The Veteran’s costochondritis is not manifested by muscle injury approximating moderate level of impairment. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for back disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 2. The criteria for a rating higher than 10 percent for right hip disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 3. The criteria for a compensable rating for costochondritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1986 to January 1987 and from June 1989 to November 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded the claims on appeal for additional development. The case is again before the Board for appellate review. Increased rating claims The Veteran has been service connected for costochondritis and low back disability since November 1993. Since then, costochondritis has been rated 0 percent disabling while back disability has been rated 20 percent disabling. Right hip disability has been service connected since January 2007 and has been rated 10 percent disabling since then. In November 2012, the Veteran claimed entitlement to increased ratings for each disability. In the November 2013 rating decision on appeal, the RO denied her claims. A disability rating is determined by the application of VA’s Schedule 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 (DCs) identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which two evaluations should be applied, the higher evaluation 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. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease or injury is encountered, it will be rated by analogy under a DC built up using the first 2 digits from that part of the Rating Schedule most closely identifying the body part or system affected and by using “99” for the last 2 digits. Id. When rating musculoskeletal disability, VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided by DeLuca must be followed in adjudicating claims where a rating under the DCs governing limitation of motion should be considered. However, pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain alone does not constitute function loss but is just one fact to be considered when evaluating functional impairment). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In rating disabilities, VA is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. In such cases, the reasonable doubt doctrine requires that all symptoms be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Back disability The Veteran’s back disability has been rated as 20 percent disabling under DC 5099-5002. Diagnostic Code 5002 addresses multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process. Note (1) of DC 5002 states that examples of conditions rated using this diagnostic code include, but are not limited to, rheumatoid arthritis, psoriatic arthritis, and spondyloarthropathies. Under DC 5002, the next-highest rating over 20 percent is the 40 percent rating warranted for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. Diagnostic Code 5002 does not provide a definition for an “incapacitating exacerbation.” However, under the same chapter for evaluating musculoskeletal disabilities (38 C.F.R. § 4.71a), an “incapacitating episode” is defined as a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). Based on the findings of record of back ankylosis, the Board also notes the relevance here of other provisions under 38 C.F.R. § 4.71a. Thoracolumbar spine disability is rated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-43. When rating under the former formula, VA is directed to evaluate orthopedic disability separately with any associated objective neurologic abnormalities under an appropriate diagnostic code, and then combine the separate ratings under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-43, Note (1). A rating under the latter formula is warranted where incapacitating episodes are present due to intervertebral disc syndrome (IVDS). An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). VA should then select whichever formula results in the higher evaluation. Under these formulas, disability ratings of 10, 20, 40, 50, 60, and 100 percent are authorized for thoracolumbar disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-43. The back disability at issue here has been rated 20 percent disabling throughout the appeal period, so the Board will limit its analysis to whether a higher rating is warranted. Under the General Rating Formula for Diseases and Injuries of the Spine, a 40 percent rating is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less. Forty, 50, and 100 percent ratings are warranted under the General Rating Formula for Diseases and Injuries of the Spine for disorders manifested by ankylosis. Ankylosis is defined as “stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint[.]” Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The normal combined range of motion of the thoracolumbar spine is 240 degrees with 90 degrees flexion, 30 degrees extension, 30 degrees each for left and right lateral flexion, and 30 degrees each for left and right rotation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-43, Note (2); Plate V. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. The evidence of record pertaining to this claim consists of lay assertions, VA and private treatment records, and VA examination reports. This evidence indicates that a higher rating has not been warranted during the appeal period. This evidence does not indicate systemic arthritis such as rheumatoid arthritis, does not indicate incapacitating episodes, does not indicate forward flexion of the thoracolumbar spine limited to 30 degrees or less, and does not indicate ankylosis of the entire thoracolumbar spine. The Veteran was provided a VA back examination in November 2020, where her range of motion was limited to 80 degrees forward flexion. Although the Veteran’s range of motion did not change after repetitive use testing, the examiner predicted that her range of flexion would be further reduced to 75 degrees with repeated use over time. The examiner noted that the Veteran has pain during forward flexion. She has functional loss that restricted heavy lifting or repetitive bending. The Veteran did not report flare-ups during this exam. Moreover, there was no