Citation Nr: 1803080 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 03-17 945 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a bilateral knee disorder, to include as secondary to residuals of a remote fracture of the right third metatarsal. 3. Entitlement to a disability rating in excess of 10 percent for residuals of a remote fracture of the right third metatarsal disability (right foot disability) from December 14, 2001, to August 10, 2009, and in excess of 20 percent since August 11, 2009. 4. Entitlement to a temporary total rating due to a hospitalization in excess of 21 days for depressive disorder, from December 5, 2006, to December 28, 2006. 5. Entitlement to service connection for hypertension. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Hodzic, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1974 to August 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2002, November 2007, and January 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified before a Veterans Law Judge (VLJ) via videoconference in September 2013. A transcript of the hearing has been associated with the Veteran's claims file. In a June 2017 letter, VA notified the Veteran that the VLJ who conducted his hearing was no longer with the Board, and that he had a right to another hearing on these matters, if he so desired. He was also advised that if he did not respond within 30 days, the Board would assume he did not want to have another hearing and it would proceed accordingly. The Veteran did not request another hearing within 30 days of this notice. See 38 C.F.R. § 20.702(e) (2017). The Board remanded the increased rating claim for a right foot disability in December 2008. The Board also remanded this claim, as well as the claim of entitlement to a TDIU, in October 2010. Furthermore, the Board remanded all of the issues on appeal in June 2013 and June 2014 for additional evidentiary and procedural development. The issues of entitlement to service connection for hypertension 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 Veteran's current hepatitis C is not caused by or otherwise related to his active duty service, to include receiving vaccinations. 2. The Veteran's current bilateral knee disorder did not manifest in service or within one year of separation from service, is not caused or otherwise related to his active duty service, and it is not caused or aggravated by his service-connected right foot disability. 3. The Veteran's residuals of a remote fracture of the right third metatarsal disability did not manifest as moderately severe prior to August 11, 2009, and it has not manifested as severe at any time during the appeal period. 4. The Veteran did not undergo a period of hospitalization lasting longer than 21 days due to a service-connected disability in December 2006. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. The criteria for service connection for a bilateral knee disorder, to include as secondary to residuals of a remote fracture of the right third metatarsal, have not been met. 38 U.S.C. §§ 1110, 1131, 1137 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2017). 3. The criteria for a disability rating in excess of 10 percent for residuals of a remote fracture of the right third metatarsal disability from December 14, 2001, to August 10, 2009, and in excess of 20 percent since August 11, 2009, 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, Diagnostic Code (DC) 5299-5284 (2017). 4. The criteria for a temporary total rating due to a hospitalization in excess of 21 days for depressive disorder, from December 5, 2006, to December 28, 2006, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.29 (2017). 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 June 2002, April 2005, August 2009, May 2011, and September 2015, as well as an addendum VA medical opinion in December 2015, for the issues the Board is adjudicating below. In a May 2017 statement, the Veteran's representative contended that the September 2015 VA examinations for the Veteran's bilateral knee disorder and hepatitis C were inadequate because the knee disorder examination did not consider the Veteran's lay statements and the hepatitis C examination did not list the Veteran's other risk factors for contracting hepatitis C. However, the September 2015 VA examiners considered the Veteran's self-reported symptoms and history, reviewed his pertinent records, and conducted in-person examinations. The September 2015 VA examination report for hepatitis C includes the Veteran's risk factors, and the September 2015 VA examination report for the Veteran's bilateral knee disorder, in conjunction with the December 2015 VA addendum medical opinion, shows that the examiner considered the lay statements of record. The Board determines that the VA examinations listed above and the December 2015 VA addendum medical opinion 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 June 2014, the Board remanded the case to associate with the claims file outstanding VA, private, and Social Security Administration (SSA) records, schedule the Veteran for VA examinations for his hepatitis C, bilateral knee disorder, and right foot disability claims, and issue a supplemental statement of the case (SSOC) if any benefit was denied. There was substantial compliance with the Board's remand directives for the claims the Board is adjudicating below. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection, Generally The Veteran contends that he contracted his current hepatitis C when he received vaccinations during active duty service. Furthermore, he contends that his current bilateral knee disorder was caused or aggravated by his service-connected right foot disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 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 disability 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). The Veteran currently has arthritis in his knees, which is a chronic disease listed under 38 C.F.R. § 3.309(a); 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 (such as arthritis) 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, 1110, 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. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 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. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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). Hepatitis C The Veteran contends that he contracted hepatitis C in service when he was vaccinated with a needle from a booster air gun that was previously used on another service member. The record shows that he has a current diagnosis of hepatitis C. Specifically, various VA treatment records, as well as a September 2015 VA examination report, show that the Veteran was diagnosed with hepatitis C. Thus, the first element of service connection-evidence of a current disability-is met. Regarding the second element of service connection, i.e., an in-service incurrence of a disease or injury, the Veteran's service treatment records do not note or document any treatment for a blood-related disorder, including hepatitis C. Specifically, his February 1974 entrance evaluation and his August 1975 separation evaluation do not mention this disorder. In fact, the record is silent as to any treatment for this disability until 2002, approximately 27 years after separation from active duty service. Nonetheless, the Veteran has contended in multiple statements since filing his claim for service connection in January 2007 that his current hepatitis C stems from being inoculated with a booster air gun in service after several other individuals were inoculated with the same instrument. In fact, he testified as to this in-service occurrence during the September 2013 Board hearing. He also submitted several articles from the Internet discussing the use of booster air guns in the military in the United States; however, the Board notes that these articles did not pertain to the Veteran and did not discuss his specific circumstances in service. Apart from the Veteran's statements regarding his in-service incurrence of hepatitis C, the claims file contains a medical examination and opinion from a September 2015 VA examiner discussing the causal relationship between the Veteran's current hepatitis C and his active duty service. During the September 2015 VA examination, the Veteran told the examiner his contentions that he was infected with hepatitis C from vaccinations while in service. After reviewing the Veteran's records, performing an in-person examination, and noting the Veteran's lay statements, the examiner determined that the Veteran was first diagnosed with hepatitis C in 2002. The examiner noted that the Veteran's risk factors for hepatitis C included intravenous drug use or intranasal cocaine use, and other direct percutaneous exposure to blood, such as a remote history of promiscuity and sharing needles. The examiner opined that it is less likely as not (less than 50 percent probability) that the Veteran's current hepatitis C was incurred in or caused by his active duty service, including being vaccinated in service. The examiner explained that there is no evidence in the medical literature that confirms transmission of hepatitis C by the means that the Veteran described occurred to him in service. The examiner cited to medical literature to note that although it is possible in theory, there is not enough evidence to confirm this as a risk factor and that attempts to obtain service connection by claiming air gun infection during military service have been controversial. The examiner further explained that the Veteran has a history of other known risk factors associated with hepatitis C, such as intravenous drug use or intranasal cocaine use and other direct percutaneous exposure to blood. The Veteran's current hepatitis C is not caused or otherwise related to his active duty service, to include receiving vaccinations during service. The Board acknowledges the Veteran's contentions that his current disability is related to his in-service vaccinations. The Veteran is competent to report events and 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 hepatitis C 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). Hepatitis C requires specialized training for a determination as to diagnosis, causation, and progression, and is 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 disability. The September 2015 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 hepatitis C is less likely as not related to or caused by the Veteran's active duty service, to include his vaccinations during service. The examiner concluded that the Veteran's current disability was due to other risk factors, including drug use and a remote history of promiscuity. This examiner's opinions are highly probative evidence regarding the cause of this disorder because of the examiner's expertise, training, education, proper support and explanations, and thorough review of the Veteran's records and self-reported symptoms. To the extent that the Veteran testified during the September 2013 Board hearing and asserted during the September 2015 VA examination that he does not have risk factors for contracting hepatitis C through illicit drug use, the Veteran's statements are not credible as they are inconsistent with the record. The Board notes that the Veteran's claims file contains numerous treatment records of hospitalizations due to alcohol, drugs, and polysubstance abuse, including in 2006 and 2011. Additionally, the record shows that the Veteran was arrested and incarcerated for possession of certain illegal substances during the appeal. Given this evidence, the Board finds that the preponderance of the evidence is against entitlement to service connection for hepatitis C. The benefit of the doubt doctrine does not apply, and the Veteran's claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. Bilateral Knee Disorder The Veteran contends that his current bilateral knee disorder is caused by his service-connected right foot disorder of residuals of a remote fracture of the right third metatarsal. The Veteran has a current bilateral knee disability. Specifically, numerous VA treatment records, including a September 2015 VA examination report show that he was diagnosed with degenerative arthritis in both knees. Thus, the first element of direct and secondary service connection is met. Regarding the second element of direct service connection, the evidence does not show that the Veteran's current bilateral knee disorder manifested in service or within one year of separation from service. Specifically, the Veteran's service treatment records do not show any complaints of or treatment for abnormal knee symptoms. Evaluators noted that his lower extremities were normal during the February 1974 entrance evaluation and August 1975 separation evaluation. Likewise, the Veteran denied having any abnormal knee symptoms at entrance and separation from active duty service. Post-service evidence indicates that there was no continuity of symptomatology for the Veteran's bilateral knee arthritis. The Veteran first complained of painful right knee symptoms in June 2003 (approximately 28 years following service discharge). Since that time, the Veteran's VA and private treatment records show that he has been diagnosed with bilateral knee disorders; however, these records do not discuss the cause of the current knee disorders. A September 2015 VA examiner opined that the Veteran's current bilateral knee disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner explained that the Veteran's service treatment records do not show any evidence of bilateral knee symptoms or disorders and that his 1975 service separation evaluation was negative. The examiner noted that there was no evidence of the Veteran's right knee disorder symptoms until 2004 and no evidence of the left knee disorder until the September 2015 examination. Given this evidence, the Board finds that the Veteran's current bilateral knee disorder did not manifest in service or within one year of separation from service and that it is not caused or otherwise related to his active duty service. The Board finds the September 2015 examiner's opinions to be highly probative evidence regarding the cause of the bilateral knee disorder because of the examiner's expertise, training, education, proper support and explanations, and thorough review of the Veteran's records and self-reported symptoms. As noted by the examiner, and as reflected in the claims file, there was no continuity of symptomatology of the Veteran's bilateral knee disorder as it did not manifest in the right knee until approximately 28 years after separation from service and approximately 40 years in the left knee after service. The Board notes that the Veteran does not contend that his current bilateral knee disorder is caused by his active duty service. Rather, he asserts that his current bilateral knee disorder is caused or aggravated by his service-connected right foot disability. Apart from the Veteran's numerous statements, the claims file contains the opinions of the September 2015 VA examiner, with an addendum VA medical opinion in December 2015, regarding the causal relationship between the Veteran's service-connected right foot disability and his bilateral knee disorder. The September 2015 VA examiner concluded that it is less likely than not (less than 50 percent probability) that the Veteran's bilateral knee disorder is proximately due to or the result of the Veteran's service-connected right foot disability. The examiner explained that the Veteran's recent radiographic results showed that there was no fracture of the third metatarsal of the right foot. The examiner noted that the Veteran's bilateral knee arthritis, or degenerative joint disease (DJD), were related to his obesity and due to a generalized and/or aging process. In the December 2015 VA addendum medical opinion report, the examiner concluded that it is not at least as likely as not that the Veteran's current bilateral knee disorder was aggravated beyond its natural progress by the Veteran's service-connected right foot disability. The examiner explained that the Veteran's recent radiographic results demonstrated no evidence of previous fractures to the third metatarsal in the right foot. The examiner also noted that there was no significant post-traumatic arthropathy on the right foot and that the Veteran has DJD on bilateral knees, not only on the right. The examiner also noted that the Veteran was obese, which makes his diagnosis most likely a generalized and/or part of the aging process. Given this evidence, the Board finds that the Veteran's current bilateral knee disorder is not caused or aggravated by his service-connected right foot disability. As noted above, the Board finds the September 2015 examiner's opinions, in conjunction with the December 2015 addendum VA medical opinion, to be highly probative evidence regarding the causal relationship between the Veteran's service-connected right foot disability and his bilateral knee disorder because of the examiner's expertise, training, education, proper support and explanations, and thorough review of the Veteran's records and self-reported symptoms. Accordingly, as the preponderance of the evidence is against entitlement to service connection for a bilateral knee disorder, to include as secondary to residuals of a remote fracture of the right third metatarsal, the benefit of the doubt doctrine does not apply, and the Veteran's claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. Increased Rating for a Right Foot Disability The Veteran contends that his residuals of a remote fracture of the right third metatarsal disability 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 filed an increased rating claim for this disability in April 2002; however, as discussed in more detail below, the RO assigned a 10 percent disability rating for this disability, effective December 14, 2001, because the evidence showed worsening symptoms within one year prior to the Veteran's filing of the claim for increase. The Veteran's right foot disability is rated as 10 percent disabling from December 14, 2001, to August 10, 2009, and as 20 percent disabling since August 11, 2009, under 38 C.F.R. § 4.71a, DC 5299-5284. DC 5284 rates other foot injures, which contemplate his residuals of a fracture of the right third metatarsal. A 10 percent disability rating is assigned for moderate symptoms. A 20 percent disability rating is assigned for moderately severe symptoms. A 30 percent disability rating is assigned for severe symptoms. The rating criteria direct that a 40 percent disability rating should be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5283, Note. 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. The provisions of 38 C.F.R. § 4.40 allow 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). A December 2001 VA podiatry note shows that the Veteran had a history of trauma to his feet while in service and that he had pain in his feet when walking. A VA progress note from the same date shows that the Veteran complained of hardly being able to walk in the morning. A physical evaluation showed the presence of foot pain, but no cyanosis and clubbing or edema in the Veteran's extremities. Additionally, the Veteran's pedal pulses and light sensation were intact, and a visual inspection of his extremities was normal. An x-ray showed mild degenerative change in the right metatarsal phalangeal joint. A February 2002 VA social worker's note indicates that the Veteran's active problems include foot pain and that he dealt with his pain through illicit drug use. In April 2002, the Veteran filed a claim for an increased rating for his right foot disability. He asserted that his feet had worsened to the point that the cannot stand. He also stated that he experienced extreme, constant pain in both feet. As noted above, the RO assigned an increased rating of 10 percent since December 14, 2001, in a May 2002 rating decision due to the symptoms noted in the VA podiatry note, progress note, and x-ray from December 2001. A June 2002 private initial psychiatric evaluation report shows that the Veteran was diagnosed with bilateral chronic foot pain. He reported ongoing pain since he broke his right foot in 1974. During a June 2002 VA examination, the Veteran complained of swelling and pain in his right foot due to prolonged periods of standing and working as a laborer at the docks. He told the examiner that this disability did not impact his daily living at home. A physical examination showed some swelling of the right foot and tenderness to palpation of the mid-tarsal area. The Veteran was able to squat and perform heel and toe touches. The examiner noted that there was no weakness or incoordination in the toes and ankles and that repeated motion of the ankles did not caused increased pain. A July 2003 VA podiatry note showed the Veteran's complaints of right foot pain at the metatarsal area. The doctor noted that the Veteran's symptoms had improved from two weeks prior. He was prescribed shoes with extra depth but he preferred not to wear them because of how they looked. The Veteran asked the doctor for documentation that his pain was severe for VA rating purposes. An April 2005 VA x-ray showed an impression of an essentially normal right foot. During an April 2005 VA examination, the Veteran complained of a throb in the right foot, especially with weight bearing, but stated that he did not have any pain while non-weight bearing. He indicated that his foot pain was normally a 2 or 3 out of a possible 10, but that it can be as high as a 4 or 5 out of a possible 10. He also endorsed persistent and intermittent swelling in this area. He asserted that he was unable to work due to his right foot symptoms. He did not have any heat or redness in the area. He indicated that he previously used aspirin, Motrin, and tramadol but with minimal improvement. He stated that he rested and elevated the foot when he had flare-ups, but that flare-ups did not cause any additional functional impairment. He did not have any limitation in his activities of daily living. He again noted that he was issued corrective shoes but that he did not wear them for cosmetic reasons. A physical examination showed essentially normal vascular, neurologic, and skin symptoms. The examiner noted pain with dorsiflexion and plantar flexion, but no pain with inversion or eversion of the right foot and the ankle. The examiner noted that there was no pain in the ankle with a re-examination. Ankle joint dorsiflexion was 10 degrees bilaterally, and the first metatarsophalangeal joint had crepitus. The examiner noted 20 degrees of dorsiflexion and 10 degrees of plantar flexion. The examiner determined that the Veteran's disability of status-post supposed right metatarsal fracture had not worsened since the previous examination. The examiner noted that the Veteran's symptoms were all subjective and that there was no evidence of any increased complications or sequalea of this disability. During an August 2009 VA examination, the Veteran complained of pain, stiffness and lack of endurance while standing and walking, but he did not have any swelling, heat, redness, fatigability, or weakness in the right foot due to his service-connected disability. He denied having flare-ups and the examiner noted that there was no functional limitation on walking or standing. He indicated that he can stand for 10 to 15 minutes without pain in his foot. The Veteran stated that he used corrective shoes and over-the-counter arch support inserts. A physical examination showed pain with dorsiflexion of the fourth digit, mild tenderness in the midfoot region with inversion and eversion of the subtalar joint, tenderness with palpation along the entire shaft of the third metatarsal, and tenderness with dorsal to plantar compression to the third and fourth metatarsal heads. The Veteran's gait was normal and there were no signs of antalgia. An x-ray showed mild spur formation in the plantar aspect of the calcaneus associated with mild calcific tendinitis of the Achilles tendon insertion site. The examiner determined that the Veteran's right foot disability moderately impacted his ability to do chores, shopping, exercise, sports, and drive, but mildly impacted his ability to dress, participate in recreation, and travel. This disability did not impact his ability to groom, bathe, or feed himself, or use the toilet. The examiner determined that the Veteran's right foot disability did not significantly limited functional ability during flare-ups or with extended use. The examiner noted no additional functional loss due to pain on use, weakened movement, excess movement, excess fatigability, or incoordination that could be attributed to this disability. The examiner noted that the x-ray evidence did not show a previous fracture of the third metatarsal. A physical examination showed symmetrical feet with no restrictions on range of motion or muscle strength, and no residual edema, malalignment, or significant post-traumatic arthropathy. In a November 2009 rating decision, the RO increased the rating for the Veteran's right foot disability to 20 percent disabling, effective August 11, 2009, due, in part, to the symptoms noted during the August 2009 VA examination. In a March 2010 statement, the Veteran's previous representative contended that the August 2009 VA examination showed that the Veteran's right foot symptoms were severe. During a May 2011 VA examination, the Veteran complained of intermittent pain in the right foot, which was aggravated by walking and climbing ladders. He indicated that this disability impacted his ability to work. He took tramadol medication for foot and knee pain. Although the Veteran complained of pain in the dorsum over the third metatarsal, he did not have any swelling, heat, redness, stiffness, fatigability, lack of endurance, weakness, or flare-ups of the right foot. He was able to stand for one hour and walk a quarter of a mile. He did not require the use of an assistive device. Although a physical examination showed painful motion and tenderness in the right foot, there was no abnormal weight bearing, swelling, instability, weakness, or any other foot disorder, such as hammertoes, hallux valgus or rigidus, skin or vascular foot abnormality, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, flatfoot, muscle atrophy of the foot, or an abnormal gait. An x-ray showed minimal degenerative changes in the first metatarsal phalangeal joint and calcaneal spurs in the intersection of the plantar fascia and at the insertion of the Achilles tendon. The examiner determined that this disability did not impact the Veteran's ability to use the toilet, travel, drive, or feed, bathe, dress, or groom himself. The disability mildly affected his ability to do chores and shop, moderately affected his ability to exercise and participate in recreational activities, and severely impacted his ability to participate in sports. The examiner noted that this disability would prevent the Veteran from working in a physical employment but would not prevent him from working in a sedentary environment. During the September 2013 Board hearing, the Veteran testified that his right foot affected his ability to work because it hurt when he would climb ladders. He stated that he sometimes had pain during the night and in the morning. He also testified that use throughout the day caused painful symptoms in the evening. He stated that he wore special shoes from time to time, but not all the time. He also testified that he did not use a cane often. During the September 2015 VA examination, the Veteran complained of pain and occasional swelling in his right foot. He stated that he wore orthopedic shoes but he denied any new injures or infection to the foot. He described his pain as achy and he indicated that his foot swelled and hurt more during flare-ups, which contributed to functional loss. The examiner noted that the Veteran's right foot had pain to palpation of the third metatarsal and that the severity of this disability was moderate. The examiner also noted that this disability impacted the Veteran's weight bearing and that caused him to have to wear arch supports, custom orthotic inserts, or shoe modifications. This disability manifested as pain on weight bearing, pain on non-weight bearing, and disturbance of locomotion. The examiner noted that the Veteran's foot disability caused difficulty walking during periods of flare-ups or when the foot was used repeatedly over a period of time. The examiner noted that the Veteran occasionally used a cane. The examiner determined that the Veteran's foot disability caused difficulty while driving, climbing ladders, or walking on roofs. Given this evidence, the Board finds that the Veteran's residuals of a remote fracture of the right third metatarsal disability did not manifest as moderately severe prior to August 11, 2009, and it has not manifested as severe at any time during the appeal period. Specifically, as noted by VA treatment records, as well as June 2002 and April 2005 VA examination reports, the Veteran's right foot symptoms included pain, swelling, flare-ups due to overuse, and the need to use over-the-counter medication to alleviate symptoms, but did not include limitations of his activities of daily living due to this disability, heat, redness, or additional functional impairment during flare-ups. Accordingly, the Veteran's disability picture from December 14, 2001, to August 10, 2009, approximates a moderate foot injury and does not warrant a rating in excess of 10 percent. See 38 C.F.R. § 4.71a, DC 5299-5284. The record shows that the Veteran's symptoms worsened in August 2009 as shown during the VA examination, which included the Veteran's complaints of stiffness, lack of endurance, and pain while walking and standing. This examination showed that the Veteran's right foot disability moderately impacted his ability to do chores, shop, exercise, participate in sports, and drive, but mildly impacted his ability to dress, participate in recreation, and travel. Additionally, this disability did not impact his ability to groom, bathe, or feed himself, or use the toilet. The examiner noted that the Veteran's feet were symmetrical with no restrictions on range of motion or muscle strength, any residual edema, malalignment, or significant post-traumatic arthropathy. Likewise, the May 2011 and September 2015 VA examinations showed similar results. Although the May 2011 examiner noted that the Veteran's right foot disability would severely impact his ability to participate in sports, the overall evidence shows that the Veteran's disability has been moderately severe since August 11, 2009. In fact, the September 2015 VA examiner determined that the Veteran's symptoms amounted to a moderate injury of the foot. Thus, the Veteran's right foot disability has not warranted a rating in excess of 20 percent since August 11, 2009. 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. 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 range of motion, and even after considering the effects of pain and functional loss, the Veteran's right foot did not manifest with moderately severe symptoms prior to August 11, 2009, and it has not manifested with severe symptoms at any time on appeal. Thus, a higher rating under these provisions is not approximated in the Veteran's disability picture. Accordingly, the Board concludes that the Veteran's residuals of a remote fracture of the right third metatarsal disability does not warrant a disability rating in excess of 10 percent from December 14, 2001, to August 10, 2009, and in excess of 20 percent since August 11, 2009. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3; Gilbert, 1 Vet. App. at 49. 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 claim for the right foot disability. 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). Temporary Total Rating Due to Hospitalization from December 5, 2006, to December 28, 2006 The Veteran contends that he is entitled to a temporary total evaluation based upon a hospitalization from December 5, 2006, to December 28, 2006, for his posttraumatic stress disorder (PTSD) with depression. A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period in excess of 21 days or hospital observation at VA expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. Subject to the provisions of paragraphs (d), (e), and (f), this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. Id. A December 2006 VA Medical Center (VAMC) report of hospitalization shows that the Veteran was hospitalized in a VA medical facility on December 5, 2006, for polysubstance. Similarly, a December 2006 VA status change document (VA From 10-7132) shows that the Veteran was hospitalized for over 21 consecutive days for, in part, polysubstance dependency and depressive disorder not otherwise specified (NOS). However, the Board notes that only the Veteran's residuals of a remote fracture of the right third metatarsal and tinea versicolor disabilities were service connected at the time of the December 2006 hospitalization. The Veteran's PTSD with depression disability was granted service connection effective January 30, 2007. Thus, while the Veteran was hospitalized for over 21 days in December 2006, the hospitalization was not for a service-connected disability. See 38 C.F.R. § 4.29. The record does not show, and the Veteran has not alleged, that he was hospitalized for his service-connected right foot or tinea versicolor disabilities in December 2006. Therefore, the requirement for a hospitalization over 21 days for a service-connected disability is not met. Accordingly, there is no legal basis for the allowance of a temporary total rating, despite the Veteran's inpatient treatment in December 2006, and his claim must be denied. ORDER Service connection for hepatitis C is denied. Service connection for a bilateral knee disorder, to include as secondary to residuals of a remote fracture of the right third metatarsal, is denied. A disability rating in excess of 10 percent for residuals of a remote fracture of the right third metatarsal disability from December 14, 2001, to August 10, 2009, and in excess of 20 percent since August 11, 2009, is denied. A temporary total rating due to a hospitalization in excess of 21 days for depressive disorder, from December 5, 2006, to December 28, 2006, is denied. REMAND The Board must remand the Veteran's claims of entitlement to service connection for hypertension and entitlement to a TDIU for additional development. Specifically, the Veteran asserted in an October 2015 statement that his hypertension disorder is caused by his service-connected PTSD with depression disability. Although the claims file contains a September 2015 VA medical opinion discussing the causal relationship between the Veteran's current hypertension disorder and his active duty service, the record does not contain a medical opinion answering the question as to whether the Veteran's current service-connected PTSD with depression disability causes or aggravates his hypertension disorder. Thus, an addendum VA medical opinion is necessary to adjudicate the Veteran's claim of entitlement to service-connection for hypertension. The claim for entitlement to a TDIU rating is inextricably intertwined with the claim for service connection, and this claim will be deferred pending the additional development. Accordingly, the case is REMANDED for the following actions: 1. Return the claims file to the September 2015 examiner and request that he re-review the claims file and respond to the below inquiries regarding the Veteran's service connection claim for hypertension. 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 hypertension disorder. 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 September 2015 VA examination report, and sound medical principles, the VA examiner should provide an opinion as to: i. Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's current hypertension was caused by or aggravated (permanently worsened) beyond normal progression due to the Veteran's service-connected PTSD with depression disability. ii. If the examiner finds that PTSD aggravates hypertension, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for hypertension prior to aggravation. If the examiner is unable to establish a baseline for the hypertension prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. 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 hypertension and entitlement to a TDIU 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 that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ A. P. SIMPSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs