KNEE ANKYLOSIS

REBECCA N. POULSON · 2026 · Case ID: A26040233

MIXED

Summary

The veteran, who served in the Navy from December 1999 to September 2003 with subsequent Reserve service, appealed the denial of service connection for right knee ankylosis, right foot plantar fasciitis, and for higher disability ratings for major depressive disorder (MDD), right knee extension limitation, right knee flexion limitation, and GERD. The Board denied service connection for right knee ankylosis, finding no evidence of ankylosis or its functional equivalent, and noting the VA examiner's finding of no ankylosis. Service connection for right foot plantar fasciitis was denied due to a lack of evidence of in-service injury to the right foot and no current diagnosis or functional impairment of earning capacity related to the right foot, and the Board found VA's duty to obtain an examination was not triggered. The Board denied higher ratings for MDD, finding the veteran's symptoms most consistent with occupational and social impairment with reduced reliability and productivity, corresponding to the existing 50 percent rating, and not meeting the criteria for a higher rating. Similarly, the Board denied higher ratings for right knee extension and flexion limitations, finding the veteran's functional impairment, even with pain and flare-ups, did not meet the criteria for higher ratings under the applicable diagnostic codes. The GERD claim was denied a compensable rating, as the evidence showed a documented history without daily symptoms or requirement of daily medication, and no evidence of esophageal stricture causing dysphagia, thus not meeting the criteria for a 10 percent rating or higher under the revised diagnostic code. The Board remanded claims for migraine headaches, tinnitus, left knee disability (claimed as ankylosis), and left ankle disability (claimed as ankylosis) for further development and adequate medical opinions regarding etiology, nexus to service, and secondary aggravation.

Rationale

No finding of right knee ankylosis or functional equivalent; VA examiner found no ankylosis; Veteran's opinion on ankylosis not probative

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250504-544831

Full Decision Text

Citation Nr: A26040233
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 250504-544831
DATE: April 29, 2026

ORDER

Service connection for right knee ankylosis is denied.

Service connection for right foot plantar fasciitis is denied.

A disability rating higher than 50 percent for major depressive disorder (MDD) is denied.

A disability rating higher than 30 percent for limitation of right knee extension due to patellofemoral syndrome (PFS), status post anterior cruciate ligament (ACL) repair and meniscectomy, is denied.

A disability rating higher than 10 percent for limitation of right knee flexion due to PFS, status post ACL repair and meniscectomy, is denied.

A disability rating higher than 0 percent for gastroesophageal reflux disease (GERD) is denied.

REMANDED

Service connection for migraine headaches is remanded.

Service connection for tinnitus is remanded.

Service connection for left knee disability (claimed as ankylosis) is remanded.

Service connection for left ankle disability (claimed as ankylosis) is remanded.

FINDINGS OF FACT

1. During the period on appeal the Veteran did not have right knee ankylosis or the functional equivalent.

2. During the period on appeal the Veteran has not been found to have a diagnosis of right foot plantar fasciitis or functional impairment of earning capacity related to his right foot.

3. During the period on appeal the Veteran's MDD produced occupational and social impairment with reduced reliability and productivity, but not deficiencies in most areas and not total social and occupational impairment.

4. During the period on appeal, the Veteran's right knee disability was not productive of limitation of extension to 30 degrees; there is no tibia or fibula impairment, no instability or subluxation, and no ankylosis or the functional equivalent thereof.

5. During the period on appeal, the Veteran's right knee disability was not productive of limitation of flexion to 30 degrees; there is no tibia or fibula impairment, no instability or subluxation, and no ankylosis or the functional equivalent thereof.

6. During the period of appeal, the Veteran's GERD produced pyrosis but did not produce dysphagia, regurgitation, or substernal or arm or shoulder pain, did not have documented history of recurrent or refractory esophageal stricture causing dysphagia, and did not require daily medications to control dysphagia.

CONCLUSIONS OF LAW

1. The criteria for service connection for right knee ankylosis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303.

2. The criteria for service connection for right foot plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310.

3. The criteria for a disability rating higher than 50 percent for MDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9434.

4. The criteria for a disability rating higher than 30 percent for limitation of right knee extension due to patellofemoral syndrome, status post ACL repair and meniscectomy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.71a, Diagnostic Code 5261.

5. The criteria for a disability rating higher than 10 percent for limitation of right knee flexion due to patellofemoral syndrome, status post ACL repair and meniscectomy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.71a, Diagnostic Code 5260.

6. The criteria for a disability rating higher than 0 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4
flexion due to patellofemoral syndrome, status post ACL repair and meniscectomy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.71a, Diagnostic Code 5260.

6. The criteria for a disability rating higher than 0 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.114, Diagnostic Code 7206.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from December 1999 to September 2003 with subsequent Reserve service.

In a September 2024 claim, the Veteran sought increased disability ratings for right knee PFS status post ACL repair and meniscectomy, and for GERD. In an October 2024 claim, he sought service connection for migraine headaches, tinnitus, MDD, inability to sleep, right foot plantar fasciitis, ankylosis in both knees, and ankylosis in both ankles.