ankylosis found. The Veteran also submitted private treatment records that reflect an evaluation from January 2018. At that time, the Veteran reported back pain and her range of motion was limited to 75 degrees forward flexion. This evidence shows that the Veteran’s back disability significantly limits her mobility and her ability to stand, squat, and bend. Private treatment records from January 2017 reflects that the Veteran had backache. The Veteran rated her pain as 4/10 and the evaluator estimated that her range of motion is reduced by 50 percent. The Veteran’s private treatment records from June 2015 show that she had back pain, which was temporarily relieved by medications such as Advil, Aleve, muscle relaxant and heating pads. The Veteran underwent VA examination in March 2013, where she endorsed back pain and stiffness. At the time, her range of motion was limited to 70 degrees forward flexion with pain starting at that point. Her range of motion was unchanged after repetitive use testing. The exam noted functional loss to the extent the Veteran had less movement than normal and pain on movement. There was no guarding or muscle spasm noted during the exam. The Veteran is constantly required to use a cane as assistive device. In general, the exam shows that the Veteran’s back disability limits heavy lifting, bending, twisting, prolonged standing, or walking. The Veteran reported flare-ups triggered by walking/bending during the exam. The Board is cognizant that the March 2013 examiner did not specifically provide the Veteran’s range of motion during flare-ups. However, to the extent the Veteran’s flare-ups are caused by repeated activities, the repetitive use testing captured her disability picture. Notably, the Veteran was provided another examination in November 2020, as indicated above, where she did not report any flare-ups. The Board recognizes that the Veteran believes that the severity of her impairment is worse than contemplated by the 20 percent rating currently assigned. The Board has considered the statements from her aunt and her sister, submitted in January 2013, that demonstrates that the Veteran’s physical activities are limited due to her back pain. The Board is sympathetic to the reports that her back pain causes her to miss work and family functions. However, the objective medical evidence of record does not demonstrate that the Veteran’s impairment results in forward flexion limited to 30 degrees or less even when accounting for pain that causes additional functional loss after repetitive use over period of time. Nor is there evidence of ankylosis. That is, while she experiences some limitation, the Veteran still has significant range of motion, which is consistent with the finding of no ankylosis. The Veteran’s functional losses due to her pain are fully contemplated by the disability rating assigned. Furthermore, there is no evidence that the Veteran’s disability has resulted in IVDS requiring prescribed bed rest. Therefore, the Board finds that preponderance of the evidence of record weighs against finding that a rating higher than 20 percent has been warranted during the appeal period. Accordingly, the benefit-of-the-doubt doctrine is not for application, and the claim for a rating higher than 20 percent for back disability is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Right hip disability The Veteran’s right hip disability is rated as 10 percent disabling under DC 5003. DC 5003 provides that degenerative arthritis that is established by x-ray finding will be rated on limitation of motion under the appropriate DC for specific joint or joints involved. Where the limitation of motion of the specific joint or joint involved is noncompensable under the appropriate DC, a 10 percent rating is assigned for each major joint or group of minor joints affected. In the absence of limitation of motion, a 20 percent rating may be assigned, where there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. The hip is considered a major joint. 38 C.F.R. § 4.45 (f). Limitation of extension of the thigh (and adjacent hip) is rated under DC 5251, which provides a maximum 10 percent rating for limitation of extension of the thigh to 5 degrees. Limitation of flexion of the thigh (and adjacent thigh) is rated under DC 5252, which provides a 10 percent rating for limitation of flexion of the thigh to 45 degrees, a 20 percent rating for limitation of flexion to 30 degrees, a 30 percent rating for limitation of flexion to 20 degrees, and a 40 percent rating for limitation of flexion to 10 degrees. Under DC 5253, a 10 percent disability rating is warranted for limitation of rotation (cannot toe-out more than 15 degrees of affected leg) or where adduction is limited such that legs cannot be crossed. A 20 percent rating is assigned for limitation of abduction of, motion lost beyond 10 degrees. See 38 C.F.R. § 4.71a. Normal hip flexion is from zero to 125 degrees, and normal hip abduction is from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. In this case, the medical evidence of record reflects that the Veteran does have limitation of motion of the right hip. Thus, under DC 5003, the Board must consider whether she is entitled to a rating higher than 10 percent under DCs 5251, 5252, and 5253. The Veteran underwent VA hip and thigh conditions examination in November 2020. She reported right hip pain that limits her ability to squat. The Veteran did not endorse flare-ups. Her range of flexion was limited to 80 degrees and her extension was limited to 20 degrees. She otherwise had normal range of abduction, adduction, external rotation, and internal rotation during range of motion testing. The Veteran’s range of motion was unchanged after repetitive use testing. However, the examiner noted that pain significantly limited functional ability with repeated use over a period of time. The examiner predicted that her range of motion would be 80 degrees flexion, 20 degrees extension, 40 degrees abduction, 20 degrees adduction, 55 degrees external rotation, and 35 degrees internal rotation after repeated use over a period of time. The examination did not find ankylosis of the right hip. The examiner concluded that the Veteran’s range of motion itself does not contribute to functional loss. However, the Veteran had pain that causes functional loss. Private medical records submitted from January 2018 reflect that the Veteran’s range of motion was manifested by flexion of 100 degrees and abduction limited to 25 degrees. The evaluator noted that she had functional loss that limit her ability to rise from sitting position, stand, walk, squat, step, bend, and twist. A March 2013 VA examination found that the Veteran had range of flexion limited to 110 degrees and extension limited to 5 degrees. The examiner noted that abduction was not lost beyond 10 degrees. The adduction is not limited such that the Veteran cannot cross legs. Nor did she have limited rotation such that she cannot toe-out more than 15 degrees. Her range of motion was unchanged after repetitive use testing. The Veteran endorsed flare-ups triggered by prolonged standing and walking. Although the examination does not specifically reflect the range of motion during flare-ups, the repetitive use testing reflects the Veteran’s range of motion limitation with physical activity that requires repetitive movement. The Veteran has functional loss to the extent she has less movement than normal and pain on movement. The exam did not find ankylosis. The examiner noted that her right hip condition causes functional impact to the extent it limits prolonged standing or walking, heavy lifting, bending, and twisting. In summary, the medical evidence of record does not reflect that the Veteran had limitation of motion of the right hip that warrants a rating higher than 10 percent. In fact, the March 2013 examination that noted extension limited to 5 degrees is the only range of motion testing result that shows a compensable level of limitation of motion. But that limitation is only consistent with a 10 percent rating under DC 5251. All of the Veteran’s range of motion testing results otherwise reflect a range of motion that is higher than contemplated for compensable rating much less a rating higher than 10 percent under any of the DCs applicable to limitation of motion of the hip. Therefore, the Board finds that the 10 percent disability rating assigned fully contemplates the Veteran’s pain and functional loss. The Board recognizes that the Veteran believes that her right hip disability should be assigned an evaluation higher than 10 percent. The Board has fully considered the statements from her aunt and sister that reflect that the Veteran’s hip pain impacts her mobility requiring her to use a cane and causing her to miss work, as well as family function. However, as noted above, the 10 percent disability rating assigned contemplates the Veteran’s pain and the functional loss she experiences as a result. The objective medical evidence does not reflect that the Veteran’s right hip disability results in limitation of motion that warrants the higher 20 percent rating under the applicable DCs. Under such circumstances, the Board concludes that the preponderance of the evidence of record weighs against the claim. Based on the foregoing, the Board finds that a rating higher than 10 percent is not warranted at any point during the period on appeal based on limitation of motion of the right hip. Similarly, because the Veteran has limitation of motion of the right hip, a 20 percent rating based on X-ray evidence of arthritis is not warranted under DC 5003. Accordingly, the benefit-of-the-doubt doctrine is not for application, and the claim for rating higher than 10 percent for right hip disability is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Costochondritis The Veteran’s service-connected costochondritis is not specifically listed in the rating schedule; therefore, it is rated analogously to a disability in which not only function is affected, but also anatomical localization and symptoms are closely related. 38 C.F.R. § 4.20. The Veteran’s current condition is assigned a noncompensable disability rating under DC 5299-5297 of 38 C.F.R. § 4.71a. Under DC 5297, compensable ratings are warranted for removal or regeneration of the ribs. As the Veteran has experienced neither, a higher rating would be unwarranted under DC 5297. However, a VA examination in November 2020 found that the Veteran had injury to muscle group XXI. For this reason, the Board has also assessed whether a compensable rating could be assigned under DC 5321 of 38 C.F.R. § 4.73. Under DC 5321, a noncompensable rating is warranted for a slight disability, a 10 percent rating is warranted for a moderate disability, and a 20 percent rating is warranted for a severe or moderately severe disability. For VA ratings purpose, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. A slight muscle disability is defined as a simple wound of the muscle without debridement or infection. Such a wound should have a history of brief treatment and return to duty, exhibiting healing with good functional results, and no cardinal signs and symptoms. Residuals include minimal scar, no impairment of function, no retained metallic fragments, and no evidence of fascial defect, atrophy, or impaired tonus. 38 C.F.R. § 4.56 (d)(1). A moderate muscle disability is defined as a through and through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. Such a wound should result in consistent complaint of one or more of the cardinal signs and symptoms, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Residuals include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue, and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d)(2). A through and through injury with muscle damage shall be evaluated at no less than a moderate disability. 38 C.F.R. § 4.56 (b). A moderately severe muscle disability is defined as a through and through or deep penetrating wound by a small high velocity missile or a large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Such a wound should have a record of prolonged hospitalization for treatment, a record of consistent complaint of cardinal signs and symptoms, and, if present, evidence of inability to keep up with work requirements. Residuals include entrance and (if present) exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and tests of strength and endurance with positive evidence of impairment compared with the sound side. 38 C.F.R. § 4.56 (d)(3). A severe muscle disability is defined as a through and through or deep penetrating wound due to a high velocity missile or large and multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding, and scarring. Such a wound should have a record of prolonged hospitalization for treatment, a record of consistent complaint of cardinal signs and symptoms worse than those shown for a moderately severe disability, and, if present, evidence of inability to keep up with work requirements. Residuals include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track; palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in the wound area; abnormal swelling and hardening in muscle contraction; and tests of strength, endurance, or coordinated movements indicating severe impairment of function compared to the sound side. A severe disability can also be shown by x-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of scar to bone; diminished muscle excitability to pulsed electrical current; visible or measurable atrophy; adaptive contraction of an opposing muscle group; atrophy of muscle groups not in the track of the missile; or induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(4). An open comminuted fracture with muscle or tendon damage will be evaluated as severe unless muscle damage is minimal. 38 C.F.R. § 4.56 (a). In this case, the Veteran underwent VA examination in November 2020, where the examiner noted that she had non-penetrating muscle injury to muscle group XXI: Muscles of respiration: thoracic muscle group on the right side. She reported intermittent pain on the right side of her chest and flare-ups that occur every six months or so. The examiner found no other signs or symptoms of muscle injury. Nor were there any other pertinent physical findings. Specifically, the Veteran did not have any known fascial defects or evidence of fascial defects associated with the muscle disorder. The muscle disorder also did not affect muscle substance or function. She had no cardinal signs or symptoms of a muscle disability. In addition, there was no muscle atrophy. The examiner also reported that the condition had no impact on the Veteran’s ability to work. A May 2013 respiratory examination shows that the Veteran reported chest pain associated with physical activity that occurred twice a year for a few days. The examiner noted that the Veteran would be required to stay home from work to rest and take NSAID. The Board has carefully reviewed the remaining record from the appeal period in its entirety but finds no other probative evidence of record showing that the Veteran’s costochondritis is more severe for compensation purposes than demonstrated on the VA evaluations discussed above. The evidence of record demonstrates that the Veteran’s costochondritis symptoms are overall shown to be slight under the standards required in 38 C.F.R. § 4.56. While the Veteran has flare-ups manifested by pain that requires rest and causes her to miss work few days out of the year, the evidence does not reflect that she was unable to keep up with her work requirements. In general, during the period on appeal, the symptoms of Veteran’s costochondritis were never shown to be more than slight. Indeed, the evidence does not indicate the type of disability warranting a compensable rating, such as moderate disability – i.e., one that resulted from a through and through or deep penetrating wound with residuals of debridement, or prolonged infection, or that results in consistent complaints of lowered threshold of fatigue after average use, loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue. 38 C.F.R. § 4.56 (d)(2); 38 C.F.R. § 4.73, DC 5321. The Board acknowledges the Veteran’s assertions that her costochondritis warrants compensable evaluation. However, the evidence of record does not demonstrate that the Veteran has had a moderate, moderately severe, or severe disability of the thoracic muscle group, as required for a compensable evaluation under DC 5321. As such, the preponderance of the evidence is against the assignment of a compensable evaluation for the Veteran’s costochondritis. Therefore, the Veteran’s claim of entitlement to a compensable evaluation for costochondritis must be denied. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.73, DC 5321. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND Right knee disability In September 2018, the Board remanded the claim for service connection for right knee disability to obtain an adequate opinion that considers whether the Veteran’s right knee disability is secondary to her service-connected disabilities. In response, a nexus opinion was obtained in November 2020. The examiner concluded that it is less likely than not that the Veteran’s right knee disability is related to her military service or that it is caused or aggravated by her service-connected disabilities. Nevertheless, an addendum opinion which explains the examiner’s findings should be obtained. TDIU Because a decision on the remanded issue of entitlement to service connection for right knee disability could significantly impact a decision on the issue of TDIU, the issues are intertwined. As such, remand of the TDIU claim is required. The matters are REMANDED for the following action: Return the case to the VA examiner who provided the November 2020 opinion addressing the right knee, or to a suitable substitute, for issuance of an addendum medical opinion. After reviewing the claims file, the examiner should address the following questions again. (1) Is the right knee disorder at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease? The examiner should consider and comment on reports of bilateral knee pain in service. (2) If the answer to (1) is negative, is the right knee disorder at least as likely as not caused by service-connected disability? (Continued on the next page) (3) If the answers to (1) and (2) are negative, is the right knee disorder at least as likely as not aggravated by service-connected disability? The examiner is asked to provide a complete explanation for all opinions rendered, citing to the medical record when necessary to support the conclusion reached. If an opinion cannot be provided without resorting to speculation, the examiner must state why this is the case. C. J. McEntee Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Solomon 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.