Citation Nr: 1647505 Decision Date: 12/21/16 Archive Date: 12/30/16 DOCKET NO. 14-16 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to an increased initial disability rating for cervical spondylosis with associated early degenerative disc disease, presently rated as 10 percent disabling prior to September 12, 2014, and as 20 percent disabling thereafter. 2. Entitlement to an increased initial disability rating for diffuse disc bulging of the lumbosacral spine (L2-L3 to L5-S1) with mild narrowing, presently rated as 10 percent disabling prior to September 12, 2014, and as 20 percent disabling thereafter. 3. Entitlement to an initial disability rating in excess of 10 percent for left shoulder impingement syndrome. 4. Entitlement to an initial compensable disability rating for spondylotic changes at the right side of the sternum at the junction with the 4th rib, initially claimed as chest nodules. 5. Entitlement to service connection for a psychiatric disability initially claimed as depression/anxiety/sleep issues. 6. Entitlement to service connection for bilateral hand and arm cramps. 7. Entitlement to service connection for a bilateral eye disorder, including blurry vision and crying eyes. 8. Entitlement to service connection for tinea unguium with onychogryphosis, initially claimed as toe nail disorder. 9. Entitlement to service connection for abdominal wall hernia. 10. Entitlement to total disability based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Pryce, Associate Counsel INTRODUCTION The Veteran served honorably in the Army National Guard with periods of active service from October 1982 to March 1983, November 2001 to July 2002, February 2003 to February 2004, and July 2009 to July 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2011 and January 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In June 2016, the RO issued a rating decision which denied service connection for radiculopathy, previously claimed as hand/arm cramps. As the issue of service connection for a disability manifested by hand and arm cramps was already perfected on appeal to the Board, the Board will include that decision as part of the issue on appeal and consider the merits of that decision as well. In April 2016, the Veteran testified before the Board at a hearing held at the RO. A transcript of that hearing has been prepared and is associated with the electronic claims file. The Court of Appeals for Veterans Claims (Court) has held that the issue of entitlement to TDIU is part and parcel of an increased rating claim when it is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran was denied entitlement to TDIU in a February 2014 rating decision. He did not appeal that decision; however, in his April 2016 Board hearing, he testified that he is no longer able to work as he did before. As such, the Board finds that entitlement to TDIU has been raised by the record and is part and parcel of the increased rating claims on appeal. As such, the Board has added it to the issues on the title page. The issues of entitlement to an increased initial disability rating for cervical spondylosis with associated early degenerative disc disease, diffuse disc bulging of the lumbosacral spine (L2-L3 to L5-S1) with mild narrowing, and left shoulder impingement syndrome; and entitlement to service connection for bilateral hand and arm cramps, tinea unguium, and abdominal wall hernia; and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's loss of vision is caused by a refractive error which is a congenital defect. 2. The Veteran's mild allergic conjunctivitis, mild dry eye, and mild posterior blepharitis are not etiologically related to any incident of active service, to include overseas environmental exposure. 3. The Veteran does not have a presently diagnosed psychiatric disability. 4. The Veteran' spondylotic changes of the sternum near the 4th rib have not resulted in the loss of any ribs; have not resulted in loss of range of motion; and do not involve 2 or more major joints or minor joint groups. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral eye disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.159, 4.9 (2015). 2. The criteria for service connection for a psychiatric disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.159. 3. The criteria for a compensable rating for spondylotic changes at the right side of the sternum at the junction with the 4th rib, initially claimed as chest nodules, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.71a, Diagnostic Code (DC) 5003, 4.72, DC 5297 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). Here, the duty to notify was satisfied by way of a letter sent in September 2010. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished and all available evidence pertaining to the matter decided herein has been obtained. The RO has obtained the Veteran's VA treatment records, service treatment records, VA examination reports, various medical and internet articles provided by the Veteran, hearing testimony, and statements from the Veteran and his representative. Neither the Veteran nor his representative has notified VA of any outstanding evidence, and the Board is aware of none. Hence, the Board is satisfied that the duty-to-assist was met. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). II. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A. Bilateral Eye Disorder The Veteran seeks service connection for a bilateral eye condition. The Veteran has a present diagnosis of mild allergic conjunctivitis and mild dry eyes. He also has a diagnoses of refractive error. (See VBMS, VA Examination, 12/10/2010). The Veteran also has a diagnosis of mild posterior blepharitis. (See VBMS, VA Examination, 9/18/2014). He asserts that his eye conditions are the result of environmental exposures during his various periods of deployment in Africa and the Middle East. At the outset, with regard to the Veteran's refractive error, which has been attributed to his loss of vision, the Board finds that service connection cannot be granted. A refractive error, defined to include astigmatism, myopia, hyperopia, and presbyopia, is considered to be a congenital defect. See M21-1, Part III, Subpart iv, 4.B.1.d. Generally, congenital defects are not diseases for VA compensation purposes. 38 C.F.R. § 3.303 (c) (2015); see also 38 C.F.R. § 4.9 (2015); see also, e.g., Winn v. Brown, 8 Vet. App. 510, 516 (1996). In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects or refractive errors of the eyes, even if visual acuity decreased in service, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for either a congenital defect or a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (July 18, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Concerning the diagnosed mild allergic conjunctivitis, mild dry eye, and mild posterior blepharitis, a review of the Veteran's service treatment records has not revealed any complaints of or diagnosed eye disorders, to include any allergies. The Veteran, for his part, asserts that his allergic conjunctivitis and dry eye is the result of environmental exposures during his periods of deployment overseas. In support of this, the Veteran has submitted a document listing possible environmental exposure risks at the location where he was deployed, to include airborne dust, endemic diseases, drinking water, hazardous waste sites, and agricultural emissions. (See VBMS, Medical treatment Record-Government Facility, 2/14/2014). The medical evidence of record shows that on December 2012, the Veteran was afforded a VA examination which diagnosed conjunctivitis, dry eye and refractive error. No etiology was given for those disabilities. (See VBMS, VA Examination, 12/10/2010). In September 2014, the Veteran was afforded a new VA examination in connection with the claim. The diagnoses given previously were confirmed and the Veteran was also diagnosed as having mild posterior blepharitis. The examiner stated that the Veteran's allergic conjunctivitis did not cause a decrease in visual acuity. The examiner also considered the Veteran's history of overseas environmental exposures and opined that the condition was less likely than not incurred in or caused by active service. In support of this opinion, the examiner again confirmed that the Veteran's loss of vision was due to refractive error and his other symptoms were due to conjunctivitis and dry eye. The examiner then noted that the service treatment records are silent for any ocular conditions and that he is no longer exposed to any hazardous environmental pollutants. Allergic conjunctivitis may be seasonal or perennial. Seasonal conjunctivitis is caused by ragweed, pollen, grass, etc., and is worse during spring and fall. Non-seasonal (perennial) conjunctivitis occurs continuously on and off year-round and is related to year-round, usually indoor, allergens such as dust mites, animal dander, molds, etc. Allergic conjunctivitis is part of a systemic atopic reaction to a systemic allergen. The condition tends to recur if exposure to the offending allergen continues. The examiner noted that there was no mention of conjunctivitis or dry eye while in service, and because the Veteran is no longer exposed to any such allergens he experienced in service, which would account for his present symptoms, it is less likely that any environmental hazards experienced in service were the cause of his present symptoms. (See VBMS, VA Examination, 9/18/2014). Regarding the newly diagnosed mild posterior blepharitis, the examiner stated that it was not the result of environmental hazardous air pollutant exposure in service. Specifically, posterior blepharitis is caused by an irregular oil production by the glands of the eyelids, which creased a favorable environment for bacterial growth. It was not previously diagnosed, and had only recently manifested. There was no indication of such a diagnosis in his service treatment records. (See VBMS, VA Examination, 9/18/2014). In light of the above, the Board finds that the Veteran's various eye disabilities, to include allergic conjunctivitis, mild dry eye, and mild posterior blepharitis, should not be service connected. Although the Veteran has confirmed diagnoses of these disabilities, and although he did serve overseas where he may have been exposed to various environmental hazards, the medical evidence of record does not support a medical nexus between the two. In reaching this conclusion, the Board acknowledges the Veteran's argument that his various eye disabilities have been caused by his overseas service; however, although lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this case, the Veteran is not a medical professional with expertise to provide such an etiology opinion. As such, the Board finds the September 2014 medical opinion the be more persuasive. In conclusion, after a careful review of the entire record, because the weight of the evidence is against a finding of a nexus between the Veteran's in-service environmental exposures and the current eye disabilities, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a bilateral eye disability. The Board does recognize that certain chronic diseases may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. In this case, the Veteran's mild allergic conjunctivitis and mild dry eye were initially diagnosed in December 2010, roughly five months after separation from service. Neither of those diagnosed eye disabilities, however, is listed as chronic diseases eligible for presumptive service connection in the Code of Federal Regulations. As such, presumptive service connection is not appropriate in this matter. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet App. 49 (1990); 38 C.F.R. § 3.102 (2015). B. Psychiatric Disability The Veteran seeks service connection for a psychiatric disability, which he has claimed is manifested by depression, anxiety and sleep difficulties. The Board finds that service connection should not be granted. As discussed above, in order for service connection to be granted, the first criterion that must be met is a presently diagnosed disability. In December 2011, the Veteran was afforded a VA examination in connection with his claim. At that time, the examiner declined to give a diagnosis of a psychiatric disability or disorder. Specifically, the examiner stated that the Veteran "complains of normal, mild, stress related symptoms which occurred upon his return from deployment in Africa, but which have been resolved. As present, he had not mental disorder affecting his social and/or occupational functioning." (See VBMS, VA Examination, 12/1/2011). In October 2015, the Veteran was again afforded a VA examination, at which time the examiner again declined to provide a diagnosis of a psychiatric disability. Specifically, the examiner stated that the Veteran described instances where he experienced variable symptoms, mostly of anxiety and some depression, but they were not considered diagnostic of any specific mental disorder, as they had not occurred in continuous fashion, nor had he felt the need to seek treatment for any disability. The examiner also noted that his reported sleep difficulties were the result of difficulties with his CPAP machine on account of his service-connected sleep apnea. (See VBMS, C&P Examination, 10/15/2015). Apart from his lay statements and testimony, the Veteran has not provided any evidence of a diagnosed psychiatric disability which would refute the non-diagnosis provided in both VA examination reports. Therefore, because the Veteran does not have a presently diagnosed psychiatric disability, the Board must deny the claim. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. III. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's spondylotic changes at the right side of the sternum at the junction with the fourth rib, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7 (2015). The Veteran is presently service connected for spondylotic changes at the right side of the sternum at the junction with the fourth rib. He seeks a compensable rating for that disability. The Diagnostic Code does not specifically address the disability which has been service connected. When a disability is not listed in the rating schedule, it may be rated by analogy to a closely related disease or injury in which not only the functions affected, but also the anatomical area and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2015). The strict application of criteria in an analogous Diagnostic Code is not generally appropriate because analogous ratings under 38 C.F.R. § 4.20 requires only "closely analogous"-and not identical-functional impairment, anatomic localization, and symptoms between an unlisted and a listed disability. See Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006) (faulting the Board's strict application of Diagnostic Code criteria to a condition being rated by analogy). Spondylosis is defined as "degenerative spinal changes due to osteoarthritis." See Dorland's Illustrated Medical Dictionary, 1754 (32nd Ed., 2012). Under Diagnostic Code 5003, which addresses degenerative arthritis such as hypertrophic arthritis or osteoarthritis, the disability is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. Only when the limitation of motion for the joint or joints involved is noncompensable, is a rating of 10 percent assigned for any major joint, or group of joints. Limitation of motion must be objectively confirmed. In the absence of limitation of motion, a 10 percent rating is assigned with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating episodes. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2015). The only Diagnostic Code which addresses the ribs or the joint between the ribs and sternum is Diagnostic Code 5297, which accounts for removal of the ribs. Under that Diagnostic Code, a 10 percent rating is assigned for one or resection of two or more ribs without regeneration. A 20 percent rating is assigned for the removal of two ribs. A 30 percent rating is assigned for the removal of three or four ribs. A 40 percent rating is assigned for the removal of five or six ribs. And a 50 percent rating is assigned for the removal of more than six ribs. 38 C.F.R. § 4.72, Diagnostic Code 5297 (2015). The evidence of record indicates that in December 2010, the Veteran was diagnosed as having spondylotic changes at the right side of the sternum at the junction with the 4th rib. A clinical history of palpable abnormalities related to the sternum was provided, specifically, a history of a nodule in the chest area. There was no acute fracture or dislocation of the sternum. No abnormal bone erosions were noted. The disability did not affect the Veteran's usual daily activities. (See VBMS, VA Examination, 12/15/2010). A November 18, 2010 chest CT, contained in the Veteran's VA medical records shows the same findings. (See VVA, CAPRI, 1/10/2012, p. 7). Although they document a history of spondylotic changes at the sternum, a review of the Veteran's other available medical records do not show any further treatment for, or degeneration of that condition. (See, generally, VVA, CAPRI, 3/11/2014). The Board recognizes that the Veteran has not been provided an examination of his disability since the initial 2010 examination; however, the evidence of record does not indicate worsening since that time, and the Veteran did not testify as to worsening. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991) (VA's duty to assist requires to provide a new VA examination when the evidence of record does not reflect the current state of the disability). In light of the available evidence, the Board finds that the Veteran's spondylotic changes at the sternum have been correctly rated as noncompensably disabling, and an increased rating is not warranted for any period on appeal. Particularly, in this case, there is no evidence that the Veteran's condition has resulted in the dislocation, removal, or resection of any ribs. Likewise, there is no indication of any loss of range of motion sue to the condition. Neither is there any evidence of involvement of 2 or more major joints or joint groups. As such, a non-compensable rating is appropriate for the disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim for an increased rating, that doctrine does not apply. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a bilateral eye condition is denied. Service connection for a psychiatric disability is denied. Entitlement to a compensable rating for spondylotic changes at the right side of the sternum at the junction with the 4th rib is denied. REMAND Inasmuch as the Board regrets any further delay in the adjudication of the claims on appeal, recent action by the United States Court of Appeals for Veterans Claims (Court) requires the Board to issue an additional remand in this matter. On July 5, 2016, the Court issued a precedential decision in the matter of Correia v. McDonald which involved determining the proper interpretation of the final sentence of 38 C.F.R. § 4.59 (2015), which reads, "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found the final sentence of § 4.59 to be ambiguous because the regulation, considered as a whole, is meant to guide adjudicators in determining the proper level of disability of joints, and if the range of motion testing listed in the last sentence is not required, it is unclear how an adjudicator could adequately rate a claimant's joint disability and account for painful motion. Compelled by § 4.59's place in the regulatory scheme (it preceded the disability rating schedule), the Court held that the final sentence of § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. Correia v. McDonald, 28 Vet. App. 158 (2016). Specifically, the Court stated that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59." Id. at 169-170. Although VA's Office of General Counsel has filed a motion for reconsideration in that case, at present, VA has interpreted the Court's holding to imply that all range of motion testing must include active motion, passive motion, weight-bearing motion, and nonweight-bearing motion, and must be compared to the opposite joint, when possible (opposite joint testing is only applicable where there is an opposite joint, and thus excludes spine claims; it also excludes opposite joint testing when the opposite joint is "damaged," meaning it has a disorder that would make it abnormal). In June 2016, the Veteran was afforded a VA examination to address the issues of cervical spondylosis and lumbar disc bulging. Unfortunately, the resulting examination reports did not include range of motion and pain findings based on passive movement. Likewise, the Veteran's most recent shoulder examination, conducted in September 2014, also did not include passive range of motion measurements. As such, the Board will remand the claims so that the Veteran can be afforded a VA examination which complies with all directives of 38 C.F.R. § 4.59. For issues not subject to the holding in Correia, once VA undertakes to provide an examination in a service connection claim, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has perfected a claim for service connection for an abdominal wall hernia. A VA examination dated December 15, 2010, gave a diagnosis of a hiatal hernia, but did not address any possible etiology. A subsequent October 2015 VA examination also showed inguinal hernia and ventral hernia, but failed to provide any etiology opinion regarding either diagnosis. Although a review of the Veteran's service treatment records do not reveal any treatment for a hernia during active service, the Veteran has testified that during his various periods of active service, he was required to engage in various types of heavy lifting and carrying of heavy objects. As the Veteran is competent to testify as to facts which he has firsthand knowledge, the Board finds that a new VA examination should be conducted that addresses the Veteran's various hernia diagnoses and provides an etiology opinion for any confirmed diagnosis. Regarding the claim for service connection for bilateral cramps of the hands and arms, the Board finds that a new examination must be conducted to clarify discrepancies in the previous examination reports. Particularly, the Veteran was afforded a VA examination in September 2012, at which time he was diagnosed with bilateral carpal tunnel syndrome, which the examiner opined was not likely related to his service-connected neck and shoulder disability. A subsequent June 2016 examination confirmed that opinion. Although those opinions address the Veteran's complaints of hand pain and cramps, the Veteran has also seeks service connection of intermittent cramps and pain in his arms. The September 2012 examination report appears to acknowledge these symptoms and attributes them to the Veteran's cervical spine disability, despite no evidence of radiculopathy. (See VBMS, VA Examination, 9/26/2012, p. 41-42). The June 2016 examination report states that there is no evidence of radiculopathy, but does not address the findings of the September 2012 examiner, and does not provide any possible diagnosis for the symptoms previously recorded. Symptoms alone, however, such as cramps, are not disabilities within the law for which service connection may be granted. See Sanchez-Benitez v. Brown, 13 Vet. App. 282 (1999) (finding that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted). Although the September 2012 examination report notes the Veteran's arm cramps and attributes them to his cervical spine disability, it does not clarify whether those symptoms constitute a separately diagnosed disability. As such, the Veteran should be afforded a new VA examination which clarifies whether the Veteran's arm cramps, which the VA examiner has stated are secondary to his cervical spine disability, constitute a separate disability for which service connection may be granted. VA's duty to assist requires it to provide a VA examination when the evidence of record does not contain sufficient competent medical evidence to decide a claim, but (a) contains competent evidence of a current diagnosed disability; (b) establishes that the Veteran suffered an event, injury or disease in service; and (c) indicates that the claimed disability or symptoms may be associated with the established event, injury or illness. 38 C.F.R. § 3.159(c)(4)(i) (2015). That a disability "may be associated" with service is a "low threshold" standard. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In this case, the Veteran has a confirmed diagnosis of tinea unguium, which was diagnosed in November 2010, several months after his final period of active service. (See VVA, Capri, 3/11/14, p. 188). He also has testified that he noticed symptoms, which he described as fungus, during periods of active service, particularly during deployment in Africa where he was required to wear boots in hot weather. (See VBMS, Hearing Testimony, 4/6/2016, p. 9). The Board notes that the Veteran is competent to report observable symptomatology of an injury or illness, such as discoloration of the toenail. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). To date, the Veteran has not been afforded a VA examination in connection with this claim. As such, an examination should be provided. Finally, as the issue of TDIU has been raised as part and parcel of the increased rating claims on appeal, that issue is inextricably intertwined with those issues, and must also be remanded pending the outcome of the below ordered development. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a new VA examination in connection with his claim for an increased disability rating for left shoulder impingement syndrome. A complete copy of the claims file must be made available to the examiner. The examiner should provide a complete description of the Veteran's left shoulder disability, to include degrees of flexion, abduction, external rotation, and internal rotation for the left shoulder, and whether the shoulder is ankylosed. Additional limitation of motion due to pain, weakness, fatigability, or incoordination should be reported (that determination must be expressed in terms of degrees of additional limitation of motion). All findings must include range of motion testing in active motion and passive motion and provide comparison to the right shoulder. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 2. Schedule the Veteran for a new VA examination in connection with his claims for an increased disability ratings for cervical spondylosis and lumbar disc bulging. A complete copy of the claims file must be made available to the examiner. The examiner should report the ranges of motion of the spine, or whether any segment of the spine is ankylosed. Additional limitation of motion due to pain, weakness, fatigability, or incoordination should be reported (that determination must be expressed in terms of degrees of additional limitation of motion). All findings must include range of motion testing in active motion and passive motion, as well as weight-bearing and nonweight-bearing motion. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 3. Return the file to the September 2012 examiner for an addendum opinion regarding the Veteran's arm cramps. If the September 2012 examiner is no longer available, forward the complete claims file to a qualified medical examiner for an addendum opinion. The need for a new examination is left to the discretion of the examiner. The examiner should review all evidence of record and state whether the Veteran's arm pain and cramps, which was acknowledged and attributed to his cervical spine condition in the September 2012 examination report, and which is separate from his diagnosed carpal tunnel syndrome, constitutes a separate and distinct diagnosed disability from his cervical spine disability. A complete rationale should be provided for any opinion or answer given and should include citation to evidence in the record, known medical principles and medical treatise evidence. 4. Schedule the Veteran for a new VA examination to address his variously diagnosed abdominal hernias. A complete copy of the claims file must be made available to the examiner. The examiner should conduct a thorough examination of the Veteran and give a diagnosis for any and all abdominal hernias found. Thereafter, for each diagnosed hernia disability, the examiner should state if it is at least as likely as not that it was incurred in or the result of any incident of active service, to include any heavy lifting during service, as reported by the Veteran. A complete rationale should be provided for each opinion rendered and should include citation to evidence in the record, known medical principles, and medical treatise evidence. The examiner is reminded that the Veteran is competent to report any heavy lifting completed during active service. 5. Schedule the Veteran for a VA examination in connection with his claim for service connection for tinea unguium. A complete copy of the claims file must be made available to the examiner. The examiner should conduct a thorough examination of the Veteran, to include taking a detailed history from the Veteran of his observed symptoms. Thereafter the examiner should state whether the Veteran's diagnosed tinea unguium had onset during any period of active service, or, in the alternative, if it clearly and unmistakably preexisted service, was aggravated beyond its normal progression thereby. A complete rationale should be provided for each opinion rendered and should include citation to evidence in the record, known medical principles, and medical treatise evidence. The examiner is reminded that the Veteran is competent to report any observable symptomatology during active service. 6. Thereafter, readjudicate all claims on appeal in light of all evidence of record. If any benefit sought on appeal should remain denied, issue the Veteran and his representative a supplemental statement of the case and afford adequate time to respond before returning the outstanding claim to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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 2014). ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs