Citation Nr: 22011542 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 15-42 149 DATE: March 1, 2022 REMANDED Entitlement to service connection for a right foot disability, including metatarsalgia but not plantar fasciitis, is remanded. Entitlement to service connection for a left foot disability, including metatarsalgia but not plantar fasciitis, is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a right thigh disability is remanded. Entitlement to service connection for a disability of the toes of the right foot is remanded. Entitlement to service connection for a disability of the toes of the left foot is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a left-hand disability is remanded. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome, right knee is remanded. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome, left knee is remanded. Entitlement to an initial compensable rating for medial tibial stress syndrome, left leg, is remanded. Entitlement to an initial compensable rating for medial tibial stress syndrome, right leg, is remanded. Entitlement to an initial rating in excess of 10 percent for a cervical strain is remanded. Entitlement to an initial rating in excess of 10 percent for a lumbar strain prior to August 17, 2021 and 20 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2007 to July 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in January 2019. The Board remanded this matter in June 2019, February 2021, and July 2021 for additional development. The matter is now returned to the Board for further appellate review. In an October 2021 rating decision, the agency of original jurisdiction (AOJ) granted the Veteran service connection for left foot and right foot plantar fasciitis, rated 10 percent disabling and effective July 9, 2010. The Veteran has not submitted a notice of disagreement with either the effective date or the disability rating assigned. Therefore, as service connection has been granted, the full benefit sought has been granted and the issues are not in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). In July 2021, the Board remanded this matter, in part, to obtain a medical examination addressing the severity of the Veteran's service-connected lumbar strain. VA obtained an examination in August 2021. Although the October 2021 rating decision provided a partial grant of the benefit sought on appeal, the Veteran has not indicated that he is satisfied with the increased rating to 20 percent, effective August 17, 2021, and 10 percent prior. Thus, the issue is still on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he/she indicates otherwise). 1. Entitlement to service connection for a right foot disability, including metatarsalgia but not plantar fasciitis, is remanded. 2. Entitlement to service connection for a left foot disability, including metatarsalgia but not plantar fasciitis, is remanded. In July 2021 the Board remanded these claims to obtain an examination and medical opinion addressing the Veteran's claimed right and left foot disabilities. VA provided the Veteran an examination in August 2021. The August 2021 examiner diagnosed the Veteran with left and right foot plantar fasciitis and left and right foot metatarsalgia. As noted above, the AOJ granted the Veteran service connection for left and right foot plantar fasciitis in an October 2021 rating decision. The August 2021 examiner, however, did not provide a medical opinion addressing whether the Veteran's left and right foot metatarsalgia had its onset in service or is otherwise related to his active-duty service. The Veteran originally filed his service connection claim for a bilateral foot condition, and he did not limit his claim to plantar fasciitis. The Boards finds a remand is necessary to obtain a medical opinion addressing whether the Veteran's left and right foot metatarsalgia is related to his active-duty service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 3. Entitlement to service connection for a right hip disability is remanded. The Board remanded this matter, in part, to obtain a medical examination and opinion to determine the etiology of the Veteran's claimed right hip disability. VA provided the Veteran an examination in August 2021; unfortunately, it is inadequate to adjudicate the Veteran's claim. The August 2021 VA examiner provided a negative direct service connection nexus opinion, in part, because the Veteran's service treatment records do not reflect complaints or a diagnosis of a right hip condition. The Veteran, however, has consistently reported that he began to experience right hip pain while on active duty. In other words, the examiner appears to have impermissibly dismissed the Veteran's reports of right hip problems solely because these complaints were not documented in medical treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). The August 2021 VA examiner provided a negative secondary service connection opinion. The examiner provided the same rationale for both "causation" and "aggravation" theories of entitlement. A medical opinion addressing the issue of secondary service connection is inadequate where it fails to adequately encompass the question of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 141 (2013). In El-Amin, the Court held that the Board's conclusion that a medical examination was adequate was clearly erroneous where the examiner only stated that the claimed condition was "related to" other factors. See El-Amin, 26 Vet. App. at 140. Terms such as "caused by" or "the result of" do not encompass aggravation because "[t]hese options do not permit the examiner to opine on any question other than one of direct causation." Id. at 140-41 The examiner also reported the Veteran does not have any objective findings of a condition that would cause or aggravate the Veteran's right hip, yet provided no explanation for why the service-connected knee, back or shin disabilities did not constitute an objective condition that would cause or aggravate a hip condition. The examiner did not provide any further rationale to support the negative nexus opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). The August 2021 VA examiner diagnosed the Veteran with right hip iliopsoas tendinitis. The Veteran provided a Hip and Thigh Disability Benefits Questionnaire completed by C.N.B, MD. Dr. C.N.B. diagnosed the Veteran with bilateral osteoarthritis of the hip, bilateral femoral acetabular impingement, and bilateral iliopsoas tendinitis. On remand, a new examination is necessary to address the etiology of all of these diagnoses. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (Board must obtain an opinion addressing whether diagnoses in the record were made in error where a VA examiner finds that there is no current diagnosis). A remand is also appropriate to obtain an opinion concerning whether obesity is an "intermediate step" between the Veteran's service-connected cervical spine strain, lumbar spine strain, and left knee patellofemoral syndrome and his right hip disability. Neither the record, the Veteran, nor Dr. C.N.B contend any of the Veteran's other service-connected disabilities caused the Veteran's obesity. The Board observes that obesity is not considered a disease for purposes of VA benefits. See VAOPGCPREC 1-2017 (holding the "longstanding policy of [VA], that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis, is consistent with title 38, United States Code" and "[o]besity per se is not a 'disability' for purposes of 38 C.F.R. § 3.310 "). However, although obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131, and therefore may not be service connected on a direct or secondary basis, obesity may be an "intermediate step" between a service-connected disability and a current disability that may be connected on a secondary basis (1) if a previously service-connected disability caused him to become obese; (2) that obesity was a substantial factor in causing secondary disability; and (3) the secondary disability would not have occurred but for the obesity. See VAOPGCPREC 1-2017. Moreover, a recent decision by the United States Court of Appeals for Veterans Claims (Court) determined that obesity may be an intermediate step between a claimed condition and a service-connected disability when reasonably raised by the record. The Court provided a non-exhaustive list of six considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step, including (1) mobility limitations or reduced physical activity as a result of a service-connected physical disability; (2) reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; (3) side effects of medication where the medication is prescribed for a service-connected disability; (4) treatise evidence suggesting a connection between all or some combination of obesity, service-connected disability, and the claimed condition; (5) lay statements by a veteran attributing weight gain or obesity to the service-connected disability; and (6) statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability. The Court determined the critical commonality among the nonprecedential decisions was that "there is some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition." Garner v. Tran, 33 Vet. App. 241, 248 (2021). Here, the Veteran is service connected for cervical spine strain, lumbar spine strain, and left knee patellofemoral syndrome disabilities; the record reflects the Veteran is obese; Dr. C.N.B. reported the Veteran gained weight after his active-duty service because of his cervical spine strain, lumbar spine strain, and left knee disabilities; and Dr. C.N.B. reported that the Veteran's obesity likely aggravated the Veteran's right hip disability. Based on the above, a new examination and opinion are necessary to address this theory of entitlement. 4. Entitlement to service connection for a left ankle disability is remanded. 5. Entitlement to service connection for a right ankle disability is remanded. The Board remanded these matters, in part, to obtain a medical examination and opinion to determine the etiology of the Veteran's claimed left and right ankle disabilities. VA provided the Veteran an examination in August 2021; unfortunately, it is inadequate to adjudicate the Veteran's claim. The August 2021 VA examiner provided negative direct service connection nexus opinions, in part, because the Veteran's service treatment records do not contain a left or right ankle diagnosis. The Veteran, however, has consistently reported that he began to experience right and left ankle pain while on active duty. In other words, the examiner appears to have impermissibly dismissed the Veteran's reports of right and left ankle pain solely because these complaints were not documented in medical treatment records. See Dalton, 21 Vet. App. at 39-40; see also Buchanan at 1337. The August 2021 VA examiner provided a negative secondary service connection opinion. The examiner provided the same rationale for both "causation" and "aggravation" theories of entitlement. A medical opinion addressing the issue of secondary service connection is inadequate where it fails to adequately encompass the question of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 141 (2013). In El-Amin, the Court held that the Board's conclusion that a medical examination was adequate was clearly erroneous where the examiner only stated that the claimed condition was "related to" other factors. See El-Amin, 26 Vet. App. at 140. Terms such as "caused by" or "the result of" do not encompass aggravation because "[t]hese options do not permit the examiner to opine on any question other than one of direct causation." Id. at 140-41. The examiner also reported the Veteran does not have any objective findings of a condition that would cause or aggravate the Veteran's left or right ankle disabilities, yet they failed to explain why the Veteran's service-connected knee, back or shin disabilities were not "objective conditions" that potentially caused or aggravated the claimed ankle conditions. The examiner did not provide any further rationale to support the negative nexus opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). The August 2021 VA examiner diagnosed the Veteran with left and right ankle lateral collateral ligament sprains. The Veteran provided an Ankle Conditions Disability Benefits Questionnaire completed by C.N.B, MD. Dr. C.N.B. diagnosed the Veteran with left and right ankle lateral collateral ligament sprains, left and right deltoid ligament sprains, and left and right ankle tendonitis. On remand, a new examination is necessary to address all of these diagnoses. See Romanowsky, 26 Vet. App. 289 (2013). A remand is also appropriate to obtain an opinion concerning whether obesity is an "intermediate step" between the Veteran's service-connected cervical spine strain, lumbar spine strain, and left knee patellofemoral syndrome and his left and right ankle disabilities. Neither the record, the Veteran, nor Dr. C.N.B contend any of the Veteran's other service-connected disabilities caused the Veteran's obesity. Garner, 33 Vet. App. at 248. Here, the Veteran is service connected for cervical spine strain, lumbar spine strain, and left knee patellofemoral syndrome disabilities; the record reflects the Veteran is obese; Dr. C.N.B. reported the Veteran gained weight after his active-duty service because of his cervical spine strain, lumbar spine strain, and left knee disabilities; and Dr. C.N.B. reported that the Veteran's obesity likely aggravated his left and right ankle disabilities. Based on the above, a new examination and opinion are necessary to address this theory of entitlement. 6. Entitlement to service connection for a right thigh disability is remanded. 7. Entitlement to service connection for a disability of the toes of the right foot is remanded. The Board remanded these matters, in part, to obtain medical examinations and opinions to determine the etiology of the Veteran's claimed right thigh disability and disability of the right foot toes. VA provided the Veteran examinations in August 2021; unfortunately, they are inadequate to adjudicate the Veteran's claims. In the July 2021 remand, the Board, in part, requested the selected clinician reconcile the examination results with the July 2021 DBQs completed by Dr. C.N.B, which the Veteran submitted, if the examiner does not find the Veteran has a current right thigh diagnosis or a right foot toes diagnosis. The Board also requested the selected clinician address whether the Veteran's right thigh disability and disability of the right foot toes manifest in pain, and if so, whether the pain is productive of functional impairment and whether any functional impairment is related to the Veteran's active-duty service. The August 2021 examiner reported the Veteran does not have a right thigh diagnosis or a right foot toes diagnosis. The examiner did not address the July 2021 private DBQs. Further, the examiner did not report whether the Veteran's right thigh and right foot toes disabilities manifest in pain, are productive of functional impairment, or whether any pain is related to the Veteran's active-duty service. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (remand by Board confers upon claimant, as a matter of law, the right to compliance with remand order). Accordingly, a remand is necessary to obtain an adequate opinion that addresses these deficiencies. 8. Entitlement to service connection for a disability of the toes of the left foot is remanded. 9. Entitlement to service connection for a left shoulder disability is remanded. The Board remanded these matters, in part, to obtain medical examinations and opinions to determine the etiology of the Veteran's claimed left foot toes and left shoulder disabilities. VA did not provide the Veteran a left shoulder examination and the clinician that conducted the left foot toes examination did not provide a nexus opinion. See Stegall, 11 Vet. App. at 271. Accordingly, a remand is necessary to provide the Veteran a left shoulder examination and obtain a medical nexus opinion for the claimed left foot toes disability. 10. Entitlement to service connection for a left-hand disability is remanded. The Board remanded this matter, in part, to obtain a medical examination and opinion to determine the etiology of the Veteran's claimed left-hand disability. VA provided the Veteran an examination in August 2021; unfortunately, the medical opinion is inadequate to adjudicate the Veteran's claim. The August 2021 examiner provided negative direct and secondary service connection nexus opinions, in part, because the Veteran's medical records do not contain a left-hand diagnosis until the August 2021 examination. The Veteran, however, has consistently reported that he began to experience left-hand pain while on active duty. In other words, the examiner appears to have impermissibly dismissed the Veteran's reports of left-hand pain solely because these complaints were not documented in medical treatment records. See Dalton, 21 Vet. App. at 39-40; see also Buchanan 451 F.3d at 1337. 11. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome, right knee is remanded. 12. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome, left knee is remanded. The Board remanded these matters, in part, to obtain medical examinations to determine the severity of the Veteran's claimed service-connected left and right knee disabilities. VA provided the Veteran an examination in August 2021; unfortunately, they are inadequate to adjudicate the Veteran's claims. The Board specifically requested the AOJ obtain an opinion to determine the severity of the Veteran's service-connected right and left knee disabilities and ensure the examination included range of motion testing in both active and passive motion and in weight-bearing and nonweight-bearing. See Correia v. McDonald, 28 Vet. App.158 (2016). The Board also requested that if the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The August 2021 examination does not contain range of motion measurements for nonweight-bearing or an explanation why such measurements were not provided. Stegall, 11 Vet. App. at 271. A remand is necessary to obtain an examination with the required range of motion testing. 13. Entitlement to an initial compensable rating for medial tibial stress syndrome, left leg, is remanded. 14. Entitlement to an initial compensable rating for medial tibial stress syndrome, right leg, is remanded. The Board is remanding the Veteran's left and right knee claims for new examinations. Because the new examinations will also include an evaluation of the Veteran's service-connected left and right leg medial tibial stress syndrome, these issues are inextricably intertwined with the left and right knee issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). 15. Entitlement to an initial rating in excess of 10 percent for a cervical strain is remanded. 16. Entitlement to an initial rating in excess of 10 percent for a lumbar strain prior to August 17, 2021 and 20 percent thereafter is remanded. The Board remanded these matters, in part, to obtain an examination addressing the severity of the Veteran's service-connected cervical strain and lumbar strain. VA provided the Veteran examinations in August 2021; unfortunately, they are inadequate to adjudicate the Veteran's claims. The Board specifically requested the selected clinician conduct range of motion testing of the Veteran's cervical spine and lumbar spine in both active and passive motion and in weight-bearing and nonweight-bearing and if the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. See Correia, 28 Vet. App.158. The August 2021 examination does not contain range of motion measurements for nonweight-bearing or an explanation why such measurements were not provided. Stegall, 11 Vet. App. at 271. A remand is necessary to obtain an examination with the required range of motion testing. The matters are REMANDED for the following action: 1. Obtain an opinion, preferably from a clinician that has not previously provided an opinion, regarding the etiology of the Veteran's right and left foot metatarsalgia. Schedule the Veteran for an examination only if deemed necessary by the clinician selected to provide the opinion. The selected clinician must provide an opinion addressing whether the Veteran's right and left foot metatarsalgia is at least as likely as not (at least an approximate balance of positive and negative evidence) a result of an in-service event, disease, or injury. If the bilateral metatarsalgia is not directly related to service, the examiner must opine as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) caused or aggravated by the Veteran's service-connected plantar fasciitis, or knee, back and shin disabilities. Causation and aggravation are distinct concepts and must be addressed individually. The examiner must be advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examiner may not dismiss the Veteran's reports of right and left foot pain solely on the basis that they are not documented in contemporaneous treatment records. The examination report must include a complete rationale for the opinion provided. 2. Obtain opinions, preferably from a clinician that has not previously provided an opinion, regarding the etiology of the Veteran's right hip disability, left ankle disability, and right ankle disability. Schedule the Veteran for an examination only if deemed necessary by the clinician selected to provide the opinion. The selected clinician must provide an opinion addressing whether the Veteran's right hip disability, left ankle disability, and right ankle disability are at least as likely as not (at least an approximate balance of positive and negative evidence) a result of an in-service event, disease, or injury. If service connection on a direct basis is not established for any of the claimed conditions, then the examiner must also address the secondary service connection theory of entitlement. Specifically, the examiner must address whether the Veteran's claimed right hip, left ankle and right ankle disabilities are caused or aggravated by the Veteran's service-connected cervical spine strain, lumbar spine strain, left knee patellofemoral syndrome, right knee patellofemoral syndrome, left medial tibial stress syndrome, right medial tibial stress syndrome, left foot plantar fasciitis, and/or right foot plantar fasciitis disabilities. If the selected clinician determines that the Veteran's claimed right hip, left ankle and right ankle disabilities are neither directly related to his active-duty service nor secondary to his service-connected cervical spine strain, lumbar spine strain, left knee patellofemoral syndrome, right knee patellofemoral syndrome, left medial tibial stress syndrome, right medial tibial stress syndrome, left foot plantar fasciitis, and/or right foot plantar fasciitis disabilities, then the clinician must also provide an opinion as to whether the Veteran's service-connected cervical spine strain, lumbar spine strain, and/or left knee patellofemoral syndrome caused him to become obese or aggravated his obesity. If the examiner determines the Veteran's obesity is the result of one or more service-connected disabilities or has been aggravated by one or more service-connected disabilities, he or she must provide an opinion as to whether or not the obesity caused or aggravated by the service-connected disability was a substantial factor in causing the Veteran's right hip disability, left ankle disability and/or right ankle disability. If the examiner determines both that obesity was caused or aggravated by a service-connected disability or disabilities and that the Veteran's right hip disability, left ankle disability, or right ankle disability were caused by the obesity, he or she must provide an opinion as to whether or not the claimed condition would not have occurred but for the obesity caused or aggravated by the service-connected disability or disabilities. The secondary service connection and obesity opinions must address causation and aggravation separately to be deemed adequate. A mere conclusion regarding aggravation without a separate rationale is not sufficient. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression; there is no requirement that such aggravation be permanent. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. The selected clinician must specifically address the July 2021 DBQ completed by Dr. C.N.B, which suggests the Veteran's obesity acted as an intermediate step between his service-connected cervical spine strain, lumbar spine strain, and/or left knee patellofemoral syndrome and his right hip disability, left ankle disability, and right ankle disability. The selected clinician must specifically address the July 2021 DBQ completed by Dr. C.N.B, which indicates the Veteran has additional diagnoses of osteoarthritis of the hip and femoral acetabular impingement. If the clinician determines that the Veteran has not had osteoarthritis of the hip or femoral acetabular impingement at any point during the appeal period, the examiner must explain why he or she concluded that these diagnoses reflected in the record were made in error or have since resolved. If the clinician determines that the Veteran has had osteoarthritis of the hip or femoral acetabular impingement at any point during the appeal period, then the examiner must opine whether these conditions are related to the Veteran's active-duty service. The selected clinician must specifically address the July 2021 DBQ completed by Dr. C.N.B, which indicates the Veteran has additional diagnoses of left and right deltoid ligament sprains and left and right ankle tendonitis. If the clinician determines that the Veteran has not had left and right deltoid ligament sprains and left and right ankle tendonitis at any point during the appeal period, the examiner must explain why he or she concluded that these diagnoses reflected in the record were made in error or have since resolved. If the clinician determines that the Veteran has had left and right deltoid ligament sprains and left and right ankle tendonitis at any point during the appeal period, then the examiner must opine whether these conditions are related to the Veteran's active-duty service. The examiner must be advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examiner may not dismiss the Veteran's reports of right hip, left ankle, and right ankle pain solely on the basis that they are not documented in contemporaneous treatment records. The examination report must include a complete rationale for the opinion provided. 3. Obtain an opinion, preferably from a clinician that has not previously provided an opinion, regarding the etiology of the Veteran's right thigh, right foot toes, left foot toes, left shoulder, and left-hand disabilities. Schedule the Veteran for an examination only if deemed necessary by the clinician selected to provide the opinion. The selected clinician must provide an opinion addressing whether the Veteran's right thigh, right foot toes, left foot toes, left shoulder, and left-hand disabilities are at least as likely as not (at least an approximate balance of positive and negative evidence) a result of an in-service event, disease, or injury. If service connection on a direct basis is not established for any of the claimed conditions, then the examiner must also address the secondary service connection theory of entitlement. Specifically, the examiner must address whether the claimed left shoulder and left-hand disabilities are caused or aggravated by the Veteran's service-connected cervical spine strain disability. The examiner must also address whether the Veteran's claimed right thigh, right foot toes, and left foot toes disabilities are caused or aggravated by the Veteran's service-connected lumbar spine strain, left knee patellofemoral syndrome, right knee patellofemoral syndrome, left medial tibial stress syndrome, right medial tibial stress syndrome, left foot plantar fasciitis, and/or right foot plantar fasciitis disabilities. If the examiner determines the Veteran does not have a left shoulder, left hand, right thigh, left foot toes, or right foot toes disability, the examiner must explicitly reconcile this finding with the July 2021 DBQ submitted by the Veteran, which suggest the presence of a current disability with respect to all these claims. If any claimed disability is manifest by pain without an identifiable underlying pathology, the examiner must indicate whether the pain is productive of functional impairment. If so, the examiner must address whether the pain is related to any aspect of the Veteran's active-duty service. The examiner must be advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examiner may not dismiss the Veteran's reports of right thigh, right foot toes, left foot toes, left shoulder, and left-hand disabilities pain solely on the basis that they are not documented in contemporaneous treatment records. The examination report must include a complete rationale for the opinion provided. 4. Schedule the Veteran for new neck, back, and knee examinations to assess the severity of his service-connected disabilities, preferably with an examiner who has not previously examined him. The selected examiner should conduct all indicated tests and studies, to include range of motion testing. The joints in question should be tested in both active and passive motion and in weight-bearing and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station, and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during aflare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). If the examiner determines the Veteran does not experience flare-ups, the examiner must explicitly reconcile this report with the July 2021 DBQ, which documents flare-ups of all the joints in question. The examiner must also assess any neurological impairment associated with the Veteran's service-connected cervical and lumbar spine disabilities. If the examiner determines the Veteran does not have neurological impairment associated with his service-connected cervical and/or lumbar spine disability, the examiner must explicitly reconcile this report with the July 2021 DBQ, which documents both cervical and lumbar radiculopathy. The examination report must include a complete rationale for the opinion provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.