In a February 2025 rating decision, the agency of original jurisdiction (AOJ), a Department of Veterans Affairs (VA) Regional Office (RO), assigned right knee PFS ratings of 30 percent for limitation of extension and 10 percent for limitation of flexion. The RO denied a rating higher than the existing 0 percent rating for the Veteran's GERD. In addition, the RO denied service connection for migraine headaches and right foot plantar fasciitis.

In a March 2025 rating decision the RO denied service connection for tinnitus, right knee ankylosis, left knee ankylosis, and left ankle ankylosis. The RO granted service connection for MDD (claimed as MDD and inability to sleep) and assigned a disability rating of 50 percent.

The Veteran appealed the February and March 2025 rating decisions to the Board of Veterans' Appeals (Board) in a May 2025 VA Form 10182, Decision Review Request: Board Appeal. He appealed the February 2025 rating decision as to service connection for migraine headaches and right foot plantar fasciitis. He also appealed for higher ratings for right knee limitations of extension and flexion and for GERD.

He appealed the March 2025 rating decision as to service connection for tinnitus, right knee ankylosis, left knee ankylosis, and left ankle ankylosis. He also appealed for a higher initial rating for MDD.

The 10182 also lists entitlement to service connection for right ankle ankylosis, constipation, and hemorrhoids. However in the February 2025 and March 2025 rating decisions the RO deferred action on those issues and did not decide them. As these decisions are not initial rating decisions, the issues are not ripe for appeal.

In the Veteran's appeal he elected the Direct Review docket. Therefore, for each issue on appeal the Board may only consider the evidence of record at the time of the applicable decision on appeal. 38 C.F.R. § 20.301.

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in its decision. 38 C.F.R. § 20.300. Regarding the issues the Board is remanding, any such evidence will be considered by the AOJ on remand. Regarding the issues the Board is deciding, if the Veteran would like VA to consider any evidence that was added to the claims file 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 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.

Service connection

Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has explained that, in general, service connection requires (
VA will issue another decision on the 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.

Service connection

Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. In Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc), the Federal Circuit explained that positive and negative evidence does not have to be in exact equipoise before the benefit of the doubt should be given to the claimant. Rather, a claimant is entitled to the benefit of the doubt when the evidence is in approximate balance, that is, "nearly equal." The Federal Circuit explained that evidence is not in approximate balance or nearly equal when the evidence "persuasively favors one side or the other."

1. Service Connection for right knee ankylosis

The Veteran is seeking service connection for right knee ankylosis. In an August 2003 claim he sought service connection for right knee disability. In an April 2005 rating decision the RO granted service connection for right knee disability, specifically PFS, status post ACL repair and meniscectomy. In the October 2024 claim the Veteran listed as a new disability "ankylosis in knee, bilateral." In the March 2025 rating decision, the RO denied service connection for right knee ankylosis. The Veteran appealed that denial to the Board.

The Veteran's representative contends that right ankylosis is secondary to the service connected right knee extension and flexion, and also contends that the VA examiner did not provide an aggravation opinion.

DC 5256 relates to ankylosis. A 60 percent rating is warranted for extremely unfavorable knee ankylosis, in flexion at an angle of 45 degrees or more. This is the highest rating under the DC. The lowest rating under the DC, 30 percent, is for ankylosis. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012).

Acknowledged is Chavis v. McDonough, 34 Vet. App. 1, 11 (2021), which stated that "application of [38 C.F.R.] §§ 4.40 and 4.45 permits consideration under the General Rating Formula of an evaluation based on ankylosis if a claimant's functional loss is consistent with that contemplated by ankylosis in other words, if it is the functional equivalent of ankylosis." The Chavis case related to DCs associated with spine disabilities and not to the DC related to knee ankylosis (5256). Assuming (without deciding) that Chavis and the concept of functional ankylosis can be extended to DC 5256 and knee ankylosis, a higher or separate rating is still not warranted.

The record on appeal does not contain any finding of right knee ankylosis. Evidence from around the time of the Veteran's ankylosis service connection claim includes the report of VA examination in October 2024. The examiner found that the right knee did not have ankylosis. The examiner found that the knee had flexion to 125 degrees and extension to 0 degrees initially. The examiner estimated there would be flexion to 115 degrees and extension to 0 degrees after repeated use over time, or with a flare-up. In VA treatment in November 2024 the Veteran reported ongoing bilateral knee pain. A clinician reviewed x-rays and planned occupational/physical therapy.

In this regard, even when considering the
.

In this regard, even when considering the functional limitations present during a flare-up and the functional limitations shown generally, the Veteran's disability picture or any additional limitation did not more nearly approximate functional ankylosis.

The Veteran's opinion that his right knee disability includes ankylosis has been considered. However, as he has not been shown to have the medical expertise to render such diagnosis, his opinion in this regard is not considered probative evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

As the Veteran did not have right knee ankylosis or the functional equivalent during the period on appeal, the Board denies service connection for right knee ankylosis.

2. Service connection for right foot plantar fasciitis

The Veteran contends that he has right foot plantar fasciitis that is secondary to his service-connected right knee disability. He asserts that right knee injury in service never healed properly and that this in turn caused right foot plantar fasciitis. See October 2024 claim.

The Veteran's service treatment records (STRs) show that in February 2002 he Veteran was treated for left great toe pain after accidentally kicking a wall. A clinician assessed soft tissue injury. He had right knee injury in October 2002 and right knee surgery in December 2002. The STRs do not reflect any complaint of injury, impairment, or symptoms in his right foot. On separation examination in August 2003 he reported right knee injury and surgery but marked no for history of foot trouble. The examiner marked normal for the condition of the Veteran's feet.

The Veteran filed a VA compensation claim in August 2003. He sought service connection for a broken toe incurred in February 2002 and right knee injury incurred in October 2002.

On VA examination in February 2005, history of right knee injury and surgery was noted. An examiner observed a normal stable gait. The Veteran did not use crutches, brace, or cane. The Veteran reported that his work involved prolonged weightbearing, which aggravated right knee pain. The Veteran related history of right great toe trauma in service in 2001. He stated that he had not sought treatment for that toe since separation from service. He indicated that he had no current symptoms or complaints. Examination was negative from problems. X-rays of the left great toe were requested. The Veteran stated that his problem was with his right great toe, and that toes was x-rayed. A radiologist found that those x-rays showed no radiographic evidence of bone or joint abnormality. The bones examiner stated that the examination was negative.

In VA treatment in March 2006, the Veteran complained of athlete's foot on the soles of both feet. A clinician observed patchy, crusty lesions on the soles of both feet. The clinician referred the Veteran to podiatry. In an April 2006 podiatry consultation, the podiatrist observed dry, skin on the soles of both feet. He diagnosed tine pedis and prescribed medications.

In VA treatment in February 2015, the Veteran reported worsening right knee pain with walking or running. He stated that sometimes he could not put weight on his right heel and needed to walk on the toes of that foot. The clinician made observations about the right knee but not the right foot.

In VA treatment in July 2019, the Veteran reported a two-month history of pain in his left heel. He noted that right knee pain led him to lean on his left lower extremity. The clinician found tenderness of the left heel toward the arch. The clinician diagnosed plantar fasciitis of the left foot. In August 2019 the Veteran reported three months of left ankle pain. He stated that he also was having metatarsal pain on the right and was limping, but that the symptoms on the right side had resolved. The clinician found that both feet and ankles were nontender at the plantar fascial insertion and other areas. He observed a normal gait.

In a VA podiatry visit later in August 2019, the
the Veteran reported a two-month history of pain in his left heel. He noted that right knee pain led him to lean on his left lower extremity. The clinician found tenderness of the left heel toward the arch. The clinician diagnosed plantar fasciitis of the left foot. In August 2019 the Veteran reported three months of left ankle pain. He stated that he also was having metatarsal pain on the right and was limping, but that the symptoms on the right side had resolved. The clinician found that both feet and ankles were nontender at the plantar fascial insertion and other areas. He observed a normal gait.

In a VA podiatry visit later in August 2019, the Veteran reported left heel pain that began the month before. He reported that prescribed medication helped and that he had been pain-free for about a week, with no other pedal complaints. The podiatrist's assessment was left foot plantar fasciitis and left foot achilles tendinitis, each resolved.

The Veteran had VA podiatry visits in September and October 2019 and January and February 2020, to address pain in his left heel. He did not report any symptoms in his right foot.

In a VA podiatry visit in October 2024, the reported tightness in his feet. He stated that his heels and achilles tendons hurt at times. The podiatrist noted bilateral equinus deformity. There was no pain on palpation of the achilles tendons, heels, or medial arches. The podiatrist's assessment was history of plantar fasciitis and achilles tendinitis.

The AOJ did not obtain a VA medical examination or opinion regarding the Veteran's right foot plantar fasciitis claim. The United States Court of Appeals for Veterans Claims (Court) has noted that VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has current disability or signs and symptoms of a current disability, there is evidence of an event, injury, or disease in service, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that indicate that a current disability may be associated with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. For purposes of determining whether an examination or opinion is warranted, the threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83.

The Veteran is competent to report pain in his heels. However, he is not competent to provide a diagnosis or etiology opinion. There is no evidence of a event, injury, or disease in service affecting the Veteran's right foot. Therefore the evidence did not trigger VA's duty to obtain an examination or opinion regarding the Veteran's right foot plantar fasciitis claim.

During the period on appeal, the Veteran has not been diagnosed with right foot plantar fasciitis. The Board acknowledges the holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, the medical evidence reveals no functional impairment of earning capacity with respect to the Veteran's right foot.

Evidence of a current disability is a fundamental requirement for a grant of service connection. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Board therefore denies service connection for the claimed right foot plantar fasciitis.

3. Rating for MDD

The Veteran appealed the initial 50 percent rating the RO assigned for his MDD effective October 1, 2024. In the March 2025 rating decision, the RO evaluated the Veteran's acquired psychiatric disability as one condition, described as MDD (claimed as MDD and inability to sleep). The RO explained that a VA examiner noted that the Veteran's sleep problems were subsumed by the MDD diagnosis as sleep problems
21 Vet. App. 319, 321 (2007); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Board therefore denies service connection for the claimed right foot plantar fasciitis.

3. Rating for MDD

VA assigns disability ratings 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 his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Court also has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim for an increased rating was filed until a final decision is made. See Hart. v. Mansfield, 21 Vet. App. 505 (2007).

The RO has evaluated the Veteran's MDD under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9434. The rating schedule provides a General Rating Formula for Mental Disorders for multiple DCs including 9434. Under that formula, a 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name.

A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships.

A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.

Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. As the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptoms driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms listed are not
Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. As the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptoms driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type of degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas," i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.' " Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130.

Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. Vazquez-Claudio, 713 F.3d at 115. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a).

In other words, VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017).

The Veteran has not reported receiving mental health treatment. In VA treatment in September 2024, he stated that he could not sleep.

On VA mental disorders examination in February 2025, the Veteran indicated that his knee pain and GERD had contributed to depression and sleep difficulties. He reported current depression. He related feeling down and tired. He stated that he had trouble sleeping, with early morning wakefulness. He related a high degree of loss of interest and pleasure. He reported a large appetite with weight gain of about 50 pounds. He noted restlessness, fidgeting, and problems concentrating. He reported history of periods of heavy alcohol use, with current sobriety for a year and a half. The Veteran reported ongoing employment as a firefighter. He indicated that he lived with his wife and children and that his relationships with his family were fine. He indicated that he socialized with peers. He stated that alcohol made socializing easier, and that since he stopped drinking socializing had been more difficult.

The examiner observed that the Veteran was oriented, with an appropriate affect and logical and coherent thinking. Memory was grossly intact, speech was normal, and judgment and insight were good. Test results were consistent with moderately severe depression. The examiner found that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner assigned a diagnosis of MDD and explained that the Veteran's sleep impairment was part of his depressive disorder. The examiner found that the Veteran's occupational and social impairment level was best summarized by reduced reliability and productivity.

The Board has considered the Veteran's lay statements and the VA examiner's observations and findings. The Veteran's psychiatric symptoms have included depressed mood, diminished interest and pleasure, anxiety, restlessness, problems concentrating, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board finds that such symptomatology is most consistent with occupational and social impairment with reduced reliability and productivity, which corresponds with a 50 percent rating. The record does not explicitly address the frequency and duration of the symptoms, but rather presents a picture of fairly static severity over the years closely preceding the 2025 examination.

The Board has also considered the Veteran's symptoms which are not included in the rating criteria listed under 38 C.F.R. § 4.130 and whether they constitute symptoms that would be comparable in type and degree (frequency,
, diminished interest and pleasure, anxiety, restlessness, problems concentrating, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board finds that such symptomatology is most consistent with occupational and social impairment with reduced reliability and productivity, which corresponds with a 50 percent rating. The record does not explicitly address the frequency and duration of the symptoms, but rather presents a picture of fairly static severity over the years closely preceding the 2025 examination.

The Board has also considered the Veteran's symptoms which are not included in the rating criteria listed under 38 C.F.R. § 4.130 and whether they constitute symptoms that would be comparable in type and degree (frequency, severity, and duration) to the criteria for a 70 percent rating. The Veteran has been noted to have restlessness and problems concentrating. The symptoms of anxiety and suspiciousness are contemplated by a 30 percent rating.

Although these symptoms are significant, the Board does not find the occupational and social impairment necessary to warrant a 70 percent rating. He is independent in activities of daily living. The Veteran reported a history of steady employment. His occupational impairment did not approach deficiency in his work. He maintains relationships with family and socializes with peers despite some difficulty.

During the appeal period the severity, duration, and frequency of the Veteran's psychiatric symptoms and the resulting impairments did not more nearly approximate the criteria for a rating higher than 50 percent. Simply put, the overall evidence is not reflective of occupational and social impairment with deficiencies in most areas. The Board therefore denies a rating higher than 50 percent for his MDD.

4. Rating for limitation of right knee extension due to PFS status post ACL repair and meniscectomy

5. Rating for limitation of right knee flexion due to PFS status post ACL repair and meniscectomy

The Veteran appealed the February 2025 rating decision denying right knee PFS ratings higher than 30 percent for limitation of extension and 10 percent for limitation of flexion.

The Veteran filed on September 17, 2024, an intent to file (ITF) a claim and a 2024 claim for increased ratings for right knee PFS. He appealed the February 2025 rating decision denying increased ratings. The period for which the ratings are on appeal is from September 17, 2023, a year before the ITF and claim, through the February 2025 rating decision on appeal. See 38 C.F.R. § 3.400(o)(2).

Under 38 C.F.R. § 4.71a, DC 5261, limitation of extension of the knee is rated at 50 percent if limited to 45 degrees, 40 percent if limited to 30 degrees, and 30 percent if limited to 20 degrees.

Under 38 C.F.R. § 4.71a, DC 5260, limitation of flexion of the knee is rated at 30 percent if limited to 15 degrees, 20 percent if limited to 30 degrees, and 10 percent if limited to 45 degrees.

Flexion of the knee to 140 degrees is considered full, and extension to 0 degrees is considered full. 38 C.F.R. § 4.71a, Plate II.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. Consideration must also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a, a separate or higher rating under § 4.40 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

Evaluation of joints that have painful motion also should include consideration of whether there is pain on both active and passive motion, consideration of whether there is pain with and without weightbearing
based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a, a separate or higher rating under § 4.40 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

Evaluation of joints that have painful motion also should include consideration of whether there is pain on both active and passive motion, consideration of whether there is pain with and without weightbearing, and comparison of the range of motion to that of any opposite undamaged joint. 38 C.F.R. § 4.59; see Correia v McDonald, 28 Vet. App. 158 (2016).

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), it was held that, although a VA examination need not be conducted during a flare-up and/or after repeated use over time, VA examiners should elicit information from the claimant regarding the condition of the relevant joint during such circumstances. Id. at 34.

The evaluation of the same disability or same manifestations under various diagnoses is to be avoided. This is otherwise known as pyramiding, which is prohibited. 38 C.F.R. § 4.14. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).

The Board is to take due consideration that the beneficial effects of medication are discounted in assessing musculoskeletal ratings as such effects are not contemplated therein and, therefore, taking medication may make a claimant appear less disabled than in reality. Ingram v. Collins, 38 Vet. App. 130 (2025).

On VA knee examination in October 2024, the examiner addressed the Veteran's right knee only. The Veteran reported gradual worsening of his right knee pain since service. He reported that presently he had intermittent moderate to severe pain. He stated that the pain was aggravated by knee movement, sitting more than 20 to 30 minutes, standing more than 30 minutes, bending, lifting weights more than 100 pounds, or walking more than half a mile. He indicated that right knee pain made him unable to run. He reported flare-ups of right knee pain with the same levels or duration of activity that aggravated right knee pain. He stated that these flare-ups occurred one to two times per week and lasted about 20 to 30 minutes each. He indicated that with those activities he had functional impairment due to pain.

The examiner diagnosed the Veteran's right knee disability as PFS status post ACL repair and meniscectomy. The initial active ranges of motion of the right knee were to 125 degrees of flexion and 0 degrees of extension. There was pain at the endpoint of flexion. The passive ranges of motion were the same, with pain at the endpoint of flexion. After at least three repetitions the ranges of motion were the same.

The examiner estimated that, after repeated use over time, pain would limit flexion to 115 degrees. He estimated that with flare-ups pain would limit flexion to 115 degrees. The examiner found that the Veteran's right knee disability had functional impact in that he had pain with knee movement, sitting more than 20 to 30 minutes, standing more than 30 minutes, bending, lifting weights more than 100 pounds, or walking more than half a mile, and was unable to run.

In VA treatment later in October 2024, the Veteran reported bilateral knee pain. The clinician ordered x-rays. In November 2024 the Veteran reported continued knee pain. The clinician discussed the x-rays, which showed arthritis in each knee. The clinician referred the Veteran to occupational and physical therapy.

In a September 2025 brief, the Veteran's representative argued that the October 2024 VA examination is inadequate because the findings were inconsistent with the Veteran's statements. The representative quoted from the examination report, but did not explain how the language in the examination report was inconsistent with the Veteran's statements.

The Board finds that the October 2024 VA examination was adequate. The examiner's findings as to functional impairment were consistent with the limitations the Veteran reported. The examiner elicited information from the Veteran regarding the condition of his knee after repeated use over time and with flare-ups. The examiner considered that information and estimated additional functional impairment under those circumstances. The Board notes that the examiner did not compare the ranges of motion of the Veteran's right knee to his left knee. However the Veteran had reported left knee pain and x-rays showed left knee arthritis. As the left knee was not undamaged, the
's statements. The representative quoted from the examination report, but did not explain how the language in the examination report was inconsistent with the Veteran's statements.

The Board finds that the October 2024 VA examination was adequate. The examiner's findings as to functional impairment were consistent with the limitations the Veteran reported. The examiner elicited information from the Veteran regarding the condition of his knee after repeated use over time and with flare-ups. The examiner considered that information and estimated additional functional impairment under those circumstances. The Board notes that the examiner did not compare the ranges of motion of the Veteran's right knee to his left knee. However the Veteran had reported left knee pain and x-rays showed left knee arthritis. As the left knee was not undamaged, the requirement to compare the right knee to an opposite undamaged joint did not apply.

During the appeal period the Veteran's right knee was not limited to 30 degrees or more of extension or to 30 degrees or less of extension. He had flare-ups and pain with motion and he had greater functional impairment with flare-ups and with repeated use over time. Even with those factors, however, his functional impairment was not consistent with limitation to 30 degrees or more of extension or to 30 degrees or less of flexion. Furthermore, because the above findings are based on procured evidence, including the Veteran's description of his knee pain at its worst, such descriptions can be expected to describe the pain that prompts the Veteran to use his reported medication, not a level of impairment that reflects the beneficial effects of such medication. See Ingram v. Collins, 38 Vet. App. 130 (2025).

Finally, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263. There is no indication of ankylosis (to include the functional equivalent thereof) and no indication of the other disabilities contemplated by these DCs.

The Board therefore denies right knee PFS ratings higher than 30 percent for limitation of extension and 10 percent for limitation of flexion.

6. Rating for GERD

The Veteran appealed the February 2025 rating decision denying a rating higher than 0 percent for his GERD.

The Veteran filed on September 17, 2024, an intent to file (ITF) a claim and a 2024 claim for an increased rating for GERD. He appealed the February 2025 rating decision denying an increased rating. The period for which the ratings are on appeal is from September 17, 2023, a year before the ITF and claim, through the February 13, 2025, rating decision on appeal. See 38 C.F.R. § 3.400(o)(2).

The RO established service connection for the Veteran's GERD effective in 2003 and assigned a disability rating of 0 percent. See April 2005 rating decision. At that time, his GERD was rated as a hiatal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346, as GERD did not previously have a separate code of its own.

During the period on appeal, the rating criteria for evaluating digestive disabilities under 38 C.F.R. § 4.114 were amended effective May 19, 2024. As of that date, the rating schedule now specifically lists GERD under Diagnostic Code 7206. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the claimant will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110.

However, it is emphasized that the revised rating criteria apply to all claims received by VA or that are pending before the RO on or after May 19, 2024. While claims pending prior to the effective date will be considered under both the old and new rating criteria and the criteria which is more favorable to the Veteran's claim(s) will be applied, the Federal Circuit has held that the Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, as the Veteran's claim was not pending before VA until after May 19, 202
5110.

Under DC 7206, a noncompensable (0 percent) rating is warranted for a documented history without daily symptoms or requirement of daily medication. A 10 percent rating is warranted for a documented history of esophageal stricture that requires daily medications to control dysphagia (difficulty swallowing) and is otherwise asymptomatic. A 30 percent rating is warranted for a documented history of recurrent or refractory esophageal stricture causing dysphagia which requires dilatation no more than two times per year. A 50 percent rating is warranted for a documented history of recurrent or refractory esophageal stricture causing dysphagia which requires at least one of the following: (1) dilatation three or more times per year, (2) dilatation using steroids at least one time per year, or (3) esophageal stent placement. An 80 percent rating is warranted for a documented history of recurrent or refractory esophageal stricture causing dysphagia with at least one of the symptoms present: (1) aspiration, (2) undernutrition, and/or (3) substantial weight loss and treatment with either surgical correction or percutaneous esophago-gastrointestinal tube (PEG tube). Substantial weight loss is defined as involuntary loss greater than 20 percent of baseline weight sustained for three months with diminished quality of self-care or work tasks. 38 C.F.R. § 4.112(a). Undernutrition means a deficiency resulting from insufficient intake of one or multiple essential nutrients, or the inability of the body to absorb, utilize, or retain such nutrients. 38 C.F.R. § 4.112(c).

Diagnostic Code 7206 contains several notes to assist in its application. Note (1) provides that findings associated with the disability in question must be documented by barium swallow, computerized tomography, or esophagogastroduodenoscopy. Note (2), directs VA to evaluate non-gastrointestinal complications of procedures of the disability at issue under the appropriate system at issue. Notes (4) and (5) define recurrent and refractory esophageal strictures as contemplated by Diagnostic Code 7206. Specifically, Note (4) defines recurrent esophageal stricture as "the inability to maintain target esophageal diameter beyond 4 weeks after the target diameter has been achieved." Comparatively, Note (5) defines refractory esophageal stricture as "the inability to achieve target esophageal diameter despite receiving no fewer than 5 dilatation sessions performed at 2-week intervals."

In VA treatment in September 2024, the Veteran stated that he had reflux. He indicated that he was not on medication for it.

On VA examination in October 2024, the Veteran related that during service he developed heartburn and reflux symptoms. He stated that in service he was treated with the over-the-counter (OTC) medication Tums. He reported that after service his reflux condition gradually worsened. He stated that he saw VA and private providers and the condition was treated with OTC medications such as Tums, Prilosec, etc. The examiner noted that the Veteran had been diagnosed with GERD. The examiner noted that the Veteran's treatment plan included taking daily Tums, Prilosec, etc., for his GERD. The examiner found that the Veteran was without daily symptoms of GERD and did not require daily medication for GERD. The examiner did not find that the Veteran had dysphagia.

In VA treatment in October 2024 the Veteran reported GERD. The clinician noted that the Veteran was resistant to proton pump inhibitor (PPI) medication, but would start on Omeprazole daily.

The Board concludes that the evidence of record persuasively weighs against entitlement to an initial compensable rating for service-connected gastroesophageal reflux disease (GERD). Throughout the entire period, the Veteran's GERD has been manifested by at most a documented history without the requirement of daily medication. However, the record does not contain any findings of the Veteran's GERD having been manifested by a documented history of esophageal stricture(s) that requires daily medications to control dysphagia otherwise asymptomatic, which would meet or more nearly approximate the criteria required for the next higher rating of 10 percent. Thus, his GERD symptoms did not meet or approximate the criteria for compensable rating under the revised criteria including DC 7206.

For the above reasons, the Board denies a compensable rating for the Veteran's GERD.

REASONS FOR REMAND

1. Service connection for migraine headaches is remanded.

The Veteran contends that he has migraine headaches as a result of constant training in service using heavy weapons and explosives. See October 2024 claim.

In the February 2025 rating decision, the RO made the favorable finding that the Veteran has been diagnosed with a disability. In the March 2025 rating decision (as to service connection for tinnitus), the RO made the favorable finding that the Veteran's service duties in the military occupational specialty (MOS) of Machinist's Mate made hazardous noise exposure highly probable. The Board is bound by those findings absent clear and unmistakable error. 38 C.F.R. § 3.104(c).

Prior to the February 2025 rating decision on appeal, the RO did not obtain a medical examination or opinion regarding the migraine headaches claim.

The United States Court of Appeals for Veterans Claims (Court) has noted that VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has current disability or signs and symptoms of a current disability, there is evidence of an event, injury, or disease in service, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006).

The types of evidence that indicate that a current disability may be associated with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. For purposes of determining whether an examination or opinion is warranted, the threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83.

In VA treatment in October 2024 the Veteran complained of migraine type headaches. The physician's assessment was migraine headache. The record contains competent evidence that the Veteran has current migraine headaches.

The Veteran attributes his migraines to persistent exposure in service to heavy weapons and explosives. The RO made a favorable finding that Veteran's MOS made hazardous noise exposure highly probable. Thus there is evidence of hazardous noise exposure in service.

The Veteran's noise exposure in service and his experience of migraine headaches are capable of lay observation. The Board finds that his accounts meet the low threshold for indicating that his current migraines may be associated with his noise exposure in service.

Thus, the criteria for obligating VA to provide medical examination or opinion have been met. The RO's failure to obtain examination or opinion was pre-decisional duty-to-assist error and remand is warranted.

2. Service connection for tinnitus is remanded.

The Veteran contends that he has tinnitus because during service he shot heavy weapons constantly. See October 2024 claim.

In the March 2025 rating decision the RO made the favorable finding that the Veteran's service duties in the MOS of Machinist's Mate made hazardous noise exposure highly probable. The Board is bound by that finding absent clear and unmistakable error. 38 C.F.R. § 3.104(c).

In addition to the conceded noise exposure, the Veteran's service records reflect
obligating VA to provide medical examination or opinion have been met. The RO's failure to obtain examination or opinion was pre-decisional duty-to-assist error and remand is warranted.

2. Service connection for tinnitus is remanded.

The Veteran contends that he has tinnitus because during service he shot heavy weapons constantly. See October 2024 claim.

In addition to the conceded noise exposure, the Veteran's service records reflect underwater training and duties potentially consistent with effects on ears. He had MOSs of Machinist's Mate and Basic Combatant Swimmer, with Navy Seal Qualification treatment. See DD Form 214. His service treatment records (STRs) show that hearing conservation data was collected. Test records consistently noted that he was routinely noise exposed and in some instances noted his duties in Seal Team 4.

The February 2025 VA hearing loss and tinnitus examination examiner expressed the opinion that the frequency and duration of ringing in the ears that the Veteran reported does not meet the Dauman and Tyler (1992) definition of tinnitus. VA must provide an examination that is adequate for VA compensation purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the VA tinnitus opinion is inadequate for VA compensation purposes as it does not explain what the Dauman and Tyler definition of tinnitus is or why a conforming diagnosis is necessary to establish a nexus..

Once VA undertakes the effort to provide an examination or medical opinion when developing a service connection claim, it must provide an adequate one or, at the minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO's failure to obtain adequate medical opinion was pre-decisional duty-to-assist error. To correct this error, the Board is remanding the matter.

3. Service connection for left knee disability claimed as ankylosis is remanded.

The Veteran contends that he has left knee disability, to include ankylosis, secondary to his service-connected right knee disability. See February 2025 C&P Exam.

In the March 2025 rating decision the RO made the favorable findings that the Veteran has left knee disability diagnosed as strain and that the Veteran has a service-connected primary disability of the right knee. The Board is bound by those findings absent clear and unmistakable error. 38 C.F.R. § 3.104(c).

On VA examination in February 2025, the Veteran reported that his right knee disability caused him to favor his right knee, which eventually led to left knee problems. The examiner noted pain, swelling, and limited ranges of motion in the left knee. She diagnosed left knee strain. She did not report observations of the Veteran's gait or any manifestations or effects of his right knee disability. She expressed the opinion that the Veteran's left knee strain was less likely than not proximately due to or the result of his right knee disability. She did not provide an opinion as to whether the left knee disability was aggravated by the right knee disability. Because of the lack of consideration of the claimed effects of the Veteran's right knee disability and the lack of opinion as to secondary aggravation, the examiner's opinion was inadequate.

The AOJ's failure to obtain adequate opinions regarding secondary causation and aggravation is pre-decisional duty-to-assist error. The Board is remanding the matter for adequate opinions.

4. Service connection for left ankle disability claimed as ankylosis is remanded.

The Veteran contends that he has left ankle disability, to include ankylosis, secondary to his service-connected right knee disability. See February 2025 C&P Exam.

In the March 2025 rating decision the RO made the favorable findings that the Veteran has left ankle disability diagnosed as strain and that the Veteran has a service-connected primary disability of the right knee. The Board is bound by those findings absent clear and unmistakable error. 38 C.F.R. § 3.104(c).

On VA examination in February 2025, the Veteran asserted that his left ankle problems were related to overcompensation for his right knee problems. The examiner noted left ankle swelling and pain. She diagnosed left ankle strain. She did not report observations of the Veteran's gait or any manifestations or effects of his right knee disability. She expressed the opinion that the Veteran's left ankle strain was less likely than not proximately due to or the result of his right knee disability. She did not provide an opinion as to whether the left ankle disability was aggravated by the right knee
service-connected primary disability of the right knee. The Board is bound by those findings absent clear and unmistakable error. 38 C.F.R. § 3.104(c).

On VA examination in February 2025, the Veteran asserted that his left ankle problems were related to overcompensation for his right knee problems. The examiner noted left ankle swelling and pain. She diagnosed left ankle strain. She did not report observations of the Veteran's gait or any manifestations or effects of his right knee disability. She expressed the opinion that the Veteran's left ankle strain was less likely than not proximately due to or the result of his right knee disability. She did not provide an opinion as to whether the left ankle disability was aggravated by the right knee disability. Because of the lack of consideration of the claimed effects of the Veteran's right knee disability and the lack of opinion as to secondary aggravation, the examiner's opinion was inadequate.

The AOJ's failure to obtain adequate opinions regarding secondary causation and aggravation is pre-decisional duty-to-assist error. The Board is remanding the matter for adequate opinions.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination as to the nature and etiology of his migraine headaches. The examination report must show that the claims file was reviewed.

The examiner is to note that VA concedes the Veteran's noise exposure in service in his duties, including as a Machinist's Mate.

The examiner is to provide opinion as to whether the Veteran's migraine headaches at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) had onset during service or are otherwise etiologically related to his active service, to include conceded noise exposure.

All opinions are to be accompanied by a complete, clearly stated rationale.

The examiner is reminded that a lack of documented treatment during service, or after service, is by itself an insufficient basis for a negative nexus opinion.

2. Schedule the Veteran for a VA examination by an appropriate clinician, preferably a clinician who has not previously examined the Veteran, as to the history and etiology of claimed tinnitus. The examination report must show that the claims file was reviewed.

The examiner is to note the following:

(a) VA concedes the Veteran's noise exposure in service in his duties, including as a Machinist's Mate; and

(b) the Veteran had scuba training and duties as a member of a Navy Seal team.

The examiner is to provide opinion as to whether the Veteran's tinnitus at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) had its onset in service or is otherwise etiologically related his active service, to include conceded noise exposure and scuba diving.

If reliance on the Dauman and Tyler definition of tinnitus is utilized in rendering this opinion, the examiner must fully detail the Dauman and Tyler definition of tinnitus in the opinion and provide a thorough rationale as to why a conforming diagnosis is necessary to establish a nexus.

All opinions are to be accompanied by a complete, clearly stated rationale.

The examiner is reminded that a lack of documented treatment during service, or after service, is by itself an insufficient basis for a negative nexus opinion.

3. Schedule the Veteran for a VA examination of his left knee. Provide the Veteran's claims file to the examiner for review.

(a) The examiner is to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently diagnosed left knee disability, to include strain, is caused by his service-connected right knee disability

(b) The examiner is to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the left knee disability was aggravated by (any worsening) the right knee disability. Specifically, would the left knee disability have been less severe but for the right knee disability, either because there is an etiological link, or because the right knee disability resulted in the inability to treat the left knee disability?

The examiner is to consider the effects of the Veteran's right knee disability on gait and other body mechanics.

All opinions are to be accompanied by a complete, clearly stated rationale.

4. Schedule the Veteran for a VA examination to address the etiology of his left ankle disability, diagnosed as strain. Provide the Veteran's claims file to the examiner for review.

The examiner is to observe and report on the Veteran's gait and body mechanics, particularly as affected by his right knee disability.

The examiner is to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently diagnosed left ankle disability, to include strain, is caused by his service-connected right knee
is to consider the effects of the Veteran's right knee disability on gait and other body mechanics.

All opinions are to be accompanied by a complete, clearly stated rationale.

4. Schedule the Veteran for a VA examination to address the etiology of his left ankle disability, diagnosed as strain. Provide the Veteran's claims file to the examiner for review.

The examiner is to observe and report on the Veteran's gait and body mechanics, particularly as affected by his right knee disability.

The examiner is to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any currently diagnosed left ankle disability, to include strain, is caused by his service-connected right knee disability, to include diagnosed patellofemoral syndrome status post ACL repair and meniscectomy.

The examiner is to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the left ankle disability was aggravated by (any worsening) the right knee disability. Specifically, would the left ankle disability have been less severe but for the right knee disability, either because there is an etiological link, or because the right knee disability resulted in the inability to treat the left ankle disability?

The examiner is to consider the effects of the Veteran's right knee disability on gait and other body mechanics

All opinions are to be accompanied by a complete, clearly stated rationale.

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board K. J. Kunz, 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.

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