Citation Nr: 1728929 Decision Date: 07/24/17 Archive Date: 08/04/17 DOCKET NO. 12-10 080 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a compensable disability rating for patellofemoral pain syndrome of the right knee prior to February 11, 2015 and entitlement to a rating in excess of 10 percent thereafter. 2. Entitlement to a rating in excess of 10 percent for right knee instability. 3. Entitlement to a rating in excess of 10 percent for a gastrointestinal disability. 4. Entitlement to an initial compensable disability rating for neuropathy of the left toes (3, 4, and 5) prior to February 11, 2015 and in excess of 10 percent thereafter. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. VanValkenburg, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1991 to April 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2009 (right knee, gastrointestinal) and April 2010 (left toe neuropathy) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. During the course of the appeal, in a March 2015 RO rating decision, service connection was granted for the Veteran's claimed acquired psychiatric condition and increased ratings were granted for the Veteran's right knee condition (including a separate rating for instability) and neuropathy of the left toes, as reflected on the title page of this decision. The grant of service connection of an acquired psychiatric condition is no longer for appellate consideration as the grant represents the full benefit sought. The increased ratings did not represent the maximum benefit sought on appeal and the matters remain before the Board. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in July 2012. A transcript of the hearing is associated with the file. In November 2014 the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for further development. The requested development as to the claims adjudicated below has been completed to the extent possible, and no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board previously referred the issue of entitlement to service connection for chronic sleep impairment as secondary to his service-connected disabilities to the AOJ in the November 2014 Remand. However, it does not appear any action has been taken. As such, the Board again refers the matter to the AOJ for appropriate action. The issues of entitlement to increased ratings for his right knee conditions are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire appeal period and resolving any reasonable doubt in favor of the Veteran, the gastrointestinal disability has been severe and manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 2. For the period prior to February 11, 2015, the Veteran's neuropathy of the left toes (3, 4, and 5) is manifested by mild incomplete paralysis of the sciatic nerve, but no more. 3. For the period beyond February 11, 2015, the Veteran's neuropathy of the left toes (3, 4, and 5) is manifested by moderate incomplete paralysis of the superficial peroneal nerve, but no more. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for a rating of 30 percent, but no more, for a gastrointestinal disability have been met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code (DC) 7319 (2016). 2. For the period prior to February 11, 2015, the criteria for an initial rating of 10 percent, but no more, for neuropathy of the left toes (3, 4, and 5) have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, DC 8520 (2016). 3. For the period beyond February 11, 2015, the criteria for a rating in excess of 10 percent for neuropathy of the left toes (3, 4, and 5) have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, DC 8522 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duty to notify and assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letter dated September 2009 and March 2010. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA also has a duty to assist a Veteran in the development of the claim. That duty includes assisting the Veteran in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The claims file contains the Veteran's service treatment records, private treatment records, relevant VA medical records and VA medical examinations, and the Veteran's own contentions. Pursuant to the November 2014 Board remand, in a February 2015 letter, the Veteran was afforded an opportunity to provided proper authorizations in order for VA to obtain his previously identified private treatment records relevant to his gastrointestinal claim. However, he did not provide necessary authorizations and the April 2017 post-remand brief does not indicate any outstanding private treatment records that the Veteran wishes to obtain. Thus, The Board finds that all necessary development as to the issues decided herein has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). Increased ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Neuropathy of the left toes (3, 4, and 5) The Veteran asserts entitlement to an initial compensable rating for neuropathy of the left toes (3, 4, and 5) prior to February 11, 2015 and a rating in excess of 10 percent thereafter. By way of history, the Veteran was initially granted service connection for neuropathy of the left toes (3, 4, and 5) in an April 2010 RO rating decision, evaluated as noncompensable from, under DC 8520 for paralysis of the sciatic nerve. The August 2009 contract VA examiner did not indicate the specific nerve involved in the examination report. During the course of the appeal, in a March 2015 RO rating decision, the RO granted a rating of 10 percent under DC 8599-8522, effective February 11, 2015. 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. 38 C.F.R. § 4.27. A Diagnostic Code ending in "-99" is an evaluation by analogy for a disability not specifically listed in the rating code. The musculocutaneous (superficial peroneal) nerve is rate under DC 8522. In February 2015, the VA examiner identified that the Veteran had moderate incomplete paralysis of the musculocutaneous (superficial peroneal) nerve. The Board will address the rating criteria for both Diagnostic Codes. Diseases of the peripheral nerves are rated are rated based on the degree of paralysis, neuritis, or neuralgia. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Under DC 8520, for the sciatic nerve, a 10 percent rating is provided for mild incomplete paralysis. A 20 percent rating is provided for moderate incomplete paralysis. A 40 percent rating is provided for moderately severe incomplete paralysis. A 60 percent rating is provided for severe incomplete paralysis with marked muscular atrophy. And an 80 percent rating is provided for complete paralysis with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. Under DC 8522, a 10 percent disability evaluation is warranted for moderate incomplete paralysis of the superficial peroneal nerve. A 20 percent evaluation is assigned for severe incomplete paralysis and a 30 percent disability rating requires complete paralysis with eversion of foot weakened. A 40 percent rating is provided for complete paralysis with dorsal flexion of the foot lost. The Veteran asserts that symptoms of numbness in his life had impacted his life negatively. It limited his mobility and his ability to rest. Prolonged activity caused pain during and after. It impacted him socially and professionally due to pain and discomfort. He reports that it has limited his ability to participate in healthy exercise and has contributed to weight gain. He had a knee brace, orthopedic inserts, heel lifts and motion control shoes. He took medication for pain. See Veteran's statement dated September 21, 2009 VA treatment records show that in March 16, 2009, the Veteran complained of left hip pain with neuropathy into the 3, 4, and 5 toes of his left foot. An assessment of neuropathy was provided with a note to rule out lumbar spine involvement. A magnetic resonance imaging (MRI) was ordered. In the April 2009 lumbar spine MRI, the reason for MRI study stated "left back pain with radiculopathy" but the findings were normal with no findings to explain symptoms. In a May 29, 2009 physical therapy record, the Veteran complained of "intermittent" numbness in the 3-5 toes of his left foot. The Veteran was afforded a VA contract examination in December 2009 with an attached addendum. The Veteran reported occasional numbness in the last three toes of his left foot. The neuropathy was noted to be due to nerve impingement from his service-connected left hip condition (left femoral acetabular impingement). Neurological examination findings revealed normal motor and sensory function of the lower extremities. In a May 2011 VA contract left knee examination, the Veteran again complained of occasional numbness in the last three toes of his left foot and an addendum clarified that the Veteran's numbness symptoms were unrelated to his left knee condition. The Veteran testified at his 2012 Board hearing regarding his neuropathy of the left toes (3, 4, and 5), which is related to his hip condition. He reported problems with his whole left side, but with toe numbness specifically, he could not feel the entire step. There were times he had mis-steps and without a brace you it would result in a fall to the ground. He used motion-corrective shoes and was issued insoles. He had instances where he didn't feel his foot, the ankle rolled and his right knee gave way. In an August 7, 2013 VA podiatry consultation, objective testing revealed light touch (sensory) to the feet was intact. Deep tendon reflexes testing was 3/3 bilaterally without clonus and Achilles was 2/3 bilaterally. The Veteran was afforded a VA peripheral nerves examination in February 2015. The diagnosis was superficial peroneal nerve entrapment neuropathy. The examiner noted in the history (including onset and course) that the numbness symptoms of his left toes 3, 4, 5 remained the same. The Veteran is right hand dominant. The Veteran did not have symptoms of constant pain, intermittent pain or paresthesias and/or dysesthesias in his left lower extremity. Muscle testing was normal 5/5 in for left knee extension and ankle plantar flexion/ dorsiflexion. Deep tendon reflexes were normal (2+) in the left lower extremity (knee and ankle). The Veteran did have moderate symptoms of numbness in his left lower extremity and sensory was absent in the left foot/toes. There were no trophic changes attributable to peripheral neuropathy. The Veteran had a bilateral antalgic gait due to his knee conditions. The musculocutaneous (superficial peroneal) nerve was affected and revealed moderate, incomplete paralysis. The examiner detailed that the neuropathy was sensory only. The loss of sensation caused the Veteran to trip occasionally while walking. For the period prior to February 11, 2015, the evidence does not indicate which nerve was impacted, only that it was associated with his left femoral acetabular impingement (hip). The Board will apply the existing rating under DC 8520 assigned by the RO for this time period as it is most beneficial to the Veteran. The Board finds that the lay and medical evidence reflects that the Veteran's neuropathy of the left foot most closely approximates mild, incomplete paralysis of the sciatic nerve. During this period, the Veteran's predominant complaint was only occasional numbness in the left toes (3 to 5). Neurological examination findings revealed normal motor and sensory function in 2009. Although the Veteran had a documented instance in 2013 of a reduced Achilles deep tendon reflex testing of 2/3, the Board finds that this does not rise to a moderate level of incomplete nerve paralysis. There is no reduction in muscle strength shown and as noted, the Veteran predominantly complained of only occasional or intermittent numbness. As such, a higher 10 percent rating under DC 8520, but no more, is warranted for the period prior to February 11, 2015. For the period beyond to February 11, 2015, the evidence indicates that the musculocutaneous (superficial peroneal) nerve is impacted. The Board will apply the existing rating under DC 8599-8522, as this contemplates incomplete paralysis of the musculocutaneous (superficial peroneal) nerve. Although a rating under DC 8520 for the sciatic nerve would be more beneficial to the Veteran, is not the most appropriate Diagnostic Code as there is no indication that this nerve is affected and the superficial peroneal nerve was specifically selected by the 2015 VA examiner. The Board finds that the lay and medical evidence reflects that the Veteran's neuropathy of the left foot most closely approximates moderate, incomplete paralysis of the superficial peroneal nerve. The VA examiner in February 2016 specifically indicated that the severity of the superficial peroneal nerve condition was moderate. The Veteran complained of numbness and the sensory examination was absent for light touch. The Board agrees with the 2016 VA examiners findings that the symptoms are moderate. Of note, there is no reduction in muscle strength or reflexes shown in the 2015 VA examination. The 2016 VA examiner detailed that the Veteran's neuropathy of the left foot symptoms are sensory, and as noted by VA regulations, wholly sensory involvement is at most, to be rated as moderate. As such, a rating in excess of 10 percent for the Veteran's neuropathy of the left foot toes is not warranted for the period beyond February 11, 2015. Throughout the entire appeal period, Veteran has not claimed or been diagnosed with complete paralysis of the sciatic or superficial peroneal nerve to warrant a higher rating under DC 8520 or DC 8522. The Board has considered all other potentially applicable diagnostic codes, but there is no evidence showing the Veteran has neurological damage associated with any other peripheral nerves, including impairment of the anterior tibial nerve, the interior popliteal nerve, the posterior tibial nerve, the anterior crural nerve, the internal saphenous nerve, the obturator nerve, the external cutaneous nerve of the thigh, or the ilio-inguinal nerve. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Extraschedular consideration involves a three step analysis. See Thun v. Peake, 22 Vet. App. 111(2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. Here, the Board has considered the Veteran's complaints of tripping while walking due to numbness in his left toes. In this regard, the February 2015 VA examiner indicated that the Veteran occasionally tripped while walking due to the condition. It was further clarified that his abnormal gait was due to his knee condition (conditions for which he is separately service-connected). Despite reports of pain, numbness and occasional tripping, the Board finds that schedular evaluations are not inadequate and the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's neuropathy of the left toes (3, 4, and 5) during the entire appeal period. A comparison between the Veteran's current symptoms and functional limitations with the criteria found in the rating schedule shows that the rating criteria reasonably describe his disability level and symptomatology, as there is no indication that his neuropathy of the left toes (3, 4, and 5) results in more than a moderate disability. The Veteran has not described any unusual or exceptional features associated with his disabilities and have not described how his disabilities affect him in unusual or exceptional manner. In short, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun, 22 Vet. App. at 115. The Board also notes the Veteran's proposition that his left toe numbness led to his current obesity due to a reduction in activity. There is no indication that the Veteran is competent to attribute any obesity present due to a reduction in activities associated with the Veteran's service-connected left toe numbness. Lacking competent evidence to make this attribution, the Board cannot find that any obesity present is related to the Veteran's service-connected left toe numbness. The record evidence finally does not otherwise indicate that the symptomatology associated with the Veteran's currently appealed service-connected disabilities is not contemplated within the relevant rating criteria found in the Rating Schedule such that he is entitled to extraschedular consideration under Johnson. In light of the above, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321 (b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Gastrointestinal disability The Veteran asserts entitlement to a rating in excess of 10 percent for his gastrointestinal condition. The Veteran's gastrointestinal condition includes post-operative laparoscopy for mesenteric adenitis (with symptoms now subsided), IBS and evidence of an umbilical hernia seen on a July 2012 imaging study of questionable clinical significance. Certain diseases of the digestive system, particularly those occurring in the abdomen, while differing in the site of pathology, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain co-existing diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to separate disability evaluations without violating the rule against pyramiding. 38 C.F.R. § 4.113. Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, may not be combined with each other. Instead, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture. 38 C.F.R. § 4.114. Under DC 7301 (peritoneum, adhesions) provides a 30 percent rating for moderately severe adhesions with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. A maximum 50 percent rating is assigned with severe adhesions, with definite partial obstruction shown by x-ray with frequent and prolonged episodes of severe colic distention, nausea or vomiting following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. Under DC 7319, (irritable colon syndrome (IBS)) a noncompensable evaluation is warranted for mild IBS manifested by disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is warranted for moderate IBS manifested by frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating requires severe IBS manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. By way of history, the Veteran was initially granted service connection for a gastrointestinal disability (characterized as post-operative laparoscopy for mesenteric adenitis) in a July 1996 RO rating decision, evaluated as 10 percent disabling, effective May 1, 1996, under DC 7301 for peritoneum adhesions. The Veteran filed an increased rating claim for his gastrointestinal disability in May 2009. The claim was denied in a November 2009 RO rating decision from which the current appeal arises. As noted, the Veteran's gastrointestinal disability evaluated as 10 percent disabling under DC 7301, which applies to peritoneum adhesions. However, the Board finds that DC 7319 for irritable colon syndrome is the most appropriate diagnostic code based on the Veteran's predominant disability picture. That is, the Veteran's gastrointestinal disability is predominantly manifested by symptoms of diarrhea, constipation, and more or less constant abdominal pain. Also, a rating under DC 7319 is more beneficial to the Veteran than a rating under DC 7301. The Veteran asserts that he has had problems with gastrointestinal issues since 1992. He reports symptoms of discharge, excessive weight gain, unpredictable bowel movements of 3-4 times per day, gas and/or stomach pressure, mucus, stomach tenderness, discomfort and post-meal stomach cramps accompanied by fatigues and at times, nausea. Frequency and unpredictability of bowel movements reduced productivity at work and affected his personal life by needing to be in close proximity. He had to leave work before due to soiling himself on the job. He took medication (dicyclomine) daily. See Veteran's statement dated September 21, 2009. VA treatment records reflect a diagnosis of IBS. In January 13, 2009, the Veteran denied frequent indigestion, chronic or recurrent nausea or vomiting, and black or red stools. He took medication for IBS in the past but was currently not taking any medication and was not experiencing unmanageable symptoms. In August 2009, the Veteran took medication for the condition (Dicyclomine). More recently, in April 21, 2014, the Veteran was noted to have IBS which was controlled with diet. The Veteran was afforded an August 2009 VA contract examination of his gastrointestinal condition. In 1992, he was hospitalized due to illness and had laparoscope surgery. He described residual symptoms of cramps, tenderness, bloating and discharge. The Veteran complained of a close to 80 pound weight gain since 1992. He reported vary degrees of bowel movements but he typically went to 3-4 times per day. After meals, he experienced stomach cramps, fatigue, nausea, sweating, weakness and shaking. Pain was located in his abdomen and occurred frequently. He reported symptoms of abdominal distention, diarrhea, constipation and mucus discharge. Eating precipitated pain but bowel movements alleviated pain. There was nausea and vomiting as often as once daily. He never vomited blood or black/ tarry stools and never fainted after meals. Overall, the condition made it difficult to participate in family actives due to a need to evacuate his bowels at unpredictable times. He needed to be within close proximity to a restroom and the frequency of bowel movements reduced his productivity. He did not report incapacitation. Upon physical examination, the Veteran was well-nourished and in no acute distress. His nutritional status was normal. The abdomen did not have striae on the abdominal wall, distension of superficial veins, ostomy, and tenderness to palpation, splenomegaly, ascites, liver enlargement or aortic aneurysm. The diagnosis was post-operative laparoscopy for mesenteric adenitis. The condition was in remission. Complete blood count testing was normal. The stomach condition did not cause significant anemia and there were no findings of malnutrition. The impact on usual occupation is using the restroom quite often. The Veteran testified at a 2012 Board hearing regarding the history and symptoms regarding his gastrointestinal condition which was largely duplicative of his statement dated September 2009, summarized above. The Veteran discussed a recent objective testing from 2012 that found an umbilical hernia near his belly button. He had three incisions near his belly button and he proposed that his abdominal wall may have been weakened to cause the umbilical hernia. He had constant pain in the lower quadrant of his abdomen, constipation, and feelings of nausea. The severity of pain changed with what he ate. Nausea was impacted by his activities and eating. He reported that he had defecated himself at work and had to leave to change clothing. Daily activities were impacted because he had a sudden onset of bathroom problems and constantly had to consider proximity to a bathroom. He reported a fluctuation in weight due to the condition. In February 2015, a VA examiner conducted a peritoneal adhesions and intestinal condition examination and provided a separate report with a discussion regarding the onset, course and current severity of the gastrointestinal condition. The Veteran's diagnosis was status-post laparoscopy for mesenteric adenitis and irritable bowel syndrome (1996). There was no current diagnosis of peritoneal adhesions. Likewise, there were no signs and/or symptoms due to peritoneal adhesions. The Veteran's abdominal/intestinal symptoms have persisted, essentially unchanged, since 1993. He passed about 4 stools daily which were mainly soft brown with mucus on the surface. Abdominal pain flared randomly as there was cramping often with ineffectual urging for stool. There was no constipation or hematochezia. Various testing such as a colonoscopy, barium enema, computerized tomography (CT) scans have revealed no pathology to explain these gastrointestinal symptoms. The Veteran was not on continuous medication for control of the intestinal condition and had no surgical treatment for his IBS condition. The Veteran did not have severe peritonitis, a ruptured appendix, a perforated ulcer, an operation with drainage. Symptoms of IBS included diarrhea, alternative diarrhea and constipation (constipation was intermittent/random), and abdominal distention (often with loose stool). The Veteran had frequent episodes of IBS bowel disturbances with abdominal distress or exacerbations or attacks of the intestinal condition. However, the examiner did not indicate that the Veteran had "more or less constant abdominal stress." There was no weight loss, malnutrition (or other serious complications or general health effects) or benign or malignant neoplasm or metastases attributable to an intestinal condition. There were scars attributable to the laparoscopy but they were not painful and/or unstable or of a total area greater than 39 square centimeters. The Veteran had moderate-severe right lower and mild let lower quadrant abdominal tenderness. There were no masses or megaly palpable. No umbilical hernia palpable. Complete blood count testing was conducted in July 2013. There was no impact of the intestinal condition on his ability to work. The Veteran had an abdominal computerized tomography (CT) scan in June 2012, with no evidence of small bowel abnormality, no bowel obstruction. There was no acute process demonstrated in the abdomen or pelvis. The appendix was visualized and appeared normal. There was constipation, hepatic steatosis and a small fat- containing umbilical hernia. The VA examiner explained in a separate report that the Veteran's symptoms of mesenteric adenitis have subsided, and mesenteric adenitis was not noted on the June 2012 abdominal CT. However, symptoms of pain have shifted primarily to the right lower abdominal quadrant in the area of the cecum or ileocecal valve with tenderness on examination. These symptoms, at least as likely as not, represent a progression of the Veteran's disease, especially because his frequent loose and mucus stool symptoms persist unchanged. The Veteran gives a reliable history of constant abdominal pain fluctuating in severity and intermittently associated with constipation and minor stool leakage. There was no nausea. Loose mucus stool continues, about 4 times daily. The examiner reiterated that the Veteran's service-connected status post laparoscopy for mesenteric adenitis progressed into IBS. It is at least as likely as not that the mesenteric adenitis was merely the early signs of evolving IBS, a condition which onset in-service. However, the cause of the symptoms remains unknown as objective testing does not reveal possible causes. The small fat-containing umbilical hernia noted on the June 2012 CT is of questionable significance and there was no umbilical hernia on physical examination. The Board finds that with resolution of reasonable doubt in the Veteran's favor, a 30 percent rating, but no more, is warranted for the gastrointestinal condition. The Board finds that the Veteran's gastrointestinal condition most closely approximates symptoms of severe IBS with chronic diarrhea, or alternating constipation and diarrhea, productive of more or less constant abdominal distress. The Board observes that neither VA examiner in 2009 or 2015 specifically concluded that the Veteran suffered from constant abdominal stress. However, the 2015 examiner found that the Veteran provided a reliable history of "constant abdominal pain." Regardless, the Veteran is competent to report symptoms such as abdominal pain and the Board has no reason to doubt his credibility. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). This represents the maximum disability rating under DC 7319. The Board has also considered whether another diagnostic code for disabilities of the digestive system would allow for a higher evaluation, mindful that DC 7301-7329, 7331, 7342, and 7346-7348 cannot be combined. See 38 C.F.R. § 4.114. The record does not show additional symptoms such as melena, anemia, weight loss, or malnutrition that would warranted a higher rating under any of these diagnostic codes. Thus, none of these provides for a higher rating based on the Veteran's current symptoms. The Board also notes the Veteran's proposition that his gastrointestinal disability led to his current obesity. Despite noting a report of weight gain from the Veteran, neither VA examiner indicated that the gastrointestinal condition resulted in an abnormal nutritional status or malnutrition. Otherwise, there is no indication that the Veteran is competent to attribute any obesity present due to his service-connected gastrointestinal condition. Lacking competent evidence to make this attribution, the Board cannot find that any obesity present is related to the Veteran's service-connected gastrointestinal disability. The Board finds that a separate rating is not warranted for the Veteran's umbilical hernia found in 2012, under DC 7339 for post-operative ventral hernias. Here, the February 2015 VA examiner detailed that the small fat-containing umbilical hernia found on a 2012 imaging study was of "questionable significance" and on examination, it was not found. There is no medical evidence indicating any associated symptoms of this umbilical hernia. Thus, there is no indication of weakening of the abdominal wall or indication of for a supporting belt required for a compensable 20 percent disability rating. Nor is there a large ventral hernia, not well supported by a belt under ordinary conditions, or massive or persistent hernia with severe diastasis or recti muscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable, as required for higher rating 40 or 100 percent ratings, respectively. The Board finds that a separate rating under DC 7332 for impairment of sphincter control associated with his gastrointestinal disability is not warranted. The Board observes the Veteran's reports that he has defecated himself. The February 2015 VA examiner explained that the Veteran has symptoms of abdominal pain which is only intermittently associated with "minor" stool leakage. Here, symptoms to do not represent that "constant slight" or "occasional moderate" leakage is shown to warrant a compensable, 10 percent, disability rating. Nor have any occasional involuntary bowel movements necessitating waring of pad, extensive leakage and fairly frequent involuntary bowel movements or complete loss of sphincter control been shown to warrant higher 30, 60 and 100 percent ratings, respectively. For the reasons discussed above, the Board finds the weight of the evidence supports a disability rating of 30 percent, but no higher, for his gastrointestinal disability. Neither the Veteran nor his/her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER For the entire appeal period, entitlement to a rating of 30 percent, but no more, for the Veteran's gastrointestinal condition is granted, subject to the law and regulations governing the payment of monetary benefits. For the period prior to February 11, 2015, a rating of 10 percent, but no more, for the Veteran's neuropathy of the left toes (3, 4, and 5) is granted, subject to the law and regulations governing the payment of monetary benefits. For the period beyond February 11, 2015, a rating in excess of 10 percent for the Veteran's neuropathy of the left toes (3, 4, and 5) is denied. REMAND The Board finds that additional evidentiary development is necessary regarding the Veteran's increased rating claim for his right knee conditions. In February 2015, the Veteran underwent a VA examination of the right knee. Correia v. McDonald, 28 Vet. App. 158 (2016) requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In other words, if there is not a discussion of these measurements in a VA examination report, the examination is inadequate-unless the examiner determines that these listed range of motion testing cannot be conducted. The February 2015 VA examination does not include the required joint testing described in Correia, and a new examination is warranted. Additionally, the Board notes that the February 2015 VA examiner also indicated evidence of pain with range of motion, but failed to indicate where pain started, stating that it did not result or cause functional loss. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to assess the current severity of his right knee disability. The Veteran's electronic claims file should be made available to and reviewed by the examiner. The examiner should provide a complete rationale for any opinions provided. The examiner is asked to specifically test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). 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. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, as well as whether such pain on movement results in any loss of range of motion. The examiner is requested to review the VA examinations containing range of motion findings pertinent to the Veteran's right knee conducted in August 2009 and February 2015. In this regard, the examiner is requested to offer an opinion as to the range of motion findings for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to do so, he or she should explain why. In addition, the examiner should provide information concerning the functional impact of the Veteran's service-connected right knee disability. 2. After undertaking any other development deemed appropriate, the RO will readjudicate the issues on appeal. If any benefit sought is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs