Citation Nr: 22018155 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 18-03 121 DATE: March 28, 2022 ORDER A 10 percent disability rating for right leg surgical scar is granted for the entire initial rating period on appeal. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted for the entire rating period prior to January 4, 2020. REMANDED Entitlement to an initial compensable disability rating for right leg hamstring, status post release and lengthening with residuals, is remanded. Entitlement to service connection for a back disability is remanded. FINDINGS OF FACT 1. Throughout the initial rating period, the Veteran has had one surgical scar on the right leg that has been numb and occasionally swells; however, the evidence has not demonstrated that it is deep, is associated with underlying tissue damage, or covers an area of 144 square inches or greater, nor is there any evidence that the scar is unstable or has had disabling effects. 2. Throughout the rating period prior to January 4, 2020, the Veteran had a service-connected disability rated as at least 60 percent disabling, and he was rendered unable to obtain or maintain substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for a 10 percent disability rating, but no higher, for the right leg surgical scar have been met for the entire initial rating period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Codes (DCs) 7800 - 7805. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for a TDIU were met for the entire rating period prior to January 4, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from January 2009 to June 2012 and is a recipient of a Combat Action Badge. This matter comes before the Board of Veterans' Appeals (BVA or Board) from March 2016 and May 2017 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a February 2020 videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims folder. In April 2020, the Board remanded this case for further development. Except as provided in the remand portion of this decision, the development requested was completed and the case is now appropriate for appellate review. Disability Ratings Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Staged ratings are appropriate for an initial or increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. A 10 percent disability rating for right leg surgical scar is granted for the entire initial rating period on appeal. The Veteran is in receipt of a noncompensable, or zero percent, disability rating for his right leg surgical scar under the provisions of 38 C.F.R. § 4.118, DC 7805, throughout the initial rating period on appeal. For the reasons discussed below, the Board finds that the evidence is at least in equipoise as to whether a 10 percent disability rating is warranted for the right leg surgical scar throughout the initial rating period on appeal. Reviewing the most relevant evidence, at an April 2017 VA Hip and Thigh Conditions examination, the examiner noted a scar on the right leg measuring 8 by 3 centimeters that was well-healed, nontender, and nonadherent, but slightly numb. In his June 2017 notice of disagreement, the Veteran stated that his scar was numb to the touch and disfigured. At the February 2020 Board hearing, the Veteran testified that the scar was dark and large, and that sometimes it "sank" or became puffy on contact with water and with temperature change. He stated that he had no sensation of the skin around the scar with occasional pins and needles sensation. At a July 2020 VA scar examination, the Veteran reported constant numbness around the scar. He described an intermittent tearing sensation inside the scar rated at 8 out of 10 that occurred especially with certain movements and exercise. The examiner noted that the impact of the scar was significant because it was a large scar. It measured 2 by .25 centimeters, did not have underlying tissue damage, had no frequent loss of covering of skin over the scar, and did not result in limitation of function or impact his ability to work. The rating criteria for the skin were amended effective August 13, 2018. The amendment permits claims filed prior to the effective date to be considered under either the old or new rating criteria. However, if the August 2018 amendments are applied, the effective date of the award cannot be prior to August 13, 2018. The amendments introduce a General Rating Formula for skin conditions, add paragraph (a) and (b), and redefine the language for scars pursuant to DC 7801 and 7802. The amendment also revises Diagnostic Codes 7806, 7809, 7813, 7815-7817, 7820-7822, and 7824-7829. The Board finds that a 10 percent disability rating is warranted for the right leg surgical scar for the entire initial rating period on appeal under the criteria of DC 7804, 38 C.F.R. § 4.118. DC 7804 was not affected by the recent amendments. Under that code, a rating of 30 percent is assigned when there are five or more scars that are unstable or painful. A rating of 20 percent requires three or four scars that are unstable or painful. A rating of 10 percent requires one or two scars that are unstable or painful. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. In this case, throughout the initial rating period on appeal, the evidence has demonstrated that the Veteran experiences a sensation of numbness around the area of the scar. While numbness is not explicitly listed in the rating criteria for scars, the Board finds that the numbness is a sensation commensurate in its effect with the pain contemplated in the rating criteria, such that a 10 percent disability rating is warranted. The Board has considered whether any other diagnostic code would allow for an even higher disability rating but finds none. Both the pre-amended and amended versions of DC 7800 apply to scars or other disfigurement of the head, face, or neck. As the Veteran's scar is located on his leg, this code is not for application. The pre-amended version of DC 7801 applies to scars that are deep and nonlinear and provides for a 10 percent disability rating when such scars cover an area or areas of at least 6 square inches (39 sq. cm.). Note (1) states that a deep scar is one associated with underlying soft tissue damage. The amended version also applies to scars that are associated with underlying soft tissue damage. As the Veteran's scar has not been assessed as deep and nonlinear, or associated with underlying soft tissue damage, this code is not for application. Under pre-amended DC 7802, scars not of the head, face, or neck, that are superficial and nonlinear are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. Under amended DC 7802, scars not of the head, face, or neck, that are not associated with underlying soft tissue damage are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. In this case, throughout the initial rating period on appeal, the Veteran's scar covers a combined area significantly less than 929 square centimeters. Accordingly, this code is not for application. Under both versions of DC 7805, scars, other (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804, are evaluated on the basis of any disabling effects not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. The evidence in this case does not demonstrate any disabling effects from the Veteran's service-connected right leg scar. In sum, the Board finds that the criteria for a 10 percent disability rating have been met throughout the initial rating period on appeal based on the presence of one scar that is numb, which is commensurate with one painful scar, under the provisions of DC 7804. There is no basis upon which to assign an even higher disability rating (in excess of 10 percent) for the right leg scar at any time during the initial rating period on appeal. Namely, throughout the initial rating period on appeal, there is no evidence that the right leg scar is deep, is associated with underlying tissue damage, or covers an area of 144 square inches or greater, nor is there any evidence that the scar is unstable or has had disabling effects. The Board has considered the Veteran's statements that he is entitled to a higher rating for his right leg scar; indeed, his report of numbness serves as the basis for the award of a 10 percent rating herein. However, the findings of the VA examiners in this case are the most probative evidence of record with regard to determining the most appropriate rating for the right leg scar and they do not demonstrate the criteria for a rating in excess of 10 percent. In sum, resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise as to whether a 10 percent disability rating is warranted for the right leg scar for the entire initial rating period on appeal. To the extent any higher level of compensation is sought, the evidence weighs persuasively against this claim, and, hence, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted for the entire rating period prior to January 4, 2020. A March 2020 rating decision granted a TDIU effective from January 4, 2020, the day following the last date the Veteran worked. The Veteran contends that he is entitled to a TDIU due to the impairment caused by his service-connected disabilities for the entire period on appeal prior to January 4, 2020 (from March 2, 2017). On his VA Form 21-8940, the Veteran stated that he is unable to work due to his service-connected PTSD and right hamstring disability. For the reasons discussed below, the Board agrees that the criteria for an award of a TDIU have been met for the entire rating period prior to January 4, 2020. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. 38 U.S.C. § 1155. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). The central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to his or her level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment is work that is more than marginal, which permits the individual to earn a "living wage." See Moore v. Derwinski, 1 Vet. App. 356 (1991). In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes his case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. 361. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). In this case, prior to January 4, 2020, the Veteran's service-connected disabilities included PTSD, evaluated as 70 percent disabling; and right leg hamstring, status post release and lengthening with residuals, and right leg surgical scar, both evaluated as noncompensably disabling. For the entire period prior to January 4, 2020, the Board finds that the combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are met because the Veteran has one service-connected disability rated at at least 60 percent (his PTSD). Moreover, after a review of all the evidence, the Board concludes that the evidence is at least in equipoise as to whether the Veteran was unable to secure or follow substantially gainful employment due to his service-connected disabilities prior to January 4, 2020. At an April 2017 VA PTSD examination, the examiner assessed occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, due to PTSD symptoms. The Veteran had worked in security, at a Starbucks, and as a temporary worker after his discharge from active service. He had repeatedly left jobs because he felt like everything was temporary, he did not feel he belonged, and he isolates. He last worked in August 2016. He attended Rutgers University for 2 years post-military, but he failed out. At an April 2017 VA Hip and Thigh Conditions examination, the examiner stated that, in terms of occupational impact, the Veteran would be limited in his ability to run and perform prolonged standing or walking due to the service-connected hamstring disability. A May 2017 VA Counseling Record - Narrative Report indicates that due to service-connected PTSD, the Veteran reported bouts of anger, anxiety, and difficulty concentrating on tasks. The counselor stated that this impairment was found to result in substantial part from his service-connected PTSD. He had currently been unemployed for over almost a year, and his service-connected disabilities limited his functioning. Further, the Veteran had a history of not following through on tasks and had been academically dismissed from college in the past. His disabilities limited his ability to interact with others and perform physical job tasks. On his January 2020 VA Form 21-8940, the Veteran stated that he had been trying to work for the last 5 years, but after years of trying to find stable work, he realized that his back, PTSD, and hamstring problems were preventing him from finding gainful employment. He stated that his employers found that he was unable to perform his job duties without problems due to his mental health. He listed his employment history, which included multiple very short-term jobs in 2019 and 2020. Most recently, from December 4, 2019 to January 17, 2020, he worked 40 hours per week doing housekeeping; he had lost 20 hours during that time due to disability. A January 2020 VA Form 21-4192 from the Veteran's most recent employer stated that the Veteran worked for them from December 8, 2019 until January 3, 2020 as a housekeeping aid, working 40 hours per week. No concessions were made by reason of age or disability, and he did not lose any time from work due to disability but used 2 hours of sick leave. He resigned from the job. It was based on this form that the RO assigned the effective date of January 4, 2020 for the award of a TDIU. In a February 2020 letter, D.K., Vocational Rehabilitation Services Supervisor (VA), indicated support for an award of TDIU. D.K. reviewed the Veteran's VA medical records, spoke to his VA social worker, his former supervisor, and met with the Veteran individually. The Veteran was employed for one week at a VA Community Based Outpatient Clinic; during this time, he was easily angered, oblivious to social cues from others, constantly distracted, and struggled to work as part of a team and receive/follow basic work instructions. His social worker had observed the same behaviors. The Veteran stated that he attended college for 5 years from 2012 to 2017, after which time he moved around the country frequently. His longest period of employment was 3 months at a Starbucks. He stated that he felt constant anxiety and his sleep pattern was disjointed, usually consisting of 2-to-3-hour naps. He also stated that he moved frequently when people "got on his nerves." D.K. stated that the Veteran was not dealing with his PTSD symptoms effectively, and that such people display a flight mentality as they are looking for some sort of stability in their lives. They are not suitable for any type of work since they cannot yet deal with the realities of the workplace, and their PTSD symptoms make them highly unreliable and easily agitated. A June 2020 VA Counseling Record - Narrative Report indicated that the Veteran was currently unemployed, and his work history was limited, short term, and had not been suitable. He lacked the education/training to obtain suitable employment that did not worsen his service-connected conditions. As a result of his physical diagnoses (including right hamstring disability), he was unable to bend, stoop, squat, or lift repeatedly. He could not stand or walk for extended periods of time or perform arduous labor. As a result of his PTSD, he had difficulty managing stress, building interpersonal relationships, and adapting to new environments. He reported struggling with a lack of motivation, difficulty following through with tasks, and withdrawing from society. His service-connected disabilities contributed to the overall significant vocational impairment. His service-connected disabilities were severe in nature and were the cause for the intermittent, short-term, and unsuitable work history. His psychological symptoms significantly hindered his ability to effectively communicate with others, handle stressors, and maintain employment. It is clear based on the above as well as the combined 70 percent disability rating in effect prior to January 4, 2020 that the Veteran had significant occupational impairment due to his service-connected disabilities. While the Veteran managed to obtain several very short-term jobs, the evidence demonstrates that his service-connected disabilities have had a consistent, significant impact on his ability to maintain gainful employment. The Board has relied in particular on the VA Counseling Records and letter from the VA Vocational Rehabilitation Services Supervisor discussed above in resolving reasonable doubt in favor of the Veteran to find that the criteria for a TDIU prior to January 4, 2020 were met. In sum, the Board finds that the evidence is at least in equipoise as to whether the Veteran was unable to secure and maintain gainful employment due to his service-connected disabilities prior to January 4, 2020. Resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a TDIU were met for the entire rating period prior to January 4, 2020. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to an initial compensable disability rating for right leg hamstring, status post release and lengthening with residuals, is remanded. The Veteran has a noncompensable disability rating for the entire initial rating period on appeal. While still in active service, in October 2011, he reported right knee pain while running since 2009, as well as snapping/popping of the medial hamstring tendon over the medial knee joint line. He had improved knee range of motion and strength in physical therapy since May 2011 but had not been able to return to running without pain. He had difficulty extending the right knee while running. The clinician recommended a knee arthroscopy, semitendinosus release, semimembranosus fractional lengthening, and bursal removal procedure, which was performed later that year. At the February 2020 Board hearing, the Veteran testified that his service-connected right hamstring disability manifested constant pain and difficulty standing, walking, and performing any physical activity secondary to increased pain. He also stated that he experiences severe cramping in the hamstring muscle, especially when sitting for prolonged periods, and that he has to walk with a limp, particularly when going up stairs. He also described weakness in the right leg. Private treatment records from May 2020 indicate that the Veteran sought treatment for right knee pain following a sensation that the knee popped out of place, but the treatment note discusses the history of the hamstring injury in service, indicating a possible correlation. The Board observes that the inception of the now service-connected hamstring disability in service also began with a report of right knee pain. Pursuant to the Board's remand, in July 2020, the Veteran was afforded a VA Muscle Injuries examination. The examiner concluded that the Veteran did not have a current muscle injury, despite the Veteran's report of symptoms as described above, including constant right leg pain and right hamstring cramping and pain after prolonged walking. The examiner further indicated that the Veteran's muscle injury did not affect muscle substance or function and checked a box indicating "no" when asked if the Veteran had any of the following symptoms attributable to muscle injuries - loss of power, weakness, lowered threshold of fatigue, fatigue and/or pain, impairment of coordination, etc., despite the Veteran's report of symptoms which directly contradict the examiner's finding. The Board finds that the July 2020 VA examination is inadequate to assess the current severity of the service-connected right hamstring disability. Namely, the right hamstring disability seems to have mostly manifested complaints involving the knee and impairment thereof, as demonstrated by the service treatment records and more recent private treatment records. Therefore, the Board finds that the Veteran should be afforded an examination i.e., a knee examination that adequately assesses the impairment caused by his right hamstring disability. In addition, the examiner should also assess whether, even if there is no underlying diagnosis based on physical examination, there is functional impairment resulting from the Veteran's reports of pain, cramping, stiffness, weakness, etc. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 2. Entitlement to service connection for a back disability is remanded. The Veteran contends that he has a current low back disability that began during active service and/or was aggravated by an altered gait due to his service-connected right hamstring disability. He was afforded a VA examination in July 2020. The examiner opined that the back condition, diagnosed as degenerative arthritis of the spine, was not caused by the service-connected right hamstring disability as no evidence of a hamstring disorder was found; thus, the examiner discounted or did not consider at all the Veteran's statements regarding his right hamstring symptoms and consequential altered gait. Next, the examiner opined that the back condition was not aggravated by the service-connected hamstring disability, reasoning that he only recently had onset of back pain (in 2019), there were no current clinical findings of pathology, and it appeared that prior treatment had resolved the problem. However, the Veteran has consistently reported back pain since 2011, including at the July 2020 VA examination, contradicting the examiner's rationale. Finally, the examiner indicated that the Veteran was not treated or evaluated for back problems in service, which is false, as service treatment records document back problems in April 2011. Therefore, a remand is necessary to afford the Veteran an adequate examination and opinion regarding the nature and etiology of his claimed back disability. The matters are REMANDED for the following action: 1. Afford the Veteran the opportunity to attend a knee examination (and any other examination deemed necessary by the examiner) with an appropriate specialist in order to determine the current severity of his service-connected right leg hamstring disability. The examiner should interview and examine the Veteran, conduct all indicated evaluations, studies, and tests deemed necessary, and offer a rationale for any opinion expressed. The claims file should be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. The examiner should identify any and all current right leg/hamstring disabilities, to include a description of any functional impairment of the right leg due to the hamstring disability, including any functional impairment of the right knee. The examiner must document any functional impairment described by the Veteran, to include his reports of right leg pain, cramping, and difficulty walking/standing/sitting for prolonged periods. The examiner is advised that the Veteran is competent to describe such symptoms and is presumed to be credible for purposes of this examination. 2. Afford the Veteran an opportunity to attend a VA examination with an appropriate specialist regarding the nature and etiology of his back disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file, including a copy of this decision, must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should first identify any and all current back disabilities, to include a description of any functional impairment of the back. (b.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's back disability was incurred during or caused by active service? In providing the opinion, the examiner must address the service treatment records showing back problems in April 2011 and the Veteran's statements that he has experienced back pain since 2011. The examiner is advised that the Veteran is competent to describe symptoms that are observable by a lay person, such as back pain. If the examiner rejects the Veteran's reports regarding his symptoms, the examiner must provide a reason for doing so. (c.) Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's back disability was caused or aggravated by the service-connected right leg hamstring disability, to include as a result of an altered gait? The examiner must consider the Veteran's competent statements regarding his right leg symptoms and description of how the right leg disability affects his gait in rendering the opinion. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. [CONTINUED ON NEXT PAGE] All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.