Citation Nr: 1800931 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 11-23 121 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial compensable disability rating for service-connected athlete's foot. 2. Entitlement to a disability rating in excess of 20 percent for service-connected degenerative disc disease (DDD) of the lumbar spine (lumbar spine disability) from January 10, 2013, to July 5, 2017, and in excess of 40 percent since July 6, 2017. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for a chronic disability of the right knee, to include as secondary to a service-connected lumbar spine disability. 6. Entitlement to service connection for a chronic disability of the left knee, to include as secondary to a service-connected lumbar spine disability. 7. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to February 1, 2016. REPRESENTATION Veteran represented by: Lawrence Stokes, Jr., Agent ATTORNEY FOR THE BOARD A. Hodzic, Associate Counsel INTRODUCTION The Veteran had active duty service from June 1973 to August 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2010, December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, and a January 2016 rating decision of the RO in Winston-Salem, North Carolina. The Agency of Original Jurisdiction (AOJ) over the Veteran's case is the RO in Winston-Salem. The Board remanded the increased rating and service connection claims for additional procedural and evidentiary development in December 2014, and the Board remanded all of the claims on appeal in April 2017. The record shows that the Veteran has a maximum combined disability rating of 100 percent, effective February 1, 2016. Thus, after reviewing the facts and procedural history of this case, the Board determines that the issue of entitlement to a TDIU should be re-characterized and is more accurately stated as listed on the title page of this decision. The issues of entitlement to service connection for a chronic disability of the right knee and a chronic disability of the left knee, as well as the issue of entitlement to a TDIU prior to February 1, 2016, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's athlete's foot disability has affected less than five percent of his entire body or exposed areas, and he has treated this disability with only topical therapy. 2. From January 10, 2013, to July 5, 2017, the Veteran's lumbar spine disability manifested with pain and a limitation in forward flexion of the thoracolumbar spine greater than 30 degrees but less than 60 degrees, at worst, but this disability did not manifest with unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine at any time during the appeal period. 3. The Veteran's current bilateral hearing loss disability did not manifest in service or within one year of separation from active duty service and it is not otherwise related to his active duty service. 4. The Veteran's tinnitus disability did not manifest in service or within one year of separation from active duty service and it is not otherwise related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating for service-connected athlete's foot have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code (DC) 7813-7806 (2017). 2. The criteria for a disability rating in excess of 20 percent for service-connected DDD of the lumbar spine from January 10, 2013, to July 5, 2017, and in excess of 40 percent since July 6, 2017, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5242 (2017). 3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 4. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has not raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"). VA's duty to assist includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A (2012); 38 C.F.R. §§ 3.159(c)(4), 3.326(a) (2017); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The VA examination and/or opinion must be adequate to decide the claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran was afforded VA examinations in January 2010, November 2013, September 2015, and July 2017. In an April 2017 decision, the Board determined that the November 2013 VA medical opinions pertaining to the causal connection between the Veteran's bilateral hearing loss and tinnitus disabilities and his military service were inadequate; however, the remainder of the November 2013 VA audiological examination report was valid. The Board determines that the January 2010, November 2013, September 2015, and July 2017 VA examination reports, apart from the November 2013 VA audiological medical opinions regarding the nexus between the current disabilities and the Veteran's active duty service, are adequate to decide the Veteran's claims. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (holding that examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion). In April 2017, the Board remanded the case to provide the Veteran with a supplemental statement of the case (SSOC) for his athlete's foot claim, ask the Veteran to identify any outstanding treatment records, associate with the claims file all identified records and any outstanding VA treatment records since April 2014, provide the Veteran with VA examinations for his back, bilateral hearing loss, and tinnitus disorders, and issue an SSOC if any benefit was denied. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings, Generally, The Veteran asserts that his athlete's foot and DDD of the lumbar spine disabilities should be rated higher than the currently-assigned disability ratings. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns DCs to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs - a practice known as pyramiding - is prohibited. See 38 C.F.R. § 4.14. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). The Veteran appealed the initially-assigned disability rating for his athlete's foot following the grant of service connection, effective October 22, 2003, and he filed an increased rating claim for his lumbar spine disability that was received by VA on January 10, 2013. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2017). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a) (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Athlete's Foot The Veteran's bilateral athlete's foot disability is rated under 38 C.F.R. § 4.118, DC 7813-7806, which rates dermatophytosis (including tinea pedis of the feet). This DC instructs that such a disability should be rates as disfigurement of the head, face, or neck (DC 7800), scars (DCs 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. Id. As indicated by the evidence below, the Veteran's athlete's foot disability is predominantly rated under the criteria for dermatitis. 38 C.F.R. § 4.118, DC 7806 rates skin disorders associated with dermatitis or eczema. A noncompensable evaluation is warranted where dermatitis or eczema covers less than five percent of the entire body or less than five percent of exposed areas affected and no more than topical therapy was required during the previous twelve month period. A 10 percent evaluation is assigned when dermatitis or eczema is at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past twelve month period. A 30 percent evaluation is assigned when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past twelve month period. A maxim rating of 60 percent is assigned when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the previous twelve month period. 38 C.F.R. § 4.118, DC 7806. Systemic therapy is defined as treatment affecting the body as a whole, while topical therapy is defined as treatment particular to a defined surface area and affecting only that area. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). In interpreting DC 7806, systemic therapy will be distinguished from topical therapy based on the scale of the treatment and how much of the body is affected by the treatment. See id. In October 2003, the Veteran filed a claim for service connection for athlete's foot. A May 2004 VA nursing note showed that the Veteran was seen for routine foot and nail care. He was noted to have blisters and was instructed on proper footwear and foot hygiene. During a May 2007 Board hearing regarding service connection for athlete's foot, the Veteran testified that his feet itched and were sore. He indicated that prolonged wearing of shoes and hot weather exacerbated his symptoms. He testified that his only treatment for this disability was topical creams, such as ointments and salves. A July 2009 VA primary care physician's note showed that the Veteran complained of athlete's foot and eczema. The Board notes that the Veteran's eczema disability, which is mostly located on his arms, legs, and torso is already service connected. Thus, analyzing symptoms of eczema in connection with rating the Veteran's athlete's foot disability, which manifested as tinea pedis throughout the appeal, would amount to pyramiding. See38 C.F.R. § 4.14. A physical evaluation showed no edema or cyanosis in the extremities, but did indicate bilateral tinea pedis with peeling on the feet and fungal infections of the great toenails. The Veteran was instructed to continue his treatment with topical therapy in the form of Tolnaftate medication, as needed. The Veteran was afforded a VA examination for this disability in January 2010, during which the Veteran complained of pain, itching, and pruritus. He stated that he used topical hydrocortisone 1 percent cream and Tolnaftate cream on a daily basis to treat this disability. He indicated that he has not used oral corticosteroids or immunosuppressive or light therapy. A physical evaluation showed that the Veteran's tinea pedis involved both feet. The Veteran's symptoms involved zero percent of exposed skin and approximately two percent of the Veteran's total body. The examiner determined that the Veteran's athlete's foot did not manifest as disfigurement or definite scarring of the feet. The Veteran underwent another VA skin examination for his feet in July 2011, during which the Veteran complained of pain in his feet and difficulty walking due to eczema and tinea pedis symptoms. The examiner determined that the Veteran's athlete's foot disability did not cause any disfigurement but that it required constant or near-constant topical Tolnaftate treatment in the previous 12 months. The examiner determined that the Veteran did not have any debilitating or non-debilitating episodes in the previous year due to his skin symptoms. The examiner determined that his eczema and dermatitis symptoms covered less than five percent of his total body and they did not include any exposed areas. A June 2013 VA primary care note showed that the Veteran was prescribed Ketoconazole shampoo for his feet and he was told to continue his Tolnaftate solution treatment for his toenails. In fact, the Veteran's VA treatment records, including a May 2015 nurse practitioner note, show that the Veteran treated his athlete's foot disability with topical therapy, including Ketoconazole cream and Tolnaftate solution, throughout the appeal. A September 2015 VA examination for the Veteran's feet shows that he was being treated with antifungal cream on a daily basis for his athlete's foot. The Veteran told the examiner that this disability was not well-controlled with the cream and that his symptoms are worse when he wears socks. A physical examination showed flaking skin and hyperpigmentation on both feet. The examiner noted the Veteran's statements that his symptoms are severe, but the examiner determined that the objective evidence indicated otherwise. The examiner noted that the Veteran's tinea pedis covered less than five percent of his total body are and zero percent of his exposed area. The examiner determined that from the examination, the Veteran's tinea pedis was well-controlled and did not appear to be giving him much discomfort. The examiner concluded that the Veteran's current symptoms did not cause any functional impairment, did not require any oral therapy, and were controlled with just topical medication. Given this evidence, the Board finds that the Veteran's athlete's foot disability has affected less than five percent of his entire body or exposed areas for the entire period on appeal, as shown by the January 2010, July 2011, and September 2015 VA examination reports. Additionally, these examination reports, as well as the various treatment records throughout the appeal, show that the Veteran has treated this disability with only topical therapy. Thus, while the Board has considered the Veteran's statements that his athlete's foot is severe, the evidence does not show that this disability has affected at least five percent of his entire body or exposed areas, or that he has intermittently used systemic therapy, such as corticosteroids or other immunosuppressive drugs. Accordingly, this disability has not warranted a compensable disability rating at any time during the appeal period. The evidence does not show that an initial compensable disability rating is warranted during the appellate period for the Veteran's athlete's foot. See 38 C.F.R. § 4.118, DC 7813-7806. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim must be denied. See 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lumbar Spine Disability The Veteran also contends that his lumbar spine disability should be rated higher than the currently-assigned disability ratings. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint). Furthermore, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). All spinal disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Degenerative arthritis of the spine, to include DDD, is to be evaluated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (DC 5243), whichever method results in the higher rating. Under the General Rating Formula, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The General Rating Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate DC. Id. at Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). The Formula for Rating IVDS Based on Incapacitating Episodes provides a 60 percent rating for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243 (2017). An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). In January 2013, the Veteran filed a claim for increase for his lumbar spine disability. A June 2013 VA primary care physician's note showed the Veteran's complaints of back pain, which the doctor noted was stable. During a November 2013 VA examination, the Veteran denied having flare-ups. Range of motion testing showed that his forward flexion was to 45 degrees with pain at 45 degrees, extension to 20 degrees with pain at 20 degrees, right and left lateral flexion to 25 degrees with pain at 25 degrees, and left and right lateral rotation to 25 degrees with pain at 25 degrees. Same range of motion results were shown after repetitive use testing. The examiner noted that the Veteran had less movement than normal and pain on movement after repetitive use testing; however, he did not have pain to palpation, localized tenderness, ankylosis, muscle spasms, or guarding of the thoracolumbar spine. Muscle strength, sensory, and reflex testing showed normal results, and the Veteran did not have any muscle atrophy. The Veteran did not have any bladder or bowel problems. The examiner noted that the Veteran did not have any radiculopathy; however, the examiner determined that the Veteran's back disability would limit his ability to work in a physical job. In a March 2014 statement, the Veteran asserted that he had degenerative arthritis in his back. He stated that his symptoms included pain that started in his back and travelled to his knees and feet. In an October 2014 statement, the Veteran contended that he had congenital arthritis in his back. A May 2015 VA nurse practitioner noted that the Veteran had pain with flexion, extension, and rotation of the torso. He was also tender to palpation over paraspinal muscles, but there was no tenderness to palpation over the spinous process. An October 2015 VA examination for the Veteran's bladder symptoms showed that it is less likely than not that the Veteran had any urinary dysfunction stemming from the Veteran's lumbar spine disability. While an examiner noted that the Veteran had subjective complaints of urinary symptoms, the Veteran's history and current examination did not show incontinence caused by any spinal nerve involvement. An April 2017 VA primary care physician's note showed that the Veteran was occasionally using a cane to ambulate, but that he was able to drive. He did not complain of any joint or back pain and he did not have any muscle weakness. A July 2017 VA examination showed that the Veteran was diagnosed with degenerative arthritis of the spine and lumbosacral strain. The Veteran complained of not being able to bend over due to back pain and an imbalance due to multiple strokes. He stated that he used a back brace for stability and that he wanted to lie on the floor due to his back pain. He reported flare-ups and increased back pain with standing, sitting, walking for extended periods of time, using stairs, attempting to run or bend, sudden motion of his back, and lifting, carrying, pushing, or pulling of any objects. Range of motion testing showed forward flexion to 10 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 20 degrees. The examiner noted that the Veteran had pain during the examination, but the pain did not result in functional loss. The Veteran was unable to perform repetitive use testing due to instability and pain. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing showed active movement against some resistance in all muscles tested. The examiner noted that the Veteran did not have any muscle atrophy, his bilateral knee and right ankle reflexes were hypoactive, but his left knee reflexes were normal. A sensory examination showed normal results in the thighs and knees, but decreased sensation in the lower legs, ankles, feet, and toes. The Veteran was unable to perform straight leg raises. Although the Veteran complained of radiculopathy signs and symptoms, and he was noted to have mild constant and intermittent pain, paresthesias and/or dysthesias, and numbness, the examiner determined that the Veteran did not have any signs of radiculopathy. The examiner explained that the Veteran's radicular symptoms were due to his multiple strokes and diabetes mellitus, which are not service connected. The examination did not show the presence of ankylosis in the spine, and the Veteran did not have any bladder or bowel problems. The examiner noted that the Veteran wore a brace and used a cane on a regular basis. Given this evidence, the Board finds that from January 10, 2013, to July 5, 2017, the Veteran's lumbar spine disability manifested with pain and a limitation in forward flexion of the thoracolumbar spine greater than 30 degrees but less than 60 degrees, at worst, but this disability did not manifest with unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine at any time during the appeal period. Specifically, the November 2013 VA examination report showed that the Veteran's forward flexion of the thoracolumbar spine was limited to 45 degree with pain noted at 45 degrees. Furthermore, this examination showed that the Veteran did not have any ankylosis. While other VA treatment records show that the Veteran was treated for back pain, the evidence does not indicate that his thoracolumbar spine was limited in forward flexion to 30 degrees or less until worsening symptoms were shown during the July 2017 VA examination. The July 2017 VA examination report shows that the Veteran's forward flexion was limited to 10 degrees; however, the evidence again did not show any symptoms or presence of ankylosis in the thoracolumbar or the entire spine. Accordingly, the Veteran's lumbar spine disability did not warrant a rating in excess of 20 percent from July 10, 2013 to July 5, 2017, and it did not warrant a rating in excess of 40 percent since July 6, 2017. The Board has considered whether a higher rating should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that a higher rating is not warranted for the Veteran's disability picture during the appellate period. The range of motion testing conducted during the medical evaluations considered the thresholds at which pain limited motion. The Veteran reported flare-ups of his symptoms and several medical examinations showed that he had additional functional impairment due to pain. However, even though there is evidence of reduced forward flexion and overall range of motion, and even after considering the effects of pain and functional loss, forward flexion is not limited to 30 degrees or less for the thoracolumbar spine prior to July 6, 2017, and the Veteran has not had ankylosis during the appeal period. Thus, a higher rating under these provisions is not approximated in the Veteran's disability picture. The Board has also considered the application of the Formula for Rating IVDS Based on Incapacitating Episodes to the Veteran's symptoms, but determines that a rating under these criteria would not provide a higher benefit. Specifically, none of the evidence indicates that the Veteran experienced incapacitating episodes of IVDS lasting a total of at least four weeks, but less than six weeks, during any 12-month period on appeal. In fact, the Veteran has not alleged any incapacitating episodes during the appeal, and there is no indication in the record that rest was prescribed by a treating physician or that it lasted more than four weeks at a time. See 38 C.F.R. § 4.71a, DC 5243, Note (1). Thus, the application of the Formula for Rating IVDS Based on Incapacitating Episodes would not provide a higher benefit for the Veteran's disability picture. The Board has also considered whether separate ratings are warranted for neurological symptoms associated with the Veteran's back. However, the record, including the November 2013 VA examination for the Veteran's back and October 2015 VA examination for the Veteran's bladder symptoms, shows that the Veteran does not have any bladder or bowel symptoms associated with his back disability. Furthermore, the July 2017 VA examiner explained that the Veteran's lower extremity neurological symptoms are associated with his nonservice-connected multiple strokes and diabetes mellitus disorders. Thus, separate ratings for neurological symptoms associated with the Veteran's lumbar spine disability are not warranted. Accordingly, the preponderance of the evidence is against a disability rating in excess of 20 percent for DDD of the lumbar spine from January 10, 2013, to July 5, 2017, and in excess of 40 percent since July 6, 2017. The benefit-of-the-doubt rule does not apply, and the Veteran's claim must be denied. See 38 C.F.R. § 4.3; Gilbert, 1 Vet. App. at 55. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claims for athlete's foot and DDD of the lumbar spine. See Yancy v. McDonald, 27 Vet. App. 484 (2016); see also Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). Service Connection for Bilateral Hearing Loss and Tinnitus The Veteran contends that his current bilateral hearing loss and tinnitus disorders were caused by noise exposure he experienced during military service. Because evidence pertaining to these disorders is located in the same or similar lay and medical records, the Board shall analyze them together below. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331, 1340 (Fed. Cir. 2013). Sensorineural bilateral hearing loss and tinnitus (organic diseases of the nervous system) are chronic disorders listed under 38 C.F.R. § 3.309; thus, 38 C.F.R. § 3.303(b) is applicable. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. Under VA regulations, hearing impairment constitutes a disability for VA purposes when auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran had a VA examination to determine the extent of his hearing loss in November 2013. An audiogram showed the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 30 30 40 60 65 75 LEFT 35 40 50 65 70 75 The Veteran's Maryland CNC speech recognition scores showed speech recognition of 86 percent in both ears. The examiner determined that the Veteran had sensorineural hearing loss in both ears. As noted above, the Board previously determined that the November 2013 VA examiner's rationale regarding the causal relationship between the Veteran's hearing loss and tinnitus and his active duty service was inadequate; however, the audiological results are valid to rate the Veteran's claims. The Veteran underwent another VA audiological examination in July 2017, which showed the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 25 25 25 30 25 40 LEFT 10 25 25 35 45 35 The Veteran's Maryland CNC speech recognition scores showed speech recognition of 96 percent in both ears. The examiner determined that the Veteran had sensorineural hearing loss in both ears. The examiner also noted that the Veteran denied ringing, buzzing, humming, or roaring symptoms in his ears, but did indicate that he heard popping in his ears. The examiner determined that the Veteran did not have tinnitus. However, evidence of tinnitus symptoms is highly subjective. The Board finds the Veteran's testimony and statements regarding his current tinnitus to be credible, and thus, the first element of service connection is met for this disorder. Although the July 2017 VA examiner determined that the Veteran had sensorineural hearing loss in both ears, the examiner also indicated that the Veteran did not have disabling hearing loss in the right ear. Specifically, the July 2017 VA pure tone thresholds did not indicate the presence of a hearing loss disability in the right ear for VA purposes. See 38 C.F.R. § 3.385. However, after affording the Veteran the benefit of the doubt, and as indicated in the November 2013 VA examination report, the Veteran has a hearing loss disability in both ears during the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the current disability requirement is satisfied when the claimant has a disability at the time the claim is filed or during the pendency of the appeal even though the disability may resolve prior to adjudication). Accordingly, the first element of service connection is met for this disorder as well. Regarding the second element of service connection for bilateral hearing loss and tinnitus, the Veteran's service treatment records do not show complaints of or treatment for abnormal hearing symptoms. His February 1973 entrance Report of Medical Examination audiometer results, in decibels, were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 10 10 5 X 5 X LEFT 20 5 5 X 5 X An "X" designation indicates that the pure tone frequency was not tested or is otherwise unavailable. The evaluator assigned a "1" rating assessing the Veteran's hearing under the PULHES profile system, indicating that the Veteran's hearing was then in a high level of fitness. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the "PULHES" profile reflects the overall physical and psychiatric condition of a veteran's capacity). The PULHES profile reflects the overall physical and psychiatric condition of a veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service, with the "P" standing for stamina, "U" standing for upper extremities, "L" standing for lower extremities, "H" standing for hearing, "E" standing for eyes, and "S" standing for psychiatric symptoms. The Veteran denied having hearing loss or any abnormal ear symptoms, such as ear trouble or runny ears, in the entrance Report of Medical History. The Veteran's March 1977 post-service Report of Medical Examination audiometer results, in decibels, were: HERTZ 500 1000 2000 3000 4000 6000 RIGHT 0 0 0 X 0 X LEFT 0 0 0 X 0 X Nevertheless, the Veteran contends that he was exposed to noise in service in the form of field artillery and that his bilateral hearing loss and tinnitus symptoms have persistent since his active duty service. Given this evidence, and after affording the Veteran the benefit of the doubt, he was exposed to excessive noise during his active duty service, as noted in the April 2017 Board decision. Overall, the lay and medical evidence does not demonstrate that the Veteran's current bilateral hearing loss and tinnitus symptoms manifested in service or within one year of separation from service, or have been continuous since separation from service in August 1976. There were no complaints, diagnosis, or treatment for this disorder for decades following service discharge. Specifically, the Veteran was first diagnosed with sensorineural hearing loss in November 2013 in connection with this claim for service connection. In fact, multiple VA treatment records from December 2003 to March 2006 show that the Veteran's hearing was intact and that he did not have any gross hearing deficits. The absence of post-service complaints, findings, diagnosis, or treatment for approximately 37 years after service is one factor that tends to weigh against a finding of continuous symptoms since separation from service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that the Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). Thus, the only question to be answered is whether the Veteran's current bilateral hearing loss and tinnitus were caused or are otherwise related to his active duty service. The claims file includes the Veteran's statements contending that his current bilateral hearing loss and tinnitus symptoms were caused by his in-service exposure to artillery noise. In contrast, after reviewing the Veteran's claims file, conducting an audiological examination, and noting the Veteran's self-reported symptoms and history, the July 2017 VA examiner concluded that the Veteran's current bilateral hearing loss and tinnitus were less likely as not related to or caused by his military noise exposure, which was conceded. The examiner explained that the Veteran's service treatment records showed that the Veteran's hearing was normal at entrance and separation, with no significant permanent shift in hearing thresholds greater than normal measurement variability. The Veteran's records also did not show evidence of any permanent auditory damage during active service. The examiner noted that the Veteran's service treatment records do not show complaints or treatment for these disorders and that the claims file does not show chronicity or continuity of care for the hearing loss and tinnitus disorders since military separation. The examiner explained that although excessive noise exposure during active duty service was conceded, auditory damage and hearing loss and tinnitus have not been conceded as stemming from noise exposure alone, which requires a nexus of auditory damage on active duty to relate the current and future hearing loss and tinnitus symptoms to noise exposure during active duty service. The examiner further explained the claims file contains objective evidence against a nexus between the Veteran's current bilateral hearing loss and tinnitus and his active duty service. The Veteran's current bilateral hearing loss and tinnitus disabilities are not caused by or otherwise related to his active duty service. The Board acknowledges the Veteran's contentions that his current bilateral hearing loss and tinnitus are related to his in-service noise exposure. The Veteran is competent to report symptoms that he perceived through his own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer an opinion as to etiology of his current bilateral hearing loss and tinnitus due to the medical complexity of the matters involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Hearing loss and tinnitus require specialized training for a determination as to diagnosis, causation, and progression, and are therefore not susceptible to lay opinions on causation or aggravation. Thus, the Veteran is not competent to render an opinion or attempt to present lay assertions to establish the causation of his current bilateral hearing loss and tinnitus. The July 2017 VA examiner's opinions, which are competent on the issue of causation of medically complicated matters, are of more probative value. This examiner concluded that the Veteran's current hearing loss and tinnitus disorders are less likely as not related to or caused by the Veteran's in-service noise exposure. This examiner's opinions are highly probative evidence regarding the cause of these disorders because of the examiner's expertise, training, education, proper support and explanations, and thorough review of the Veteran's records and self-reported symptoms. Therefore, as the preponderance of the evidence is against entitlement to service connection for bilateral hearing loss and tinnitus, the benefit of the doubt doctrine does not apply, and the Veteran's claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. ORDER An initial compensable disability rating for service-connected athlete's foot is denied. A disability rating in excess of 20 percent for service-connected DDD of the lumbar spine from January 10, 2013, to July 5, 2017, and in excess of 40 percent since July 6, 2017, is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. REMAND The Board must remand the claims of entitlement to service connection for a chronic disability of the right knee and a chronic disability of the left knee for an addendum VA medical opinion. Specifically, in its April 2017 remand directives, the Board instructed a VA examiner to provide opinions as to: (1) whether it is at least as likely as not that the Veteran's right and left knee disorders are related to the Veteran's military service; (2) whether it is at least as likely as not that the Veteran's right and left knee disorders are caused by his service-connected lumbar spine disability; and, (3) whether it is at least as likely as not that the Veteran's right and left knee disorders were, if not caused by, aggravated beyond normal progression by his service-connected lumbar spine disability. The Veteran underwent a VA examination in July 2017 during which an examiner provided negative nexus opinions for questions (1) and (2) above, i.e., whether the current bilateral knee disorders were caused by the Veteran's military service and his service-connected lumbar spine disability. However, the VA examiner did not provide opinions regarding aggravation. While this medical opinion is adequate to adjudicate the Veteran's claims of direct service connection for a chronic disability of the right and left knee disorders, the Board determines that it is inadequate to adjudicate the Veteran's theory of entitlement based on secondary service connection. See 38 C.F.R. § 3.310 (2017); see also Stegall, 11 Vet. App. at 268; Barr, 21 Vet. App. at 312. Thus, an addendum VA medical opinion is necessary to answer whether it is at least as likely as not that the Veteran's chronic disability of the right knee and chronic disability of the left knee are aggravated beyond normal progression by his service-connected lumbar spine disability. Accordingly, these claims are REMANDED for the following actions: 1. Return the claims file to the July 2017 VA examiner and request that she re-review the claims file and respond to the below inquiries regarding the Veteran's service connection claims for a chronic disability of the right and left knee. If that examiner deems it necessary or is otherwise unavailable, schedule the Veteran for an appropriate VA examination to assist in determining the nature and cause of his current right and left knee disorders. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, the July 2017 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's right and left knee disorders, to include knee strains and degenerative joint disease (DJD), were aggravated (permanently worsened) beyond normal progression due to the Veteran's service-connected lumbar spine disability. The examiner must provide a rationale for each opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 2. After completing Step 1, and any other development deemed necessary, readjudicate the claims of entitlement to service connection for a chronic disability of the right knee and a chronic disability of the left knee, and entitlement to a TDIU due to service-connected disabilities prior to February 1, 2016, in light of the new evidence. If the benefit sought on appeal remains denied, an SSOC should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity to respond. 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). This case 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. §§ 5109B, 7112 (2012). ______________________________________________ A. P. SIMPSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs