Citation Nr: 21027156 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 14-44 316 DATE: May 4, 2021 ORDER An acquired psychiatric disability, including posttraumatic stress disorder (PTSD) and major depressive disorder with insomnia, is granted. Service connection for a sleep disorder other than insomnia is denied. Service connection for a lumbar spine disability is granted. Service connection for radiculopathy, or right foot numbness, including as secondary to a lumbar spine disability, is granted. Service connection for sensitive teeth is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for a right knee strain with limitation of extension prior to October 6, 2019, and a rating in excess of 20 percent thereafter is remanded. Entitlement to an initial rating in excess of 10 percent for right knee instability prior to March 10, 2021, and a compensable rating thereafter is remanded. Entitlement to service connection for a gastrointestinal disability, including irritable bowel syndrome (IBS) and diarrhea, is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a total disability rating based on individual unemployability due to service-connected disabilities prior to January 23, 2019, including on an extraschedular basis, is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), major depressive disorder, and the correlating symptom of insomnia, is related to a period of active service. 2. The weight of the evidence shows that the Veteran's insomnia is a symptom of his acquired psychiatric disability and not a separate and distinct disability. 3. The evidence is at least in equipoise as to whether the Veteran's lumbar spine disability is related to a period of active service. 4. The evidence is at least in equipoise as to whether the Veteran's lower extremity radiculopathy, or right foot numbness, is proximately due to or the result of his now service-connected lumbar spine disability. 5. The Veteran's sensitive tooth #25 is due to the lack of oral hygiene is not related to active service and is not a disability for which service connection for compensation purposes may be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a sleep disorder other than insomnia have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a lumbar spine disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for lower extremity radiculopathy, or right foot numbness, including as secondary to a lumbar spine disability, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a). 5. The criteria for service connection for sensitive teeth have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 2000 to August 2000, June 2001 to August 2001, and from October 2001 to August 2002. He had additional periods of subsequent active service in the reserves until December 2017. These matters comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for a right knee injury and assigned a 10 percent disability rating, effective March 31, 2010, and denied service connection for headaches, diarrhea, posttraumatic stress disorder (PTSD), low back disability, sleeping problems, sensitive teeth, and right foot numbness. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in September 2016. A copy of the transcript has been reviewed and associated with the claims file. These matters were before the Board in March 2019, at which time they were remanded for additional evidentiary development. In a December 2020 rating decision, the RO granted service connection for right knee instability and assigned a 10 percent disability rating, effective September 25, 2019. In a subsequent March 2021 rating decision, the RO increased the disability rating to 20 percent for right knee strain with limitation of extension, effective October 6, 2019, and decreased the rating for right knee instability to noncompensable, effective March 10, 2021. In a January 2021 rating decision, the RO granted TDIU, effective January 23, 2019. Service Connection Service connection will be granted for a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be granted for a disability, which is proximately due to, the result of, or aggravated by, an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 449 (1995). Service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with applicable criteria; (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f); Anglin v. West, 11 Vet. App. 361, 367 (1998). The term "veteran" is defined in 38 U.S.C. § 101(2) as "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, or air service" includes (1) active duty, (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and (3) any period of inactive duty training (IDT) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a); see Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). ACDUTRA is defined, in part, as "full-time duty in the Armed Forces performed by reserves for training purposes." 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). The term IDT is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of Title 32 [U. S. Code] or the prior corresponding provisions of law. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). In adjudicating these claims, the Board must assess the competence and credibility of the Veteran. Washington v. Nicholson, 19 Vet. App. 362 (2005). Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 1. Entitlement to an acquired psychiatric disability, including posttraumatic stress disorder (PTSD), major depressive disorder, and insomnia; 2. Entitlement to service connection for a sleep disorder other than insomnia The Veteran had active service from October 2001 to August 2002. During this time, he was an infantryman and deployed to Egypt during Operation Noble Eagle. In September 2010 and February 2012 statements, the Veteran indicated that he underwent hostile fire during his time in Egypt. In an August 2013 Statement of Medical Examination and Duty Status, the US Army Reserves confirmed he was deployed to Sinai, Egypt from October 2001 to August 2002 and "saw a lot of bad things" during his deployment for Operation Noble Eagle. In an October 2013 Line of Duty Determination, the Department of the Army confirmed that his diagnosis of posttraumatic stress disorder (PTSD) was incurred during Operation Noble Eagle during this time period. Accordingly, the Board finds that an in-service incurrence during his active service has been confirmed. The Veteran submitted a PTSD Disability benefits questionnaire by F.N., Ph.D., dated in June 2019, which confirmed his diagnosis of PTSD and concluded that it was due to his in-service stressor in Sinai, Egypt. The examiner reasoned that PTSD is produced by life threatening stressors and the firefight endured in Sinai was life threatening. The Veteran underwent a VA examination in November 2020, at which time the examiner assessed him with major depressive disorder due to the combat conditions in the Sinai. The examiner reasoned that the Veteran became depressed due to the horror he witnessed while in Egypt. The examiner concluded that his current insomnia was subsumed under his current diagnosis of major depression and was not a separate diagnosis. Although the examiner indicated that he was exposed to a traumatic event, he concluded that he did not meet the diagnostic criteria for PTSD. After a review of the record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's PTSD and major depressive disorder with symptoms of insomnia are related to his deployment to Egypt from October 2001 to August 2002. In this regard, the October 2013 Line of Duty Determination confirms that his PTSD was found to be incurred during this time period. Moreover, Dr. F.N. concluded that his PTSD was related to his service in Egypt. Moreover, the November 2020 VA examiner concluded that his major depressive disorder was related to the stressors incurred in Egypt. The Board acknowledges that the April 2011 and November 2020 examiners concluded that the Veteran did not have a diagnosis of PTSD. However, the Veteran's treatment records, including a March 2020 letter from R.M., M.D., his VA treating healthcare provider, and Dr. F.N., a psychologist, concluded that he meets the criteria for a diagnosis of PTSD. Accordingly, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a diagnosis of PTSD. Lastly, throughout the rating period, the Board finds that a separate and distinct diagnosis of a sleeping disorder has not been found. However, as confirmed by the November 2020 examiner, the Veteran's insomnia is subsumed and a symptom of his acquired psychiatric disability. In view of the foregoing, and in consideration of the credible medical evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran's acquired psychiatric disabilities, including major depressive disorder and PTSD and his associated symptom of insomnia, were incurred during his active service. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 3. Entitlement to service connection for a lumbar spine disability; 4. Entitlement to service connection for right foot numbness, including as secondary to a lumbar spine disability The Veteran's service treatment and personnel records reveal multiple line of duty determinations for back pain. During active service, in July 2001, he received a permanent profile for chronic back pain and it was noted that he was unable to walk with field gear and rucksacks. Subsequently, in April 2007, May 2007, February 2010, and in February 2011, he was given profiles for chronic back pain. In an August 2013 Statement of Medical Examination and Duty Status, the US Army Reserves confirmed that his lower back pain began when he was deployed in active duty status and worsened over the years. Accordingly, the Board finds that in-service incurrences during a period of active service have been shown by the evidence. Throughout the rating period on appeal, the Veteran has been assessed with degenerative arthritis of the lumbar spine and bilateral lower extremity radiculopathy. He submitted an Independent Medical Evaluation (IME) by J.E., M.D., dated in July 2019. Dr. J.E. concluded that the Veteran's lumbar spine disc disease was more likely than not incurred during his active service. In this regard, he strained his lower back in the line of duty during physical training and was required to carry heavy ammunition, rucksacks, and rifles. This caused him to strain his muscles, ligaments, and structures of the lumbar vertebrae while carrying heavy ammunition rucksacks and rifles, as well as with vigorous physical training. His lumbar spine disability also caused impingement of bilateral L5 and S1 spinal nerves down his legs. The Veteran underwent a VA examination in November 2020, at which time he was diagnosed with spondylolisthesis and bilateral lower extremity radiculopathy. The examiner gave conflicting opinions. In one opinion, she indicated that his lower back disability was not related to service and was acute only. In another opinion, she indicated that his lumbar spine disability was related to service given that his heavy lifting caused lower back pain that later progressed to disc degenerative disease and his radiculopathy was due to his lower back disability. In a January 2021 addendum opinion, she clarified that the back disability was related to his repeated heavy lifting during training and the continued aggravation caused progression of his disc degenerative disease of the lumbar spine and associated right foot numbness. After a review of the evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran's lumbar spine disability was incurred in his first period of active service and sustained continued aggravation during his subsequent periods of active service. In this regard, in July 2001, he received a permanent profile for chronic back pain and continued to receive profiles for his back pain. Dr. J.E. concluded that his lumbar spine disability was related to his lower back strain in the line of duty and physical training. Moreover, the November 2020 examiner ultimately concluded in a January 2021 addendum report that his lumbar spine disability was due to his repeated heavy lifting in service and continued aggravation, which caused his disc degenerative disease to progress. Lastly, Dr. J.E. and the November 2020 examiner concluded that his bilateral lower extremity radiculopathy was due to his lumbar spine disability. The Board notes that the Veteran has asserted that his lumbar spine disability is secondary to his service-connected right knee disability. Given the award of service connection on a direct basis, the Board need not consider this theory of entitlement. In view of the foregoing, and in consideration of the credible medical evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran's lumbar spine disability was incurred during his active service. Moreover, the evidence reveals that his lower extremity radiculopathy was proximately due to or caused by his lumbar spine disability. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 5. Entitlement to service connection for sensitive teeth Under current legal authority, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150. Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, but only if such bone loss is due to trauma or osteomyelitis, and not due to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. at Notes. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purposes of establishing eligibility for outpatient dental treatment and cannot be considered for compensation purposes. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. A line of duty report dated in June 2007 indicated that the Veteran hit his chin while taking tent stakes apart and caused tiny chips in his #9 and #24 teeth. He underwent enameloplasty and would need no further treatment. The Veteran underwent a VA examination in June 2011, at which time the examiner indicated that teeth #9 and #24 had been chipped very minimally and had been subsequently smoothed over. He indicated that his current sensitivity was coming from tooth #25, which had a small chip, but was not caused by the in-service event of the tent stake, which hit teeth #9 and #24. The examiner also indicated that his problems with the sensitivity was due to his lack of oral hygiene. After a review of the evidence, the Board finds that service connection for compensation purposes for a dental disability is not warranted. In this regard, although the Veteran chipped teeth #9 and #24 in service, these teeth were repaired. His current sensitivity was found to be due to his lack of oral hygiene and from a chip in tooth #25 rather than from the in-service incident, as confirmed by the June 2011 VA examiner. The evidence does not reveal that the Veteran suffers from impairment of the mandible, loss of a portion of the ramus, and/or loss of a portion of the maxilla due to the in-service chipped teeth #9 and #24. Accordingly, as there is no evidence that the Veteran has a dental disability listed in 38 C.F.R. § 4.150, the preponderance of the evidence is against the claim, and there is no basis for service connection for compensation purposes. The Board also notes that a claim of service connection for a dental disorder is also a claim for VA outpatient dental treatment. See Mays v. Brown, 5 Vet. App. 302 (1993). In this regard, the determination of whether service connection may be established for the purpose of outpatient dental treatment is based on the criteria set forth under 38 C.F.R. § 3.381. As provided at 38 C.F.R. § 3.381(a), treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service-connected solely for the purpose of establishing eligibility for outpatient dental treatment. In determining service connection, the condition of teeth and periodontal tissues at the time of entry into active duty will be considered. Treatment during service, including filling or extraction of a tooth, or placement of a prosthesis, will not be considered evidence of aggravation of a condition that was noted at entry, unless additional pathology developed after 180 days or more of active service. See 38 C.F.R. § 3.381(c). With respect to dental conditions noted at entry and treated during service, 38 C.F.R. § 3.381(d) sets forth principles for determining whether a grant of service connection for treatment purposes is warranted. Such guidelines are as follows: (1) Teeth noted as normal at entry will be service- connected if they were filled or extracted after 180 days or more of active service. (2) Teeth noted as filled at entry will be service- connected if they were extracted, or if the existing filling was replaced, after 180 days or more of active service. (3) Teeth noted as carious but restorable at entry will not be service-connected on the basis that they were filled during service. However, new caries that developed 180 days or more after such a tooth was filled will be service- connected. (4) Teeth noted as carious but restorable at entry, whether or not filled, will be service-connected if extraction was required after 180 days or more of active service. (5) Teeth noted at entry as non-restorable will not be service-connected, regardless of treatment during service. (6) Teeth noted as missing at entry will not be service connected, regardless of treatment during service. In addition to the above principles, 38 C.F.R. § 3.381(e) indicates specific dental conditions that will not be considered service connected for treatment purposes: (1) Calculus; (2) Acute periodontal disease; (3) Third molars, unless disease or pathology of the tooth developed after 180 days or more of active service, or was due to combat or in-service trauma; and (4) Impacted or malposed teeth, and other developmental defects, unless disease or pathology of these teeth developed after 180 days or more of active service. Finally, 38 C.F.R. § 3.381(f) provides that teeth extracted because of chronic periodontal disease will be service-connected only if they were extracted after 180 days or more of active service. 38 C.F.R. § 3.381. In the present case, the tooth in question has not been filled or extracted and does not otherwise meet the criteria for service connection for treatment purposes. Thus, service connection on either a compensation basis or a treatment only basis are both denied. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for a right knee strain with limitation of extension prior to October 6, 2019, and a rating in excess of 20 percent thereafter is remanded; 2. Entitlement to an initial rating in excess of 10 percent for right knee instability prior to March 10, 2021, and a compensable rating thereafter is remanded. The Veteran underwent multiple VA examinations to assess his service-connected right knee disability following the Board's March 2019 remand in March 2019, October 2019, June 2020, September 2020, and March 2021. However, these examinations are insufficient to determine the present claim. In this regard, the examiners indicated that the Veteran had pain with weight bearing and non-weight bearing but failed to provide the correlating range of motion findings pursuant to the remand instructions and Correia v. McDonald, 28 Vet. App. 158 (2016). Moreover, the March 2021 examiner indicated that the Veteran did not have associated right knee instability and did not ambulate with a cane. However, the June and September 2020 examiners assessed him with right knee instability and indicated that he used a cane for stability constantly. Accordingly, the Board finds that a new VA examination is warranted on remand. Lastly, a Supplemental Statement of the Case (SSOC) was issued in January 2021. A VA examination was performed in March 2021 to assess the severity of the Veteran's right knee disability. However, the RO did not prepare an SSOC considering this newly VA generated evidence. Accordingly, a remand is required for the issuance of an appropriate SSOC that considers the additional VA treatment records, VA examinations, and any other relevance evidence since the January 2021 SSOC. See 38 C.F.R. §§ 19.31, 19.37, 20.1305(c). 3. Entitlement to a gastrointestinal disability, including irritable bowel syndrome (IBS) and diarrhea, is remanded. In a post-deployment health reassessment dated in September 2007, the Veteran reported diarrhea following his deployment in 2002. In a letter dated in March 2020, the Veteran's primary care physician at the VA, Dr. R.M., indicated that the Veteran had chronic IBS with intermittent episodes of diarrhea and constipation. The Veteran underwent a VA intestinal examination in November 2020, at which time the examiner indicated that he had no diagnosis. The examiner further concluded that his diarrhea was acute only. After a review of the evidence, the Board finds that a new VA examination is warranted. In this regard, the March 2020 letter from Dr. R.M. indicated that the Veteran had a current diagnosis of IBS. Accordingly, a new VA examination is warranted in order to assess the nature and etiology of his IBS. 4. Entitlement to service connection for headaches is remanded. In May 2010, the Veteran was given a temporary profile for headaches. He subsequently reported headaches during his periodic examinations. In a February 2012 statement from the Veteran, he reported that his headaches began in basic training and he has had problems since then. The Veteran submitted a July 2019 IME by Dr. J.E. Dr. J.E. concluded that the Veteran started having headaches after his traumatic brain injury (TBI) in service. The Veteran underwent a VA examination in November 2020, at which time the examiner assessed the Veteran with migraine headaches and listed the date of diagnosis as 2007. However, she indicated that the date of onset was reported as 2001. The examiner ultimately concluded that the headaches were not related to service given that there was no evidence of chronicity of care and symptoms were subjective only. After a review of the evidence, the Board finds that the July 2019 IME and November 2020 examination are insufficient to determine the present claim. In this regard, there is no evidence that the Veteran suffered a TBI in service and he is not currently service-connected for a TBI. Moreover, the November 2020 examiner disregarded the Veteran's reported symptoms because they were subjective only. The Board notes that the Veteran's headache symptoms are documented in his service-treatment records and personnel records. Furthermore, the Veteran is competent to identify and discuss his head pain. Accordingly, the Board finds that a new VA examination is warranted on remand in order to assess the nature and etiology of the Veteran's headaches. 5. Entitlement to service connection for a total disability rating based on individual unemployability due to service-connected disabilities prior to January 23, 2019, including on an extraschedular basis, is remanded. The Board notes that prior to January 23, 2019, the Veteran does not currently meet the schedular criteria for a TDIU rating. However, given that the Veteran has been service-connected for a psychiatric disability and a lumbar spine disability and associated radiculopathy in this decision, the Board will defer adjudication at this time until the Regional Office issues a disability rating for each of these disabilities. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records from March 2021 to the present. 2. After completion of # 1, schedule the Veteran for a VA examination by an appropriate clinician to determine the severity of his service-connected right knee disability. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran's pertinent medical history and such review should be noted in the examination report. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. Specifically, active and passive range of motion testing as well as weight-bearing and non-weight-bearing testing must be conducted and recorded. The examiner should indicate how far back (i.e., one year, two years, etc.) these results would apply if possible. The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The extent of additional limitation should be expressed in degrees. Flare ups have been reported and the examiner must express an opinion on whether the flare-ups are associated with additional functional loss. If so, he or she should estimate the degree of lost motion during such flare-ups. The examiner is to attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees cannot be given. Should the examiner maintain that they cannot do so without resorting to speculation, they must explain why this is so. Note: Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large and not the insufficient knowledge of the examiner. The presence or absence of ankylosis should be noted. The examiner is to indicate the presence or absence of lateral instability and/or recurrent subluxation in the Veteran's right knee, if any. If instability is not found, the examiner should explain why in light of the instability found in the June and September 2020 VA examinations. If instability is present, the examiner is to state whether such instability is slight, moderate, or severe. If instability is present and found to be present from February 7, 2021, and ongoing, the examiner should also state whether it manifests in a sprain, incomplete ligament tear, complete ligament tear (repaired, unrepaired, or failed repair), causing persistent instability and/or whether a medical provider prescribed an assistive device and/or bracing for ambulation. If a diagnosed patellar instability is found involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon), the examiner should discuss whether it manifests in recurrent instability, required surgical repair, and/or requires a prescription from a medical provider for a brace, cane, or walker. Further, the examiner must indicate whether there is cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion of the joint or partial removal of the semilunar cartilage. The examiner must also indicate whether there is an impairment of the tibia and fibula. If so, the examiner should discuss whether there is nonunion of, with loose motion, requiring a brace or malunion of with marked, moderate, or slight knee or ankle disability. If so, from February 7, 2021, and ongoing, the examiner should also discuss whether it requires treatment, the duration of such treatment, and whether it is responsive to such treatment, including conservative, surgical, or shoe orthotics treatment. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. After completion of #1, schedule the Veteran for a VA examination to assess the etiology of his IBS and headache disability by an examiner who has not previously provided an opinion in this matter. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. The examiner should respond to the following: is it at least as likely as not (probability of at least 50 percent) that the Veteran's headache and/or IBS disability had their onset in and/or are otherwise etiologically related to a period of active service? The examiner must provide a comprehensive rationale for each opinion provided. The examiner should discuss the Veteran's statements of record, his hearing testimony, the July 2019 IME report, his post-deployment health reassessment dated in September 2007, and his May 2010 profile for headaches. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 4. Thereafter, readjudicate the issues on appeal, to include consideration of the additional VA examination reports and treatment records from the date of the January 2021 SSOC. If the benefits sought on appeal are not granted in full, issue the Veteran and his representative a Supplemental Statement of the Case (SSOC) and provide the Veteran an opportunity to respond. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. (Hurley) Merrick 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.