Citation Nr: 22016395 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 17-54 073 DATE: March 22, 2022 ORDER Entitlement to service connection for right knee patellofemoral syndrome with osteoarthritis is granted. REMANDED Service connection for sarcoidosis is remanded. Service connection for a left knee condition is remanded. Service connection for a left foot condition is remanded. Service connection for a right foot condition is remanded. FINDING OF FACT The Veteran's right knee patellofemoral syndrome with osteoarthritis began during service. CONCLUSION OF LAW The criteria for entitlement to service connection for right knee patellofemoral syndrome with osteoarthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1977 to February 1980 with additional service in Reserves. Unfortunately, the Veteran died in April 2018 during the pendency of his appeal. The appellant is his surviving spouse, whose substitution has been acknowledged. These matters come to the Board of Veterans' Appeals (Board) on appeal from October 2016 and August 2017 rating decisions issued by the Department of Veterans' Affairs (VA) Regional Office (RO). The Board previously remanded these claims in December 2020 for additional development. As will be discussed in more detail below, remand is again necessary to ensure substantial compliance with the December 2020 remand directives as it pertains to all claims except for service connection for the right knee which is decided herein. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to service connection for right knee patellofemoral syndrome with osteoarthritis is granted. The appellant contends that the Veteran had a right knee disability related to service. The Board finds service connection for right knee patellofemoral syndrome with osteoarthritis is warranted. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Certain chronic diseases, including arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). When service connection cannot be established on a presumptive basis, the Court has held that the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (1994). The elements of direct service connection are: "(1) the existence of a present disability; (2) 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," also known as the nexus element. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the Veteran served on active duty from February 1977 to February 1980 prior to which he completed an entrance examination. As indicated above, the Veteran has both active duty service and additional Reserves service with currently unverified periods of INACDUTRA and ACDUTRA. Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101; 38 C.F.R. § 3.6; Biggins v. Derwinski, 1 Vet. App. 474 (1991). Turning to the relevant evidence of record, the Veteran's entrance examination in November 1976 reveals a clinically normal evaluation for the lower extremities. A notation of "both knees dislocation make cracking noise at times" was included in the notes section. In the corresponding report of medical history, the examiner again noted that the Veteran had both knees dislocated but the Veteran declined experiencing "trick" or locked knee. In 1978, service treatment records (STRs) note that the Veteran complained of right knee locking and pain. See October 1978 STRs. Imaging was within normal limits. The Veteran's separation examination in January 1980 was normal with "trick" or locked knee indicated in the corresponding report of medical history. In a 1985 report of medical history, the Veteran declined experiencing knee or joint problems. He was clinically evaluated as normal upon examination. In a February 1991 report of medical history, the Veteran declined experiencing knee or joint problems. In the corresponding examination, he was clinically evaluated as normal without defects or abnormalities. In June 1991, the Veteran twisted his right knee when he stepped into a hole. Imaging revealed degenerative changes but no fracture. See 1991 STRs. In 1993, the Veteran endorsed experiencing continued symptoms since the 1991 fall. Imaging revealed degenerative changes of the right patella. The Veteran continued to endorse symptoms and requested an orthopedics consult. See November 1993 STRs. The Veteran was noted to have chronic right knee pain secondary to a 1991 fall. In a physical profile note from 1994, the Veteran was noted to have right patellofemoral syndrome. See 1994 physical profile. He was put on a permanent profile with no running or jogging. In a 1995 report of medical history, the Veteran endorsed experiencing "trick" or locked knee. He was clinically evaluated as normal but was noted to have a profile for legs with no running. On December 11, 1999, while performing duty under 32 U.S.C. § 502, the Veteran was injured and given emergency care at a nearby hospital. He stated that while working on a vehicle, he slipped while standing on the bumper and fell into the engine compartment spraining his right knee and hurting his back. A fellow service member stated that he saw the Veteran's accident in the motor pool describing the Veteran as hanging down the side of the wheel well with his foot lodged into the motor. The fellow service member stated that he had to release the Veteran's foot and help him down. Emergency room treatment records reference a severe sprain on the right leg. An informal line of duty was initiated. See December 1999 personnel records. Treatment records indicate he had minimal effusion and was noted to have a right knee sprain, patella alta. He was given a sick slip which referenced a possible torn ligament. Treatment records in the days following indicate that the Veteran's imaging suggested a questionable ligament tear requiring follow-up. Assessment notations referenced a right knee sprain. He was noted to be in continued pain, experiencing swelling, and not completely bearing weight. See December 1999 treatment records. The record contains conflicting line of duty determinations regarding this incident. In the December 1999 Statement of Medical Examination and Duty Status, it is noted that the Veteran's injury was not incurred in the line of duty but then elsewhere states he had been present for INACDUTRA and the injury was considered to have been incurred in the line of duty. Later in February 2000, the Army determined that the right patellar tendon rupture was not a work related injury. See February 2000 personnel records. Then in March 2000, there was a determination of approval in the line of duty. See March 2000 personnel records. In January 2000, the Veteran was found unfit for performance of his duties from January 1, 2000, through January 31, 2000. See January 2000 personnel records. In follow-up treatment records, the Veteran was noted to have a "ruptured patella." He continued to experience pain and swelling in the months following. See July 2000 treatment records. In March 2000, he was noted to have begun physical therapy for the right knee. In a July 2000 report of medical history, the Veteran indicated he experiences "trick" or locked knee, swollen or painful joints, and arthritis. A VA examination was completed in May 1994 during which the Veteran stated that his knee was bothering him for quite a few years but was unable to specifically say when the pain started. See May 1994 VA examination. While he initially denied any specific injury prior to the onset of his knee discomfort, he later endorsed suffering an injury while playing basketball outside of service in 1985. He stated that he experiences swelling and buckling. Upon examination, there was audible crepitus. Imaging revealed mild chondromalacia of the right knee patella and a ligamentous injury. The examiner stated that "it is apparent that the ligamentous injury occurred outside of service. He stated that it is difficult to separate the mild chondromalacia patella from the ligamentous injury that the patient suffered as to what is the etiology of his knee at the time of the examination. Another VA examination occurred in August 2000 during which the Veteran stated that he injured his right knee during service when he was standing on a vehicle and his foot slipped causing the Veteran to fall backwards, striking his back on the wheel well of the truck and twisting his right knee. See August 2000 VA examination. Since then, the Veteran stated that he has experienced pain, weakness, and stiffness in his knee. He endorsed clicking and popping sounds with intermittent swelling. Imaging revealed chondromalacia in the right knee with degenerative changes. In 2004, the Veteran endorsed experiencing knee pain. See June 2004 VA treatment records. The Veteran was afforded another VA examination in January 2005 during which the examiner noted diagnoses of right patellofemoral syndrome with osteoarthritis. The examiner opined that it is at least as likely as not the Veteran's current knee pain is related to the knee injuries in 1991, 1993, and 1994. The examiner reasoned that the Veteran has patella alta, which is a mechanical risk factor for patellofemoral syndrome. The examiner explained that the injuries from service as well as over-use during exercise such as jumping usually aggravates the symptoms of patellofemoral syndrome and eventually results in degenerative changes in the knee joint. The Veteran stated that he had no pain prior to joining the service in 1976. See January 2005 VA examination. He endorsed experiencing pain in 1977 that has worsened since then. He stated that he experienced three falls in the past 1991, 1993/1994, and 1999. The first fall in 1991 was during INACDUTRA when he stepped into a hole and injured his right knee. Then in 1993/1994 he fell again. In 1999, he fell from a truck and required a brace for six months as well as physical therapy. The examiner noted that imaging in 1991 revealed degenerative changes on the patella. 1999 imaging revealed patella alta as well as degenerative changes. Imaging in 2009 revealed patella alta associated with partial, if not, subtotal patellar tendon tear at and just below the base of the patella which appears "chronic and possible represents injury superimposed" upon more distant injury due to the presence of injury of the remaining tendon and patellofemoral compartment osteoarthritic changes. Correlation with history of other injury in the past is suggested. Following the Board's December 2020 remand, additional VA opinions were obtained. The March 2021 VA examiner opined that the Veteran's right knee patellofemoral pain syndrome and osteoarthritis were less likely than not related to service. The examiner reasoned that medical record review did not reveal continuous ongoing medical treatment or aggravation of an acute or chronic right knee condition upon separation or thereafter. As part of an addendum, the examiner also reasoned reports of medication history from 1995 and 2000 did not reveal physical examination findings for acute or chronic treatment of a right knee condition. The examiner reasoned that the condition clearly and unmistakably existed prior to service and was less likely than not permanently aggravated by the rigors of service. In the most recent August 2021 addendum, the examiner opined that the Veteran's right knee condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated during service. The examiner reasoned that the Veteran's STRs reference subjective history of right knee locking in 1980 and complaints of right knee pain in 2000. For purposes of establishing service connection, every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C. §§ 1111; 38 C.F.R. § 3.304. Upon review, the Board acknowledges that the only entrance examination of record was in 1976 prior to the Veteran's period of active duty. The Veteran was not provided an entrance examination prior to the ACDUTRA and / or INACDUTRA periods correlating to the right knee injuries in 1991, 1993/1994, and 1999. In the absence of such examinations, there is no basis from which to determine whether the Veteran was in sound condition upon entry into service for those periods. Consequently, the presumption of soundness for this period cannot apply. Smith, 24 Vet. App. at 45-46. The Board acknowledges that the most recent VA examiner opined that the Veteran's right knee condition clearly and unmistakably existed prior to service, however, this opinion is not supported by a rationale thus the Board finds it not probative. See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Further, and of most significance, the 1976 entrance examination reveals the Veteran's lower extremities were clinically evaluated as normal. While there is a notation that he had a history or prior injury of knee dislocation, the examination does not note a pre-existing condition. Indeed, according to 38 C.F.R. § 3.304, the term "noted" denotes only such conditions that are recorded in examination reports. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304; Crowe v. Brown, 7 Vet. App. 238 (1994). The Board finds, upon review, the record lacks clear and unmistakable evidence that the Veteran had a pre-existing right knee condition. The Board also notes while the record lacks verification of the Veteran's periods of ACDUTRA versus INACDUTRA, this claim stems from injuries incurred during service and as such, the designation of ACDUTRA or INACDUTRA is not significant given that benefits can be awarded in either instance for injuries incurred in or aggravated in the line of duty. 38 U.S.C. § 101 (21), (24); 38 C.F.R. § 3.6 (a), (d); Biggins v. Derwinski, 1 Vet. App. 474 (1991). Upon review, the Board finds the Veteran suffered multiple right knee injuries during service. Indeed, the Veteran first reported complaints of right knee locking and pain in 1978 without a noted diagnosis. In 1991, STRs note the Veteran twisted his right knee when he stepped into a hold with corresponding imaging revealing degenerative changes. The Veteran then reported experiencing continued symptoms since the 1991 fall through 1993. His diagnosis was then updated to right patellofemoral syndrome and he was put on permanent profile with no running. Thereafter, the Veteran continued to endorse experiencing problems related to the knee including a noted "trick" or locked knee in a 1995 report of medical history. Then, the Veteran fell in 1999 with a "severe sprain on the right knee" noted and patella alta. He was thought to have a possible torn ligament. He was also evaluated as having a "ruptured patella." The Board finds these STRs indicate the Veteran had multiple right knee injuries during service including diagnoses of right knee patellofemoral syndrome with degenerative changes. The Board finds highly probative the January 2005 VA examination finding that the Veteran's right knee patellofemoral syndrome with osteoarthritis was at least as likely as not related to injuries during service. While the examiner listed 1991, 1993, and 1994, the Board notes in the examiner's rationale in support thereof he also discussed the 1999 injury. Dyment v. West, 13 Vet. App. 141 (1999) (holding medical examiner's word choice is not error where opinion is unambiguous). It is clear from the entirety of the opinion and rationale in support that the examiner was referring to all of the in-service right knee injuries. The January 2005 VA examiner's opinion is supported by an adequate rationale and is corroborated by the medical and lay evidence of record. Indeed, the Veteran's injuries are documented in his STRs, and he endorsed experiencing right knee symptoms during service and thereafter. The Board acknowledges the May 1994 VA examination during which the Veteran did not attribute his right knee to any specific injury during service, but rather, playing basketball outside of service in 1985. While the examiner offered a negative nexus opinion, he failed to address or consider the multiple documented right knee injuries during service. Thus, the Board assigns more probative value to the January 2005 VA examination. Regarding the most recent 2021 VA examinations, the Board finds the examiner offered a negative nexus opinion that is inconsistent with the medical evidence of record. The examiner reasoned that the medical evidence of record does not reveal continuous ongoing medical treatment or aggravation of a right knee condition during discharge to present day. Upon review, however, the Board notes the Veteran's 1980 separation examination noted "trick" or locked knee in the corresponding report of medical history. Further, the examiner failed to address or consider the multiple right knee injuries after 1980 including in 1991, 1993, and 1999 as well as the Veteran's lay statements of experiencing symptoms that began during service and continued thereafter. Thus, the Board assigns the most recent VA opinions lesser probative value. Upon review of the record, the Board finds service connection for right knee patellofemoral syndrome with osteoarthritis is warranted. REASONS FOR REMAND 1. Service connection for sarcoidosis is remanded. The appellant contends that the Veteran's sarcoidosis was caused by or incurred during service. The Board finds the evidence of record is insufficient to resolve this claim. At the outset, the Board notes records reflect the Veteran has multiple periods of Reserves service including possible periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). Upon review, however, the Veteran's periods of active duty service, including INACDUTRA and ACDUTRA have not been verified. As this claim surrounds a disease rather than an injury, the Veteran's ACDUTRA versus INACDUTRA status is relevant. Accordingly, under the duty to assist, VA must attempt to verify the Veteran's period of active duty service as well as status (ACDUTRA versus INACDUTRA). See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. A VA opinion was obtained in March 2021 with additional addendum opinions. The examiner offered a negative nexus opinion. The examiner, however, failed to address the Veteran's 2013 exposure assessment. During the assessment, it was noted that the Veteran was exposed to exhaust fumes from motor pool from February to March 1997 after which he endorsed "coughing up small amounts of blood" and having a sore / hoarse throat. Additionally, the Veteran stated that after working with diesel fuel (fog oil) during Reserves, he had a productive cough that progressed to pneumonia in 1987, ultimately leading to a sarcoidosis diagnosis. The 2013 assessor indicated that fumes from combustion including vehicle exhaust produces substances that are irritating to the respiratory tract and that some individuals exposed, especially persons with a history of cigarette smoking, can develop lung problems from these exposures. The assessor also referenced a study showing a possible increased risk of developing sarcoidosis in persons exposed to respiratory irritants. The examiner, however, failed to reconcile his opinion against this 2013 assessment. Additionally, the examiner was directed to "identify by diagnosis each extra-pulmonary involvement" with a corresponding opinion including consideration of renal dysfunction, toes, and eyes. The examiner opined that sarcoidosis growths can occur in the lungs, lymph nodes, eyes, and skin. The examiner, however, did not specifically provide a diagnosis for each extra-pulmonary involvement nor did he render a corresponding opinion for each diagnosis. Thus, remand is necessary for compliance with this portion of the Board's December 2020 remand directives. See Stegall, 11 Vet. App. at 271. Accordingly, the Board finds remand is necessary for consideration of the 2013 assessment, lay statements therein, and referenced study within the assessment. 2. Service connection for a left knee condition is remanded. The appellant contends that the Veteran had a left knee condition that was related to service. The Board finds the evidence of record is insufficient to resolve this claim. As part of the Board's December 2020 remand directives, a VA examiner was to opine whether the Veteran had a left knee disability that was at least as likely as not related to service. Accordingly, a VA opinion was obtained in March 2021 with subsequent addendums. The examiner opined that the Veteran's left knee condition was less likely than not related to service with a rationale in support thereof. The examiner, however, failed to address whether the Veteran's complaints of pain amounted to functional impairment. Additionally, the examiner failed to address or consider the 1994 VA examination indicating complaints of left knee pain for "quite a few years" with the right knee worse than the left. The examiner also failed to address or consider the references to a history of degenerative joint disease in both the left and right knees. Finally, the examiner also failed to reconcile the 2013 assessment indicating that the Veteran sustained exposure to excessive weight-bearing and that musculoskeletal injuries sustained by military personnel are due to the cumulative effect of weight-bearing physical training. Rather, the examiner merely opined that the 1995 and 2000 reports of medical history and examinations did not revealed treatment for a left knee condition "caused by excessive weightbearing and musculoskeletal injuries." Upon review, however, the 1995 report of medical history notes "trick" or locked knee, which remains unaddressed. Clarification as to any diagnosis of the left knee is needed as well as its relation, if any, to service. Thus, this claim is remanded for an addendum opinion. 3. Service connection for a left foot condition is remanded. The appellant contends that the Veteran had a left foot condition that was related to service. The Board finds the evidence of record is insufficient to resolve this claim. A VA opinion was obtained in March 2021 with subsequent addendums wherein the examiner opined that the Veteran's treatment records in 2009 reflect mild hallux valgus and degenerative joint disease of the first metatarsal joint. The examiner opined that these diagnoses were less likely than not related to service because the Veteran's 1995 and 2000 examinations did not reveal any ongoing acute or chronic treatment of a left foot condition. Further, medical records did not reveal continuous, ongoing medical treatment or aggravation of an acute or chronic left foot condition at discharge or thereafter. The examiner also opined that there was not functional loss of the left foot, including pain, based on the clinical evidence of record. The examiner, however, failed to address or consider the Veteran's STRs noting an injury to the left heel in 1978 with pain and tenderness as well as the Veteran's post-separation treatment records referencing left foot pain. Accordingly, remand is necessary for consideration of the Veteran's STRs and post-separation treatment records related to the left foot. 4. Service connection for a right foot condition is remanded. The appellant contends that the Veteran had a right foot condition related to service. The Board finds the evidence of record is insufficient to resolve this claim. As part of the Board's December 2020 remand, an examiner was directed to opine whether the Veteran had a right foot disability separate from his service-connected right lower extremity radiculopathy. Upon review, the Board must seek clarification as to whether the Veteran has a separate right foot disability or if the Veteran's right foot symptoms are related to / caused by his service-connected right lower extremity radiculopathy, as it remains unclear. On one hand, the examiner stated the Veteran did not have an additional right foot disability. Elsewhere, the examiner stated he experienced right foot pain but did not opine whether this pain amounted to functional impairment. The examiner then opined that the Veteran's right foot pain was not a symptom of radiculopathy without reconciling treatment records referencing right lower extremity radiculopathy with persistent pain, numbness, and tingling. Accordingly, remand is necessary to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Attempt to verify the Veteran's periods of service including ACDUTRA and / or INACDUTRA. All attempts made should be documented in the claims file. 2. Only after the development in paragraph one, return the entire claims file and this remand to the March 2021 VA examiner, if available or to another examiner for review. The examiner should render an opinion, including rationale, addressing the following: (a.) When was the Veteran diagnosed with sarcoidosis? In so opining, the examiner is directed to provide a date of diagnosis based on the evidence of record. (b.) Whether it is at least as likely as not the Veteran's sarcoidosis is related to service. In so opining, the examiner is directed to address and consider: - The Veteran's contentions of exposure to chemicals including exhaust fumes and diesel fuel (fog oil); - The 2013 assessment of record referring to exhaust fumes as respiratory irritants that can lead to development of lung problems, especially in persons with a history of smoking, as well as the referenced a study discussing a possible relationship between exposure to respiratory irritants and sarcoidosis; and - The Veteran's lay statements during the 2013 assessment of "coughing up small amounts of blood," having a sore / hoarse throat, and having a productive cough leading to the diagnosis of sarcoidosis during service. (c.) Whether the Veteran had extra-pulmonary involvement including in relation to renal dysfunction, toes, skin, and eyes due to sarcoidosis; and if so, for each extra-pulmonary involvement whether it is at least as likely as not due to sarcoidosis. In so opining, the examiner is directed to address and consider the Veteran's treatment records referencing a "partial left nephrectomy secondary to sarcoidosis (per patient)" as well as references to a sarcoidosis eye condition and skin condition. 3. Return the entire claims file and this remand to the March 2021 VA examiner, if available or to another examiner for review. The examiner should render an opinion, including rationale, addressing the following: (a.) Whether the Veteran had a left knee disability, to include degenerative joint disease. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. In so opining, the examiner is directed to address the Veteran's complaints of left knee pain as well as the reference to degenerative joint disease in the left knee. (b.) For any arthritis diagnosis, did it at least as likely as not (1) begin during active service, (2) manifest within a year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? (c.) For any other left knee disability, was it at least as likely as not related to service, to include contended excessive weight-bearing and physical training? In so opining, the examiner is directed to address and consider the 2013 assessment discussing excessive weight-bearing and musculoskeletal injuries. (d.) Whether it is at least as likely as not the Veteran's left foot degenerative joint disease of the first metatarsal joint (1) began during active service, (2) manifested within a year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? In so opining, the examiner is directed to address and consider the Veteran's STRs noting complaints of left heel pain in 1978 and post-separation treatment records noting left foot pain. (e.) Whether the Veteran's left foot degenerative joint disease of the first metatarsal joint and hallux valgus were at least as likely as not caused by or incurred during service. In so opining, the examiner is directed to address and consider the Veteran's STRs noting complaints of left heel pain in 1978 and post-separation treatment records noting left foot pain. (f.) Whether the Veteran has a right foot disability separate from service-connected right lower extremity radiculopathy. In so opining, the examiner is directed to address and consider the treatment records referencing right foot pain in association with complaints of radiculopathy. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. (g.) If the Veteran has a right foot disability that is not a symptom of service-connected right lower extremity radiculopathy, whether it is at least as likely as not related to service. In so opining, the examiner is directed to address and consider the 1999 fall during which the Veteran stated he was hanging from his right foot on a vehicle. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. After the above development, and any other development deemed necessary, readjudicate the claims. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.