Case A26032397

LEETRA J. HARRIS · 2026 · Case ID: A26032397

MIXED

Summary

The veteran, who served from December 1980 to December 1983, appeals the denial of service connection for otitis media and the dismissal of claims for 38 U.S.C. § 1151 compensation for left foot and bladder disabilities, and tinnitus. The Board found that no new and relevant evidence was submitted to warrant readjudication for the § 1151 claims and tinnitus, dismissing these matters. The denial of service connection for otitis media was upheld as the veteran has no current diagnosis and her testimony at the Board hearing indicated confusion about the condition, focusing instead on tinnitus. However, the Board found new and relevant evidence was submitted for left and right knee disabilities, warranting readjudication. The veteran's theory that the 2017 SCS surgery caused her knee disabilities was considered new as it was not previously raised. The Board remanded claims for service connection for a back disability and left lower extremity (LLE) radiculopathy due to inadequate VA examination opinions. The examiner's rationale for denying the back claim, based solely on the passage of time, was found insufficient. The LLE radiculopathy claim was remanded due to its intertwinement with the back and knee claims. The bilateral knee claims, including theories of direct service connection for in-service injuries and § 1151 claims related to the 2017 surgery, were also remanded due to inadequate VA examinations. The Board noted that the RO had not obtained VA opinions on these theories. The case was remanded for new VA examinations to determine the etiology and nexus for the back, LLE radiculopathy, and bilateral knee disabilities, and to assess § 1151 claims for the knees.

Special Benefit

§1151

Docket No.

210630-169404

Full Decision Text

Citation Nr: A26032397
Decision Date: 04/08/26 Archive Date: 04/08/26

DOCKET NO. 210630-169404
DATE: April 8, 2026

ORDER

As new and relevant evidence has not been submitted to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a left foot disability, the claim is dismissed as a matter of law.

As new and relevant evidence has not been submitted to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a bladder disability, the claim is dismissed as a matter of law.

As new and relevant evidence has not been submitted to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for tinnitus, the claim is dismissed as a matter of law.

As new and relevant evidence has been submitted to warrant readjudication of the claim seeking service connection for a left knee disability, the claim is readjudicated.

As new and relevant evidence has been submitted to warrant readjudication of the claim seeking service connection for a right knee disability, the claim is readjudicated.

Entitlement to service connection for otitis media is denied.

REMANDED

Entitlement to service connection for a back disability is remanded.

Entitlement to service connection for left lower extremity (LLE) radiculopathy is remanded.

Entitlement to service connection and compensation under 38 U.S.C. § 1151 for a left knee disability is remanded.

Entitlement to service connection and compensation under 38 U.S.C. § 1151 for a right knee disability is remanded.

FINDINGS OF FACT

1. The Department of Veterans Affairs (VA) did not receive new and relevant evidence to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a left foot disability.

2. The VA did not receive new and relevant evidence to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a bladder disability.

3. The VA did not receive new and relevant evidence to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for tinnitus.

4. The VA received new and relevant evidence to warrant readjudication of the claim seeking service connection for a left knee disability.

5. The VA received new and relevant evidence to warrant readjudication of the claim seeking service connection for a right knee disability.

6. The Veteran does not have a current disability of otitis media.

CONCLUSIONS OF LAW

1. The criteria for readjudicating the claim to establish service connection for a left foot disability are not met. 38 C.F.R. § 3.2501.

2. The criteria for readjudicating the claim to establish service connection for a bladder disability are not met. 38 C.F.R. § 3.2501.

3. The criteria for readjudicating the claim to establish service connection for tinnitus are not met. 38 C.F.R. § 3.2501.

4. The criteria for readjudicating the claim to establish service connection for a left knee disability are met. 38 C.F.R. § 3.2501.

5. The criteria for readjudicating the claim to establish service connection for a right knee disability are met. 38 C.F.R. § 3.2501.

6. The criteria for service connection for otitis media are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from December 1980 to December 1983.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2020 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In the June 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on December 9, 2024, and a transcript is included within the record.

Therefore, the Board may only consider the evidence of record at the time of the November 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If
appeal from a November 2020 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

Therefore, the Board may only consider the evidence of record at the time of the November 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the denied claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims seeking service connection for back, LLE radiculopathy, and bilateral knee disabilities, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

New and Relevant Evidence

VA will readjudicate a claim if new and relevant evidence is presented or secured. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(d); 38 C.F.R. § 3.2501. New evidence is evidence not previously part of the actual record before agency adjudicators. 38 C.F.R. § 3.2501(a)(1). Relevant evidence is information that tends to prove or disprove a matter at issue in a claim, including evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(2). If new and relevant evidence is not presented or secured, the AOJ will issue a decision finding that there was insufficient evidence to readjudicate the claim. Id.

Service Connection

Service connection will be granted for a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).

Service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Lastly, service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish secondary service connection there must be evidence: (1) of a current disability (for which secondary service connection is sought); (2) of an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection). For the purposes of aggravation, the central question was whether any worsening of the nonservice-connected disability is actually
disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection). For the purposes of aggravation, the central question was whether any worsening of the nonservice-connected disability is actually due to the service-connected disability, or whether the worsening is due to the natural progression of the disability. 38 C.F.R. § 3.310(b).

Compensation under 38 U.S.C. § 1151

Section 1151(a) of title 38, U.S. Code, provides that a veteran may be compensated for a "qualifying additional disability" if that disability was not the result of the veteran's willful misconduct and is actually and proximately caused by VA medical care or treatment. 38 C.F.R. § 3.361(c)(1). "To determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the... medical or surgical treatment... upon which the claim is based to the veteran's condition after such... treatment." 38 C.F.R. § 3.361(b). An additional disability is caused, in fact, by VA medical care or treatment where the care or treatment "resulted" in the disability. 38 C.F.R. § 3.361(c)(1). An additional disability is proximately caused by VA medical care or treatment where it results from either the "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault" on the part of VA, or from "an event not reasonably foreseeable." 38 U.S.C. § 1151(a); 38 C.F.R. § 3.361(d)(1).

To be entitled to compensation under 38 U.S.C. § 1151(a), a claimant must show that an additional disability was not merely coincidental with VA medical treatment, but stems from some fault in the care with which he or she was provided, including "carelessness, negligence, lack of proper skill, error in judgment, or some other similar instance of fault." 38 U.S.C. § 1151(a); 38 C.F.R. § 3.361(d)(1); Mangham v. Shinseki, 23 Vet. App. 284, 288 (2009).

1. Whether new and relevant evidence has been submitted to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a left foot disability

2. Whether new and relevant evidence has been submitted to warrant readjudication of the claim seeking compensation under 38 U.S.C. § 1151 for a bladder disability

Prior to the rating decision on appeal, the Veteran previously sought compensation under 38 U.S.C. § 1151 for left foot and bladder disabilities allegedly caused during an October 2017 surgery at a VA medical center. The RO denied the claims in a July 2018 rating decision. When the Veteran subsequently refiled her claim, the RO found that new and relevant evidence had not been submitted to warrant readjudication of the claims in a January 2019 rating decision. After the Veteran refiled her claims in a February 2020 VA Form 21-0995, Supplemental Claim Application, the RO once again found that new and relevant evidence had not been submitted to warrant readjudication of the claims in the November 2020 rating decision on appeal.

After review of the evidence, the Board finds new and relevant evidence has not been submitted to warrant readjudication of the claims.

In filing her original December 2017 VA Form 21-526EZ, Fully Developed Claim, the Veteran's representative submitted an argument in which she alleged the Veteran's disabilities were caused by an October 2017 surgery at a VA medical center. The representative explained that a VA medical center implanted a spinal cord stimulator (SCS) within the Veteran in 2009 to treat symptoms associated with spinal stenosis. The VA replaced the SCS in September 2015 without incident. In October 2017, the VA once again replaced the Veteran's SCS. Following the procedure, the representative claimed, the Veteran experienced LLE pain, numbness, and weakness, including left foot drop. Along with these disabilities, the representative noted the Veteran was seeking service connection for uro
Form 21-526EZ, Fully Developed Claim, the Veteran's representative submitted an argument in which she alleged the Veteran's disabilities were caused by an October 2017 surgery at a VA medical center. The representative explained that a VA medical center implanted a spinal cord stimulator (SCS) within the Veteran in 2009 to treat symptoms associated with spinal stenosis. The VA replaced the SCS in September 2015 without incident. In October 2017, the VA once again replaced the Veteran's SCS. Following the procedure, the representative claimed, the Veteran experienced LLE pain, numbness, and weakness, including left foot drop. Along with these disabilities, the representative noted the Veteran was seeking service connection for urological issues, right shoulder pain, and low back pain, but did not specify whether they were alleging that these disabilities were caused by the surgery.

Upon VA examination in June 2018, the examiner reviewed the Veteran's claims file, including her surgical treatment records, and conducted an examination which included soliciting the Veteran's statement. The examiner opined that, while the Veteran's disabilities were caused by the VA surgery, the additional disabilities were neither unforeseen nor related to fault on the of VA personnel. As a rationale, the examiner noted that the Veteran had consented to the surgery and was cautioned that bleeding and/or swelling were possible outcomes for the procedure and that, in some cases, could lead to paralysis and death.

The RO denied the Veteran's claim in a July 2018 rating decision, in which the RO noted its review of the Veteran's VA medical records, including the surgery treatment records, the Veteran's representative's December 2017 argument, and the June 2018 VA examination and opinion. Specifically, the RO noted a VA Form 10-0431a, Consent for Clinical Treatment/Procedure, signed by the Veteran on August 23, 2017, stating that the procedure might not cure or relieve symptoms and that her symptoms might even worsen. Additionally, known risks included damage to nerves causing temporary or permanent pain, numbness, or weakness. The form is included in the Veteran's VA treatment records. Relying on the June 2018 VA examination, the RO found that the additional disabilities were neither unforeseen nor related to fault on the of VA personnel.

The Veteran sought readjudication of the claims through filing an August 2018 VA Form 21-0995, Supplemental Claim Application. She submitted a statement in which she detailed her symptoms following the October 2017 surgery. The Veteran did not make any new allegations as to the cause of her disabilities. The Veteran also submitted VA treatment records previously associated with the record.

The RO denied the Veteran's claims in a January 2019 rating decision, finding that the evidence submitted was either duplicative or not relevant such that readjudication of the claims was not warranted.

The Veteran sought readjudication of her claim once more through filing a February 2020 VA Form 21-0995, Supplemental Claim Application. The Veteran submitted an accompanying March 2020 VA Form 21-4138, Statement in Support of Claim, and an additional statement in March 2020. The Veteran did not make any new allegations which would tend to prove or disprove an issue in dispute since the prior adjudications. The Veteran also submitted previously-reviewed VA treatment records.

While the Veteran testified at a December 2024 Board hearing, she did not present any new arguments or evidence tending to prove a matter at issue which was not already considered in the previous denials.

The Board finds that the evidence received since the prior January 2019 rating decision is neither new nor relevant, as the Veteran's statements repeat previously-made allegations and the medical records were already considered during the prior adjudication. Given this, new and relevant evidence has not been submitted to warrant readjudication of the claims, and the claims must be dismissed.

3. Whether new and relevant evidence has been submitted to warrant readjudication of the claim seeking service connection for tinnitus

The Veteran seeks readjudication of a previously-denied claim seeking service connection for tinnitus.

After review of the evidence, the Board finds that readjudication is not warranted.

The Veteran originally sought service connection for tinnitus through filing a March 2019 VA Form 21-526EZ, Fully Developed Claim. Upon VA examination in April 2019, the examiner opined that the Veteran's disability was not incurred in or caused by service. While the examiner noted the Veteran's report of tinnitus in her left ear, the examiner stated that there was no significant threshold shift between the Veteran's June 1980 entry and November 1983 exit audiograms. As there was no shift, the examiner opined, the Veteran's tinnitus was not caused by her military noise exposure. In denying the claim
tinnitus.

After review of the evidence, the Board finds that readjudication is not warranted.

The Veteran sought readjudication of her claim through filing a February 2020 VA Form 21-0995, Supplemental Claim Application. In an accompanying VA Form 21-4138, Statement in Support of Claim, the Veteran alleged that her tinnitus was caused by firing weapons.

At the December 2024 Board hearing, the Veteran repeated her allegations that her tinnitus was caused by firing weapons and the other training associated with her service.

The Board finds that new and relevant evidence has not been submitted to warrant readjudication of the claim. In so finding, the Board notes that the issue of nexus remained at issue following the March 2019 rating decision denying the claim. However, the evidence received since that denial does not tend to prove nexus. As such, readjudication of the claim is not warranted, and the claim is dismissed.

4. Whether new and material evidence has been submitted to warrant readjudication of the claim seeking entitlement to service connection for a left knee disability

5. Whether new and material evidence has been submitted to warrant readjudication of the claim seeking entitlement to service connection for a right knee disability

The Veteran seeks readjudication of a previously-denied claims seeking service connection for bilateral knee disabilities.

After review of the evidence, the Board finds that readjudication is warranted.

The Veteran originally sought service connection for bilateral knee disabilities through filing an August 2018 VA Form 21-526EZ, Fully Developed Claim. She did not make any specific allegations as to the cause of her disabilities. Upon VA examination in September 2018, the examiner opined that the Veteran's disability was not incurred in or caused by service. The Veteran told the examiner that she had bilateral knee pain during training and had to stop running as a result. She stated that she was diagnosed with chondromalacia and continued to have knee pain with weight-bearing activities. The examiner noted the Veteran's 2014 ACL injury. As a rationale for their opinion, the examiner noted there were no records of a knee disability or symptoms between the Veteran's discharge and her 2014 injury. The RO relied on this negative nexus opinion in denying the Veteran's claim in a January 2019 rating decision.

In filing her February 2020 VA Form 21-0995, Supplemental Claim Application, seeking readjudication of her knee claims, the Veteran submitted a VA Form 21-4138, Statement in Support of Claim, in which she alleged that the 2017 SCS surgery caused her knee disabilities. The Veteran had not raised this theory of entitlement in her past claim. As relevant evidence includes evidence that raises a theory of entitlement that was not previously addressed, readjudication of the claim is warranted. 38 C.F.R. § 3.2501(a)(1).

6. Entitlement to service connection for otitis media

The Veteran seeks service connection for otitis media, also called a middle ear infection.

After review of the evidence, the Board finds that service connection is not warranted.

The Veteran's post-service medical treatment records do not show a diagnosis of otitis media or symptoms associated with middle ear infections.

Upon VA examination in October 2020, the examiner declined to diagnosis otitis media. The examiner recorded the Veteran's statement that she was diagnosed with serious bilateral ear infections in August 1980, but that she had not experienced ear infections since that time.

At the December 2024 Board hearing, the Veteran declined knowing what otitis media was and instead stated that she suffered from tinnitus.

There is no evidence that the Veteran currently experiences middle ear infections, also known as otitis media. As the first element of service connection cannot be established, the Board denies the claim seeking service connection for otitis media.

REASONS FOR REMAND

Although the Board regrets the delay, upon review of the claims file, the Board finds that additional development is warranted to correct?a pre-decisional?duty
media. The examiner recorded the Veteran's statement that she was diagnosed with serious bilateral ear infections in August 1980, but that she had not experienced ear infections since that time.

At the December 2024 Board hearing, the Veteran declined knowing what otitis media was and instead stated that she suffered from tinnitus.

REASONS FOR REMAND

Although the Board regrets the delay, upon review of the claims file, the Board finds that additional development is warranted to correct?a pre-decisional?duty to assist error. See?38 C.F.R. § 20.802(a).

1. Entitlement to service connection for a back disability is remanded.

2. Entitlement to service connection for LLE radiculopathy is remanded.

At the outset, the Board notes that the RO previously denied the Veteran's claim seeking service connection for these disabilities. In the November 2020 rating decision on appeal, the RO found that new and relevant evidence had been submitted such that readjudication was warranted. This favorable finding is binding on the Board. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). As such, the Board now proceeds to adjudication.

In various statements, including her December 2024 Board hearing, the Veteran asserted that her back disability was caused when she fell while carrying a dresser down the stairs of her barracks.

Upon VA examination in September 2020, the examiner opined that the Veteran's disability was not incurred in or caused by service. While the examiner acknowledged the Veteran's in-service back injury, they relied on the passage of time between the injury and the 2017 SCS procedure. Unfortunately, the Board finds the examiner's rationale lacking, as simply the passage of time is not enough to justify a denial of service connection. Therefore, the Board finds that the examiner failed to provide a medically supported rationale with supporting data and reasoned medical explanations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The failure to provide adequate examination and opinion constitutes a pre-decisional duty to assist error. Therefore, further opinion with complete rationale is warranted. See U.S.C. § 5103A; 38 C.F.R. §?3.159; Barr v. Nicholson,?21?Vet. App.?303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).

Additionally, the Board notes that the Veteran alleged that her LLE radiculopathy was either caused by the 2017 SCS procedure or is secondary to her back disability. As such, the two claims are inextricably intertwined as the former could have significant impact on the other. Harris v. Derwinski, 1 Vet. App. 180 (1991). When a pending claim is inextricably intertwined with a claim currently on appeal, the appropriate remedy is to remand the claim on appeal pending adjudication of the inextricably intertwined claim. Id. Thus, entitlement to service connection for LLE radiculopathy must also be remanded. Additionally, in a March 2020 VA Form 21-4138, Statement in Support of Claim, the Veteran attributed her LLE radiculopathy to her knee disabilities. The Board will seek a VA medical opinion on that theory of entitlement upon remand.

3. Entitlement to service connection and compensation under 38 U.S.C. § 1151 for a left knee disability is remanded.

4. Entitlement to service connection and compensation under 38 U.S.C. § 1151 for a right knee disability is remanded.

As noted, the Veteran has raised three theories of entitlement for service connection and compensation under 38 C.F.R. § 1151 for knee disabilities. First, she alleged a theory of direct service connection within the September 2018 VA examination that her knee disabilities were caused by her in-service injuries and subsequent continued pain during training. Within her December 2024 Board hearing testimony, she also alleged that her in-service fall, which she claimed injured her back, also injured her right knee. Second, she has alleged in her present claim that her knee disabilities were caused by the 2017 SCS procedure. As such, her latter claim
under 38 U.S.C. § 1151 for a right knee disability is remanded.

As noted, the Veteran has raised three theories of entitlement for service connection and compensation under 38 C.F.R. § 1151 for knee disabilities. First, she alleged a theory of direct service connection within the September 2018 VA examination that her knee disabilities were caused by her in-service injuries and subsequent continued pain during training. Within her December 2024 Board hearing testimony, she also alleged that her in-service fall, which she claimed injured her back, also injured her right knee. Second, she has alleged in her present claim that her knee disabilities were caused by the 2017 SCS procedure. As such, her latter claim falls under 38 U.S.C. § 1151. Lastly, she alleged a theory of secondary service connection in her December 2024 Board hearing testimony that her right knee disability was caused by her back disability.

While the RO obtained a September 2018 VA opinion, the examiner relied on the passage of time between service and the Veteran's 2014 ACL injury to deny a nexus. As noted herein, this is an insufficient basis alone for the denial of service connection.

Because the RO did not readjudicate the knee claims, it did not obtain a VA examination on the other theories of entitlement. The Board notes that the RO has obtained adequate examinations on whether the Veteran's back and LLE radiculopathy disabilities were caused by her 2017 SCS surgery, but not on her knee disabilities.

The failure to provide adequate examination and opinion constitutes a pre-decisional duty to assist error. Therefore, further opinion with complete rationale is warranted. See U.S.C. §?5103A;?38?C.F.R. §?3.159; Barr v. Nicholson,?21?Vet. App.?303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).

The matters are REMANDED for the following action:

Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed back, LLE radiculopathy, and bilateral knee disabilities. Any indicated tests should be accomplished. The examiner(s) should review the record prior to examination and elicit from the Veteran a detailed medical history, including the onset and severity of her symptoms.

(a.) After a review of the record, the examiner(s) must opine whether it is at least as likely as not that the Veteran's back and knee disabilities were incurred in or are otherwise related to service. In so opining on all three disabilities, the examiner should consider and address the Veteran's in-service fall. In opining on the knee disabilities, the examiner should also consider and address the Veteran's in-service knee injuries during training.

(b.) Additionally, the examiner(s) must opine whether it is at least as likely as not that the Veteran's LLE radiculopathy was caused by or aggravated by a service-connected disability, to specifically include her back and bilateral knee disabilities. Further, the examiner(s) must opine whether it is at least as likely as not that the Veteran's bilateral knee disabilities were caused by or aggravated by her back disability. In so responding, the examiner is reminded that?causation and aggravation?are two separate inquiries, and each must be addressed.

(c.) Lastly, the examiner(s) must opine on whether the Veteran's knee disabilities, including her pain therefrom, constitute an additional disability. If so, the examiner(s) must opine on whether the additional knee disabilities were not merely coincidental with VA medical treatment, but stemmed from some fault in the care with which she was provided, including "carelessness, negligence, lack of proper skill, error in judgment, or some other similar instance of fault."

The examiner(s) are also advised that the Veteran is competent to report symptoms and treatment and that her reports as to the onset and nature of her symptoms, to include reports that the condition and symptoms onset in service, must be taken into account, along with the other evidence of record, in formulating the requested opinions.

The examiner(s) should specifically consider and address the Veteran's October 2018, March 2019, and two March 2020 statements, as well as her December 2024 Board hearing testimony.

A complete, well-reasoned rationale must be provided for any opinions offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner(s) must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner(s) (does not have the needed knowledge or training

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