Citation Nr: 1800971 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 11-26 397A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased a rating in excess of 10 percent for osteoarthritis left foot injury. 2. Entitlement to an increased a rating in excess of 10 percent for degenerative arthritis of the left ankle. 3. Entitlement to service connection for lumbar degenerative disc disease (DDD) as secondary to service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. 4. Entitlement to service connection for left knee strain as secondary to service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. 5. Entitlement to service connection for right knee strain as secondary to service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. 6. Entitlement to service connection for a neck disability. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: James G. Fausone, Attorney at Law ATTORNEY FOR THE BOARD Ashley Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1974 to June 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In the December 2009 rating decision, the RO denied entitlement to service connection for back, neck, and bilateral knee disabilities. Additionally, the December 2009 rating decision denied an increased rating in excess of 10 percent for osteoarthritis left foot injury (then characterized as status post fracture, left ankle with osteoarthritis of the left foot). In a September 2011 rating decision, the RO continued the 10 percent rating for the disability now characterized as osteoarthritis left foot injury and awarded a separate 10 percent rating for disability characterized as degenerative arthritis of the left ankle. The RO in the statement of the case and supplemental case, and the Board in its October 2015 remand (discussed below), indicated that the only issue on appeal in this regard was whether a rating in excess of 10 percent for the now recharacterized disability of degenerative arthritis of the left ankle was warranted. However, given that at the time of the Veteran's claim there was a single disability characterized as status post fracture, left ankle with osteoarthritis of the left foot, the RO's decision recharacterized the disability , essentially bifurcating it into separate ratings for the left ankle and left foot with separate 10 percent ratings, and the Veteran has not expressed satisfaction with the separate 10 percent rating that was granted, the Board finds that the propriety of each 10 percent rating (ankle and foot)is on appeal, as indicated on the title page. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). In the Veteran's October 2011 VA Form 9, he requested a hearing before the Board. In an August 2015 statement, the Veteran's attorney withdrew the hearing request. Therefore, the hearing requested is considered withdrawn. See 38 C.F.R. § 20.702 (2017). In October 2015, the Board remanded the Veteran's claims for further evidentiary development. The Veteran has indicated that he is unable to work due to his service-connected disabilities. See Veteran's statement dated October 2009. Thus, the question of entitlement to a TDIU is part of the instant appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes that in August 16, 2017, the Veteran's attorney requested a 90 day extension from that date. Thereafter, in a November 14, 2017, letter, the Veteran's attorney requested an additional 60 day extension following receipt of a complete copy of the Veteran's claims file since May 1, 2014. On December 20, 2017, a copy of the Veteran's claims file was sent to the Veteran's attorney. The Board finds that, in the circumstances of this case, an additional 60 day extension is not warranted. In this case and as will be shown below, the Board, herein, is rendering favorable decisions, full or in part in, and is remanding the two remaining issues, specifically, the issues of entitlement to service connection for a neck disability and entitlement to a TDIU. Therefore, the Board finds that the benefits of issuing a decision outweigh any prejudice to the Veteran in not granting an additional 60 day extension. The issues of entitlement to service connection for a neck disability and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's symptoms of osteoarthritis left foot injury have more nearly approximated moderately severe impairment. 2. The evidence is at least evenly balanced as to whether the Veteran's symptoms of degenerative arthritis of the left ankle have more nearly approximated marked limitation of motion. 3. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine DDD is proximately due to or the result of his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. 4. The evidence is at least evenly balanced as to whether the Veteran's left knee strain is proximately due to or the result of his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. 5. The evidence is at least evenly balanced as to whether the Veteran's right knee strain is proximately due to or the result of his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for a 20 percent, but no higher, for osteoarthritis left foot injury are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5284 (2017). 2. With reasonable doubt resolved in favor of the Veteran, the criteria for a 20 percent for degenerative arthritis of the left ankle are met. 38 U.S.C §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, DCs 5010- 5271 (2017). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for lumbar DDD, secondary to degenerative arthritis of the left ankle and right ankle osteoarthritis, are met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for left knee strain, secondary to degenerative arthritis of the left ankle and right ankle osteoarthritis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for right knee strain, secondary to degenerative arthritis of the left ankle and right ankle osteoarthritis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Clams Assistance Act of 2000 (VCAA) The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). As the Board is granting the service connection claims for left knee strain and right knee strain, further discussion of the VCAA as to those issues are unnecessary. As to the increased rating claims, the requirements of the statutes and regulation have been met in this case. VA notified the Veteran in September 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. In the September 2009 letter, the RO also provided additional information regarding disability ratings and the criteria applicable to the Veteran's increased rating claim in compliance with a decision of the United States Court of Appeals for Veterans Claims (Court) that was subsequently vacated by the Federal Circuit. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims and affording him VA examinations to determine the severity of his service-connected disabilities. As indicated above, the appeal was remanded in October 2015 to, among other things, afford the Veteran VA examinations to determine the severity of his service-connected disabilities. Most recently, in December 2015, the Veteran was afforded a VA examination. The Board finds that the VA examination reports of record are adequate because they are based on consideration of the Veteran's prior medical history and described the disabilities in sufficient detail to allow the Board to make fully informed evaluations. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board notes that in a November 2017 statement, the Veteran's attorney requested that the Veteran should be afforded new examinations to determine the severity of his service-connected disabilities, as time has lapsed since the Veteran's last VA examination in December 2015. To this end, the Veteran has not contended and treatment records have not shown that the service-connected disabilities in appeal have worsened since his VA examination in December 2015. The mere passage of time between the medical examination and the Board's decision is insufficient to trigger VA's duty to provide a new medical examination. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (holding that where claimant has not alleged a worsening of a service-connected disability, there exists no duty under 38 U.S.C. § 5103A for the Secretary to provide a medical examination). Furthermore, the Board, herein, granted the maximum schedular rating for the left ankle disability, absent ankylosis, and granted a higher rating for the left foot disability. Under these circumstances, the Board finds that a remand for additional VA examinations is not warranted. Neither the Veteran nor his attorney has raised any other issues with the duty to notify or duty to assist. 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."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument)." I. Increased Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2017); see Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (holding that pain "must actually affect some aspect of 'the normal working movements of the body' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating). With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45 (2017). These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206 - 07 (1995) (holding that the provisions of 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, the intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See 38 C.F.R. § 4.59 (2017). Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id; see also 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). The Board notes that in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 38 C.F.R. § 4.59 provides, "The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." In the case of the Veteran's left ankle disability, however, the Board is granting the highest rating possible under the applicable diagnostic codes based on limitation of motion, with higher ratings requiring ankylosis. Any error in not conducting Correia-complaint range of motion testing with regard to the ankle joints is therefore harmless. A. Left Foot Disability The Veteran's osteoarthritis left foot injury is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, DCs 5010- 5284. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5010 concerns arthritis due to trauma; it requires establishment by x-ray evidence. DC 5010 is to be rated the same as DC 5003. Under DC 5003, degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. However, in the absence of limitation of motion, the disability is to be rated as 10 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups; and as 20 percent disabling with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Disability ratings under DC 5003 is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added. Multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints. 38 C.F.R. § 4.45. DC 5284 provides rating criteria for other foot injuries. A moderately severe foot injury warrants a 20 percent disability evaluation and a severe foot injury is assigned a 30 percent disability evaluation. A 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5284. VA's General Counsel has determined that DC 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, DC 5284 may involve limitation of motion. VAOPGCPREC 9-98. The words "moderate," "moderately severe," and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2017). The use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). The Veteran filed a claim of entitlement to an increased rating for his osteoarthritis left foot injury in February 2009. During an October 2009 examination, the Veteran reported left foot pain, weakness stiffness, and swelling. Upon standing or walking, he experiences left foot weakness, stiffness, swelling, and fatigue. He indicated that he in unable to climb or walk for long periods of time due to his left foot disability. He denied the use of a cane, or any other assistance devices. Upon physical examination of the left foot, the examiner indicated that there was no tenderness to palpation, painful motion, weakness, edema, heat, redness, instability, atrophy, or disturbed circulation. He had active motion in the metatarsophalangeal joint of the left great toe. There was no evidence of pes planus, pes cavus, hammer toes, or hallux valgus. The examiner indicated that the Veteran does not require any type of support for his left foot. The examiner diagnosed osteoarthritis of the left foot based on x-ray evidence. The examiner concluded that the Veteran's disabilities, to include the left foot, do not impact his usual occupation or daily activities. During an April 2011 VA examination, the Veteran reported a history of a surgery of the left big toe in 1977. He stated that he currently has pain in his left toes with burning and aching that is exacerbated by physical activity. He described pain, stiffness, and swelling. Upon walking, he experiences left foot pain, weakness, stiffness, swelling, and fatigue. He has difficulty walking or standing on hard surfaces. He denied the use of a cane, or any other assistance devices. Upon physical examination of the left foot, the examiner indicated that there was no evidence of left foot abnormalities, to include no indication of weight bearing or breakdown callosities. There was tenderness to palpitation. There was no sign of pes cavus, hammer toes, hallux valgus, or limitations with standing or walking. There is active motion in the metatarsophalangeal joint of the left great toe. The examiner indicated that the Veteran does not requires any type of support for his left foot, to include shoe inserts. The examiner indicated that there was a left foot scar that was non painful scar and measured 4 centimeters (cm) by 0.3 cm. The examiner also indicated that the scar does not cause functional impairment or limit his motion. Private treatment record dated in February 2015, July 2015, and December 2015 include the Veteran's reports of left foot pain. The evidence shows that the Veteran's osteoarthritis left foot injury has manifested by symptoms including left foot pain, burning, aching, weakness stiffness, fatigue, and swelling. Furthermore, the Veteran has described that upon physical activity, such as prolonged walking; he experiences left foot pain, weakness, stiffness, swelling, and fatigue. And, he has difficulty walking or standing on hard surfaces. Based on the above evidence, including VA examination and treatment records, as well as the Veteran's own description of left foot pain with resulting limitation in functioning, the Board finds that a 20 percent rating, indicative of "moderately severe" disability under DC 5284, is warranted. The Board further notes that the Veteran's reports of left foot pain, weakness, stiffness, fatigue, swelling, and functional impairment are specifically encompassed in the Board's assignment of the 20 percent disability rating. As described above, DC 5284 provides for ratings based on the overall severity of the disability. Overall, the Board finds that the Veteran's left foot symptomatology more nearly approximates that of a moderately severe disability. In reaching this conclusion, the Board finds probative the fact that the Veteran experiences left foot pain, burning, aching, weakness stiffness, fatigue, and swelling, which impacts his ability to walk for prolonged periods. Moreover, he had has difficulty walking or standing on hard surfaces. Thus, the Board finds that the Veteran's disability picture more nearly approximates a 20 percent disability rating for the entire period under DC 5284. See 38 C.F.R. § 4.7. The Board finds that a rating greater than 20 percent is not warranted, based on lack of evidence showing severe impairment of the left foot. For example, upon physical examination of the left foot, the VA examiners found that there was no evidence of tenderness to palpation, edema, heat, redness, instability, atrophy, or disturbed circulation. Furthermore, during the October 2009 and April 2011 examinations, the Veteran denied the use of a cane, or any other assistance devices. Moreover, the October 2009 and April 2011 examiners found that the Veteran did not require shoe inserts or another type of support for in his left foot. Moreover, the evidence fails to suggest that the Veteran's osteoarthritis left foot injury is analogous to actual loss of use of the foot, as it is clear that the Veteran's left foot is functional. See 38 C.F.R. § 4.71a, DC 5284, Note. Thus, the Board finds that the symptoms have not more nearly approximated a rating greater than 20 under DC 5284. In addition, a separate rating under DCs 5010 or 5003, which pertains to degenerative and traumatic arthritis, would violate the rule against pyramiding as the Veteran's pain on use of the left foot is already compensated under DC 5284, and a rating greater than 10 percent is not available under Diagnostic Code 5003. See 38 C.F.R. § 4.14. The Board further finds that a separate rating or a higher is not warranted under any other applicable provision of the rating schedule. 38 C.F.R. § 4.71a, DCs 5276-5284. To this end, the Veteran does not have a diagnosis of or symptoms approximating pes planus, weak foot, claw foot, hammer toe, hallux valgus, metatarsalgia, or hallux rigidus. 38 C.F.R. § 4.71a, DCs 5276-5278, 5279, 5280-5282. In addition, the record contains no evidence of any malunion or nonunion of the left foot. No other pathology of the left foot has been diagnosed. The Board has also considered the Veteran's left foot scar, as noted in the April 2011 examination report. There was no evidence that the left foot scar was painful/tender, unstable, deep, nonlinear, covers an area of 144 square inches or more, or limits function of the left foot in any way. As such, a separate, compensable rating for the left foot scar cannot be assigned. See 38 C.F.R. § 4.118, DCs 7801-7805 (2016). As the preponderance of the evidence is against a rating higher than 20 percent for the Veteran's osteoarthritis left foot injury, the benefit of the doubt doctrine is not for application in this regard. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102 B. Left Ankle Disability The Veteran's degenerative arthritis of the left ankle is currently assigned a 10 percent rating under DCs 5010- 5271. Under DC 5171 (ankle, limited motion of), marked limitation of motion in the ankle warrants a 20 percent disability rating, and moderate limitation of motion in the ankle warrants a 10 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Twenty percent is the maximum disability rating under this Diagnostic Code. While the schedule of ratings does not provide any information as to what manifestations constitute "moderate" or "marked" limitation of ankle motion, guidance can be found in VBA's M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. Normal range of motion for the ankle is defined as follows: dorsiflexion from zero to 20 degrees; and plantar flexion from zero to 45 degrees. See 38 C.F.R. § 4.71, Plate I. In an October 2009 statement, the Veteran stated that he is limited, unable to perform his work duties due to his disabilities. He stated that he has difficulty walking due to his ankle and knees. In an October 2009 VA examination, the Veteran reported left ankle weakness, stiffness, swelling, giving way, lack of endurance, tenderness, and pain. He stated that he has flare-ups as often as four times per week, occurring spontaneously, lasting for one to two days each time, at a severity level of 10 (out of 10), and precipitated by physical activity and alleviated by rest. He described his functional impairment during the flare-ups as limitation of motion of the joint and not being able to walk on uneven surfaces. He has difficulty with walking and standing. He indicated that he is unable to climb. Upon physical examination, ranges of motion of the left ankle were recorded as dorsiflexion to 20 degrees with pain and plantar flexion was to 45 degrees with pain. The Veteran was able to perform repetitive ranges of motion without additional degrees of limitation. The examiner indicated that the left joint function is not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There was no instability, effusion, weakness tenderness redness, heat, deformity, subluxation, or ankylosis. The examiner diagnosed left ankle status post fracture. The examiner concluded that the Veteran's disabilities do not impact his usual occupation or daily activities. During an April 2011 VA examination, the Veteran reported the same left ankle symptoms as noted during the October 2009 examination, in addition he stated that his functional impairment during flare-ups as not being able to walk on uneven surfaces, not being able to stand for long periods of time, limitation of motion of the joint ("easy to sprain"), and lots of swelling. Upon physical examination of the left ankle, the ranges of motion of the left ankle were recorded as dorsiflexion to 20 degrees with pain at 18 degrees plantar flexion was to 45 degrees with pain at 44 degrees. The Veteran was able to perform repetitive ranges of motion without additional degrees of limitation. The examiner indicated that the left joint function is not additionally limited by pain, fatigue weakness, lack of endurance, or incoordination after repetitive use. There was tenderness to papillation. There was no evidence of edema, instability, abnormal movement, effusion, weakness, redness, ankylosis, deformity, or subluxation. An x-ray report of the left ankle showed degenerative arthritic changes and calcaneal osteophyte. In an October 2015 private disability benefits questionnaire (DBQ), the Veteran reported pain, swelling, reduced ranges of motion, fatigue, and difficulty with weight bearing. Upon physical examination of the left ankle, ranges of motion were recorded for dorsiflexion to 10 degrees and plantar flexion to 30 degrees. After repetitive use testing, ranges of motion were recorded for dorsiflexion to 10 degrees and plantar flexion to 25 degrees. The D.O. indicated that the following factors contributed to functional loss or impairment: less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, and interference with standing. The estimated the range of motion due to functional loss during flares-ups for the left ankle was dorsiflexion to 5 degrees and plantar flexion to 20 degrees. The Veteran had pain upon active, passive, and repetitive use testing with ranges of motions. He had pain on weight bearing and non-weight bearing. There was localized tenderness or pain to palpation of joint or soft tissue. Muscle strength was active movement against some resistance. There was no muscle atrophy, ankylosis, malunion or calcaneus, or talectomy. He has abnormal gait due to his left ankle disability. The D.O. diagnosed left ankle lateral collateral ligament sprain and osteoarthritis. During a December 2015 VA examination, the Veteran reported left ankle pain. He denied flare-ups. Upon physical examination of the left ankle, ranges of motion were recorded for dorsiflexion to 15 degrees and plantar flexion to 40 degrees. The examiner noted that there was pain upon ranges of motion, but it did not result in functional loss. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. There was no localized tenderness or pain on palpation the joint or associated soft tissue, amylosis, crepitus, or pain weight bearing. The examiner indicated that there was left ankle instability or dislocation suspected; no further information was provided. Muscle strength was normal. There was no muscle atrophy. The examiner diagnosed left ankle arthritic conditions. The examiner opined that the Veteran's left ankle disability impacts his ability to perform occupational task that involve heavy labor. The examiner stated that the Veteran would be able to perform other occupations that did not include heavy manual labor. Private treatment record dated in February 2015, July 2015, and December 2015 include the Veteran's reports of left ankle pain. Specifically, in the July 2015 private treatment record, the physician noted that there were decreased ranges of motion of the left ankle and tenderness to palpation. The physician indicated that there was no instability of the left ankle. The above reflects that the evidence is approximately evenly balanced as to whether the symptoms of the Veteran's left ankle disability more nearly approximate "marked" limitation of motion under DC 5271. Throughout the pendency of the claim, the Veteran has consistently complained of pain and other symptoms that limit motion of his left ankle during flare-ups. Moreover, there has been pain and other symptoms on examination have limited the range of motion of the left ankle. Ranges of motion of the left ankle were recorded to, at worst, dorsiflexion to 10 degrees and plantar flexion to 30 degrees. See private DBQ dated October 2015. Importantly, the October 2015 physician estimated the ranges of motion due to functional loss during flares-ups for the left ankle resulting in dorsiflexion to 5 degrees and plantar flexion to 20 degrees. Therefore, resolving reasonable doubt in favor of the claim, the Board finds that a 20 percent rating under DC 5271 for the left ankle is warranted for the entire period on appeal. A 20 percent rating is the maximum evaluation under DC 5271. Because the Veteran's left ankle has been assigned the maximum rating based on limitation of motion, the DeLuca criteria are not applicable. See Johnston, 10 Vet. App. at 85; see also 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07. The Veteran also has arthritis of the left ankle. However, to grant a separate rating for arthritis would amount to compensating twice for manifestations of the same disability under different diagnoses, in violation of the rule against pyramiding. As there was no evidence of ankylosis or os calcis, astragalus, or astragalectomy, warranting a higher rating under DCs 5270, 5272, 5273, or 5274, no higher or separate rating is warranted. The evidence, thus, reflects no ankylosis or other symptoms warranting a rating higher than 20 percent under any potentially applicable diagnostic code. The Board has considered the Veteran's increased rating claims and decided entitlement based on the evidence. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See 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). III. Service Connection While service connection is warranted where a current disability resulted from an injury or disease incurred in or aggravated by active military service, 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303 (a), service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). A. Lumbar DDD The Veteran seeks service connection for a lumbar spine disability. See Veteran's claim dated July 2009. The evidence of record establishes that the Veteran has a current back disability, namely lumbar DDD. See private x-ray report dated August 2009. Furthermore, the Veteran is service-connected for degenerative arthritis of the left ankle and right ankle osteoarthritis (left and right ankle disabilities). Thus, the dispositive issue is whether the Veteran's current lumbar DDD is proximately due to or the result of his left and right ankle disabilities. In this regard, the evidence of record contains two opinions that show a relationship between the Veteran's current lumbar DDD and his service-connected left and right ankle disabilities. In a June 2015 private treatment record, a private physician stated that the Veteran's low back disability is not related to his military service, but is secondary to his ankle injury. Furthermore, in an October 2015 DBQ, a private D.O., interviewed the Veteran, reviewed the claims file and opined that the Veteran's low back disability is due to or the result of his service-connected left and right ankle disabilities. The private D.O., reasoned that the Veteran's "bilateral knee condition combined with his service-connected bilateral ankle injuries would cause him to unconsciously change his gait. That change would change the alignment in his lower back resulting in undue pressure on the disc causing them to fail." Additionally, the private D.O., also stated that the Veteran's left and right ankle disabilities has caused his gait to become abnormal and has resulted in the development of lower back conditions. The Board finds that the October 2015 DBQ opinion that the Veteran's service-connected left and right ankle disabilities caused his back disability is entitled to substantial probative weight, as the D.O. explained the reason for his conclusion based on an accurate characterization of the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Moreover, there is no opinion to the contrary. In light of the June 2015 physician's findings that the low back disability is secondary to his ankle disabilities and the October 2015 DBQ opinion, the evidence is thus approximately evenly balanced as to whether the Veteran's lumbar DDD is the result of his left and right ankle disabilities. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for lumbar DDD as secondary to service connected disabilities is warranted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. B. Right Knee Strain and Left Knee Strain The Veteran seeks service connection for right and left knee disabilities. See Veteran's claim dated February 2009. The evidence of record establishes that the Veteran has current right knee and left knee disabilities, namely a right knee strain and a left knee strain. See VA examination report dated December 2015. As indicated above, the Veteran is service-connected for right and left ankle disabilities. Thus, the dispositive issue is whether the Veteran's current right knee and left knee disabilities are proximately due to or the result of his right and left ankle disabilities. In an October 2015 DBQ, a private D.O., interviewed the Veteran, reviewed the claims file and opined that the Veteran's right knee and left knee disabilities are secondary to his service-connected right and left ankle disabilities. The private D.O. reasoned that the Veteran's "ankle injury would cause him to unconsciously change his gait. That change would place undue pressure on his knees causing them to fail." Additionally, the private D.O. also stated that the Veteran's bilateral ankle disabilities has caused his gait to become abnormal and is resulting in the development of knees conditions. The Board finds that entitlement to service connection for a right knee strain and left knee strain as secondary to his service- connected right and left ankle disabilities is warranted. The Board finds that the October 2015 DBQ opinion that the Veteran's service-connected left and right ankle disabilities caused his right knee and left knee disabilities highly probative, as the October 2015 private D.O., provided a clear rationale for his opinion that was consistent with the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Significantly, the October 2015 private D.O., explained that the Veteran's service-connected left and right ankle disabilities caused an abnormal gait which resulted in bilateral knee disabilities. Moreover, there is no opinion to the contrary. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right knee strain and left knee strain as secondary to service connected disabilities, is warranted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. ORDER Entitlement to a 20 percent rating, but no higher, for osteoarthritis left foot injury is granted, subject to the legal authority governing the payment of compensation. Entitlement to a 20 percent rating, but no higher, for degenerative arthritis of the left ankle is granted, subject to the legal authority governing the payment of compensation. Entitlement to service connection for lumbar DDD as secondary to his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis is granted. Entitlement to service connection for a left knee strain as secondary to his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis is granted. Entitlement to service connection for right knee strain as secondary to his service-connected degenerative arthritis of the left ankle and right ankle osteoarthritis is granted. REMAND The Veteran claims that his neck disability is due to his paratrooper activities in service. The Veteran's DD Form 214 confirms that he was awarded a Parachute Badge. Pursuant to the October 2015 Board remand, in December 2015, the Veteran was afforded an examination. In a December 2015 examination report and in a January 2016 medical opinion, the VA examiner diagnosed a neck strain and opined that the Veteran's neck strain is not related to his military service. For a rationale, the VA examiner stated that "there is no literature to support that jumping out of airplanes puts [an individual] at an increased risk of this versus non-military career paths." The Board finds that the December 2015 opinion is flawed. The December 2015 rationale is brief and dismissive, as it only considers whether medical literature indicates that jumping out of planes creates a greater risk of a neck disability. Additionally, the Board notes that service connection does not require an in-service injury or disease that is the cause of a veteran's current disability to the exclusion of an in-service event or series of events that might be the cause thereof. See Duenas v. Principi, 18 Vet. App. 512,517 (2004) (explaining that service connection requires some evidence of an inservice event, injury, or disease); 146 CONG. REC. H9912, H9917 (daily ed. Oct. 17, 2000) (statement of Rep. Evans) (discussing the Veterans Claims Assistance Act of 2000 and explaining that the law would require the Secretary to provide a medical examination on nexus to a veteran who (1) has evidence of arthritis of the knee and (2) indicates the condition was due to his in-service duties as a paratrooper). Thus, the question presented in the October 2015 Board remand has not been properly addressed; therefore, a remand is necessary to obtain an opinion by physician with appropriate expertise to address the etiology of the Veteran's neck strain. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand confers on the appellant, as a matter of law, the right to compliance with the remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (Once VA undertakes the effort to provide an examination or opinion when developing a claim, it must provide an adequate one). Finally, with regard to entitlement to a TDIU, in an October 2009 statement, the Veteran stated that he is limited/unable to perform his work duties due to his disabilities. He stated that he has difficulty walking due to his service-connected ankle and knees. He also indicated that he has back pain, which contributes to his inability to walk. As indicated above, the Board herein awarded service-connection for his back, left knee, and right knee disabilities. Therefore, upon remand, the AOJ is to consider this issue in the first instance, to include any appropriate development. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Obtain records of treatment that the Veteran may have received at any VA health care facility since December 2015. All such available documents should be associated with the claims file. 2. Obtain the appropriate release of information forms where necessary, procure any records of outstanding treatment that the Veteran has recently received. All such available documents should be associated with the claims file. 3. Then, obtain a medical opinion from an appropriate physician as to the etiology of any neck disability. The claims file must be sent to the physician for review. The physician should first identify any current neck, i.e., since the Veteran filed his claim in February 2009. Then, as to any such disability, the physician should indicate whether it is as least as likely as not (50 percent probability or more) that such disability is at least as likely as not related to service, to include as due to his in-service paratrooper activities. A complete rationale should accompany any opinion provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinion. 4. Thereafter, readjudicate the issues on appeal, to include entitlement to a TDIU. If the benefits sought on appeal remain denied, provide the Veteran and his representative with a Supplemental Statement of the Case and afford them a reasonable opportunity to respond. Then return the case to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2016). Department of Veterans Affairs