Citation Nr: 1315849 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 09-28 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for bilateral pes planus, to include hyperpronated feet and calcaneal spurs. 2. Entitlement to service connection for allergic conjunctivitis. 3. Entitlement to service connection for vitreal floaters. 4. Entitlement to service connection for a disability affecting the knuckles of the right hand, to include "popping." 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to a compensable evaluation for a disability of the cervical segment of the spine, prior to April 14, 2008, on appeal from an initial grant of service connection. 7. Entitlement to an evaluation in excess of 10 percent for a disability of the cervical segment of the spine, after April 13, 2008, on appeal from an initial grant of service connection. 8. Entitlement to a compensable evaluation for a right ankle disability prior to January 3, 2012, on appeal from an initial grant of service connection. 9. Entitlement to an evaluation in excess of 10 percent for a right ankle disability after January 2, 2012, on appeal from an initial grant of service connection. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD Joseph R. Keselyak, Counsel INTRODUCTION The Veteran served in the US Air Force from March 1987 to March 2007. He retired from service after twenty years of honorable and faithful service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in St. Petersburg, Florida as part of the Benefits Delivery at Discharge (BDD) program. In September 2011 this matter was last before the Board at which time it was remanded for further development. With respect to the claims decided herein, that development has been completed. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). At this time, the Board remanded the Veteran's claims for service connection of a disability of the lumbar segment of the spine, to include pain and discomfort, and entitlement to service connection for foreign bodies of the eyes, to include a scar of the cornea of the right eye. Following the Board's remand, these claims were granted in an October 2012 rating decision. As the benefits sought on appeal were granted, these issues are no longer before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Also, the Board remanded the Veteran's claim for an initial compensable evaluation for a right ankle disability. In the October 2012 rating decision, the Agency of Original Jurisdiction (AOJ) increased the evaluation of this disability to 10 percent disabling effective January 3, 2012. Because the maximum benefit sought on appeal was not granted, the issue remains on appeal. Id. In the original claim, the Veteran requested service connection for popping of both hands and metacarpal subluxations; however, only the right hand was adjudicated. Thus, when this matter was last before the Board, the issue pertaining to service connection for a disability of the left hand to include popping and metacarpal subluxations was referred back to the RO for the appropriate action. It does not appear, however, from a review of the claims file, to include Virtual VA, that this claim was acted upon. The issue of entitlement to service connection for to service connection for a disability of the left hand to include popping and metacarpal subluxations has been raised by the record, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for bilateral pes planus, to include hyperpronated feet and calcaneal spurs, entitlement to service connection for allergic conjunctivitis and entitlement to service connection for vitreal floaters being remanded are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. It has been shown by competent and probative evidence to at least equipoise that the Veteran incurred a disability affecting the knuckles of the right hand, to include "popping" in service. 2. It has not been shown by competent and probative evidence to at least equipoise that the Veteran has had bilateral hearing loss throughout the relevant period, including the present. 3. Prior to April 14, 2008, the combined range of motion of the Veteran's cervical spine measured less than 335 degrees. 4. Throughout the entire applicable period, the Veteran's cervical spine disability did not manifest by forward flexion of less than 45 degrees, by combined range of motion 170 degrees or less, ankylosis or any associated neurologic abnormalities. 5. Prior to January 3, 2012, the Veteran's right ankle disability manifested by arthritis and pain on motion, but no limitation of motion. 6. Throughout the entire applicable period, the Veteran's right ankle disability did not manifest by ankylosis, malunion of the os calcis or astragulus, astragalectomy or marked limitation of motion. CONCLUSIONS OF LAW 1. Service connection for a disability affecting the knuckles of the right hand, to include "popping" is established. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002) 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for service connection for hearing loss disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385 (2012). 3. Prior to April 14, 2008, the criteria for an initial evaluation of 10 percent, but no greater, for disability of the cervical segment of the spine have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5235-5243 (2012). 4. After April 14, 2008, the criteria for an initial evaluation in excess of 10 percent, for disability of the cervical segment of the spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5235-5243 (2012). 5. Prior to January 3, 2012, the criteria for an initial evaluation of 10 percent, but no greater, are met for a right ankle disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5270-5274 (2012). 