Citation Nr: 21035186 Decision Date: 06/08/21 Archive Date: 06/08/21 DOCKET NO. 20-19 826 DATE: June 8, 2021 ORDER Entitlement to service connection for a cervical spine condition is denied. Entitlement to service connection for a left hip condition, to include as secondary to a cervical spine condition and/or service-connected lumbar strain with myositis (low back disability) disability is denied. Entitlement to service connection for a right hip condition, to include as secondary to a cervical spine condition and/or service-connected low back disability is denied. Entitlement to service connection for a left knee condition, to include as secondary to a cervical spine condition and/or service-connected low back disability is denied. Entitlement to service connection for a right knee condition, to include as secondary to a cervical spine condition and/or service-connected low back disability is denied. Entitlement to service connection for a right shoulder condition, to include as secondary to a cervical spine condition and/or service-connected low back disability is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for a left wrist condition, to include as secondary to a cervical spine condition and/or service-connected low back disability is remanded. FINDINGS OF FACT 1. The Veteran's neck, bilateral hip, bilateral knee, and right shoulder disabilities were not incurred in, and are not otherwise related to, his active military service. 2. Resolving all reasonable doubt in favor of the Veteran, his service-connected disabilities have precluded him from securing or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a left hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a left knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for a right knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for a right shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1958 to October 1960. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Board remanded the claims on appeal for further development. With regards to the issues being decided herein, the Board's remand directives have been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998). With regards to the issue of a left wrist condition, the Board's directives have not been substantially completed and will be further discussed in the remand portion of the decision. The appeal previously included claims of service connection for a low back condition, a bilateral ankle condition, a bilateral foot condition, a right wrist condition, and a right elbow condition. The RO granted the claims in December 2020 and January 2021 rating decisions. As these awards represented a full grant of the benefits sought on appeal, the claims are no longer before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In January 2021, the Veteran raised the issue of special monthly compensation based on the need for aid and attendance. Should the Veteran wish to file a claim for such, he may file an initial claim with the RO. This appeal has been advanced on the Board's docket. 38 U.S.C. § 7107(a)(2). 1. Service connection claims. The Veteran contends that his cervical spine, bilateral hip, bilateral knee, and right shoulder conditions are related to a tank explosion in service and/or secondary to a service-connected lumbar spine disability. For the reasons that follow, the Board finds that service connection is not warranted for any of the claimed conditions. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of 1) a current disability, 2) in-service incurrence or aggravation of an injury or disease, and 3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307, so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may be established for chronic diseases, to include arthritis, manifesting to a certain degree within a year after service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). In addition to service connection on a direct basis, service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The competent evidence of record shows that the Veteran has current diagnoses related to his cervical spine, bilateral hips, bilateral knees, and right shoulder. See March 2018 correspondence from Dr. C.M.Q. (noting diagnoses of degenerative joint disease of the shoulders, hips, and knees); October 2020 VA examinations (providing diagnoses of a cervical strain, right shoulder degenerative and enthesopathic changes, bilateral trochanteric pain syndrome of the hips, right knee degenerative arthritis, and bilateral patellofemoral pain syndrome). Accordingly, the first element of service connection has been established. In coming to this conclusion, the Board notes that Dr. C.M.Q. noted that the Veteran had degenerative arthritis of the hips and knees. However, at the October 2020 VA examinations, the examiner diagnosed bilateral trochanteric pain syndrome of the hips and patellofemoral pain syndrome of the left knee. VA treatment records also do not show that the Veteran has been diagnosed with degenerative arthritis of the hips or left knee. Arthritis must be objectively confirmed by x-ray. 38 C.F.R. § 4.61a, Diagnostic Code 5003. It does not appear that Dr. C.M.Q. diagnosed arthritis of the hips or left knee by x-ray, but rather based her diagnosis of the Veteran's reports of hip and knee pain. See March 2018 correspondence (noting that Veteran presents with pain radiating to the hips and knees with no mention of conducting any diagnostic testing). Thus, the Board finds that the evidence of record indicates that the Veteran does not have arthritis of the hips or left knee. The Veteran's service treatment records (STRs) are silent for any complaints, treatment, or diagnoses related to the cervical spine, hips, knees, or right shoulder. The musculoskeletal system was noted as normal on his September 1960 Report of Medical Examination at separation. On the accompanying Report of Medical History, the Veteran denied "'trick' or locked knee" but reported "yes" to "painful or 'trick' shoulder or elbow." The Veteran contends that his conditions are related to a gas tank explosion that occurred in service. The occurrence of this event has been conceded. See December 2020 rating decision (granting service connection for a number of claims are related to his incident); see also February 1960 STR (noting a blast to the left eye); June 1992 VA examination (reporting involvement in a gasoline tank explosion in 1960 while soldering a jeep gasoline tank and experiencing severe trauma to left eye). Pursuant to the August 2020 remand, the Veteran underwent VA examinations for his cervical spine, hips, knees, and right shoulder in October 2020. At the examinations, the Veteran reported that his right shoulder, bilateral hip, and bilateral knee pain began approximately 10 years ago and that his neck pain began approximately 20 years ago. The examiner opined that the claimed conditions were less likely than not related to the Veteran's active duty service. With regards to the hips and knees, the examiner explained that the Veteran reports the onset of bilateral hip and knee pain approximately 10 years ago, which is several years after active duty service in 1960. While the examiner acknowledged the February 1960 gas tank explosion, he noted that the Veteran reported his knees and hips were not affected at that time. He noted that the Veteran reported only having problems with his eye, shoulder, elbow, wrist, hand, feet, and low back due to the tank explosion. It was further noted that the Veteran's separation examination showed no evidence of any hip or knee complaint, injury, or diagnosis. The examiner concluded that the Veteran's current bilateral hip and knee conditions manifested several years after service and are completely unrelated to service. Regarding the Veteran's cervical spine and right shoulder conditions, the examiner explained that the Veteran was diagnosed with a cervical spine condition and right shoulder condition many years after service and that his STRs are silent regarding any diagnoses or symptoms of a cervical spine or right shoulder condition during active service. He also noted that there is no evidence of any manifestation or diagnosis of a cervical spine or right shoulder condition within a year of separation from service. The examiner also acknowledged the gas tank explosion but noted that based on STRs, there is no objective evidence that the incident produced any trauma or affected the Veteran's cervical spine or right shoulder. Regarding secondary service connection, the examiner also opined that the claimed conditions were less likely than not related to or aggravated by the Veteran's service-connected lumbar spine condition. The examiner explained that medical evidence supports the fact that the lumbar spine and bilateral hip and knee joints are in different anatomical areas with different bony structures and nerve supplies that are unrelated to each other. The examiner also noted that there is no evidence that the bilateral hip or knee conditions were aggravated by the low back condition. The examiner further explained that the Veteran's bilateral hip condition has a multifactorial etiology, but the most common causes are repeated use or overuse of the hip muscles. He also noted that the Veteran's arthritis is due to the normal progression of the aging process and that the patellofemoral pain syndrome, while it has a multifactorial etiology, could be due to overuse, problems with knee cap alignment, sports training, changes in foot ware, change in sport activities, sport injuries, or mechanical injuries. The examiner further noted that as part of the normal aging process, muscle changes occur, such as less collagen and flexibility, and that patients are more prone to overuse of the knee. The examiner also opined that the Veteran's right shoulder condition was less likely than not related to or aggravated by the Veteran's low back condition. The examiner explained that the medical literature establishes that the Veteran's right shoulder condition is caused by the aging process and does not support that the low back condition could be a cause. He also reported that there is no objective evidence in the Veteran's medical records that indicate this condition was aggravated beyond its natural progression. It also was noted that the right shoulder arthritis occurs when cartilage that covers the top of bones, known as articular cartilage, degenerates or wears down and that osteoarthritis is part of the aging process. While the examiner noted that arthritis can result from an injury or trauma, he indicated that such was seen in younger people. He also noted that the right shoulder and low back are in different anatomical positions and that any incident or diagnosis that could affect one of the sites is independent from the other. See December 2020 addendum opinion; January 2021 addendum opinion. The Board will not address the opinions provided regarding whether the Veteran's bilateral hip, knee, or right shoulder conditions are secondary to the Veteran's cervical spine condition as the Board is denying service connection for a cervical spine condition. The Board notes that a review of the aggravation opinion related to the Veteran's right shoulder indicates that the examiner may have been addressing aggravation of a pre-existing condition rather than secondary aggravation. However, it does not appear that the examiner applied the permanent worsening standard. Rather, a holistic review of his opinion and rationale indicates that he considered whether there was any increase in the disability beyond its natural progression. Thus, it appears that the examiner used the correct standard of aggravation. There is no prejudice to the Veteran in this regard. The Board finds these opinions, supported by a rationale based on an accurate medical history with clear conclusions and supporting data, is highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran believes his right shoulder, bilateral knee, and bilateral hip, and neck conditions are related to an in-service injury, event, or disease, including a gas tank explosion, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it involves internal disease processes and requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board acknowledges that a private physician, Dr. C.M.Q., opined that it was more probable than not that the Veteran's musculoskeletal diseases were secondary to his military service. However, no rationale for provided for the opinion. Thus, it is afforded no probative weight. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran has contended that he injured his hips, knees, neck, and right shoulder at the time of the gas tank explosion, such is contradictory to the other evidence of record. At the October 2020 VA examination for his hips, knees, and neck, the Veteran denied injuring them at the time of the explosion and reported that the onset of his symptoms began approximately 10 and 20 years ago respectively, many years after service. Additionally, an April 2014 VA treatment record shows that the Veteran reported experiencing right knee pain after trauma with a chair several weeks earlier. Moreover, while the Veteran reported at the VA examination for his shoulder that he injured his shoulder in the explosion, at the October 2020 VA examination for his low back, the Veteran only reported injuring his ankles, feet, low back, and left eye during the explosion. An August 2014 VA treatment record shows that the Veteran complained of right shoulder pain since approximately two months prior and denied any falls or trauma. Moreover, as the Veteran's STRs show that he was evaluated after the explosion, it is expected that any injury or pain to the neck, bilateral hips, knees, or right shoulder also would have been noted at that time. See Buczynski v. Shinseki, 24 Vet. App. 221 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (clarifying that the absence of evidence is not negative evidence unless it is the type of information that would necessarily have been recorded). Thus, the Board finds the weight of the evidence weighs against a finding that the Veteran suffered an injury to his hips, knees, neck, or shoulders during the explosion. While the Veteran reported "yes" to "painful or 'trick' shoulder or elbow" on his Report of Medical History at separation, it is not clear that such was in reference to shoulder pain as no condition was further noted or explained. However, as it has been found that the Veteran has an elbow condition that is related to his service, the Board finds it reasonable to conclude that this notation was in reference to an elbow condition. Moreover, as explained above, the preponderance of the evidence indicates that the Veteran's right shoulder pain began many years after service. The Board also acknowledges that it does not appear the October 2020 VA examiner considered the Veteran's report of injuring his right shoulder during the explosion in rendering his etiology opinions. However, as the Board finds that the preponderance of the evidence weighs against a finding that the Veteran injured his right shoulder in the explosion, such omission is non-prejudicial. Additionally, while the Veteran reported in a March 2019 statement that he was taken to the hospital after the gas tank explosion, the Board finds that such was in reference to sick call/on-base medical facility. In this regard, the Veteran's STRs do confirm that he was treated after the explosion but do not indicate that he was taken to any other facility for treatment. Thus, the Board finds that there are no outstanding, relevant in-service hospital records. Moreover, the Board acknowledges that the October 2020 VA examiner addressed whether the Veteran's cervical spine condition was caused by the Veteran's service-connected low back condition but did not address aggravation. However, it is unclear why such opinion was obtained, as the August 2020 Board remand did not request such an opinion, the Veteran never has indicated that his cervical spine condition is secondary to his low back condition, and no evidence of record has raised such a theory. As secondary service connection for the cervical spine condition has not been raised by the Veteran or by the evidence of record, the Board finds that a remand to obtain an aggravation opinion would cause unnecessary delay with no benefit flowing to the Veteran. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). The Board has considered whether service connection for arthritis is warranted on a presumptive basis for chronic diseases. 38 C.F.R. § 3.309(a). However, the Veteran does not contend, and the evidence does not show, that he suffered from right shoulder or right knee symptoms in and since service or, that his conditions manifested to a compensable degree within a year of separation. Therefore, the Veteran's right shoulder and right knee arthritis is not presumed to have been incurred in service. 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In sum, while the Veteran was involved in a gas tank explosion in service, the competent and probative evidence weighs against a finding that his cervical spine, right shoulder, bilateral hip, or bilateral knee conditions are related to such incident. 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. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Entitlement to a TDIU. The Veteran contends that his service-connected disabilities preclude him from obtaining or maintaining substantially gainful employment. For the reasons that follow, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a TDIU is warranted. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); see Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment). Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion; factors such as age or impairment caused by nonservice-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19. "Substantially gainful employment" is that employment "which is ordinarily followed by the non-disabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). In the Court's March 2019 Panel Decision, it explained that "substantially gainful employment" contains economic and noneconomic components. Ray v. Wilkie, 31 Vet. App. 58 (2019). The economic component means "an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person," while the noneconomic component requires consideration of a veteran's ability to secure or follow that type of employment. Id. Section 4.16(a) provides a rating hurdle for schedular consideration of a TDIU. If there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. Id. The Veteran is service-connected for: (1) bilateral hearing loss, rated noncompensable from May 18, 2016, and 60 percent from February 26, 2020; (2) bilateral plantar fasciitis, rated 30 percent from April 27, 2018; (3) right carpal tunnel syndrome, rated 30 percent from April 27, 2018; (4) lumbosacral strain with myositis, rated 20 percent from April 27, 2018; (5) tinnitus, rated 10 percent from May 18, 2016; (6) right elbow strain, rated 10 percent from April 27, 2018; (7) right wrist sprain, rated 10 percent from April 27, 2018; (8) left ankle tendonitis, rated 10 percent from April 27, 2018; and (9) right ankle tendonitis, rated 10 percent from April 27, 2018. In pertinent part, the Veteran's combined evaluation is 80 percent from April 27, 2018, and 90 percent from February 26, 2020. Given the forgoing, the Veteran meets the schedular criteria for a TDIU for the entire appeal period. The Veteran contends that he has not been gainfully employed since the 1980's. See September 2020 Veteran's Application for Increased Compensation Based on Individual Unemployability (VA 21-8940); February 2021 VA 21-8940. A review of the record shows that the Veteran completed high school and primarily worked as a welder. Id. As an initial matter, in his September 2020 and February 2021 VA 21-8940s, the Veteran indicated that both service-connected and nonservice-connected disabilities rendered him unemployable. For example, the Veteran reported that PTSD with a head injury contributed to his inability to be gainfully employed. However, the Veteran is not service-connected for a PTSD or a head injury. As such, any impairment caused by these conditions may not be considered in the Board's analysis. With regards to the Veteran's hearing loss and tinnitus, the Veteran initially underwent a VA examination in June 2018 at which time the Veteran reported difficulty understanding conversations. However, the examiner noted that no occupational effects were reported and opined that the Veteran's tinnitus did not impact his ability to work. At the October 2020 VA examination, the examiner opined that the Veteran's hearing loss would impact his ability to work. The Veteran reported difficulty with hearing the television, telephone, and communicating with friends and family. At the October 2020 VA examination for the Veteran's low back, he reported experiencing daily low back pain with a severity of six out of ten with stiffness and flares with more pain upon standing and walking. He also reported difficulty lifting heavy objects. The Veteran also underwent a VA examination for his feet in October 2020. At the examination the Veteran reported daily foot pain with a severity of five out of ten. He also reported experiencing flares with prolonged standing and walking. With regards to the Veteran's bilateral ankle condition, at the October 2020 VA examination the Veteran reported daily pain on the back of his ankles. He noted that he experienced flare-ups with prolonged standing and walking. On clinical evaluation, his ankle range of motion was half of the normal range of motion for the ankle joint, and after repeated use over a period of time, it was further decreased to just one quarter of the normal range of motion for the ankle. The Veteran also underwent a VA examination for his elbow condition in October 2020. The Veteran reported that he limited heavy weight activities due to his elbow. The examiner opined that the Veteran's elbow condition would impact his ability to perform occupational tasks. The examiner explained that the elbow condition would limit functional activities due to no repetitive elbow movements and no heavy lifting, carrying, pushing, or pulling activities. Regarding the Veteran's right wrist, at the October 2020 VA examination, the Veteran reported that his right wrist limits his ability to carry heavy objects. Again, the examiner opined that the Veteran's right wrist condition would impact his ability to perform occupational tasks. The examiner explained that the right wrist condition would limit functional activities due to no repetitive wrist twisting or bending and no heavy lifting, carrying, pushing, or pulling activities. Based on a review of all of the evidence of record, and all resolving reasonable doubt in the Veteran's favor, the Board finds that his service-connected disabilities would reasonably preclude him from securing and maintaining substantially gainful employment consistent with his education and work experience. The Veteran's previous work history includes only work as a welder, a position that requires physical labor. It is clear from the record that the Veteran would be unable to engage in any type of physical work due to his service-connected musculoskeletal disabilities. Specifically, the evidence of record shows that it is unlikely that the Veteran would be able to do any heavy lifting or prolonged standing and walking, skills that would necessarily be required in a physical labor position. While the Veteran's service-connected musculoskeletal disabilities would not preclude work in a non-physical employment field, such as working in an office, his high school education and history of working entirely as a welder would preclude him from obtaining a position in such a field. Accordingly, resolving all reasonable doubt in the Veteran's favor, the criteria for TDIU have been met. The claim for TDIU is granted. BREASONS FOR REMAND Entitlement to service connection for a left wrist condition, to include as secondary to a cervical spine condition and/or service-connected low back disability. The Veteran seeks service connection for a left wrist condition. The Board finds that a remand is warranted in order to ensure substantial compliance with the Board's prior remand directives. In the August 2020 remand, the Board requested that the Veteran undergo a VA examination for his claimed right and left wrist condition. The Board requested the examiner to provide a diagnosis for each wrist, and if no diagnosis was appropriate, to note whether pain alone results in functional impairment and note the functional limitation caused by such pain. It also requested the examiner to opine whether the wrist conditions were either directly related to service or secondary to a cervical spine condition or service-connected low back condition. Pursuant to the remand, the Veteran underwent a VA examination in October 2020. However, a review of the examination report indicates that only the right wrist was examined. Specifically, the examiner only listed right wrist pain as the condition pertaining to the examination, did not provide a diagnosis for the left wrist, and did not address whether left wrist pain results in functional impairment. Moreover, in the accompanying etiology opinions addressing direct and secondary service connection, the examiner did not address the Veteran's left wrist. In light of the foregoing deficiencies, a remand is required in order to provide the Veteran a VA examination for his claimed left wrist condition and substantially comply with the August 2020 Board remand. Stegall, 11 Vet. App. at 268. The Board notes that although the August 2020 remand requested the examiner to address whether the claimed left wrist condition was secondary to a cervical spine condition, as the Board has determined that service connection is not warranted for a cervical spine condition, it will not request an opinion addressing this theory on remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed left wrist condition. The examiner must review the claims file and a copy of this Remand. The examiner is asked to: a) State whether the Veteran has a clinical diagnosis related to the left wrist. If no clinical diagnosis is appropriate, the examiner should offer an opinion as to whether the Veteran's pain related to the left wrist would result in functional impairment of earning capacity. b) Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's left wrist condition had its onset in, or is otherwise related to, active service, to include the February 1960 gas tank explosion. c) Opine whether it is at least as likely as not that the Veteran's left wrist condition is caused or aggravated by any service-connected disability, to include his service-connected lumbosacral strain with myositis and/or right wrist disability. The term "aggravation" means any incremental worsening of a disability beyond its natural progression. If aggravation is found, then, to the extent possible, the examiner should establish a baseline level of severity of the left wrist condition prior to aggravation by the service-connected disability, to include the low back disability and/or right wrist disability. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran's lay statements. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Mortimer, 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.