Citation Nr: 1322986 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 04-43 334 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for bilateral hearing loss disability. 3. Entitlement to service connection for a left upper extremity disorder. 4. Entitlement to service connection for hiatal hernia and gastroesophageal reflux disease (GERD). 5. Entitlement to service connection for a pulmonary disorder, to include as secondary to the service-connected chronic sinusitis. 6. Entitlement to service connection for a right hip disorder, to include as secondary to the service-connected degenerative joint disease of the right knee. 7. Entitlement to service connection for impingement syndrome and tendonitis of the right shoulder, to include as secondary to the service-connected fracture, right clavicle, healed with mild to moderate angulation. 8. Entitlement to a rating in excess of 20 percent for lumbosacral strain with facet syndrome, for the periods from November 20, 2002 to January 10, 2005; September 1, 2005 to September 19, 2006; and, January 1, 2007 to April 22, 2008. 9. Entitlement to a rating in excess of 40 percent for lumbosacral strain with facet syndrome, for the periods from April 23, 2008. 10. Entitlement to a rating in excess of 10 percent for varicosities and post-phlebitic syndrome of the right leg with edema and stasis dermatitis for the period prior to April 17, 2012. 11. Entitlement to a rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the right leg with edema and stasis dermatitis from April 17, 2012. 12. Entitlement to a rating in excess of 10 percent for varicosities and post-phlebitic syndrome of the left leg with edema and stasis dermatitis for the period prior to April 17, 2012. 13. Entitlement to a rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the left leg with edema and stasis dermatitis from April 17, 2012. 14. Entitlement to a compensable rating for eczema with history of tinea and neurodermatitis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran served on active duty from May 1969 to June 1991. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision issued by the RO. In the February 2004 rating decision, the RO, in pertinent part, increased the rating for the Veteran's low back disability from 0 to 10 percent, effective November 20, 2002; continued a noncompensable rating for eczema; and assigned separate 10 percent ratings for varicosities of each right and left leg, effective November 20, 2002. The RO, in pertinent part, also denied the claims for entitlement to service connection for hypertension, a prostate disorder, bilateral hearing loss disability, a left upper extremity disorder, hiatal hernia and GERD, a pulmonary disorder, a right hip disorder, impingement syndrome and tendonitis of the right shoulder and a right knee disorder. In August 2006, the Veteran testified during a Board videoconference hearing before the undersigned Veterans Law Judge at the RO; a transcript of the hearing is of record. In an April 2007 decision, the Board granted a higher 20 percent rating for the Veteran's service-connected low back disability, and denied higher ratings for varicosities of the right and left leg and for eczema. The Veteran, in turn, appealed to the United States Court of Appeals for Veterans Claims (the Court). In October 2008, counsel for VA's Secretary and the Veteran's representative (the parties) filed a Joint Motion for Partial Remand with the Court. By Order dated in December 2008, the Court granted the motion, vacating the Board's decision, in part, and remanding the matter to the Board for further proceedings consistent with the Joint Motion. In the April 2007 decision, the Board also remanded the following claims for service connection for additional development: hypertension, prostate disorder, bilateral hearing loss, a right knee disability, a left upper extremity disorder, a pulmonary disorder, a right hip disorder, GERD/hiatal hernia; and impingement syndrome and tendonitis of the right shoulder secondary to service-connected fracture of the right clavicle. That development was completed and these issues on appeal have been returned to the Board for appellate review. During the pendency of the appeal, the RO, in a November 2009 rating decision, granted service connection for degenerative joint disease of the right knee and assigned a 10 percent rating for the disability, effective on November 20, 2002. In a November 2012 rating decision, the RO granted service connection for neurogenic bladder and assigned a 40 percent rating for the disability, effective on April 23, 2008. Therefore, his appeal concerning the issues of entitlement to service connection for a right knee disorder and entitlement to service connection for a prostate disorder have been resolved. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of the claim concerning the compensation level assigned for the disability). The Board points out that higher ratings have been granted for the Veteran's low back and varicosities and post-phlebitic syndrome of the right and left leg disabilities during the pendency of this appeal. Because higher ratings for these disabilities are assignable during the relevant time period and the Veteran is presumed to seek the maximum available benefit, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Finally, the Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal herein decided. The issues of entitlement to service connection for bilateral hearing loss, a left upper extremity disorder, hiatal hernia and GERD, a pulmonary disorder, a right hip disorder and impingement syndrome and tendonitis of the right shoulder secondary to service-connected fracture of the right clavicle 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. Hypertension was not manifest during service or within one year of separation. Hypertension is not attributable to service. 2. Prior to April 23, 2008, the Veteran's lumbosacral strain has caused at most moderate limitation of motion with flexion greater than 30 degrees. The disorder is not manifested by ankylosis nor has it resulted in incapacitating episodes of approximately 4 weeks during any 12 month period. 3. Beginning April 23, 2008, the Veteran's lumbosacral strain has caused at most severe limitation of motion with flexion limited to 20 degrees. Unfavorable ankylosis or intervertebral disc syndrome resulting in incapacitating episodes of at least 6 weeks during any 12 month period have not been demonstrated. 4. Manifestations of the varicosities and post-phlebitic syndrome of the right leg have most nearly approximated that of persistent edema, incompletely relieved by elevation of extremity with or without beginning stasis pigmentation or eczema, throughout the appeal period. Persistent edema and stasis pigmentation or eczema with or without ulceration is not demonstrated. 5. Manifestations of the varicosities and post-phlebitic syndrome of the left leg have most nearly approximated that of persistent edema, incompletely relieved by elevation of extremity with or without beginning stasis pigmentation or eczema, throughout the appeal period. Persistent edema and stasis pigmentation or eczema with or without ulceration is not demonstrated. 6. The Veteran's dermatitis is shown to affect at least 5 percent but less than 20 percent of the total body area. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by service and hypertension may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for the assignment of a rating in excess of 20 percent for the lumbosacral strain with facet syndrome prior to April 23, 2008 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5237, 5243 (2012), DC 5292 5293, 5295 (2003). 3. The criteria for the assignment of a rating in excess of 40 percent for the lumbosacral strain with facet syndrome beginning on April 23, 2008 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a Diagnostic Code (DC) 5237, 5243 (2012), DC 5292 5293, 5295 (2003). 4. The criteria for a 20 percent rating for varicosities and post-phlebitic syndrome of the right leg prior to April 17, 2012 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7120, 7121 (2012). 5. The criteria for a rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the right leg are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7120, 7121 (2012). 6. The criteria for a 20 percent rating for varicosities and post-phlebitic syndrome of the left leg prior to April 17, 2012 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7120, 7121 (2012). 7. The criteria for a rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the left leg are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7120, 7121 (2012). 8. The criteria for a 10 percent rating for dermatitis are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.104 Diagnostic Code (DC) 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2011). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in September 2003 and March 2012 letters issued prior and subsequent to the rating decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The March 2012 letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. An additional letter set forth applicable criteria for ratings for the lumbar spine, varicosities and post-phlebitic syndrome of the right and left legs and dermatitis disabilities. The December 2012 Supplemental Statement of the Case (SSOC) reflects readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records are in the claims file and were reviewed by both the RO and the Board in connection with his claim. The Veteran has not identified any other outstanding records that are pertinent to the issues herein decided. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, private treatment records, records associated with the Veteran's Social Security Administration file, VA treatment records and examination reports. Further, the Board is aware that this appeal was, most recently, remanded by the Board in March 2012. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). The development requested in that remand has been completed. Accordingly, the Board finds that there has been substantial compliance with its previous remand and it may proceed to adjudication of this appeal. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Boards remand order). In summary, the Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. He was an active participant in the claims process submitting evidence and argument and presenting for a VA examination. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Finally, the Veteran was afforded an opportunity to present testimony at a hearing before the Board. During the hearing, the undersigned Veterans Law Judge (VLJ) clarified the issues on appeal, identified evidentiary deficits with regards to the issues on appeal and suggested the submission of additional evidence to support the Veteran's claims. The VLJ also left the record open for a 60-day period following the hearing to allow for the submission of such additional evidence. The actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing. 38 C.F.R. § 3.103. SERVICE CONNECTION Laws and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Establishing service connection generally requires (1) evidence of a current disability; (2) 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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). As noted, hypertension is a chronic disease. 38 U.S.C.A. § 1101. The appellant does have hypertension. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis The Veteran's service treatment records document that in January 1978, he received treatment in the emergency department for a right knee injury. His blood pressure reading was 130/90. A June 1981 record reflects that he received treatment for lower left quadrant pain. His blood pressure reading was 124/90. A January 1983 service treatment record reflects that the Veteran's blood pressure reading was 140/98. A September 1985 and March 1986 service treatment records reflect that his blood pressure reading was 130/90. In October 1986, the Veteran was seen for complaints of dizziness, lack of concentration, and left sided numbness for the past three weeks; the assessment was questionable hypertension. February 1988 service treatment record reflects that the Veteran's blood pressure reading was 140/90; March 1988 service treatment records reflect that the Veteran's blood pressure readings were 150/98 and 140/92, on separate dates. In a May 1981 service treatment record just prior to his retirement, the Veteran's blood pressure reading was 136/86 In this case, the Veteran asserts that hypertension had onset in service. A September 1991 report of VA examination reflects that the Veteran's blood pressure readings were 140/80 and 120/94. The Veteran reported a history of hypertension for which he took Motrin to regulate. The examiner questioned whether the Veteran had true hypertension and concluded, "no hypertension." A November 2002 VA treatment record documents that the Veteran's blood pressure reading was 158/106. The assessment was elevated blood pressure. The Veteran was issued a blood pressure monitor to monitor his home blood pressure. A November 2004 private back disorder treatment record indicates that the Veteran had a past medical history significant for hypertension. An April 2006 VA treatment record documents that the Veteran was prescribed Terazosin for the regulation of high blood pressure. In the report of November 2008 VA examination, the examiner opined that the Veteran's current hypertension was less likely as not (less than 50/50) probability caused by or a result of elevated blood pressure readings documented in service. The examiner explained that there was no indication or evidence that the Veteran was diagnosed to have hypertension in his military service. The examiner acknowledged that the Veteran did have elevated blood pressure readings in some clinical visits. However, in subsequent clinical visits, his readings were normal. The examiner explained that for hypertension to be diagnosed, the blood pressure readings have to be consistently elevated. The examiner explained that the Veteran was diagnosed to have hypertension in 2003, approximately 12 years after discharge from service and approximately 17 years after the initial discovery of elevated blood pressure in the clinic visit in service. The examiner noted that the sporadic incidents of elevated blood pressure readings in service but also noted that subsequent visits revealed normal blood pressure readings. In this case, while the Veteran contends that his hypertension had onset in service, the more probative opinion concludes that there is no relationship, or nexus, between the current hypertension and the Veteran's active service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 2013 WL 628429 at *8. The Board acknowledges the service treatment records document elevated blood pressure readings. However, no examiner during service, or since, has established the isolated findings were sufficient to establish chronicity. In the November 2008 report of VA examination, the examiner explicitly opined that the Veteran's current hypertension was less likely as not (less than 50/50) probability caused by or a result of elevated blood pressure readings documented in service. The examiner explained that for hypertension to be diagnosed, the blood pressure readings have to be consistently elevated. In sum, although there was in-service symptomatology, characteristic manifestations sufficient to identify the disease (hypertension) entity were not noted. Further, despite the Veteran's report of a continuity of symptomatology, the more probative nexus opinion weighs against his claim. In a May 1981 service treatment record just prior to his retirement, the Veteran's blood pressure reading was 136/86. In the September 1991 VA examination shortly after his retirement, the Veteran's blood pressure readings were 140/80 and 120/94. The Veteran reported a history of hypertension for which he took Motrin to regulate. The examiner questioned whether the Veteran had true hypertension and concluded, "no hypertension." Again, as explained in the November 2008 report of VA examination, for hypertension to be diagnosed, the blood pressure readings have to be consistently elevated. Consistently elevated blood pressure readings have simply not been documented in this case and no examiner during service, or since, has established the sporadic findings were sufficient to establish a finding of hypertension. Additionally, there is no evidence of hypertension within one year of separation from service. 38 U.S.C.A. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The only other evidence of record supporting the Veteran's claim is his various general lay assertions. In this case, the Board finds that the Veteran is competent to state that he had an onset of hypertension in service. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Here, some of the lay assertions are credible. However, his lay assertions are in conflict with the overall findings of the evidence of record which shows a lack of consistently elevated blood pressure readings and the more probative evidence regarding etiology tends to weigh against such a finding. Thus, the Board finds that the lay opinion is less informed and less probative than the reasoned medical opinion. The Board finds the opinion of the VA examiner in the November 2008 report of VA examination to be most probative. The VA examiner is a medical professional who has reviewed the claims file, considered the reported history and performed physical examination. The examiner used his expertise in reviewing the facts of this case and determined that the current hypertension was unrelated to the Veteran's service. It is clear that the examiner fully understood the basis for the Veteran's claim yet still determined, after reviewing the facts of the case, that the current hypertension was related to causes other than the Veteran's period of service. The Veteran has not suggested that the November 2008 examination was performed in an insufficient manner. For the foregoing reasons, the Board finds that the claims of entitlement to service connection for hypertension must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). [INCREASED] RATINGS Laws and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has 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). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007. Here the disabilities have not significantly changed and uniform evaluations are warranted. The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2010); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Lumbar spine The criteria for evaluating spine disorders were revised during the pendency of this appeal. Prior to September 2003, under DC 5295 (lumbosacral strain), a rating of 20 percent is warranted with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. A rating of 40 percent is assigned for severe lumbosacral strain with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo- arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. Under DC 5292 (limitation of motion of the lumbar spine), a 20 percent evaluation was assigned for moderate limitation of motion and a 40 percent evaluation was warranted for severe limitation of motion. Since the record shows that the Veteran has degenerative disc disease, the provision of Diagnostic Code 5293 for intervertebral disc syndrome should be considered as well. Under this Code, a rating of 20 percent is warranted for moderate intervertebral disc syndrome; recurring attacks. The next higher rating of 40 percent is warranted for severe intervertebral disc syndrome; recurring attacks, with intermittent relief. The higher rating of 60 percent under this Code is for application for pronounced intervertebral disc syndrome; with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, little intermittent relief. Effective September 2003, evaluation of the thoracolumbar spine disability under DC 5237 is for application. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating diseases and injuries of the spine. See 38 C.F.R. § 4.71a. Under the formula, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is in order for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is in order for unfavorable ankylosis of the entire spine. Under the formula the "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Associated objective neurological abnormalities (e.g., bladder and bowel impairment) are to be evaluated separately. Also under the formula, intervertebral disc syndrome can either be evaluated under the general rating formula as noted above or based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the formula for rating intervertebral disc syndrome based on incapacitating episodes, a 20 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months s. A 60 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 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. Periods from November 20, 2002 to January 10, 2005; September 1, 2005 to September 19, 2006; and, January 1, 2007 to April 22, 2008 For the time periods from November 20, 2002 to January 10, 2005; September 1, 2005 to September 19, 2006; and, January 1, 2007 to April 22, 2008, the Board concludes that the symptoms of the Veteran's lumbosacral strain do not warrant assignment of a rating in excess of 20 percent. A November 2002 VA treatment record reflects that the Veteran had loss of the lumbosacral spine curvature; there was no tenderness on palpation. The assessment, in pertinent part, was low back pain. A February 2003 x-ray report of the lumbar spine revealed moderate disc disease and osteoarthritis. The January 2004 report of VA spine examination documents the Veteran's complaint of daily pain in the lumbar spine. He described the low back pain as sharp. The intensity of the pain in the lower back was described as a 9 on a scale from 0 to 10. Flare up pain of the lumbar spine was reported to be 10/10 and occurred once daily lasting for 30 minutes. Precipitating factors included leaning over, and alleviating factors included putting his legs up on a chair. It was noted that functional impairment would be 90 percent as he stated that he needed to try and realign his entire back from his neck to his low back as this interfered with his work as a mailman. The Veteran also described some numbness of his lower extremities and he had erectile dysfunction, which he believes is related to his low back pain. He walked unaided; he used no bracing. He indicated that he had some unsteadiness and he had had some falls when his knees have given out on two different occasions. His gait was wide based, his head was midline. His arms were held comfortably at his side and he had a normal slow rhythm of the spinal motion. Range of motion of the lumbar spine was: flexion of 90 degrees with pain; extension to 15 degrees; lateral flexion to 30 degrees, bilaterally with pain; and, rotation to 45 degrees, bilaterally. He had evidence of painful motion, particularly when he straightened out back to the vertical position. There was no spasm great enough to interfere with his gait. There were no fixed deformities. Sensory examination was normal, bilaterally. Motor examination was equally strong bilaterally. Deep tendon reflexes were brisk bilaterally. Lasegue's signs were negative bilaterally. There were no periods of incapacitation reported. X-rays showed disc disease with facet osteoarthritis of the lumbar spine. The pertinent diagnosis was lumbar degenerative disc and joint disease. A June 2004 private treatment record documents that the Veteran received interlaminar epidural steroid injection in the L3-4 area under fluoroscopic guidance and verification. Private treatment records dated from August 2004 to October 2004, document ongoing treatment the Veteran received for his chronic low back disability. An August 2004 private treatment record reflects that on physical examination the Veteran had good range of motion of his back. Straight leg raising was unremarkable. Motor examination showed normal tone and strength throughout; gait was stable. In a November 2004 statement, the private physician described the Veteran's continued severe pain in his back with radiating pain into his legs, left side greater than the right; he also reported problems with numbness. It was noted that he presented after having failed conservative treatment including therapy, pain medications, morphine, injection therapy and rest. Subsequent private and VA treatment records document ongoing evaluation and treatment for several disabilities, including his lumbar spine disability. A March 2006 VA MRI report showed an anterior displacement of an interbody fusion device at L4/5 with some asymmetric broad based disc bulging which extended more prominently into the inferior left foramen and was associated with enhancement suggestive of associated granulation tissue. There was likely compression of the left L4 nerve root and possible irritation of the right L4 nerve root. An April 2006 private treatment record reflects the Veteran's complaint of pain of an intensity level ranging from 7-8 out of 10. He also complained of paraspinous tenderness in the area just below the surgical scar. He also had varying degrees of lower extremity pain, primarily in the posterior thighs, calves, knees and lateral hip areas. On examination, he preferred to stand. There was no evidence of gross motor deficits and the Veteran did not have a significant antalgic gait. There was pain with palpation in the L5 segment (below the surgical scar) and the Veteran exhibited some associated mechanical pain with flexion and extension. The physician suggested that L5-S1 facet joint injections might help with the complaints of pain. At his personal hearing in August 2006, the Veteran indicated that he had had several back surgeries as a result of his lumbosacral spine disorder; he stated that he was currently wearing a back brace, which he only took off to sleep and to shower. He related that he had been prescribed a walker. He described the severity of his back pain as an 8 on a scale from 1 to 10. He indicated that he has been prescribed bed rest a couple of days at a time. The Veteran indicated that he worked for the post office as a mailman; however, he has been placed on profile as a result of his back disorder. He indicated that he lost approximately 1 month out of the last year as a result of his back. The Veteran testified that he experienced numbness and tingling in his hips, thighs and legs; he also reported that he experienced bowel and bladder problems. Based on the above, the Board does not find that the criteria have been met for a rating in excess of 20 percent for lumbosacral strain for the time period in question. In this regard, the Board notes that the evidence establishes that the Veteran's lumbar spine disability has not been productive of severe limitation of motion of the lumbar spine (former criteria DC 5292), severe lumbosacral strain with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo- arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion (former criteria DC 5295), or forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Rather, the evidence shows that the Veteran's lumbar spine disability has been productive of at most moderate limitation of motion or muscle spasm all about the lumbar spine (i.e., muscle spasm on extreme forward bending forward) for the time period in question. Additionally, given that the Veteran is not shown to have experienced pronounced intervertebral disc syndrome or intervertebral disc syndrome with incapacitating episodes totaling at least 4 weeks during the past 12 months, a rating based on intervertebral disc syndrome is not warranted under the former criteria or revised criteria during this time period in question. The Board has also considered the Veteran's assertions as to the severity of his symptoms; however, the Board finds the objective medical evidence to be more probative than his lay assertions in determining that his lumbosacral strain does not meet the criteria for a rating in excess of 20 percent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here despite the Veteran's complaints, the more credible and probative evidence established that he simply did not have requisite manifestations to warrant a rating in excess of 20 percent. In this regard, despite his complaints of pain, the evidence shows his lumbar range of motion was forward flexion to 90 degrees (combined range of motion was 255). There was not spasm severe enough to interfere with his gait and there was no evidence of fixed deformities. In short, the Veteran's pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In a November 2002 rating decision, the RO granted separate ratings for neurogenic bladder, radiculopathy of the left lower extremity, radiculopathy of the right lower extremity and bowel dysfunction. The Veteran has not appealed the ratings assigned for those associated objective neurologic abnormalities. Accordingly, those issues are not before the Board. For all the foregoing reasons, the Board finds that a rating in excess of 20 percent for the lumbosacral strain is not warranted at any time pertinent to this appeal for the periods from November 20, 2002 to January 10, 2005; September 1, 2005 to September 19, 2006; and, January 1, 2007 to April 22, 2008. Period from April 23, 2008 For the time period from April 23, 2008, the Board concludes that the symptoms of the Veteran's lumbosacral strain do not warrant assignment of a rating in excess of 40 percent. The April 2008 report of VA spine examination documents the Veteran's complaint of moderate to severe pain, especially with bending or standing up from sitting position. It was difficult for the Veteran to lift or carry light loads. His walking was slow and unstable. The Veteran also reported daily incapacitating pain that required him to rest on a reclining chair for hours. Objectively he had spasm, guarding, pain with motion, tenderness and weakness severe enough to cause abnormal gait or abnormal spinal contour. Motor examination was normal. There was no ankylosis of the thoracolumbar spine. Range of motion of the lumbar spine was: flexion to 20 degrees with pain; extension to 10 degrees; lateral flexion to 20 degrees, bilaterally with pain; and, rotation to 25 degrees, bilaterally. He did not experience additional loss of motion on repetitive use. The April 2012 report of VA spine examination documents the Veteran's complaint of constant pain that radiated down both posterior lower extremities. It was difficult for the Veteran to walk, sit or stand for too long (more than 15 minutes). His back pain was aggravated by standing, walking, sitting, or bending. Objectively, range of motion of the lumbar spine was: flexion to 20 degrees (with objective evidence of painful motion beginning at 20 degrees); extension to 10 degrees (with objective evidence of painful motion beginning at 10 degrees); lateral flexion to 15 degrees, bilaterally (with objective evidence of painful motion beginning at 15 degrees); and, rotation to 10 degrees, bilaterally (with objective evidence of painful motion beginning at 10 degrees). He did not experience additional loss of motion on repetitive use. He had functional loss and/or functional impairment manifested by less movement than normal, weakened movement, pain on movement, disturbance of locomotion and interference with sitting, standing and/or weight bearing. The Veteran did have intervertebral disc syndrome; however, it was not productive of any incapacitating episodes over the past 12 months. Based on the above, the Board finds that the criteria have not been met for a rating in excess of 40 percent for lumbosacral strain for the period from April 23, 2008. In this regard, the Board notes that a 40 evaluation is the maximum evaluation for limitation of motion. Additionally, given that the Veteran is not shown to have experienced pronounced intervertebral disc syndrome or any incapacitating episodes of disc disease, higher ratings based on intervertebral disc syndrome are not warranted at any time pertinent to this period in question. Clearly he does not have ankylosis or unfavorable ankylosis. We also note the diagnostic criteria under diagnostic criteria 5293 ended long before the change in his manifestations. The Board has also considered the Veteran's assertions as to the severity of his symptoms; however, the Board finds the objective medical evidence to be more probative than his lay assertions in determining that his lumbosacral strain does not meet the criteria for a rating in excess of 40 percent for this time period. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here despite the Veteran's complaints, the more credible and probative evidence established that he simply did not have requisite manifestations to warrant a rating in excess of 40 percent. As separate ratings were granted for neurogenic bladder, radiculopathy of the left lower extremity, radiculopathy of the right lower extremity and bowel dysfunction and the Veteran has not appealed the ratings assigned for those associated objective neurologic abnormalities, those issues are not before the Board. For all the foregoing reasons, the Board finds that a rating in excess of 40 percent for the lumbosacral strain is not warranted at any time pertinent to this appeal for the period from April 23, 2008. Varicosities and Post-phlebitic Syndrome of the Right and Left Legs with Edema and Stasis Dermatitis The RO evaluated the Veteran's varicosities and post-phlebitic syndrome of the right and left legs with edema and stasis dermatitis under diagnostic codes (DC) 7120 and 7121. The criteria are wholly the same for these diagnostic codes. See 38 C.F.R. § 4.104. A 10 percent rating is warranted for where there is intermittent edema of the extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. A 20 percent rating is warranted where there is persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is assigned where there is persistent edema and stasis pigmentation or eczema with or without ulceration. A 60 percent rating is warranted where there is persistent edema and stasis pigmentation or eczema and persistent ulceration. A 100 percent rating is assigned where there is massive board-like edema with constant pain at rest. The Board finds that the medical and lay evidence reflects that the Veteran's varicosities and post-phlebitic syndrome of the right and left legs with edema and stasis dermatitis disabilities warrant increase to 20 percent rating, respectively, prior to April 17, 2012, and throughout the appeal period. The Board finds that the level of severity of the Veteran's varicosities and post-phlebitic syndrome of the right and left legs with edema and stasis dermatitis disabilities did not significantly change during the course of his appeal. A January 2004 report of VA arteries and veins examination reflects that the Veteran indicated that he had difficulty with breathing and sinus problems which was related to the infection in his right leg. He complained that he had pain in the right leg at rest with walking, but mostly with prolonged standing; he described the intensity of the pain as a 4 on a scale of 1 to 10. It was noted that he had had edema in the leg for which he was given compressive type hosiery, which helped; he stated that elevation of the leg was of no help. There were no vesicles or palpable varicosities. There were no ulcers. There was no edema. There was discoloration consistent with stasis pigmentation and from dry skin, which the Veteran felt was related to eczema. The pertinent diagnosis was post-phlebitic syndrome with residual areas of stasis pigmentation in the lower legs, bilaterally. In the June 2008 Joint Motion for remand, the parties agreed that the examination was inadequate because the report was inconsistent regarding the objective findings recorded and were unclear as to whether the symptoms were relative to the right leg, left leg or both. Accordingly, the Board remanded this issue on appeal for further development of the record in March 2012, to specifically include providing the Veteran with an adequate VA exam. The April 2012 report of VA artery and veins examination reflects that the relevant diagnoses were post-phlebetic syndrome and varicose veins. The examiner indicated that the symptoms associated with the Veteran's disability included aching and fatigue in the legs after prolonged standing or walking, incipient stasis pigmentation or eczema and persistent edema that is incompletely relieved by elevation of extremity. In light of the Veteran's consistent reports of persistent edema unrelieved by elevation of the extremities and the most recent examination (April 2012) documenting persistent edema that is incompletely relieved by elevation of extremity with incipient stasis pigmentation or eczema, the Board finds that the Veteran's varicosities and post-phlebitic syndrome of the right and left legs most nearly approximate persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema, for each leg respectively. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, his varicosities and post-phlebitic syndrome of the right and left legs warrant 20 percent ratings, respectively for each leg throughout the appeal period. In this regard, the Veteran's claims are granted. As persistent edema and stasis pigmentation or eczema with or without ulceration of the legs has not been demonstrated, higher ratings are not warranted at any time. For all the foregoing reasons, the Board finds that 20 percent, but no higher, ratings for varicosities and post-phlebitic syndrome of the right and left legs, respectively are warranted throughout the appeal period, but that ratings in excess of 20 percent are not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria 20 30 percent ratings are met, but finds that the preponderance of the evidence is against assignment of higher ratings. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). Skin- Dermatitis The RO evaluated the Veteran's skin disability under diagnostic codes (DC) 7806. Under Diagnostic Code 7806, dermatitis or eczema covering at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period warrants a 10 percent disability rating. Dermatitis or eczema covering 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period warrants a 30 percent disability rating. Dermatitis or eczema covering more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period warrants a 60 percent disability rating. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2006). The Board finds that the medical and lay evidence reflects that the Veteran's skin disability warrants increase to 10 percent rating throughout the appeal period. The Board finds no evidence that the level of severity of the Veteran's skin disability significantly changed during the course of his appeal. The January 2004 report of VA skin examination reflects that the Veteran had a history of intermittent breaking out of a red rash, which was at times itchy about his face, head, and body. There was no etiology for the rash; it did not appear to come with heat or exercise, and no diagnosis had ever been found. At the time of the examination, there were no lesions present to gauge the percentage of the body affected or type of lesion present. The examiner stated that, because of a lack of lesions present, the diagnosis was not able to be verified beyond a non-specific dermatitis. The April 2012 report of VA skin examination reflects that the relevant diagnosis was stasis dermatitis. The examiner indicated that the dermatitis affected at least 5 percent but less than 20 percent of the Veteran's total body area. In light of the Veteran's consistent reports of skin disability and the most recent examination (April 2012) documenting that the dermatitis affected at least 5 percent but less than 20 percent of the Veteran's total body area, the Board finds that the Veteran's skin disability most nearly dermatitis or eczema covering at least 5 percent, but less than 20 percent of the entire body. In light of the lay evidence, we are not convinced that the appellant became worse on the day of an adequate VA examination. Therefore, his skin disability warrants a 10 percent rating throughout the appeal period. In this regard, the Veteran's claim is granted. As dermatitis or eczema covering 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, during the past 12-month period has not been demonstrated a higher rating is not warranted at any time. For all the foregoing reasons, the Board finds that 10 percent, but no higher, ratings for eczema with history of tinea and neurodermatitis is warranted throughout the appeal period, but that ratings in excess of 10 percent is not warranted at any time pertinent to this appeal. The Board has applied the benefit-of-the-doubt doctrine in determining that the criteria 20 30 percent ratings are met, but finds that the preponderance of the evidence is against assignment of higher ratings. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56(1990). Extra-schedular The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point have the disabilities been shown to be so exceptional or unusual as to warrant the assignment of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms and effects of the Veteran's lumbar spine varicose veins and skin disabilities are fully contemplated by the applicable rating criteria. The Board's analysis above reflects that the symptoms, effects, and overall disability picture from the Veteran's lumbar spine, varicose veins and skin disabilities is contemplated by the assigned ratings as noted herein, which take account of both the individual symptoms and the overall impairment caused by the lumbar spine, varicose veins and skin disabilities. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the above evidence reflects that the effects of the lumbar spine, varicose veins and skin disabilities on the Veteran's employment did not constitute marked interference with employment, i.e., beyond that contemplated by the assigned noncompensable rating. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability"). Moreover, there is no evidence of frequent hospitalization, or indication that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of an extraschedular rating for lumbar spine, varicose veins and skin disabilities is not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to service connection for hypertension is denied. Entitlement to a rating in excess of 20 for lumbosacral strain with facet syndrome, for the periods from November 20, 2002 to January 10, 2005; September 1, 2005 to September 19, 2006; and, January 1, 2007 to April 22, 2008 is denied. Entitlement to a rating in excess of 40 for lumbosacral strain with facet syndrome, for the period from April 23, 2008 is denied. A 20 percent rating is granted for varicosities and post-phlebitic syndrome of the right leg with edema and stasis dermatitis for the period prior to April 17, 2012, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the right leg with edema and stasis dermatitis from April 17, 2012 is denied. A 20 percent rating is granted for varicosities and post-phlebitic syndrome of the left leg with edema and stasis dermatitis for the period prior to April 17, 2012, subject to controlling regulations governing the payment of monetary awards. A rating in excess of 20 percent for varicosities and post-phlebitic syndrome of the left leg with edema and stasis dermatitis from April 17, 2012 is denied. A 10 percent rating is granted for eczema with history of tinea and neurodermatitis, subject to controlling regulations governing the payment of monetary awards. REMAND In this case, the Veteran contends that his currently diagnosed GERD and hiatal hernia developed as a result of service; he indicates that hiatal hernia was documented during service. The veteran also indicates that, as a result of his military specialty as an aircraft maintenance technician, he developed hearing loss during service. Further, he maintains that he has developed a pulmonary condition as a result of his service-connected chronic sinusitis. He also states that he has also developed arthritis in the right hip secondary to his right knee and other orthopedic disorders. Finally, he notes that the impingement syndrome and tendonitis in his right shoulder is related to the fracture of the right clavicle. With regard to the Veteran's claim for entitlement to service connection for GERD and hiatal hernia, pursuant to the April 2007 Board remand, the Veteran underwent VA examination to evaluate the etiology of the claimed disorder. In the November 2008 report of VA examination, the examiner concluded that "the current GERD and hiatal hernia is less likely as not (less than 50/50 probability) caused by or had its onset during the Veteran's period of military service." The examiner rationalized that the Veteran never had symptoms of heartburn or reflux during his military service. Rather, he complained of abdominal pain and constipation which were not the typical symptoms from heartburn or reflux. The examiner noted that the Veteran had several visits to the medical clinic for abdominal pain associated with diarrhea and "the only time there was mention of dysphagia, which might be related to reflux was when he was being seen at the VA facility in Las Vegas." The examiner noted that the Veteran did have evidence of hiatal hernia based on upper GI x-rays performed in 1977; however another upper GI x-ray performed in 1984 showed normal findings. The examiner goes on to state that nowhere in the service medical records was there evidence the Veteran complained of heartburn or reflux symptoms. The Veteran saw a GI specialist in 2006 for symptoms of dysphagia; he was already taking a PPI. In this case, the opinion and supporting rationale are confusing as to etiology of the GERD and hiatal hernia. Thus, clarification is needed. Once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Under these circumstances, the Board finds additional VA examination is necessary to address whether the claimed hiatal hernia and GERD onset due to disease or injury incurred in service. With regard to the Veteran's claim for entitlement to service connection for hearing loss, pursuant to the April 2007 Board remand, the Veteran underwent VA examination to evaluate the etiology of the claimed disorder. In the report of November 2008 VA audio examination, the Examiner concluded that she could not opine as to whether the Veteran's hearing loss was due to acoustic trauma sustained in service without resort to mere speculation due to the possible middle ear pathology in the left ear. In Jones v. Shinseki, 23 Vet. App. 382 (2009), the Court held that, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Id. at 390. It must also be clear that the physician has considered "all procurable and assembled data." Id (citing Daves v. Nicholson, 21 Vet. App. 46 (2006)). Finally, the physician must clearly identify precisely what facts cannot be determined. Id. In this case, the VA examiner in November 2008 offered no rationale or supporting explanation for her statement. Additionally, the Veteran asserts that he developed pulmonary, right hip and right shoulder disabilities secondary to service-connected disabilities. The Board notes that under 38 C.F.R. § 3.310(a) (2012), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006) (see 38 C.F.R. § 3.310(b)). In this case, the Board finds that the evidence of record fails to address the Veteran's contention of secondary service connection, i.e., whether his claimed right hip disorder was caused or aggravated by the now service-connected right knee disability ; or whether his claimed right shoulder impingement syndrome and tendonitis was cause or aggravated by the right clavicle disability. Once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Under these circumstances, the Board finds additional VA examination is necessary to address whether the claimed right hip disorder, was caused or aggravated by his service-connected right knee disorder or whether his right shoulder impingement syndrome was caused or aggravated by his service-connected right clavicle disability. The Board is aware that the November 2008 report of VA pulmonary examination seems to indicate that the Veteran does not have a current disability for which he seeks service connection. Further, the examiner concludes that Veteran's respiratory symptomatology is less likely as not caused by or a result of service-connected chronic sinusitis. However, the examiner then states that the Veteran's respiratory symptomatology is at least as likely as not related to service or to service-connected chronic sinusitis. Thus, the opinion is confusing as to existence or etiology of the claimed pulmonary disorder and clarification is needed. Once VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Under these circumstances, the Board finds additional VA examination is necessary to address whether the Veteran has a current pulmonary disorder that was caused or aggravated by his service-connected chronic sinusitis. Finally, regarding the claim for service connection for a left upper extremity disorder, the Board notes that the United States Court of Appeals for Veterans Claims (Court) has determined that a remand by the Board confers upon a claimant, as a matter of law, the right to compliance with remand orders. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). In the April 2007 remand, the Board requested that the RO schedule the Veteran for a VA examination to address the etiology of his claimed disabilities. Despite being offered examination on the other claimed disabilities, the Veteran was not afforded a VA examination that addressed his claimed left upper extremity disorder. Thus, further remand is required to correct this deficiency. See Stegall supra. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to evaluate his complaints of a left upper extremity disorder. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current left upper extremity disorder is due to disease or injury sustained in service. The examination report must include complete rationale for all opinions and conclusions reached. 2. Schedule the Veteran for a VA examination to evaluate his complaints of hiatal hernia and GERD. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current hiatal hernia or GERD is due to disease or injury sustained in service. The examination report must include complete rationale for all opinions and conclusions reached. 3. Schedule the Veteran for a VA examination to evaluate his complaints of hearing loss. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current hearing loss is due to acoustic trauma sustained in service. The examination report must include complete rationale for all opinions and conclusions reached. If an opinion cannot be provided without resorting to speculation, the examiner then must provide an appropriate explanation for that conclusion (i.e., the examiner must clearly identify precisely what facts cannot be determined). 4. Schedule the Veteran for a VA examination to evaluate his complaints of right hip disorder. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current right hip disorder is related to service. In addition, the examiner should determine whether it is at least as likely as not the service-connected chronic right knee disability caused or aggravated the Veteran's right hip disorder? If aggravation of the right hip disorder by the service-connected right knee disability is shown, the examiner should objectively quantify the degree of aggravation above and beyond the level of impairment had no aggravation occurred. The examination report must include complete rationale for all opinions and conclusions reached. 5. Schedule the Veteran for a VA examination to evaluate his complaints of right shoulder impingement syndrome and tendonitis. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current right shoulder impingement syndrome and tendonitis is related to service. In addition, the examiner should determine whether it is at least as likely as not the service-connected chronic right clavicle disability caused or aggravated the Veteran's right shoulder impingement syndrome and tendonitis disorder? If aggravation of the right shoulder impingement syndrome and tendonitis by the service-connected right clavicle disability is shown, the examiner should objectively quantify the degree of aggravation above and beyond the level of impairment had no aggravation occurred. The examination report must include complete rationale for all opinions and conclusions reached. 6. Schedule the Veteran for a VA examination to evaluate his complaints of a pulmonary disorder. The claims file should be made available to the examiner for review prior to examination. All indicated tests and studies should be performed and clinical findings should be reported in detail. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After a thorough review of the evidence, the examiner should provide an opinion with supporting rationale as to whether it is at least as likely as not (50 percent probability or better) any current pulmonary disorder is related to service. In addition, the examiner should determine whether it is at least as likely as not the service-connected chronic sinusitis caused or aggravated the Veteran's pulmonary disorder? If aggravation of the pulmonary disorder by the service-connected chronic sinusitis is shown, the examiner should objectively quantify the degree of aggravation above and beyond the level of impairment had no aggravation occurred. The examination report must include complete rationale for all opinions and conclusions reached. 7. After completing all indicated development, the claims remaining on appeal should be readjudicated in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, as indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs