Citation Nr: 1611908 Decision Date: 03/24/16 Archive Date: 03/29/16 DOCKET NO. 12-17 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a bilateral leg disorder. 2. Entitlement to service connection for a bilateral hand disorder. 3. Entitlement to service connection for left lower extremity radiculopathy, to include sciatica. 4. Entitlement to service connection for migraines. 5. Entitlement to service connection for frequent urination. 6. Entitlement to an initial rating in excess of 20 percent for thoracolumbar spine status post discectomy with residual intervertebral disc syndrome (IVDS) and degenerative arthritis (low back disability). 7. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy. 8. Entitlement to an initial rating in excess of 10 percent for right elbow bursitis. 9. Entitlement to an initial rating in excess of 10 percent for right hip strain with limitation of extension. 10. Entitlement to an initial compensable rating for right hip strain with limitation of flexion. 11. Entitlement to an initial rating in excess of 10 percent for right hip strain with limitation of adduction. 12. Entitlement to an initial rating in excess of 10 percent for left hip strain with limitation of extension. 13. Entitlement to an initial compensable rating for left hip strain with limitation of flexion. 14. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral syndrome. 15. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome. 16. Entitlement to an initial rating in excess of 20 percent for left foot plantar fasciitis. 17. Entitlement to an initial compensable rating for bilateral hearing loss. 18. Entitlement to an initial rating in excess of 10 percent for tinnitus. 19. Entitlement to an initial compensable rating for hypertension. 20. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD). 21. Entitlement to an initial rating in excess of 10 percent for status post kidney stones with history of hematuria. 22. Entitlement to an initial compensable rating for umbilical hernia. 23. Entitlement to an initial compensable rating for erectile dysfunction. 24. Entitlement to an initial compensable rating for left testicle vasocongestion. 25. Entitlement to an initial rating in excess of 10 percent for status post head concussion. 26. Entitlement to an initial compensable rating for a head scar status post head concussion. 27. Entitlement to an initial compensable rating for a lumbar scar status post discectomy. 28. Entitlement to an initial compensable rating for an umbilicus scar status post hernia repair surgery. 29. Entitlement to a higher (increased) level of special monthly compensation (SMC). REPRESENTATION Veteran represented by: Ashley B. Thomas, Attorney ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from October 1985 to August 2010, which included service in Southwest Asia during the Persian Gulf War. This case comes before the Board of Veterans' Appeals (Board) on appeal from October 2010 and June 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The RO in St. Petersburg, Florida, certified the case to the Board. In April 2015, the Veteran withdrew his request for a hearing before the Board. In a June 2013 rating decision, the RO granted separate ratings for right and left hip strains, 10 percent ratings for right and left knee disabilities, a separate rating for a head scar status post head concussion, and a 10 percent rating for status post head concussion. However, because the Veteran is presumed to seek the maximum available benefits, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA paperless claims processing systems. Any future consideration of this Veteran's case must take into consideration the existence of these electronic records. The Board also notes that additional evidence has been received since the last adjudication of the claims by the Agency of Original Jurisdiction (AOJ). In February 2016, the Veteran submitted additional evidence along with a waiver of AOJ review; however, other evidence has been received without a waiver. See, e.g., Social Security Administration (SSA) records, private and VA treatment records received in January 2015, March 2015 VA examinations. Regarding the claims decided herein, the additional evidence is cumulative of evidence already on file at the time of the June 2013 supplemental statement of the case (SSOC) and March 2015 statement of the case (SOC). Therefore, a waiver of AOJ review is not required for these claims. Regarding the claims being remanded, there is no prejudice to the Veteran, as the AOJ will have an opportunity to review this evidence on remand. See 38 C.F.R. § 20.1304(c) (2015). The issues of entitlement to increased ratings for right and left hip disabilities, tinnitus, GERD, kidney stones, an umbilical hernia, and erectile dysfunction, are decided below. The remaining issues are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's right hip strain has not been manifested by flexion limited to less than 45 degrees or abduction lost beyond 10 degrees. 2. The Veteran's left hip strain has not been manifested by flexion limited to less than 45 degrees. 3. The Veteran's tinnitus has been assigned a 10 percent evaluation throughout the appeal period, which is the maximum rating authorized for tinnitus under Diagnostic Code 6260, for either a unilateral or bilateral condition. The rating criteria reasonably describe the Veteran's disability level and symptomatology. 4. The Veteran's GERD is not productive of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 5. The Veteran's status post kidney stones with hematuria has not manifested in frequent attacks of colic requiring catheter drainage, renal dysfunction, or severe hydronephrosis; and no required drug therapy, diet therapy, or invasive or non-invasive procedures more than twice a year. 6. The Veteran does not have any residuals of an umbilical hernia except for a scar, which is separately evaluated. 7. The Veteran's erectile dysfunction is manifested by loss of erectile power for which he receives SMC; however, there is no associated penile deformity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right hip strain with limitation of extension are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251 (2015). 2. The criteria for an initial rating in excess of 10 percent for right hip strain with limitation of flexion are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5252 (2015). 3. The criteria for an initial rating in excess of 10 percent for right hip strain with limitation of adduction are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5253 (2015). 4. The criteria for an initial rating in excess of 10 percent for left hip strain with limitation of extension are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251 (2015). 5. The criteria for an initial rating in excess of 10 percent for left hip strain with limitation of flexion are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5252 (2015). 6. There is no legal basis for the assignment of a schedular evaluation in excess of 10 percent for bilateral tinnitus, and a referral for extraschedular consideration is not warranted. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.87, Diagnostic Code 6260 (2015); Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). 7. The criteria for an initial rating in excess of 10 percent for GERD are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7399-7346 (2015). 8. The criteria for an initial rating in excess of 10 percent for status post kidney stones with hematuria are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.115b, Diagnostic Code 7508 (2015). 9. The criteria for an initial compensable rating for umbilical hernia are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7399-7338 (2015). 10. The criteria for an initial compensable rating for erectile dysfunction are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 3.102, 3.159, 3.321, 4.1-4.14, 4.115b, Diagnostic Code 7599-7522 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for his right and left hip disabilities, tinnitus, GERD, kidney stones, umbilical hernia, and erectile dysfunction. In Dingess, the Court held that, in cases 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 section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to these issues. The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, available, and relevant post-service medical records, including VA examination reports, have been associated with the claims file and were reviewed by both the RO and the Board in connection with the claims. The Veteran has not identified any other outstanding records that are pertinent to the issues herein decided. In addition, the Veteran was afforded VA examinations in May 2010 and January 2013. The May 2010 VA examiner did not indicate whether she had reviewed the Veteran's claims file. The January 2013 VA examiner indicated that she reviewed the Veteran's VA treatment records, but not the claims file. Both examiners provided findings necessary to evaluate his service-connected disabilities. To the extent the Veteran's service treatment records were not available to the examiners, the Board does not find any prejudice to the Veteran. Both examiners considered the Veteran's reported medical history, which was consistent with the underlying records. To the extent any VA or private treatment records were not available to the examiners, the Board notes that these records do not provide any relevant findings regarding the claims herein decided. They simply note that the Veteran has or has had these conditions and do not address the manifestations and severity. Therefore, the Board finds that there is no prejudice to the Veteran in proceeding with appellate review of these claims. In addition, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's right and left hip strains, tinnitus, GERD, kidney stones, umbilical hernia, and erectile dysfunction since he was last examined. 38 C.F.R. § 3.327(a) (2015). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues herein decided has been met. 38 C.F.R. § 3.159(c)(4) (2015). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. Where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. 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). However, as in this case, where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). I. Right and Left Hip Strains The Veteran's service-connected right and left hip strains have been evaluated based on limitation of motion under 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252, and 5253. Under Diagnostic Code 5251, a maximum 10 percent disability evaluation is warranted where there is limitation of extension of the thigh to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Under Diagnostic Code 5252, a 10 percent disability evaluation is assigned for flexion of the thigh limited to 45 degrees. For the next higher evaluation, a 20 percent rating, there must be limitation of flexion to 30 degrees. Limitation of thigh flexion to 20 and 10 degrees warrants 30 and 40 percent ratings, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Under Diagnostic Code 5253, a 10 percent disability evaluation is assigned for limitation of thigh rotation, with an inability to toe-out in excess of 15 degrees or where there is limitation of adduction such that one cannot cross legs. A 20 percent disability evaluation is warranted for limitation of thigh abduction, where motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Normal ranges of motion of the hip are from hip flexion from zero degrees to 125 degrees, and hip abduction from zero degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case, for the Veteran's right hip, separate 10 percent ratings have been assigned for limitation of extension, limitation of flexion, and limitation of adduction. The Board finds that schedular ratings in excess of 10 percent are not warranted. Under Diagnostic Code 5251, a 10 percent rating is the maximum evaluation for limitation of extension of the hip. Consequently, a schedular rating in excess of 10 percent is not available. Under Diagnostic Code 5252, a rating in excess of 10 percent is not warranted because right hip flexion has not been limited to less than 45 degrees at any time during the appeal period. During the May 2010 VA examination, the Veteran had a full range of flexion from 0 to 125 degrees with pain at the endpoint. During the January 2013 VA examination, flexion of the right hip was limited to 100 degrees with pain at the endpoint. The May 2010 VA examiner also indicated that there were no additional functional limitations after repetitive use. The January 2013 VA examiner did note that, after repetitive testing the Veteran had less movement than normal and pain on movement; however, limitation of flexion was still only limited to 100 degrees. Therefore, even when considering any additional functional limitation due to repetitive use and flare-up, the Veteran's right hip flexion has more nearly approximated the criteria for a 10 percent rating rather than a 20 percent rating under Diagnostic Code 5252. Under Diagnostic Code 5253, a rating in excess of 10 percent is not warranted because the Veteran's right hip has not demonstrated limitation of abduction with motion lost beyond 10 degrees. During the May 2010 VA examination, he had full range of abduction to 45 degrees with pain at the endpoint. In addition, the January 2013 VA examiner indicated that abduction was not lost beyond 10 degrees. As noted above, the May 2010 VA examiner indicated that there were no additional functional limitations after repetitive testing. The January 2013 VA examiner indicated that there was less movement than normal and pain on movement after repetitive testing; however, abduction was still not lost beyond 10 degrees. Therefore, even when considering any additional functional limitation due to repetitive use and flare-up, the Veteran's right hip disability has more nearly approximated the criteria for a 10 percent rating under Diagnostic Code 5253. For the left hip, separate 10 percent ratings have been assigned for limitation of extension and limitation of flexion. The Board finds that schedular ratings in excess of 10 percent are not warranted for the left hip. As noted above, under Diagnostic Code 5251, a 10 percent rating is the maximum evaluation for limitation of extension of the hip. Thus, a schedular rating in excess of 10 percent is not available. Under Diagnostic Code 5252, a rating in excess of 10 percent is not warranted because left hip flexion has not been limited to less than 45 degrees at any time during the appeal period. During the May 2010 VA examination, the Veteran had full range of flexion from 0 to 125 degrees with pain at the endpoint. During the January 2013 VA examination, flexion of the left hip was limited to 120 degrees with no objective evidence of painful motion. The May 2010 VA examiner indicated that there was no additional limitation of function after repetitive use. The January 2013 VA examiner indicated that after repetitive testing the Veteran had pain on movement; however, limitation of flexion was still only limited to 120 degrees. Therefore, even when considering any additional functional limitation due to repetitive use and flare-up, the Veteran's left hip flexion has more nearly approximated the criteria for a 10 percent rating rather than a 20 percent rating under Diagnostic Code 5252. The Board also finds that a separate rating for the left hip is not warranted under Diagnostic Code 5253. Throughout the appeal period, the Veteran has not had limitation of rotation with the inability to toe-out more than 15 degrees, limitation of adduction with the inability to cross the legs, or limitation of abduction with motion lost beyond 10 degrees. See, e.g., May 2010 and January 2013 VA examinations. The Board has also considered other potentially applicable diagnostic codes pertaining to the hip. However, the Veteran does not have, nor does his disability picture more nearly approximate ankylosis, flail joint, or impairment of the femur (Diagnostic Codes 5250, 5254, and 5255). Therefore, these diagnostic codes are inapplicable in this case. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). The Board has also considered the Veteran's lay statements. He has reported experiencing hip pain, stiffness, and lack of endurance. During the May 2010 VA examination, he indicated that he had flare-ups as often as once day that lasted for four hours. He said that, during flare-ups, it was difficult for him to stand and walk for long periods of time or for long distances. During the January 2013 VA examination, he reported having mild pain on a continuous basis. The Veteran is competent to report observable symptoms. The Board also finds his statements credible and consistent with the ratings assigned. Ultimately, however, in determining the appropriate ratings in this case, the specific findings and test results obtained by trained medical professionals are more probative than the Veteran's more general lay statements. For these reasons, the Board finds that increased ratings for the Veteran's right and left hip strains are not warranted. II. Tinnitus The Veteran's tinnitus is currently assigned a 10 percent evaluation pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6260 (recurrent tinnitus). Tinnitus is defined as "a noise in the ears such as ringing, buzzing, roaring, or clicking." Smith v. Principi, 17 Vet. App. 168, 170 (2003) (quoting Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994)). The Court has specifically held that tinnitus is a type of disorder capable of lay observation and description. Charles v. Principi, 16 Vet. App. 370, 374 (2002). Tinnitus is evaluated under Diagnostic Code 6260, which was revised effective June 13, 2003, to clarify existing VA practice that only a single 10 percent evaluation is assigned for "recurrent" tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2013). Note (1) to Diagnostic Code 6260 provides that a separate rating for tinnitus may be combined with a rating under Diagnostic Codes 6100, 6200, 6204, or other diagnostic code, except when tinnitus supports a rating under one of those Diagnostic Codes. Note (3) also provides that objective tinnitus (in which the sound is audible to other people and has a definable cause that may or may not be pathologic) should not be rated under Diagnostic Code 6260, but should be rated as part of any underlying condition causing the tinnitus. 38 C.F.R. § 4.87 (2015). In Smith v. Nicholson, 19 Vet. App. 63, 78 (2005), the Court held that the pre-1999 and pre-June 13, 2003, versions of Diagnostic Code 6260 required the assignment of dual ratings for bilateral tinnitus. VA appealed this decision to the Federal Circuit and stayed the adjudication of tinnitus rating cases affected by the Smith decision. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the Federal Circuit concluded that the Court erred in not deferring to the VA's interpretation of its own regulations, 38 C.F.R. § 4.25 and Diagnostic Code 6260, which limits a veteran to a single 10 percent maximum rating for tinnitus, regardless whether the tinnitus is unilateral or bilateral. Subsequently, the stay of adjudication of tinnitus rating cases was lifted. Thus, the Veteran's service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus of 10 percent under 38 C.F.R. §4.87, Diagnostic Code 6260. As there is no legal basis upon which to award separate schedular evaluations for tinnitus in each ear, the Veteran's appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). There is also no basis to "stage" the Veteran's 10 percent rating for his tinnitus, as his symptoms have remained consistent throughout the entire appeal period, and he has been in receipt of the maximum 10 percent during the entire time period. III. GERD The Veteran's GERD has been evaluated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. Unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Hence, GERD has been rated by analogy, using the criteria for hiatal hernia under Diagnostic Code 7346. Under Diagnostic Code 7346, a 10 percent evaluation is warranted for hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. During the May 2010 VA examination, the Veteran reported that he had difficulty swallowing, pain behind his breastbone when eating two times per week, and heartburn/reflux often at night two times per week. It was also noted that he had epigastric pain, scapula pain, reflux and regurgitation of stomach contents, nausea, and vomiting. The examiner indicated that the condition did not his affect body weight and that he did not experience arm pain, hematemesis, or black-tarry stools. He was not receiving any treatment for GERD and was never hospitalized for the condition. He indicated that he did not experience any overall functional impairment from the condition. On physical examination, an upper gastrointestinal series was within normal limits. The esophagus demonstrated normal distensibility, motility, and mucosal pattern. There was no reflux observed during the study despite provocative maneuvers. The examiner indicated that there was no pathology to render a diagnosis and that the Veteran's hiatal hernia/GERD did not cause significant anemia and that there were no findings of malnutrition. The January 2013 VA examiner noted that the Veteran had a diagnosis of GERD in 2008. The Veteran reported that he experienced pyrosis (heartburn), reflux, regurgitation, and sleep disturbance caused by esophageal reflux. He indicated that his symptoms occurred four or more times per year and lasted less than one day. He said he used Omeprazole for his symptoms. The Veteran did not experience anemia, weight loss, nausea, vomiting, hematemesis, or melena. The examiner indicated that the Veteran had intermittent symptoms throughout the day and night and had problems with loss of sleep during the night, which impacted his ability to work. The Veteran's VA and private treatment records note GERD on the Veteran's active problem list and/or on his past medical history, but contain no additional relevant findings. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for GERD. While the Veteran certainly has symptoms of GERD, the evidence does not show that these symptoms are accompanied by substernal or arm or shoulder pain, or are productive of considerable impairment of health. In fact, during the May 2010 VA examination, the Veteran indicated that he did not have any overall functional impairment resulting from his GERD symptoms, and an upper gastrointestinal series showed no abnormalities. The January 2013 VA examiner also indicated that his symptoms were mild and intermittent with no resulting weight loss, anemia, or malnutrition. Thus, considering the lay and medical evidence, the Board finds that the Veteran's overall physical condition has not been considerably impaired due to GERD. For these reasons, the Board does not find that an initial rating in excess of 10 percent is warranted for GERD. IV.. Kidney Stones The Veteran's status post kidney stones with hematuria has been evaluated as 10 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Code 7508. Under Diagnostic Code 7508 nephrolithiasis (calculi in the kidneys) is rated as hydronephrosis, except where there is recurrent stone formation requiring one or more of the following: (1) diet therapy; (2) drug therapy; or (3) invasive or non-invasive procedures more than two times per year. If evaluated under this code, the rating assigned will be 30 percent. 38 C.F.R. § 4.115b, Diagnostic Code 7508. Under Diagnostic Code 7509, hydronephrosis warrants a 10 percent rating where there is only an occasional attack of colic, not infected and not requiring catheter drainage. A 20 percent rating is warranted for frequent attacks of colic, requiring catheter drainage. A 30 percent rating is warranted for frequent attacks of colic with infection (pyonephrosis), kidney function impaired. Severe hydronephrosis is to be rated as renal dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7509; see also 38 C.F.R. § 4.115a (setting forth the criteria for rating renal dysfunction from 0 to 100 percent). During the May 2010 VA examination, the Veteran reported that he had had kidney stones since 1994 and that he passed one to three stones per year. It was noted that he had renal colic and bladder stones with pain, but no recurrent urinary tract infections. He did not require any procedures for his genitourinary problem and had not been hospitalized during the prior 12-month period. He reported that he did not experience any overall functional impairment from the condition. The urinalysis was normal with no protein, sugar, RBC, hyaline casts, or granular casts. The report of the January 2013 VA examination indicates that the Veteran had episodes of kidney stones during his military service with two lithotripsy procedures performed in 2006. The Veteran reported that his last kidney stone was in 2007. He reported that he was diagnosed with hyperparathyroidism and underwent surgery in April 2011. He indicated that he was told there was a direct correlation between his hyperparathyroidism and his kidney stones. The examiner noted that the Veteran was not on medication, did not have any renal dysfunction, had no signs or symptoms due to urolithiasis, and did not have a history of recurrent symptomatic urinary tract or kidney infections. The urinalysis was negative. The examiner indicated that the Veteran's kidney condition did not impact his ability to work. The Veteran's VA and private treatment records note the Veteran's history of kidney stones and hematuria, but do not indicate that he has received ongoing treatment for kidney stones or hematuria. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for status post kidney stones with hematuria. The evidence does not indicate that he has had frequent episodes of colic requiring catheter drainage. During the appeal period, he has not required diet therapy, drug therapy, or invasive or non-invasive procedures more than twice per year. In fact, during the May 2010 VA examination, the Veteran indicated that he did not have any overall functional impairment resulting from this condition, and the January 2013 VA examiner indicated that there was no functional impact on his ability to work. For these reasons, the Board does not find that an initial rating in excess of 10 percent is warranted for status post kidney stones with hematuria. V. Umbilical Hernia The Veteran's umbilical hernia has been evaluated as noncompensable by analogy using the criteria for an inguinal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7399-7338. Under Diagnostic Code 7338, a noncompensable rating is warranted where the inguinal hernia is small, reducible, or without true hernia protrusion, or where it is not operated, but remediable. A 10 percent rating is warranted where the inguinal hernia is postoperative recurrent, readily reducible and well supported by truss or belt. A 30 percent evaluation is warranted where the hernia is postoperative recurrent, or unoperated irremediable, not well supported by a truss, or not readily reducible. A 60 percent evaluation is warranted for a large, postoperative, recurrent hernia that is not well supported under ordinary conditions and not readily reducible, when considered inoperable. 38 C.F.R. § 4.114. An additional 10 percent is to be added for bilateral involvement, provided the second hernia is compensable. This means that the more severely disabling hernia is to be rated, and 10 percent, only, added for the second hernia, if the second hernia is of compensable degree. 38 C.F.R. § 4.114, Diagnostic Code 7338, Note 1. The report of the May 2010 VA examination indicates that the Veteran underwent hernia repair during his military service in 2001. He complained of some occasional pain at the scar site and said that he did not experience any overall functional impairment from this condition. On physical examination of the abdomen, the Veteran did not have a ventral hernia. There was a scar on the anterior side of the trunk, which is evaluated separately. Other than the scar, the examiner indicated that there were no residuals of the hernia repair. The report of the January 2013 VA examination indicates that the Veteran denied having any residual symptoms of the hernia repair. On physical examination, no ventral hernia was detected. The examiner stated that the Veteran had a healed postoperative ventral hernia repair. The Veteran's VA and private treatment records note that he has a history of hernia repair, but show no ongoing treatment for any residuals. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an increased evaluation for his service-connected umbilical hernia. 38 C.F.R. § 4.7. The lay and medical evidence of record does not reflect a recurrent, readily reducible hernia, well supported by truss or belt; or recurrent hernia, or unoperated irremediable, not well supported by a truss, or not readily reducible; or a large, postoperative, recurrent left inguinal hernia that is not well supported under ordinary conditions and not readily reducible, when considered inoperable. 38 C.F.R. § 4.114, Diagnostic Code 7338. Other than the scar, which is separately rated, the Veteran and the VA examiners have indicated that he does not have any residuals from the hernia repair in 2001. For these reasons, the Board finds that a compensable rating for umbilical hernia is not warranted. VI. Erectile Dysfunction The Veteran's erectile dysfunction has been evaluated as noncompensable by analogy under 38 C.F.R. § 4.115b, Diagnostic Code 7522. Under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. During the May 2010 VA examination, the Veteran reported that he had erectile dysfunction since 2005. He indicated that he could not achieve or maintain an erection and did not receive any treatment for his impotence. He also reported having left testicular pain, which is evaluated separately. On physical examination, his penis was normal without any deformity, masses, or tenderness. During the January 2013 VA examination, the Veteran reported that he began having problems obtaining and maintaining an erection in approximately 2009. He stated that he had not received any treatment or medication for this condition. The examiner indicated that the Veteran was able to achieve an erection sufficient for penetration and ejaculation without medication. On physical examination, his penis was normal. The examiner indicated that the condition did not impact his ability to work. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an increased evaluation for his service-connected erectile dysfunction. 38 C.F.R. § 4.7. The lay and medical evidence of evidence of record indicates that the Veteran has loss of erectile power, but does not indicate that he has a penile deformity. Therefore, the criteria for a 20 percent rating are not more nearly approximated. Moreover, the Board observes that the Veteran is in receipt of SMC pursuant to 38 U.S.C.A. § 1114(k) based on the loss of use of a creative organ. For these reasons, the Board finds that a compensable rating for erectile dysfunction is not warranted. VII. Other Considerations In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's service-connected disabilities are so exceptional or unusual as to warrant the assignment of higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). Regarding the Veteran's right and left hip strains, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology, which primarily consists of limitation of motion, pain, and functional impairment. As discussed above, there are higher ratings available under the diagnostic criteria, but the Veteran's disabilities are not productive of such manifestations. Indeed, for all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board finds that the schedular criteria reasonably describe the Veteran's disability picture in this case. Regarding tinnitus, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaint of ringing in his ears is contemplated in the rating criteria. Regarding GERD, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaints of heartburn and reflux are contemplated in the rating criteria. The Board notes that the Veteran's complaints of sleep impairment resulting from GERD are not specifically contemplated in the rating criteria; however, the evidence does not indicate that the GERD has resulted in hospitalization or marked interference with employment. Although the Veteran is unemployed and receiving a total disability rating based on individual unemployability (TDIU), the evidence indicates that this is due to his service-connected orthopedic disabilities rather than his service-connected GERD. The Veteran has not alleged nor does the evidence show that he has marked interference with employment due to his service-connected GERD. Regarding the Veteran's kidney stones with hematuria, umbilical hernia, and erectile dysfunction, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. The Board notes that, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms that have not been attributed to a specific service-connected disability. The Veteran and his representative have not identified any symptom resulting from the combined effect of his service-connected disabilities that are not contemplated in the rating criteria for those disorders. Thus, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Based on the foregoing, the Board finds that the requirements for extraschedular evaluations for the Veteran's service-connected disabilities under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial rating in excess of 10 percent for right hip strain with limitation of extension is denied. Entitlement to an initial rating in excess of 10 percent for right hip strain with limitation of flexion is denied. Entitlement to an initial rating in excess of 10 percent for right hip strain with limitation of adduction is denied. Entitlement to an initial rating in excess of 10 percent for left hip strain with limitation of extension is denied. Entitlement to an initial rating in excess of 10 percent for left hip strain with limitation of flexion is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to an initial rating in excess of 10 percent for GERD is denied. Entitlement to an initial rating in excess of 10 percent for status post kidney stones with hematuria is denied. Entitlement to a compensable rating for umbilical hernia is denied. Entitlement to a compensable rating for erectile dysfunction is denied. REMAND For the claims remaining on appeal, the Board finds that a remand is required for additional VA examinations. Service Connection Claims In this case, VA examinations were first conducted in May 2010; however, the VA examiners did not indicate whether they reviewed the Veteran's claims file. Additional VA examinations were conducted in January 2013. Although the VA examiners who conducted the foot examination and audiology examination indicated that they reviewed the claims file, the VA examiners who conducted the remaining examinations indicated that they did not review the claims file and only had access to VA treatment records. Therefore, it is unclear whether the examiners had access to the Veteran's full medical history when rendering their opinions regarding the nature and etiology of his claimed disabilities. In addition, the Board notes that the Persian Gulf War provisions, 38 U.S.C.A. § 1117, 38 C.F.R. § 3.317, are applicable in this case. However, it does not appear that the May 2010 and January 2013 VA examiners considered these provisions when rendering their opinions. Finally, the Board notes that additional evidence has been received since the May 2010 and January 2013 VA examinations, which may be relevant to the Veteran's service connection claims. For these reasons, the Board finds that additional VA examinations are required before a determination can be made on these claims. Increased Rating Claims Regarding the Veteran's claims for increased ratings for his service-connected low back disability and right lower extremity radiculopathy and for service connection for left lower extremity radiculopathy, the Board finds that an additional VA examination is required for clarification purposes and to consider any relevant evidence received since the last VA examination. Specifically, the Board notes that the record is unclear as to whether the Veteran has left lower extremity radiculopathy and that further clarification is needed. Regarding the Veteran's claims for increased ratings for his service-connected right elbow bursitis, right and left knee patellofemoral syndrome, left foot plantar fasciitis, hypertension, left testicle vasocongestion, and status post head concussion, VA and private medical records indicate a possible worsening of these conditions. Therefore, the Board finds that additional VA examinations are needed. Regarding the Veteran's claims for increased ratings for his service-connected head, lumbar, and umbilicus scar, the Board finds that an additional VA examination is required for clarification purposes and to assess the current severity and manifestations of these scars. The January 2013 VA examination reports contain a discrepancy in the findings. The examiner checked "yes" when asked if any of the scars were painful and/or unstable, or totalled more than 39 square centimeters (see, Hernias and Spine Disability Benefits Questionnaires (DBQs)); however, this is inconsistent with other findings contained in the report (see, Scars DBQ). Regarding the claim for an increased level of SMC, this issue is inextricably intertwined with the other issues being remanded. Accordingly, the case is REMANDED for the following actions: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed bilateral leg disorder, bilateral hand disorder, left lower extremity radiculopathy, migraines, and frequent urination, and his service-connected thoracolumbar spine disorder, right lower extremity radiculopathy, right elbow bursitis, right and left hip strains, right and left patellofemoral syndrome, left foot plantar fasciitis, bilateral hearing loss, hypertension, left testicle vasocongestion, and residuals of a head concussion. After acquiring this information and obtaining any necessary authorizations, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding, relevant VA treatment records, including from the Elgin VA Community Based Outpatient Clinic, the Pensacola VA Joint Ambulatory Center, and the Biloxi VA Medical Center. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of his claimed bilateral leg disorder, bilateral hand disorder, migraines, and frequent urination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. A. After examining the Veteran, and considering his pertinent medical history and lay statements regarding his reported symptoms, the examiner should identify all current disorders related to his claimed right and left leg symptoms. In so doing, the examiner should specifically indicate whether the Veteran has a leg disorder other than lumbar spine radiculopathy. For each diagnosis identified, the examiner should opine as to the likelihood (likely, unlikely, at least as likely as not) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service. If any symptomatology cannot be attributed to a known clinical diagnosis, the examiner should describe pertinent objective findings related to such symptomatology. B. After examining the Veteran, and considering his pertinent medical history and lay statements regarding his reported symptoms, the examiner should identify all current disorders related to his claimed bilateral hand symptoms. In so doing, the examiner should address his prior diagnosis of gout. For each diagnosis identified, the examiner should opine as to the likelihood (likely, unlikely, at least as likely as not) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service. If any symptomatology cannot be attributed to a known clinical diagnosis, the examiner should describe pertinent objective findings related to such symptomatology. C. After examining the Veteran, and considering his pertinent medical history and lay statements, the examiner should identify all current disorders related to his complaints of migraines. In so doing, the examiner should address his prior diagnosis of ocular migraines. For each diagnosis identified, the examiner should opine as to the likelihood (likely, unlikely, at least as likely as not) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service. If any symptomatology cannot be attributed to a known clinical diagnosis, the examiner should describe pertinent objective findings related to such symptomatology. D. After examining the Veteran, and considering his pertinent medical history and lay statements, the examiner should identify all current disorders related to his complaints of frequent urination. For each diagnosis identified, the examiner should opine as to the likelihood (likely, unlikely, at least as likely as not) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service. If any symptomatology cannot be attributed to a known clinical diagnosis, the examiner should describe pertinent objective findings related to such symptomatology. If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether it is at least as likely as not that there are symptoms due to any undiagnosed illness, or a medically unexplained chronic multi-symptoms illness resulting service in Southwest Asia during the Gulf War. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected low back disability and right lower extremity radiculopathy and to determine whether he has left lower extremity radiculopathy. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's low back disability under the rating criteria. In particular, the examiner should provide the range of motion of the thoracolumbar spine in degrees and state whether there is any form of ankylosis. The examiner should also state the total duration of incapacitating episodes over the past 12 months. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). In addition, the examiner should identify and describe all neurological manifestations of the service-connected spine disability, to include any radiculopathy affecting his lower extremities. Regarding left lower extremity radiculopathy, the examiner should specifically address the March 2015 VA examiner's findings of mild paresthesias and/or dysesthesias, the July 2013 magnetic resonance imaging (MRI) showing disc protrusions possibly affecting the L4 and L5 left nerve roots, and an August 2013 private medical record noting the Veteran's complaints of pain radiating into his left lower extremity and a diagnosis of lumbar radiculopathy. 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected right elbow bursitis. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's right elbow bursitis under the rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service- connected right and left knee patellofemoral syndrome. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected right and left knee patellofemoral syndrome. The examiner should report all signs and symptoms necessary for rating the Veteran's right and left patellofemoral syndrome under the rating criteria. In particular, the examiner should provide the range of motion of each knee in degrees and indicate whether there is any ankylosis; dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; or, the symptomatic removal of semilunar cartilage. He or she should also address whether the Veteran has recurrent subluxation or lateral instability, and if so, comment as to whether such symptomatology is slight, moderate, or severe. The examiner should further state whether there is any malunion or nonunion of the tibia and fibula. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors (including any additional loss of motion). 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 6. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected left foot plantar fasciitis. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for evaluating the Veteran's left foot plantar fasciitis under the rating criteria. In particular, the examiner should indicate whether the Veteran's service-connected left foot fasciitis is best characterized as moderate, moderately severe, or severe. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability due to these factors. 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. Copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 7. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his hypertension. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected hypertension. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria. In particular, he or she should indicate the predominant diastolic and systolic pressures and whether the Veteran has had a history of diastolic pressure of 100 mm Hg or more. 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 8. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of left testicle vasocongestion. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected left testicle vasocongestion. He or she should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria. 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 9. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected bilateral hearing loss. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, including the Maryland CNC test and a pure tone audiometry test. The examiner is requested to review all pertinent records associated with the claims file. He or she should discuss the effect of the disability on his occupational functioning and daily activities. 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. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 10. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected residuals of a head concussion. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for rating the Veteran's disability under the rating criteria. The examiner should include evaluation for each of the aspects that are characteristic of a traumatic brain injury (cognitive, emotional/behavioral, and physical). 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 11. The Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected head, lumbar, and umbilical scars. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should report all signs and symptoms necessary for rating the disability under the rating criteria. In particular, the examiner should provide a description of the Veteran's head, lumbar, and umbilical scars, including the sizes and locations. He or she should also indicate whether they are unstable or painful; deep or superficial; and linear or nonlinear. He or she should also indicate whether any of the scars total an area greater than 39 square centimeters, and whether the scars cause any functional loss. 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. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 , copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 12. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 13. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If any benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The SSOC should include a discussion of all relevant evidence considered and citation to all pertinent law and regulations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs