Citation Nr: 21029373 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 09-04 436 DATE: May 13, 2021 ORDER The petition to reopen the claim of entitlement to service connection for a right knee disorder is denied. The appeal is dismissed. Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for a bilateral foot disorder is denied. REMANDED Entitlement to service connection for a bilateral hip disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. In a January 2011 Board decision, the Veteran's claim of entitlement to service connection for a right knee disorder was denied. He did not appeal this decision. 2. In a September 2013 rating decision, the Veteran's petition to reopen the right knee claim was denied. He did not appeal this determination or submit new and material evidence within one year of notification of this decision. 3. Additional evidence has been received which is cumulative or redundant of the evidence of record at the time of the September 2013 rating decision and does not relate to an unestablished fact necessary to substantiate the claim for service connection for a right knee disorder. 4. The Veteran's low back disorder was not present during active duty, did not manifest within one year of discharge, and is not otherwise attributable to service. 5. The Veteran's right ankle disorder was not present during active duty, did not manifest within one year of discharge, and is not otherwise attributable to service. 6. The Veteran's bilateral foot disorder was not present during active duty, did not manifest within one year of discharge, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. The September 2013 rating decision denying reopening of the claim of entitlement to service connection for a right knee disorder is final. 38 U.S.C. §§ 7105 (2012); 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103 (2019). 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for a right knee disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for a low back disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 4. The criteria for entitlement to service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from January 1964 to December 1965. These issues come before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the issues for further development in March 2020. The case has now been returned to the Board for appellate review. The Board notes that the Veteran's claim of entitlement to a rating in excess of 10 percent for allergic rhinitis is still in remand status. As such, the Board will not address this issue at this time. 1. New and Material Evidence Right knee. A claim may be considered on the merits only if new and material evidence has been received since the time of the prior adjudication. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a); Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence is considered "new" if it was not previously submitted to agency decision makers. "Material" evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. "New and material evidence" can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The language of 38 C.F.R. § 3.156 (a) creates a low threshold for finding new and material evidence, and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Board is required to make its own determination to reopen a claim based on new and material evidence that is independent of the RO's decision to reopen a claim. Barnett v. Brown, 83 F.3d 1380, 1385 (Fed. Cir. 1996). By way of history, the Veteran submitted a claim of entitlement for a right knee disorder in July 2007. He contended that his right knee disorder was due to in-service falls. In an April 2008 rating decision, the claim was denied, noting that there was no in-service right knee complaints and that there was no evidence of a current right knee condition. The Veteran timely appealed this determination to the Board, which denied his claim in a January 2011 Board decision. He did not appeal that decision, which became final on January 6, 2011, the date the Board decision was mailed to the Veteran. 38 C.F.R. §§ 20.1100. The evidence of record at the time of the Board decision consisted of the Veteran's service treatment records (STRs) and post-service clinical records. A review of the STRs reveal no complaints or issues with the right knee. A July 2007 private medical report noted a diagnosis of right knee arthralgia. The Board found that while right knee arthritis was identified as a chronic disease subject to presumptive service connection, the Veteran was not entitled to such presumption because there was no evidence of a right knee disorder manifesting within one year of service. In addition, the Board found that direct service connection was unwarranted based on: (1) negative in-service right knee complaints in the STRs, (2) the lack of any nexus opinion linking the disorder to service, and (3) the lack of any descriptive lay statement regarding the in-service incurrence of the right knee disorder or its relationship to service. The Board noted that while a VA examination was not conducted, the evidence of record did not warrant a remand for an examination, as there was no evidence of an in-service right knee disorder or competent evidence showing a nexus between service and the right knee disorder. In May 2012, the Veteran submitted a claim of entitlement to service connection for a right knee disorder. In a September 2013 rating decision, the petition to reopen the claim was denied. The RO found that no new and material evidence had been received to warrant reopening the right knee claim. Specifically, the RO found that there was no evidence that the right knee disorder was incurred in or otherwise related to service. The evidence at the time of the RO decision included post-service VA treatment records and a September 2013 VA examination. Post-service clinical records noted complaints and treatment for right knee issues. A September 2013 VA examination noted a diagnosis of bilateral knee osteoarthritis. In addition, the examiner noted that the Veteran was seeking service connection for his right knee disorder as secondary to his claimed left knee disorder. The examiner gave a negative opinion that the left knee was the result of military service. The examiner noted that there was no evidence of a chronic condition and that any in-service left knee complaints were acute and transitory. In addition, the examiner noted that osteoarthritis is considered part of the aging process. The examiner then gave a negative opinion the right knee disorder was secondary to the left knee. The examiner noted that there was no evidence of in-service treatment for a right knee disorder and that osteoarthritis was part of the normal aging process. Evidence that does not support a claim for service connection is not considered to be new and material evidence. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran did not appeal this decision or submit new and material evidence within one year of notification of this decision, making the decision final at the one year mark. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.302, 20.1103. In September 2016, the Veteran submitted a claim of entitlement to service connection for a right knee disorder secondary to his left knee disorder. The evidence received since the time of the September 2013 rating decision includes post-service VA treatment records and a February 2021 Board decision denying service connection for a left knee disorder. This evidence is new, as it was not previously in the record. However, the new evidence is not material, as it does not raise a reasonable possibility of substantiating the Veteran's claim for service connection. Therefore, the Veteran's claim to reopen service connection for a right knee disorder must be denied. The Veteran's post-service VA treatment records include complaints and treatment for right knee issues. However, these medical records do not indicate that the right knee disability is linked to active duty. In addition, the February 2021 Board decision denied service connection for the left knee. The Board found that while there was evidence of a current left knee disorder, there was no evidence demonstrating that the left knee disorder was due to service. The Board noted that a review of the STRs revealed left knee complaints which resolved prior to leaving service. In addition, the Board noted the September 2013 VA examination report which rendered a negative opinion that the left knee disorder was due to service. In addition, the Board acknowledged the Veteran's contentions; however, it found that the first complaints of knee pain was over 36 years after his service separation. Also, the Board noted that the only medical opinion regarding nexus was the VA examination, which concluded that the left knee disorder was not due to military service. Furthermore, the Board noted that the left knee osteoarthritis qualified as a chronic condition subject to presumptive service connection. However, the Board found that the Veteran did not contend and the evidence did not support a continuity of symptomology for the left knee. Again, evidence that does not support a claim for service connection is not considered new and material evidence. The Board notes that the September 2013 examination is arguably inadequate because the examiner failed to render a complete opinion on secondary service connection for the Veteran's right knee disorder. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board must consider all evidence of record, including any new VA examinations obtained by the RO, when determining whether a claim should be reopened, but the duty to ensure that an adequate examination was provided, as set forth in Barr v. Nicholson, 21 Vet. App. 303 (2007), is not applicable unless a claim is reopened for consideration on the merits. Once the Board decides that a claim is not be reopened, the conditional duty to provide a new VA examination is extinguished. See Woehlaert, supra, at 464. Because the Board determines that the Veteran has not submitted new and material evidence, the adequacy of the above examination is moot, and there is no need to afford the Veteran a new VA examination. It is the claimant's responsibility to present and support a claim for benefits. See 38 U.S.C. § 5107 (a). The Veteran has been accorded the opportunity to submit new and material evidence and has failed to do so. Because new and material evidence has not been received, the Veteran's claim to reopen entitlement to service connection for a right knee disorder must be denied. 2. Entitlement to service connection for a low back disorder. 3. Entitlement to service connection for a right ankle disorder. 4. Entitlement to service connection for a bilateral foot disorder. The Veteran contends that his low back, right ankle, and bilateral foot disorders are the result of in-service falls. His claims for compensation were received by VA in September 2016. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131 (2012). Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board notes that the Veteran's low back, right ankle, and bilateral foot arthritis qualify as a "chronic condition" under 38 C.F.R. § 3.309 (a). As such, an alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303 (b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). The Board finds that the Veteran currently has low back, right ankle, and bilateral foot disorders. November 2020 VA examination reports noted diagnoses of degenerative arthritis of the lumbar spine, right leg fracture proximal fibulae, and bilateral foot osteoarthritis. In addition, there is evidence of an in-service injury or event. The VA examination reports noted the Veteran's reports of in-service falls. Accordingly, the two Shedden criteria are met and are not in dispute. The remaining issue, therefore, is whether there is a causal connection between the low back, right ankle and bilateral foot disorders and military service. The Board finds a preponderance of the probative evidence to be against the Veteran. As such, the claims for service connection must be denied. A review of the Veteran's STRs note no complaints or treatment for any low back, right ankle, or bilateral foot issues. Clinical examination was negative on entrance and separation. There is no indication in the STRs that the Veteran had any problems with his low back, right ankle, or feet during active duty. The record contains no medical evidence dated between December 1965 and December 1966 - within the first year of discharge from service - indicating any diagnosis or treatment for low back, right ankle, or bilateral foot disorders. The first complaint of low back, right ankle or bilateral foot issues is dated many years after discharge. There is no probative evidence of the presence of low back, right ankle, or bilateral foot arthritis to a compensable degree within one year of discharge. Service connection for low back, right ankle or bilateral foot arthritis on a presumptive basis is not warranted. A review of the Veteran's post-service VA and private treatment records show complaints and treatment for low back, right ankle, and bilateral foot issues. A March 1993 private clinical record noted an lumbar spine impairment due to an accident. A June 1994 VA examination report noted the Veteran's lumbar spine injury while working on air conditioning unit for Puerto Rico Correction Division that required lumbar spine surgery. Subsequent VA and private treatment records noted complaints and treatment for low back, right ankle, and bilateral foot issues. However, none of the treating physicians have given positive opinions that these disorders are the result of military service. Regarding the low back, the Veteran underwent a VA examination in November 2003. He was diagnosed with lumbar laminectomy, straightening of the lumbar lordosis, degenerative disc disease, left paracentral disc herniation L4-L5, left-disc herniation with compression of the thecal sac and nerve roots at L5-S1 and small right paracentral disc herniation on L1-L2. However, no etiology opinion was rendered. The Veteran underwent a second VA examination in November 2020. He was diagnosed with degenerative arthritis of the lumbar spine. The examiner noted the Veteran's report of in-service injury due to falls on duty and pain complaints. However, she gave a negative opinion that the low back disorder was the result of military service. She noted that the Veteran had history of lower back pain with history of laminectomy in 1992. She further explained that the Veteran's lumbar degenerative joint disease was a common form of arthritis and possessed marked variability of disease expression centraling [sic] around altered joint function that is associated with characteristic pathologic changes in the joint tissues. In addition, she also noted that proinflammatory factors appeared to be driving the production of the proteolytic enzymes responsible for the degradation of the extracellular matrix that results in joint tissue destruction. The examiner also noted that multiple risk factors have been linked to the pathogenesis of osteoarthritis, including age, joint injury, obesity, genetics, anatomical factors including joint shape and alignment, and gender. Furthermore, the examiner found that that there were reports of multiple falls; however, there were no medical records associated with these falls. Finally, the examiner noted that based on the lack of medical findings during service and the large time gap regarding low back complaints, she could not rule out natural progression of aging and daily activities as a cause of the low back disorder. Regarding the right ankle, the Veteran underwent a VA examination in November 2020. He was diagnosed with residue of right leg fracture proximal fibulae. The examiner noted the Veteran's report of in-service falls and current pain complaints. She then gave a negative opinion that the right ankle disorder was due to military service. The examiner noted that the post-service medical records revealed a history of fall with fracture of right fibula that healed in September 2011. While the examiner noted the Veteran's pain complaints, she also noted that there was a large time gap between service and the first complaints of injury. Furthermore, she also noted that there was a lack of medical evidence regarding "falls during military service. Regarding the bilateral foot disorder, the Veteran underwent a VA examination in November 2020. He was diagnosed with bilateral foot osteoarthritis. The examiner noted the Veteran's report of in-service falls and current pain complaints. She then gave a negative opinion that the bilateral foot disorder was due to military service. The examiner noted that the Veteran was diagnosed with mild osteoarthritis in 2018, which was consistent with his age. The examiner also noted that arthritis was one of the most common causes of chronic disability in adults due to pain and altered joint function that was associated with characteristic pathologic changes in the joint tissues. In addition, she noted that pathological findings in articular cartilage, bone, synovium, and soft tissues are present to varying degrees in all people with degenerative joint disease, suggesting a common response of the joint to a variety of insults. The examiner then noted that multiple risk factors have been linked to the pathogenesis of DJD, include age, joint injury, obesity, genetics, anatomical factors including joint shape and alignment, and gender. Furthermore, the examiner found that that there were reports of multiple falls; however, there were no medical records associated with these falls. Finally, the examiner noted that there were medical findings during service and that there was a large time gap regarding bilateral foot complaints since service. After a review of the evidence of record, the Board finds that service connection for the low back, right ankle, and bilateral foot disorders is unwarranted. The Board finds the VA opinions persuasive. The examiner noted the Veteran's self-reported medical history, indicated a review of the claims file, and based her opinions on the Veteran's interview, the claims file review, and the VA examination results. The examiner discounted the Veteran's self-reported history of continuous pain complaints during active duty and thereafter. The Board finds the examination reports are based on accurate factual backgrounds. To the extent that the Veteran has alleged he has had continuous low back, right ankle, or bilateral foot symptomology from military service to the present, the Board finds this allegation is undercut by the contemporaneous evidence of record. The STRs note no complaints for low back, right ankle, or bilateral foot issues throughout the Veteran's entire active duty service. Clinical examination at discharge was found to be normal. In addition, there is no medical evidence immediately after the Veteran's service that noted low back, right ankle or bilateral foot complaints or treatment. The first pain complaints were found many years after discharge. Of note here are the reported injury in the back in 1990's, which required him to undergo a surgery and history of fall with fracture of right fibula in 2011. The Board finds the contemporaneous evidence from active duty service is more probative than the Veteran's recent assertions that his current disorders began during active duty and remained thereafter, voiced many years after service and in connection with a claim for disability benefits. See Curry, 7. Vet. App. at 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). The Veteran's assertion of continuous symptoms during active duty and for a year after discharge service is contradicted by other evidence. Caluza v. Brown, 7 Vet. App. 498 (1995) (In assessing credibility, the Board may consider interest, bias, inconsistent statements, bad character, internal inconsistencies, factual plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). The STRs are silent as to complaints of, diagnosis of or treatment for low back, right ankle, or bilateral foot problems. The Board finds it reasonable to assume that, if the Veteran had had problems with his low back, right ankle, or feet during active duty, he would have sought treatment during active duty. He did not do so. Furthermore, the Veteran sought treatment for various other conditions post-service, but did not indicate any low back, right ankle or bilateral foot issues until many years later. Again, if the Veteran had problems post service, it follows that the Veteran would have reported these issues to the treating clinicians. The Board places greater probative weight on the contemporaneous evidence in the STRs which are silent as to any low back, right ankle or bilateral foot problems. Not only may the Veteran's memory have dimmed with time but the more recent statements may have been colored by the chance for pecuniary gain. Finally, the VA opinions are the only probative medical opinions of record that addresses the issue of medical nexus between the various disorders and active duty. In light of the probative negative nexus opinions and the lack of a probative positive opinion to contradict the negative evidence, there is simply no basis for a grant of service connection for the Veteran's various disorders. In adjudicating these claims, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his various disorders are the result of in-service falls. While the Board acknowledges that the Veteran is competent to report his experienced bilateral knee symptoms, he is not competent to link the low back, right ankle, or bilateral foot complaints to his active duty service. As a layperson, he not competent to make a complex medical determination as to the etiology of the Veteran's various disorders. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, he cannot render an etiology opinion. In addition, the credibility of the Veteran's allegations of continuous low back, right knee, or bilateral foot problems since active duty are without probative value as addressed above. Furthermore, a review of the pertinent medical evidence demonstrates that his various disorders were not caused by his military service. Since a preponderance of the evidence weighs against the claim, the Veteran is not entitled to the benefit of the doubt. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed Cir. 2001). Therefore, the claims of entitlement to service connection for low back, right ankle or bilateral foot disorders are denied. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral hip disorder. The Veteran contends that his bilateral hip disorder was the result of military service. The Board notes that this matter was remanded in March 2020 for a VA examination to determine the nature and etiology of the claimed bilateral hip disorder. A review of the claims file reveals that this examination has not been conducted. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). While it appears that the remand directive did not refer to bilateral hips specifically, the Board specified in the remand text that a VA examination must be scheduled for bilateral hips in addition to other disabilities. The Board finds that there has not been substantial compliance with its previous remand directives. Accordingly, this matter must be remanded for a VA examination to be conducted. 2. Entitlement to service connection for a left ankle disorder. The Veteran contends that his left ankle disorder is the result of in-service falls. A review of the STRs reveal no complaints or treatment for left ankle issues. Clinical examination was normal on entrance and separation. A review of the post-service VA and private treatment records note complaints and treatment for left ankle issues. Of note, the clinical records note several years of joint pain that affected the Veteran's ability to ambulate. The Veteran underwent a VA examination in November 2020. He was diagnosed with residue of right leg fracture proximal fibulae. The examiner noted the Veteran's report of in-service falls and current pain complaints. She then gave a negative opinion that the left ankle disorder was due to military service. The examiner noted that there was no clinical findings on the left ankle to warrant a current diagnosis. No other opinions or rationale were provided. The United States Court of Appeals for the Federal Circuit (Court) has held that pain in the absence of a presently-diagnosed condition can cause functional impairment, which may qualify as a disability for VA purpose. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). A review of the claims file reveals left ankle pain complaints that affect the Veteran's ability to ambulate. Therefore, in light of Saunders, a remand is necessary to obtain a VA medical opinion. The examiner is directed to report the Veteran's current symptomatology and to address whether the Veteran's reported left ankle pain results in any functional impairment. Saunders, 886 F.3d at 1362. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. The Veteran contends that he is entitled to a TDIU, stating that he is unable to work as a result of his service-connected disabilities. The Board notes that the TDIU claim is inextricable intertwined with the other claims being remanded. As such, the Board finds that the TDIU claim must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Once the above has been completed to the extent possible, schedule the Veteran for a VA examination (or a telehealth interview, if an in-person examination is not feasible) regarding the nature and etiology of the bilateral hip disorder with a qualified medical professional with appropriate expertise. The claims file must be reviewed, and a notation must be made on the examination report that the claims file was reviewed. Based on the examination results, and a review of the record, the examiner must address the following: Whether it is at least as likely as not (a 50 percent or greater probability) that the bilateral hip disorder is the result of military service? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Obtain a VA medical opinion regarding the etiology of the Veteran's left ankle disorder or functional impairment to include pain in the left ankle from a qualified medical professional with appropriate expertise. The claims file must be reviewed, and a notation must be made on the examination report that the claims file was reviewed. If the requested opinions cannot be rendered without an examination, then schedule the Veteran for an examination (or a telehealth interview, if an in-person examination is not feasible). Based on a review of the record, and a new examination if needed, the examiner must address the following: Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran has a left ankle disorder manifested by symptoms to include pain complaints and frequency that causes functional impairment. If functional impairment is found, whether it is at least as likely as not that the left ankle disorder is due to the Veteran's military service? The examiner must address the reports of left ankle joint pain found in the post-service VA treatment records. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). Y. Taylor Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.T. Massey, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.