Citation Nr: 22016906 Decision Date: 03/23/22 Archive Date: 03/23/22 DOCKET NO. 19-11 891 DATE: March 23, 2022 ORDER Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for an immune system disability claimed to be due to food poisoning and blood poisoning is denied. REMANDED Entitlement to service connection for a left ankle disability is remanded. FINDINGS OF FACT 1. The Veteran's bilateral hearing loss is related to in-service acoustic trauma. 2. The evidence of record persuasively weighs against finding that the Veteran currently has a left knee disability which began during active service, or is otherwise related to an in-service injury or disease. 3. The evidence of record persuasively weighs against a finding that the Veteran currently has an immune system disability which began during service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5107; 38 C.F.R. § § 3.102, 3.303, 3.307, 3.309, 3.385. 2. The criteria for entitlement to service connection for left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for an immune system disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to June 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for bilateral hearing loss, a left ankle disability, a left knee disability and a disability characterized as "immune system food poisoning and blood poisoning." The Veteran filed a notice of disagreement (NOD) in August 2015, and a statement of the case (SOC) was issued in February 2019. In March 2019, the Veteran submitted a substantive appeal (VA Form 9). In April 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. At the request of the Veteran, the undersigned held the record open for a period of 60 days to allow the Veteran the opportunity to submit additional evidence. To date, no additional evidence has been received. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In addition, certain chronic diseases, including arthritis and an organic disease of the nervous system such as sensorineural hearing loss, 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). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 1. Service connection for bilateral hearing loss The Veteran contends that his current hearing loss is the result of noise exposure during active duty, including from explosives, dynamite, tanks, torpedoes, and gunfire. He concedes post-service occupational noise exposure but claims that he always used hearing protection at work. The Veteran's service personnel records show that his MOS was combat engineer, a position consistent with noise exposure. He also received the M-16 Rifle Marksman Qualification Badge. His service treatment records show that at his February 1974 enlistment examination, audiometric testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 0 -- 10 LEFT 20 15 15 -- 10 In February 1976 the Veteran sought treatment for a right earache with pressure, ringing, and difficulty hearing. The impression was otitis media. In April 1976, the Veteran again complained of pressure in his right ear for two weeks and difficulty hearing out of the right ear. The impression was serous otitis media. The remaining service treatment records are negative for complaints or abnormalities pertaining to the ears. At the Veteran's March 1977 separation examination, clinical evaluation of the ears was normal. On a report of medical history, he denied having or ever having had hearing loss. Audiometric testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 5 LEFT 5 10 5 5 10 The post-service record on appeal shows that in November 1977, the Veteran filed an application for VA compensation benefits, seeking service connection for an eye disability. His application is negative for notations of hearing loss or any other disability. In April 2015, the Veteran submitted a claim of service connection for bilateral hearing loss. In pertinent part, records assembled in connection with the claim includes the results of August 2012 private audiometric testing showing pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 40 60 75 70 LEFT 35 50 75 85 85 October 2013, private audiometric testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 35 55 65 65 LEFT 25 40 65 75 75 Speech discrimination was 72 percent correct on the left and 100 percent correct on the right. A March 2015 private audiometric test revealed the following pure tone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 40 55 80 80 90 LEFT 35 60 70 85 85 Subsequent private audiometric testing shows continued hearing loss. In July 2015, the Veteran was afforded a VA medical examination in connection with his claim. He reported that in connection with his MOS as Combat Engineer, he fired weapons with the left hand without hearing protection. He indicated that he had worn privately purchased hearing aids for over 10 years. Audiometric testing showed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 50 75 75 70 LEFT 25 50 75 75 80 Speech recognition was 56 percent and 80 percent in the right and left ear, as measured by the Maryland CNC test. After examining the Veteran and reviewing the record, the examiner diagnosed the Veteran as having bilateral sensorineural hearing loss. He concluded that it was less likely than not that the Veteran's current hearing loss was caused by or a result of an event in service. The examiner explained that this was so because the Veteran exhibited normal hearing sensitivity in both ears at the time of his March 1977 separation examination. In support of his claim, the Veteran submitted a March 2021 letter from D.M., M.D., a board certified otolaryngologist. Dr. M. indicated that he treated the Veteran from 2015 to 2018 and had examined him again in March 2021. He indicated that he had also reviewed the Veteran's medical history and considered the events and circumstances of his military service from 1974 to 1977. Dr. M. indicated that the Veteran had no other known risk factors that may have precipitated his sensorineural hearing loss. After review of the records and consideration of medical literature, Dr. M. indicated that it was his professional opinion that the Veteran's current significant hearing loss and poor discrimination was more likely than not related to significant unprotected excess noise exposure in the military as a combat engineer. Applying the facts in this case to the applicable legal criteria, the Board concludes that the criteria for service connection for bilateral hearing loss have been met. First, the Board concludes that the Veteran has a current disability. Repeated audiometric testing clearly establishes that the Veteran exhibits impaired hearing which meets the definition of disability under section 3.385. Second, the Board concludes that the record establishes that it is at least as likely as not that the Veteran had noise exposure during active duty. The Veteran has competently reported noise exposure during active duty, consistent with this MOS as a combat engineer. Thus, the question becomes whether the current hearing loss disability is related to the conceded in-service noise exposure. On this question there are opinions in favor of and against the claim. The evidence against the claim includes the July 2015 VA medical opinion and the evidence in favor of the claim includes March 2021 opinion from Dr. M. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current hearing loss disability is related to in-service noise exposure. The November 2015 examiner provided a negative opinion. However, the Board assigns it low probative weight to the extent that it relied solely on the fact that the Veteran's hearing acuity was normal upon separation from service. Hensley v. Brown, 5 Vet. App. 155 (1993). Dr. M.'s opinion is also problematic as it may be based on an inaccurate factual premise, i.e. that the Veteran had no other risk factors for hearing loss beyond his military noise exposure. As noted above, the Veteran has reported post-service occupational noise exposure. Nonetheless, because Dr. M. noted that the Veteran did not wear hearing protection during active duty, the Board finds that it is sufficient to support a nexus, the third element necessary to establish service connection. Accordingly, the Board finds that service connection for hearing loss is warranted as the evidence is in relative equipoise. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for left knee disability The Veteran claims to have injured his left knee in service in a grenade blast during a training exercise in 1976. During the April 2021 Board hearing, he testified that following the blast, "work" was done on his knee in the form of "removal of stuff because that kneecap actually went to the side from the blast." See Transcript at pages 4, 6. He testified that although he receives no medical treatment for his knee at present, it felt stiff and this symptom limited his enjoyment engaging in hobbies such as fly fishing. The Veteran testified that he had previously received treatment for gout in this left knee about four to five years prior from Dr. Floyd. Alternatively, the Veteran has claimed that he hyperextended his left knee during service and also that his claimed left knee disability is secondary to his left ankle disability. See e.g., Report of General Information, received April 27, 2016. The Veteran's service treatment records are entirely negative for complaints or findings of a left knee injury, left knee symptoms or left knee impairment. During his March 1977 separation examination, the Veteran described himself as being in "good health" and specifically denied having or ever having had pertinent symptoms such as swollen or painful joints and a "trick" or locked knee. On clinical evaluation his lower extremities and musculoskeletal system were examined and determined to be normal. The Board finds that had the Veteran had a left knee injury in service or been experiencing left knee symptoms at separation, he would have mentioned that history and symptoms, along with the other relevant history and symptoms he reported at the time. The post-service record on appeal shows that in January 2015, the Veteran sought treatment for complaints of acute left knee pain. He was diagnosed with acute idiopathic gout of the left knee, viral infection. He did not report a history of an in-service left knee injury, nor did he report a history of prior knee symptoms at that time. There are no other post-service clinical records noting complaints or abnormalities of the left knee. After considering the record in its entirety, the Board finds that the criteria to establish service connection for a left knee disability have not been met. With respect to the first element necessary to establish service connection, a current disability, the Board first notes that the record does not contain clinical evidence of a current diagnosis during the pendency of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran has testified to the presence of knee stiffness which limits his enjoyment of hobbies such as fly fishing. He has not, however, provided testimony or statements further describing the type of impairment he claims to experience beyond these vague reports. He has offered no evidence tending to show that his claimed symptoms rise to a level to affect earning capacity, no statements regarding the severity, frequency, and duration of his symptoms, or any other information with which to establish that his symptoms would cause impaired earning capacity or affect his ability to function under the ordinary conditions of life. Wait v. Wilkie, 33 Vet. App. 8 (2020). The Board has considered the fact that the Veteran was diagnosed as having gout in the left knee in January 2015, several months before filing his claim. Even assuming arguendo that this clinical evidence, or the Veteran's statements of stiffness interfering with hobbies, is sufficient to establish the presence of a current disability, the Board finds that service connection would not be warranted as the second and third elements have not been met. With respect to an in-service disease or injury, the Veteran's service treatment records contain no indication of an in-service disease or injury of the left knee. The Board has considered the Veteran's hearing testimony and statements to the effect that he sustained injury to the left knee in a grenade blast in 1976 and received treatment for that injury while he was on active duty, but finds that they are not credible. The service treatment records do not document such an injury. Moreover, at his 1977 separation examination, the Veteran specifically denied having, or ever having had, abnormalities of the knees, contradicting his current assertions. The Board finds that had the Veteran, in fact, sustained a significant injury to his left knee in a grenade blast as he now claims, he would have reported it at separation as he did report an injury to his left ankle at the time. The Board's credibility conclusion is further strengthened after having had the opportunity to observe the Veteran's demeanor at a hearing. Finally, even assuming arguendo the presence of an in-service injury, the Board finds that the record contains no indication that any current left knee disability, to include gout, is associated with service. There is no indication that any claimed in-service symptoms were indicative of a chronic disability, there is no specific allegations of continuous symptoms since service, and there is nothing in the record to suggest that any current disability is otherwise causally related to service or to the left ankle disability. The Board has also considered the Veteran's assertions that in-service blood and/or food poisoning compromised his immune system, resulting in left knee gout. See e.g. April 2015 statement. The record, however, contains no indication that any current gout is related to the claimed in-service blood and/or food poisoning. No medical professional has suggested that the Veteran currently suffers from a left knee disability, to include gout, that was incurred in service, and the Veteran has not presented, identified, or even alluded to the existence of any such medical evidence or opinion. In fact, the Board notes that the January 2015 clinical record diagnosing gout described it as idiopathic, not associated with service. The Veteran himself is not competent to provide an opinion that his current left knee disability is etiologically related to an in-service injury or disease and his general contention that his disability was incurred during service is a conclusory generalized statement which is insufficient to trigger VA's duty to provide examinations. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (holding that a veteran's mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide a VA examination). The Board has considered the fact that the Veteran's spouse, a registered nurse, provided statements and statements in support of the Veteran's claims. None of those statements, however, contains a medical opinion indicating that any current left knee disability or symptoms are associated with service or to the left ankle disability. Absent any indication that a current left knee disability is associated with the claimed in-service injury or to a service-connected disability, an examination is not necessary. In conclusion, as the evidence is not in approximate balance and is persuasively against the Veteran's claim, the benefit of the doubt rule is inapplicable and the claim is denied. 38 U.S.C. § 5107(b); Lynch v. McDonough, No. 20-2067 (Fed. Cir. 2021). 3. Service connection for an immune system disability, claimed to be the result of food and/or blood poisoning The Veteran alleges that he has a lowered immune system as a result of having experienced food poisoning from spoiled C rations and/or blood poisoning in service. See e.g., April 2, 2021 Hearing Transcript, and Correspondence, received April 22, 2015. The Veteran's service treatment records reflect that on July 8, 1975, he sought treatment for fever and chills. Examination showed multiple, infected cuts. The clinician noted that the Veteran had been prescribed Ampicillin for an ear infection but had finished that medication four to five days prior. The Veteran was restarted on Ampicillin and advised to return the following morning to see a physician. The following day, on July 9, 1975, the clinician observed that the Veteran had an infected right arm. Possible blood poisoning was noted. It was also noted that he had been seen on sick call the previous day for bites to the skin. Physical examination showed a hematoma on the right arm and tenderness to the armpit. He was prescribed penicillin and admitted to the ward overnight. The following day, it was noted that he seemed to be doing much better. Some edema to the right arm was noted, although his swelling had gone down. He was advised to continue his medication. Later that day, he was examined and was "looking much better." He was returned to duty and advised to continue his medication and hot soaks. The remaining service treatment records are negative for pertinent complaints or abnormalities. At his March 1977 separation examination, the Veteran's upper extremities were normal, as were all systems. Laboratory testing was also normal. On a report of medical history completed at separation, the Veteran described himself as being in good health and specifically denied having or ever having had all pertinent symptoms. The post-service clinical records on appeal are negative for complaints or findings of a compromised immune system or any residual of claimed in-service blood poisoning or food poisoning. In an August 2015 statement, the Veteran claimed that during active duty, he received bad C-rations in the field and got caught up in a rusty wire. He indicated that he was "taken from the field to military facility due to both poisonings at the same time." He claimed that his immune system was "severely weakened." During the April 2021 Board hearing, the Veteran testified that while out on training handing out c-rations, "there was one particular meal in there that they found out was bad and the lieutenant comes running over, hey, don't eat this one. Well, sure enough that was the one nobody else wanted. I ate it. So, I guess I got a pretty good dose of food poisoning that day." Also that same day, he recalled getting cut by a rusty wire. He testified that he started sweating and felt ill and was transported to a medical facility where "they put me instantly in an ice bath because my temperature was going up to like 105 or whatever." He claimed that he was in the medical facility "for, I don't know, days, I guess." He claimed that when he was discharged, he was told that "you're going to have issues with your immune system because of that." He indicated that he now had a lowered immune system. His spouse testified that the Veteran had not been treated for a lowered immune system but he got frequent infections and got sick far more that she did. The Veteran stated that in the course of getting treatment for his frequent infections, he had never been diagnosed with an immune system disability. After considering the record in its entirety, the Board finds that the criteria to establish service connection for an immune system disability have not been met. With respect to the first element necessary to establish service connection, a current disability, the Board first notes that the record does not contain clinical evidence of a current diagnosis during the pendency of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Indeed, the Veteran has acknowledged that he has never been diagnosed as having an immune system disability. Although the Veteran and his spouse have testified to the effect that he seems to contract frequent infections, the Veteran has not provided evidence tending to show that his claimed symptoms rise to a level to affect earning capacity. Wait v. Wilkie, 33 Vet. App. 8 (2020). The Board has considered the fact that the Veteran's spouse is a registered nurse and reports that the Veteran has had frequent infections. To the extent her testimony could constitute competent evidence of a current disability manifested by a compromised immune system, the Board finds that it is not credible. This is so because the contemporaneous clinical evidence reflects that the Veteran does not, in fact, have frequent infections. For example, the record on appeal contains December 2013 private clinical records showing that the Veteran underwent an annual physical. At that time, the physician conducted a review of the Veteran's medical history and his systems, specifically noting that the Veteran denied a history of recurrent infections. In addition, in April 2014, the Veteran was seen for an upper respiratory infection and dysuria. At that time, he reported a history of a prior urinary tract infection. He did not, however, report a history of frequent infections, nor did he report a history of blood poisoning in service after which he was told that he would have a compromised immune system. The Board finds that had the Veteran, in fact, had a history of frequent infections or had been told he had a compromised immune system, he would have reported it during his physical or when seeking treatment for a urinary tract infection. The Board finds that the contemporaneous clinical records are far more probative that statements made in the context of a claim for monetary benefits. Even assuming the presence of a current disability, the Board finds that the record contains no indication that any current immune system disability is causally related to the Veteran's active service or any in-service disease or injury, to include his claimed in-service blood poisoning or food poisoning, or the documented infected right arm. The Board has considered the Veteran's testimony to the effect that when he was discharged from the medical facility after having been treated for food and blood poisoning, he was told that he was "going to have issues" with his immune system. The Board, however, does not find the Veteran's statements in this regard to be credible. First, the Veteran's account of his inpatient stay is contradicted in multiple respects by the contemporaneous clinical records. For example, he was not hospitalized "for days;" rather, the contemporaneous records show that he had a single overnight stay. In addition, he was not immediately hospitalized and instantly immersed in an ice bath with a fever of 105 degrees. Rather, the contemporaneous clinical records specifically note that upon presenting to the clinic, he was prescribed antibiotics and told to return in the morning. At that time, he was noted to have a fever of just over 100 degrees. Moreover, he was not noted to have cuts from wire or food poisoning. Rather, he was observed to have infected bites to his skin, presumably from insects. Finally, the contemporaneous clinical records contain no indication whatsoever of a compromised immune system. Rather, the Veteran was described as looking much better following discharge and was returned to duty. Moreover, the remaining service treatment records, including the 1977 separation examination, are negative for any residuals of the July 1975 infection. Indeed, the Veteran's 1977 separation examination indicates that all systems were examined at that time and were found to be normal. The Board's credibility determination is further strengthened after having had the opportunity to observe his demeanor at a hearing. The Board notes that the Veteran has not been afforded a VA examination addressing his claimed immune system disability. However, absent evidence of a current disability which may be associated with service, the Board finds that such an examination is not required. While the Veteran contends he has a compromised immune system which was incurred in service, he is not competent to provide a diagnosis or an etiological opinion regarding this matter. The issue is medically complex and is outside the competence of a lay person such as the Veteran. See Jandreau, 492 F.3d 1372, 1377 (2007). Although his spouse is a nurse, she has not provided an opinion regarding the etiology of the claimed immune system disability. The Board therefore finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for immune system and blood poisoning disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Service connection for left ankle disability is remanded. The Veteran alleges that he has a current left ankle disability as a result of an in-service injury. The Veteran contends that he tore ligaments in his ankle during basic training. He reported that his leg was placed in a cast and healed but he reinjured his left ankle during advanced training. See Correspondence, received April 22, 2015, and Hearing Transcript, received April 2, 2021. He claims that he now has no lateral support in his left ankle, which reduces his ability to perform vigorous physical activities such as walking, hiking, and fishing. Id. The Veteran's spouse reports that the Veteran treats his left ankle symptoms with over-the-counter pain medicine, knee braces, gel packs, and ace wraps. See Statement, received on April 22, 2015. The Veteran's service treatment records show that in September 1974, he sought treatment after he twisted his left ankle. X-ray studies showed soft tissue swelling but no obvious fracture. The impression was severe ligament rupture. The Veteran was instructed on the use of crutches and put on a temporary physical profile. In October 1974, the Veteran was prescribed a left ankle brace and his profile was extended until the end of the month. The remaining service treatment records are negative for complaints pertaining to the ankle. At his March 1977 separation examination, clinical evaluation of the lower extremities was normal. On a report of medical history, the Veteran described himself as being in good health. He denied swollen or painful joints, bone, joint or other deformity, or lameness. The Veteran reported that he did not know if he had current or previous foot trouble; the examiner elaborated that the Veteran reported a history of a left ankle ligament strain in 1974 which was now healed. The post-service clinical evidence of record is entirely negative for complaints or findings of a left ankle disability. During a December 2013 physical, the Veteran denied joint pain or stiffness, swelling or weakness. Examination of the extremities revealed no abnormalities, including a disability of the left ankle. In a March 2021 letter, the Veteran's spouse, a nurse, noted that the Veteran had self-treated his left ankle symptoms over the years with over-the counter pain medications, ankle supports during moderate physical activities, and restriction of all strenuous physical activity. A review of the record reflects that the Veteran has not been afforded a VA examination in connection with his claim of service connection for a left ankle disability. A medical examination is necessary if the record contains (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) (holding that the third element for triggering VA's duty to provide an examination an indication that the claimed disability may be associated with service may be satisfied by credible lay evidence of continuity of symptomatology). In this case, the service treatment records document an in-service left ankle injury. The Veteran's spouse, a registered nurse, suggests that the Veteran has a current left ankle disability as a result of the in-service injury. Although she has provided no current diagnosis, specific medical opinion, or rationale, affording the Veteran the benefit of the doubt, the Board finds that the record contains an indication that his currently claimed disability or symptoms may be associated with service. Thus, an examination is required. The matter is REMANDED for the following action: 1. Schedule the Veteran for a medical examination to determine the nature and etiology of any current left ankle disability. After examining the Veteran and reviewing the record, the examiner should provide an opinion, with supporting rationale, as to the following: Is it approximately at least as likely as not that the Veteran currently exhibits a left ankle disability? If no pathology is identified, the examiner should state whether the Veteran's left ankle symptoms reach the level of a functional impairment of earning capacity. If the Veteran exhibits a current left ankle disability, is it approximately at least as likely as not that such disability had its onset during or is otherwise related to the Veteran's active service, to include the documented in-service 1974 left ankle injury. In providing the request opinion, the examiner should consider the Veteran's documented left ankle injury as well as his reported symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran's claimed symptoms. (Continued on the next page) If there is any medical reason to accept or reject the proposition that any claimed symptoms in service and thereafter represented the onset of the currently claimed left ankle disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the current disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? The Board makes no credibility findings at this juncture, pending the opinion of the examiner. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.N., 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.