6. After January 2, 2012, the criteria for an initial evaluation in excess of 10 for a right ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.59, 4.71a, 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5270-5274 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an AOJ, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2011); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the claims for increased evaluations, in cases such as these where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, the RO provided notice to the Veteran in letters dated in January 2007 and October 2011 of how ratings and effective dates are assigned. The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case as the Veteran has not alleged any prejudice. With respect to the service connection claims, the Veteran was provided pre-adjudication notice by a letter dated in January 2007 as part of the BDD program. Notably, further notice was provided to the Veteran in an October 2011 letter, per the Board's September 2011 remand directives, and the claims were subsequently re-adjudicated in a January 2013 Supplemental Statement of the Case (SSOC). Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). VA has obtained the Veteran's service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations and obtained medical opinions as to the etiology and severity of his claimed disabilities. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The United States Court of Appeals for Veterans Claims (hereinafter "the Court") has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that VA examinations obtained in this case are adequate. They are predicated on a review of the history and medical findings and consider the Veteran's complaints, symptoms and history. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for a disease diagnosed after service discharge when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirements for service connection for hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection to be granted. The regulation does not necessarily preclude service connection for hearing loss that first met the regulation's requirements after service. Hensley v. Brown, 5 Vet. App. 155 (1993). Thus, a claimant who seeks to establish service connection for a current hearing disability must show, as is required in a claim for service connection for any disability, that a current disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record, including that pertinent to service. 38 U.S.C.A. §1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012); Hensley, 5 Vet. App. at 159-60. Hearing loss will be considered to be a disability when the auditory threshold in any of the frequencies is 500, 1000, 2000, 3000 or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 2000, 3000 or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Service connection for sensorineural hearing loss and arthritis may be granted if the disability becomes manifest to a compensable degree within one year following separation from active military service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Hearing loss will be considered to be a disability when the auditory threshold in any of the frequencies is 500, 1000, 2000, 3000 or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 2000, 3000 or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Under applicable criteria, VA shall consider all lay and medical evidence of record in a case with respect to benefits under laws administered by VA. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Hand Disability The Veteran claims that he incurred a disability of the right hand in service, characterized as affecting the knuckles, to include popping. His service treatment records reference numerous complaints of right hand knuckle pain. See e.g. October 1997 service treatment record. He did not enter service with any findings related to the right hand. See Report of Medical Examination dated in October 1986. In furtherance of substantiating his claim for service connection of a disability affecting the knuckles of the right hand, to include "popping," the Veteran was first afforded a VA examination in February 2007. That examination resulted in an assessment of "right hand with a painful, audible popping type condition." Further examination in January 2012 resulted in an assessment of trigger fingers of the long and index fingers, which the examiner felt were likely attributable to service. Nevertheless, further examination in December 2012 did not result in any assessed disability, but for an old fracture of the 5th metacarpal, which is not the subject of this decision. The December 2012 examiner did not diagnose trigger fingers. Entitlement to service connection for disability affecting the knuckles of the right hand, to include "popping," particularly trigger fingers of the long and index fingers, is granted. As noted above, the Veterans service treatment records document numerous complaints regarding the right hand. Competent VA examination in January 2012 resulted in an assessment of trigger fingers of the long and index finger and found that this condition was at least as likely as not attributable to service. Accordingly, the claim is granted. Gilbert, supra. The Board acknowledges the negative findings of the December 2012 VA examiner. Nevertheless, a review of the examination report, although indicating that the claims file was reviewed, shows that it is substantially outweighed by the January 2012 VA examination report, which the Board notes references the history of the Veteran's complaints in much greater detail. The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Moreover, a disability was shown during the pendency of the appeal. McLain v. Nicholson, 21 Vet. App. 319 (2007). Bilateral Hearing Loss The Veteran seeks service connection for bilateral hearing loss. Although a review of his service treatment records documents complaints of decreased hearing, it does not indicate that bilateral hearing loss was ever assessed. Also, numerous audiograms contained within the service treatment records do not approximate VA's standards for considering hearing loss a disability, although this is certainly not dispositive of the claim. Hensley, supra. In furtherance of attempting to substantiate his claim, the Veteran was afforded a VA audiologic examination in February 2007. On the authorized audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 20 20 LEFT 10 10 15 25 20 Pure tone averages were 15 for the right ear and 18 for the left ear. Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. In July 2008 statement the Veteran related that he had to "retake the hearing test a number of times because [he] would fail the first test." In this regard, he pointed to a September 12, 2000, audiogram that he asserted indicated that he had failed a test. He related that his wife told him "all the time to turn down the TV or radio" and that he felt that he had some hearing loss that was service-connected. He cited 20 ears of exposure to noise from jet aircraft engines and air tools. In regard to the September 12, 2000, audiogram, the Board has reviewed it. Notably, there is no indication thereon that the Veteran had failed the test and no significant threshold shift was found at the time. It does not contain audiometrics demonstrating hearing loss to a disability for VA purposes, although this is not conclusive. Hensley, supra. In January 2012 the Veteran was afforded another VA examination. On the authorized audiological evaluation pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 10 20 20 LEFT 10 10 15 25 25 Pure tone averages were 14 for the right ear and 19 for the left ear. Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 98 percent in the left ear. The Board acknowledges the Veteran's assertions that he had a loss of hearing acuity in and since service. Nevertheless, his assertions are not competent evidence to demonstrate bilateral hearing loss, which can only be shown by audiometrics. Jandreau, supra. As outlined above, no audiogram, either in or following service, has shown bilateral hearing loss to the degree specified by 38 C.F.R. § 3.385. Accordingly, the claim must be denied. Gilbert, supra. Increased Evaluation Claims Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 38 C.F.R. Section 3.321(b)(1) provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria. According to the regulation, an extraschedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." Id. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 38 C.F.R. §§ 4.40, 4.45 and 4.59 require the Board to consider a veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X- ray findings will not be combined with ratings based on limitation of motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. Id. Cervical Spine Intervertebral disc syndrome (preoperatively or postoperatively) will be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. According to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes: A 10% rating requires evidence of incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20% rating requires evidence of incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40% rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60% rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1): For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2010). Under Diagnostic Code 5242 degenerative arthritis of the spine (see also, Diagnostic Code 5003), is evaluated under the following general rating formula for diseases and injuries of the spine: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: A 10% evaluation will be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of t he cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of height. A 20% rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30% evaluation is assigned for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40% rating requires evidence of unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50% evaluation will be assigned with evidence of unfavorable ankylosis of the entire thoracolumbar spine. A 100% rating requires evidence of unfavorable ankylosis of the entire spine. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion is zero to 45 degrees, and left and right lateral rotation is zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). In March 2007, and as part of the BDD program, the Veteran was provided a VA examination. The examination report documents a history of cervicalgia and non-allopathic lesions, spondylosis and degenerative joint disease, and that there had been no doctor prescribed bed rest or incapacitation in the past 12 months. In regard to the cervical spine, the Veteran complained that his neck would "pop" all of the time, with no history of specific injury. In regard to pain, he described such at the base of the neck and without radiation and which was not constant. When pain occurred, the Veteran described it as an aching type of pain that varied from 1/10 to 4/10 in intensity. He denied any specific type of activity that would precipitate flare-ups. He denied any associated weakness, numbness or bladder/bowel incontinence. The condition had no impact on his ability to walk or on his activities of daily living or usual occupation. He had undergone physical therapy for the neck and had been prescribed muscle relaxants and anti-inflammatory medications. There was no history of surgery or injections. Physical examination revealed a well-developed individual who was alert and oriented times 3. The Veteran's posture was erect and his gait was normal. He did not use any assistive devices with respect to the neck. The neck and back were bilaterally symmetric without gross deformity or apparent congenital scoliosis. There was no deformity of the cervical spine. Deep tendon reflexes were bilaterally equal in all areas. There was no atrophy or hypertrophy and the body was symmetrical. There was no palpable spasm or tenderness. Neurologic testing was normal. Flexion of the cervical spine was from zero to 45 degrees. Extension was also from zero to 45 degrees. Right lateral flexion was to 30 degrees. Left lateral flexion was to 30 degrees. Right rotation was to 30 degrees. Left rotation was to 30 degrees. X-rays apparently revealed arthritis and "[c]ervical spine condition without any physical examination abnormalities" was assessed. The examiner related that they could not determine any additional limitation of function due to repetitive use or during periods of flare-ups without resort to speculation. An April 14, 2008, treatment record from Eglin Air Force Base documents a chief complaint of neck pain following an incident where the Veteran turned his head and felt a pop. He denied any arm numbness or tingling, but acknowledged pain, particularly on motion, relieved by non-steroidal anti-inflammatories. He also reported stiffness of the neck. The appearance of the neck was normal. Palpation showed tenderness of the neck. There was also a muscle spasm of the cervical spine. X-rays showed degenerative joint disease and degenerative disc disease of the cervical spine. Of record is an April 2008 MRI report of the cervical spine. The report notes a history of neck pain, decreased range of motion, pain in to the arm and numbness to the fingers. The report documents an impression of generous canal and neural foramina limited C5-6, limited-to-mild C6-7 spondylosis, limited encroachment and no evidence of cord or root concerns. On December 13, 2012, the Veteran was afforded another VA examination of the cervical spine. At this time, the Veteran was noted as being employed and was working as a sheet metal worker. He had not been prescribed bed rest by a doctor or had any incapacitation in the past 12 months due to his cervical spine condition. The report of the examination documents that the Veteran did not understand why further examination of the neck had been sought as it was his understanding that "this was all granted during his appeal." He denied any history of trauma, but did note that he was in 2 motor vehicle accidents while in service, but did not receive medical treatment for either. He related that he had been told by a chiropractor that his head was "not sitting properly," and had it manipulated, which provided relief. He complained of grinding and popping and that he had been informed that he had a spur. Examination showed a normal posture and gait, with no need for assistive devices. Motor examination showed no atrophy or any gross deficit. Hs coordination was adequate. Sensory examination showed no gross sensorial deficit. Microfilament testing to the upper and lower extremities was negative. There was adequate vibratory response to the upper and lower extremities. The brain/spinal cord exhibited no gross deficit, and there were no tremors or fasciculations in this regard. Diagnostic tests showed minimal degenerative disc disease at C6-7 only. EMG testing was normal with respect to the cervical spine, but did demonstrate median neuropathy of the right arm commonly seen status-post carpal tunnel release, as well as mild left ulnar neuropathy near the elbow. The Veteran denied a history of flare-ups. It is noted that service connection has been awarded for bilateral carpal tunnel syndrome (CTS) and each upper extremity has been assigned a 10 percent evaluation in this regard. Range of motion studies were performed as well. Flexion of the cervical spine was to 45 degrees or greater, with no objective evidence of painful motion. Extension was likewise to 45 degrees or greater, with no objective evidence of painful motion. Right lateral flexion was to 45 degrees or greater, with no objective evidence of painful motion. Left lateral flexion was to 45 degrees or greater, with no objective evidence of painful motion. Right lateral rotation was to 80 degrees or greater, with no objective evidence of pain on motion. Left lateral rotation was also to 80 degrees or greater, with no objective evidence of painful motion. The Veteran was able to perform repetitive use times 3, which did not cause any additional limitation of motion. He had no functional loss of the cervical spine. There was no localized tenderness or pain upon palpation of the neck. He had no guarding or muscle spasm. Muscle strength testing was 5/5 in all areas. He had no muscle atrophy. He did not have intervertebral disc syndrome. Degenerative disc disease, minimal, at C6-7, was assessed. Initially, the Board points out that the formula for evaluation of intervertebral disc syndrome based on incapacitating episodes is inapplicable in the present case. At no time has the Veteran been prescribed bed rest by a physician, as required by regulation. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). Nevertheless, Prior to April 14, 2008, and particularly since the day following the Veteran's discharge, i.e. April 1, 2007, the Board finds that a 10 percent, but no greater evaluation is warranted. 38 U.S.C.A. § 5110 (b)(1). In this regard, it is noted by the Board that upon examination in March 2007, notably prior to the Veteran's discharge, the combined range of motion of the cervical spine was measured as 210 degrees, which satisfies the criteria for a 10 percent evaluation. Accordingly, prior to April 14, 2008, a 10 percent evaluation is warranted. Fenderson, supra. After a careful review of the evidence of record, the Board finds that the criteria for an evaluation in excess of the current 10 percent are not met for the service-connected cervical spine disability. In order to warrant an evaluation in excess of 10 percent the Veteran's degenerative disc disease of the cervical spine must be manifested by a limitation of forward flexion between 15 and 30 degrees. At no time has the Veteran's flexion been measured as less than the full 45 degrees of motion. His combined range of motion has never measured or approximated 170 degrees or less. Ankylosis has never been present and repeated examination has shown no associated neurologic abnormalities. Moreover, muscle spasms or guarding sufficient to result in an abnormal gait or spinal contour is not shown by the evidence. This has been true throughout the course of this appeal. Fenderson, supra. In addition, there is no additional functional impairment on use or flare-ups. Examination findings indicate that there was no additional range of motion lost after use and the Veteran denied flare-ups in December 2012. He has not otherwise reported that he experiences any additional limitation of motion as a result of a flare-up. For these reasons the claim must be denied. In regard to neurological manifestations, the Board notes that one of the primary purposes of its remand of this matter in September 2011 was to ascertain if the Veteran had any such manifestations attributable to his cervical spine disability. It is salient to the Board, that examination in December 2012, which included neurologic testing, did not result in any attribution of neuropathy to the cervical spine, but rather bilateral carpal tunnel syndrome, which is the subject of service connection and not currently on appeal. In rendering this determination, the Board has considered the Veteran's reports of symptoms and finds them credible, competent and probative. However, the evidence as a whole, as discussed above, does not show that the criteria for a higher rating are met for any period of time that is covered by this claim. Right Ankle The RO has evaluated the Veteran's right ankle disability under 38 C.F.R. § 4.71a, Diagnostic Code 5271, as non-compensably disabling prior to January 3, 2012, and as 10 percent disabling following January 2, 2012. Fenderson, supra. Diagnostic Code 5271 provides for a 10 percent evaluation for moderate limitation of motion of the ankle. A 20 percent evaluation is assigned for marked limitation of motion of the ankle. The Board notes that normal range of motion for the ankle on dorsiflexion is to 20 degrees and to 45 degrees on plantar flexion. See 38 C.F.R. § 4.71a, Plate II. Other diagnostic codes for disabilities of the ankle follow. Ankylosis (bony fixation) of either ankle, depending upon the favorability of the angle of fixation, warrants evaluation from 20 to 40 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Ankylosis of the subastragalar or tarsal joint in good weight-bearing position warrants a 10 percent evaluation, while such ankylosis in a poor weight-bearing position warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5272. Malunion of the os calcis or astragalus with moderate deformity warrants a 10 percent evaluation, and marked deformity warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5273. Astragalectomy warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5274 (2012). Normal range of ankle motion is from 20 degrees of upward dorsiflexion to 45 degrees of downward plantar flexion. 38 C.F.R. § 4.71, Plate II. The terms "moderate," and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2011). All evidence must be evaluated in arriving at a decision regarding a higher rating. 38 C.F.R. §§ 4.2, 4.6 (2012). As part of the BDD program, the Veteran was provided a VA examination in March 2007. The report thereof notes a history of right ankle instability, stemming from an sprain in 1996. At this time, the Veteran related that the ankle would still pop on occasion and that it would tend to roll when walking along, with no specific causative action. He related discomfort, described as an ache, at a level of 2/10 in severity, which occurred about twice per month. He denied any dislocations or locking, but related that the ankle was slightly unstable at times. He had not "really fallen," but just felt like the ankle gave way on him. There were no defining moments of flare-ups that he could relate. There were no adverse effects on activities of daily living or usual occupation. He did use a neoprene-type sleeve brace on the ankle, but otherwise no assistive devices. There was no history of physical therapy, injections or surgery, although anti-inflammatory medications had been prescribed. Dorsiflexion of the ankle was from zero to 20 degrees. Plantarflexion was from zero to 45 degrees. There were no inversion or eversion abnormalities, or any excessive pain on either foot. The examiner could not comment on any additional limitation of function due to repetitive use or during periods of flare-ups without resorting to speculation, which is notably not fatal as the Veteran did not report flare-ups at examination. X-rays of the right ankle revealed changes that may have been correlated with an old fracture. The examiner assessed "[r]ight ankle condition, without any objective findings of abnormalities." Notably contained within the Veteran's service-treatment records is a March 21, 2007, MRI report of the right ankle, which notes chronic ankle pain, swelling and popping. Also noted, was the recent VA examination and X-ray report, which apparently showed a 1.8 x 1 cm. calcific density inferior to the fibula. Among other things, the MRI report documents an assessment of arthritis of the right ankle. An April 23, 2007, record from Eglin Air Force Base notes a complaint of chronic right ankle pain and complaints of instability. The ankle exhibited full range of motion, however, and was not tender to palpation. It did exhibit a large bony prominence of the lateral malleolus. Eversion, however, was weak. The Veteran was then prescribed a lace-up brace to wear. Surgery was considered, also, at this time. On January 3, 2012 the Veteran was afforded another VA examination. At this time, the Veteran complained of flare-ups with occasional twisting of the right ankle with pain and mild swelling relieved in 1 to 2 hours. He related that pain was not always present, but at a level of 4-5/10 with twisting, approximately monthly. He stated that the use of boots or high top shoes was effective in limiting eversion. Physical examination showed plantarflexion from zero to 45 degrees or greater, with no objective evidence of painful motion. Dorsiflexion was from zero to 10 degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing times 3, with no decrease in range of motion in either plane. The examiner did find functional loss and/or impairment of the ankle, particularly less movement than normal, weakened movement, deformity, disturbance of locomotion, increased lateral talar tilt on inversion stress and interference with sitting, standing and weight-bearing. The ankle did exhibit pain on palpation/localized tenderness. Muscle strength testing was normal. The ankle did exhibit laxity, but not ankylosis. He had no history of surgery, and thus scars, on this ankle. The lateral malleolus was significantly more prominent on the right side. The peroneal tendons were intact and without subluxation. There was, as mentioned, tenderness to palpation anteriolateral ankle and significant lateral talar instability was noted. Initially, the Board must note that several diagnostic codes pertaining to evaluation of ankle disabilities are inapplicable in this case. In this regard, the Board notes the absence of evidence showing ankylosis, malunion of the os calcis or astralgulus or astragalectomy. See 38 C.F.R. § Diagnostic Codes 5270, 5272, 5273, 5274. Accordingly, these diagnostic codes are not for consideration. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Resolving any doubt in the Veteran's favor, the Board finds that prior to January 3, 2012, a 10 percent evaluation is warranted. In this regard, although VA examination and the evidence of record demonstrated normal range of motion in the ankle, the Veteran did note pain and instability on use of the ankle. Saliently, MRI had documented arthritis in the ankle as of March 2007. Under 38 C.F.R. § 4.45 (f) the ankle is a major joint. Thus, under 38 C.F.R. § 4.71a, Diagnostic Code 5003, the Board concludes that a 10 percent evaluation is warranted for non-compensable painful motion of an arthritic right ankle. Fenderson, supra. Nevertheless, since the inception of the claim and throughout the course of the claim and appeal, the Board does not find that the evidence substantiates an evaluation in excess of 10 percent. To establish entitlement to an evaluation in excess of 10 percent the evidence must show marked limitation of motion of the right ankle. In this regard, the Board notes that VA examination in March 2007 showed normal range of motion of the ankle. Examination in January 2012 showed dorsiflexion to 10 degrees (out of 20) and plantar flexion to 45 degrees (out of 45). In other words, at most, and with consideration of the Deluca factors, the Veteran has retained plantarflexion and half of his dorsiflexion. In addition while there was functional impairment due to less movement than normal, weakened movement, deformity, disturbance of locomotion and interference with sitting, standing and weight-bearing, there was no additional range of motion loss shown on repetitive use. Moreover, while the Veteran reported flare-ups of pain, he has not reported that he lost any additional function of his ankle as a result thereof. The Board thus does not find that range of motion in the left ankle has been markedly limited. Accordingly, at no time during the relevant period in question is a 20 percent schedular evaluation warranted. Fenderson, supra. In rendering this determination, the Board has considered the Veteran's reports of symptoms and finds them credible, competent and probative. However, the evidence as a whole, as discussed above, does not show that the criteria for a higher rating are met for any period of time that is covered by this claim. Extraschedular Consideration According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected conditions are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities of the cervical spine and right ankle with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The criteria particularly contemplate his specific symptoms of limitation of motion and pain. In short, there is nothing in the record to indicate that the service-connected disabilities on appeal cause impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to service connection for a disability affecting the knuckles of the right hand, to include "popping" is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to a 10 percent, but no greater, evaluation is granted prior to April 14, 2008, for a disability of the cervical segment of the spine. Entitlement to an initial evaluation in excess of 10 percent for disability of the cervical segment of the spine is denied. Entitlement to a 10 percent, but no greater, evaluation is granted prior to January 3, 2012, for a right ankle disability. Entitlement to an initial evaluation in excess of 10 percent for a right ankle disability is denied. REMAND Once VA provides an examination, it must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An examination is adequate if it "takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Barr, 21 Vet. App. at 311 (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). Moreover, an examination must be based upon consideration of the Veteran's prior medical history and examinations. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). A congenital or developmental defect is not considered a disease or injury for VA purposes. See 38 C.F.R. §§ 3.303(c), 4.9 (2012). Therefore, a congenital defect, as distinguished from a disease, generally may not be service-connected as a matter of law. Further, the general presumption of soundness upon entry into service, as set forth in 38 C.F.R. § 3.304(b) (2012), does not apply to congenital defects. However, service connection may be granted if a congenital defect is subject to, or aggravated by, a superimposed disease or injury during service which results in additional disability. See 38 U.S.C.A. §§ 1110, 1111 (West 2002); VAOPGCPREC 82-90 (July 18, 1990), published at 56 Fed. Reg. 45,711 (1990); see also Quirin v. Shinseki, 22 Vet. App. 390 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996). Otherwise, a preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The presumption of aggravation is not applicable unless the pre-service disability underwent an increase in severity during service. See Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991). The determination of whether a preexisting disability was aggravated by service is a question of fact. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether such worsening constitutes an increase in disability or was the result of natural progression of the injury or disease. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition (as contrasted to the symptoms) has worsened. See Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002). In this case, pes planus was noted on the Veteran's enlistment physical examination. In January 2012 and in accordance with the Board's September 2011 remand directives, the Veteran was afforded a VA examination to address the etiology of his pes planus. In terms of etiology, the examiner rendered a negative opinion with respect to service origin. In this regard, he noted that although his review of the service records indicated that the Veteran's flat feet did become symptomatic during military service, this represented a natural progression of a pre-existing developmental deformity unrelated to the activities of his military occupation. The examiner concluded that it was more likely than not that the flat foot deformity pre-existed service and identified it as a developmental disorder apparent in early childhood, and that the use of orthotics did not represent a departure from the normal course of this disorder. The examiner also commented that the Veteran had the Veteran had a smooth and not antalgic gait, "although [the] right foot externally rotated more than [the] left," which appeared to be compensatory for the service-connected right ankle instability, "which would be more problematic if he were to have varus positioning of the right heel." Further examination is necessary to decide the claim. As the January 2012 examiner identified that the Veteran had a developmental disorder of the feet prior to service, the issue of whether there was a defect such that there may have been superimposed injury or disease in service that resulted in additional disability of the feet must be addressed. Likewise, the examiner's discussion regarding the Veteran's externally rotated right ankle, which is service-connected, raises the issue of secondary service connection. 38 C.F.R. § 3.310. Accordingly, the examination report must be returned. 38 C.F.R. § 4.2. The claim for service connection of bilateral pes planus, to include hyperpronated feet and calcaneal spurs, has not been developed on the basis of secondary service connection, including as based upon aggravation. On remand of the matter, the Veteran should be provided notice in this regard and the claim should be considered on this basis. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. The Veteran was afforded a VA examination in February 2007 to address his claim for allergic conjunctivitis. Notably, his service treatment records documented treatment for conjunctivitis, to include "vernal" conjunctivitis and the conjunctivitis was noted as chronic on at least one occasion. See e.g. November 2000 Report of Medical Examination. The examination resulted in an assessment of "no evidence of allergic conjunctivitis on today's evaluation." Likewise, subsequent VA examination in January 2012 did not result in an assessment of allergic conjunctivitis. The Veteran should be afforded another VA examination. From a review of the service treatment records, which indicate that the condition may be seasonal, the examination reports are inadequate in that they do not address the possible cyclical and seasonal nature of the claimed disability. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where record does not adequately reveal current state of claimant's disability, fulfillment of duty to assist requires contemporaneous medical examination, particularly if there is no additional medical evidence which adequately addresses level of impairment since previous examination); Ardison v. Brown, 6 Vet. App. 405, 408 (1994) (indicating that, to the extent possible, VA should schedule an examination for a condition that has cyclical manifestations during an active stage of the disease to best determine its severity); Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) (VA examination ordered during active stage of the Veteran's skin disorder); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, if possible the Veteran should be scheduled for a VA examination during the spring, i.e. vernal period, as it appears this is when the condition is active. In any event, the examiner should elicit a detailed history of this condition from the Veteran to attempt to substantiate the claim. Id. Also, along these lines, the Board feels that the Veteran should be afforded a VA examination to address his claim for service connection of vitreal floaters. In this regard, it is noted that VA examination did not disclose any such symptomatology; however, the Veteran has complained that this condition occasionally affects him. Thus, he should be afforded a new VA examination. Id. Lastly, with respect to the claim for vitreal floaters, the Board notes that the Veteran had foreign service in Saudi Arabia during the Persian Gulf War. It is unclear, however, to the Board whether the claimed vitreal floaters represent a diagnosis and under this set of facts the Board feels that upon remand the AOJ should consider the regulations pertaining to service connection for undiagnosed illness for service in Southwest Asia. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Accordingly, the case is REMANDED for the following action: 1. Consistent with the provisions of 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159, notify the Veteran of what information and evidence are needed to substantiate his claim of entitlement to service connection for bilateral pes planus, to include hyperpronated feet and calcaneal spurs, as secondary to the service-connected right ankle disability. The Veteran must be notified of what portion of that evidence VA will secure, and what portion he must submit. If requested, VA will assist him in obtaining records of treatment from private medical professionals, or other evidence, provided that he provides sufficient, identifying information and written authorization. Depending upon the Veteran's response, any and all assistance due the Veteran must then be provided by VA to him. 2. After the development directed in paragraph 1 has been completed to the extent possible, return the claims file to the examiner who conducted the January 2012 VA examination of the Veteran for an addendum. If the January 2012 VA examiner is not available, the claims file must be available to another appropriate health care provider for the requested opinion. After a review of the claims file, the author of the January 2102 VA opinion or other health care provider MUST respond to the following questions and provide a full statement of the basis for the conclusion(s) reached: a) Upon examination dated in January 2012 it was determined that the Veteran had a flatfoot deformity which is a developmental disorder. Please explain whether the Veteran's pes planus is a congenital or developmental defect or disease. [Note: a disease generally refers to a condition that is considered capable of improving or deteriorating while a defect is generally not considered capable of improving or deteriorating. VAOPGCPREC 82-90 (1990) (citing Durham v. United States, 214 F.2d 862, 875 (D.C. Circuit 1954)]. b) If it is a congenital or development defect, please explain whether it is at least as likely as not (a probability of 50 percent or greater) that there was a superimposed injury or disease in service that resulted in additional disability of the feet. Please provide a complete explanation for the opinion. c) If it is not a congenital or developmental defect, was the pes planus, which was shown on the service induction examination, at least as likely as not aggravated (i.e., permanently increased in severity) during that period of service. Please provide a complete explanation for the opinion. d) If so, was any increase clearly and unmistakably (obviously, manifestly or undebatably) due to the natural progress of the disease. Please provide a complete explanation for the opinion. e) Is it at least as likely as not (a probability of 50 percent or greater) that bilateral pes planus, to include hyperpronated feet and calcaneal spurs, is due to or caused by the service-connected right ankle disability. Please provide a complete explanation for the opinion. f) Is it at least as likely as not (a probability of 50 percent or greater) that bilateral pes planus, to include hyperpronated feet and calcaneal spurs, is aggravated beyond the natural progress by the service-connected right ankle disability. If so, examiner should indicate the approximate degree of disability or baseline before the onset of the aggravation. Please provide a complete explanation for the opinion. Any and all opinions must be accompanied by a discussion of the underlying reasons. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reason(s) for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Aggravation is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. 3. After the development directed in paragraph 1 has been completed to the extent possible, schedule the Veteran for a VA examination to determine the nature and etiology of his claimed allergic conjunctivitis and vitreal floaters, in the spring if possible, as this is reportedly when the allergy symptoms are present. The claims folder should be made available to the medical professional providing the opinion for review in conjunction with rendering the opinion. The examiner should obtain a complete, pertinent history from the Veteran and review the claims file in conjunction with the examination, giving particular attention to his service treatment records, lay assertions, and the pertinent medical evidence. Based upon the examination and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that allergic conjunctivitis, to include seasonal allergic conjunctivitis, is attributable to service. Also, with respect to the claimed vitreal floaters, based on the examination and review of the record, the examiner is requested to state whether the Veteran's complaints are attributable to a diagnosed or undiagnosed illness, including an intermittent diagnosed or undiagnosed illness. If the examiner cannot identify a disease or disability that causes this symptomatology, the examiner should so state. Likewise, if this symptomatology is not present, the examiner should so state. If any of the Veteran's complaints are attributable to diagnosed illness, the examiner should render an opinion as to whether is at least as likely as not (a 50 percent probability or greater) that such disability, including intermittent disability, is related to active military service or events therein. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reason(s) for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 4. After the development requested above has been completed to the extent possible, review the record and readjudicate the Veteran's claims, to include consideration of the claim for service connection of vitreal floaters under the criteria for establishing service connection for an undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 and the claim for service connection of bilateral pes planus, to include hyperpronated feet and calcaneal spurs under 38 C.F.R. § 3.310. The pertinent legal provisions (i.e., 38 C.F.R. §§ 3.310, 3.317) should be included in the SSOC if either claim remains denied. In any event, if any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a SSOC and given the opportunity to respond thereto before this case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs