Citation Nr: 1805967 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 06-02 070 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for a disability manifested by vision loss. 5. Entitlement to service connection for a foot disability other than flat feet, including plantar fasciitis. 6. Entitlement to a rating in excess of 10 percent for laxity of the right knee. 7. Entitlement to an increased rating for recurrent low back pain with history of muscle strain, currently evaluated as 20 percent disabling, to include consideration of a higher rating for right lower extremity radiculopathy, evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL The Veteran, his spouse, and his brother ATTORNEY FOR THE BOARD K. Hubers, Counsel INTRODUCTION The Veteran had active military service from November 1971 to April 1975 and from June 1975 to January 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In September 2009, the Veteran testified before the Veterans Law Judge (VLJ) who signed the June 2010 decision. However, that VLJ subsequently retired and the Veteran requested a new hearing. Therefore, the Veteran was afforded a November 2015 hearing before the undersigned VLJ. The claims file contains transcripts of both hearings. In August 2016, the Board remanded the above-listed issues for further development and readjudication. The requested development was completed except for the development related to the PTSD, diabetes, and vision loss issues. For reasons indicated below, the PTSD, diabetes, and vision loss claims will be remanded for further development to ensure full compliance with prior instructions. See Stegall v. West, 11 Vet.App. 268, 271 (1998). The remaining claims are ripe for adjudication on the merits. Stegall, 11 Vet.App. at 271. The issues of entitlement to service connection for PTSD, diabetes, and vision loss 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 does not have, and has not had during the appeal period, a hearing loss disability for VA purposes. 2. The Veteran does not have, and has not had during the appeal period, a foot disability other than flat feet. 3. The Veteran had no more than mild instability of the right knee and no recurrent subluxation of the right knee during the appeal period. 4. The Veteran had at least 35 degrees of forward flexion of the thoracolumbar spine and at least 120 degrees of combined ranges of motion. He had subjective complaints of pain throughout the range of motion, but no objective evidence of pain prior to 35 degrees of flexion. He did not have ankylosis, IVDS, muscle spasms, or neurological abnormalities or findings other than the separately rated radiculopathy of the right lower extremity. 5. The Veteran had no more than mild incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. The criteria for service connection for a foot disability other than flat feet have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2017). 3. The criteria for an initial disability rating in excess of 10 percent for the Veteran's service-connected laxity of the right knee have been not met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2017). 4. The criteria for an initial disability rating in excess of 20 percent for the Veteran's service-connected back disability have been not met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243 (2017). 5. The criteria for an initial disability rating in excess of 10 percent for the Veteran's service-connected radiculopathy of the right lower extremity have been not met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet.App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The points below focus on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. I. Service Connection: Bilateral Hearing Loss The Veteran asserts entitlement to service connection for bilateral hearing loss. Service connection for hearing loss shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. Most recently, on the authorized audiological evaluation in June 2017, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 25 25 LEFT 20 25 10 20 20 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 96 percent in the left ear. VA treatment records and examinations also fail to establish that the Veteran has had impaired hearing. For example, a VA examination in June 2010 produced invalid results, but valid speech recognition scores of 96 percent bilaterally. An August 1992 VA examination revealed hearing thresholds of 30 db at 4000 Hz, but no other thresholds greater than 25 db. Other records also fail to establish impaired hearing for VA purposes. In summary, the Veteran does not have hearing loss considered disabling for VA compensation purposes. See 38 C.F.R. § 3.385. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. §§ 1110, 1131. Accordingly, because audiometric testing has not shown the Veteran to have a right ear hearing loss disability for VA purposes, the criteria for establishing service connection for a bilateral hearing loss disability have not been met. 38 C.F.R. § 3.303; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability there can be no valid claim."); see also Gilpin v. West, 155 F.3d 1353, 1355 (Fed. Cir. 1998). The evidence is not in equipoise, but is against the Veteran's claim. The benefit of the doubt rule does not apply, and the Veteran's claim is denied. See 38 U.S.C.A. § 5107 (West 2014). II. Service Connection: Foot Disability Other Than Flat Feet (Pes Planus) The Veteran claims entitlement to service connection for a foot disability other than flat feet (pes planus). Notably, the claim of entitlement to service connection for flat feet was previously, finally denied in October 1999. See June 2010 Board Decision (denying reopening of the flat feet claim). During this appeal, the Veteran has continued to indicate that the disability about which he is concerned is his flat feet. That issue is not currently before the Board as it was denied by the VLJ who held the first hearing in this appeal, and that denial is final. The May 2004 VA examination indicated a diagnosis of plantar fasciitis, resolved. A July 2004 Social Security Administration (SSA) record indicated a diagnosis of plantar fasciitis two years previously (the date of this earlier diagnosis precedes the period on appeal). Subsequent treatment VA records from 2004 until the present fail to indicate the presence of any foot disability other than flat feet. For example, a September 2008 VA Podiatry Note shows painful in-growing nails and no other problems with diagnoses of diabetes mellitus, onychomycosis, and onychocryptosis. There are numerous subsequent VA treatment records including examination of the Veteran's feet that note them as normal. The Veteran underwent a VA examination in connection with this claim in August 2017. The VA examiner diagnosed bilateral flat feet (pes planus) with no other foot disabilities. In summary, the medical evidence is against finding that the Veteran has a current foot disability other than flat feet or that he has had one at any point during the appeal period. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. §§ 1110, 1131. Accordingly, because the greater weight of the evidence is against finding that the Veteran has had a foot disability other than flat feet during the appeal period, the criteria for establishing service connection for a foot disability other than flat feet have not been met. 38 C.F.R. § 3.303; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability there can be no valid claim."); see also Gilpin v. West, 155 F.3d 1353, 1355 (Fed. Cir. 1998). The evidence is not in equipoise, but is against the Veteran's claim. The benefit of the doubt rule does not apply, and the Veteran's claim is denied. See 38 U.S.C.A. § 5107 (West 2014). III. Increased Rating: General Principles The Veteran is appealing the original assignment of a disability evaluation following award of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, VA must evaluate the veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. In assigning disability ratings, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also VA Gen. Coun. Prec. 9-2004 (Sep. 17, 2004) ("[T]he key consideration in determining whether rating under more than one diagnostic code is in order is whether the ratings under different diagnostic codes would be based on the same manifestation of disability or whether none of the symptomatology upon which the separate ratings would be based is duplicative or overlapping."). VA has considered the level of the veteran's impairment throughout the entire period on appeal, including the propriety of staged ratings. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). IV. Increased Rating: Laxity of the Right Knee The Veteran currently has a 10 percent rating for her service-connected laxity of the right knee. Importantly, the Veteran's chondromalacia of the right knee is separately rated at 20 percent disabling and the claim to a higher rating for that aspect of the right knee disability was finally adjudicated in the Board's June 2010 decision. Therefore, the Board will not consider the appropriate rating for that aspect of the right knee disability and will evaluate the assigned rating with appropriate consideration of the rule against pyramiding. See 38 C.F.R. § 4.14. Disabilities of the knee joint, generally, are rated under Diagnostic Codes 5256 through 5263. See 38 C.F.R. § 4.71a. As noted above, the only issue in this appeal is the appropriate rating for the laxity of the right knee. DC 5257 provides for 10, 20, or 30 percent ratings for recurrent subluxation or lateral instability that is, respectively, slight, moderate, or severe. While the Veteran is competent to report (1) symptoms observable to a layperson (i.e. knee pain, swelling); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding the clinical significance of observable symptoms. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). This Veteran, who lacks medical training, is not competent to opine on the clinical significance of knee symptoms. See, e.g., Jandreau, 492 F.3d at 1377. Therefore, in evaluating the Veteran's claims, the Board will rely on the medical evidence of record. The Board, however, has considered the Veteran's subjective reports of symptoms, particularly as they illuminate or underscore the medical opinions of record. The Veteran has undergone several VA examinations during the period on appeal. A February 2008 VA examination revealed painful limited range of motion (0 to 90 degrees with pain), mild (1+) effusion, mild tenderness along the medial joint line, and a positive patella compression test. The Veteran reported subjective chronic, persistent pain below the knee cap with weakness, stiffness, swelling, and instability. He reported falls. The examiner did not indicate any instability. In July 2010, VA examination revealed no evidence of instability. The Veteran exhibited flexion to 85 degrees (after repetitive use testing), full extension, and no additional limitation due to fatigue, weakness, incoordination, or lack of endurance. At an April 2013 VA examination, the Veteran reported locking-up, giving way, and swelling in the right knee. Range of motion was from -5 (5 degrees of hyperextension) to 115 degrees with pain. The medial lateral and lateral collateral ligaments both tested as having normal stability. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran reported flare-ups that impacted range of motion, including stiffness. At the August 2017 VA examination, the Veteran reported continued aching, but no current treatment. He reported flare-ups of increased pain that affected his mobility. Range of motion was from 10 to 140 degrees. Joint stability testing was normal in all respects, including no history of recurrent subluxation, lateral instability, or recurrent effusion and normal anterior, posterior, medial, and lateral instability. The primary functional limitation was a limitation on ambulation and running. VA treatment records do not show any greater disability than that revealed in the VA examinations. For example, a March 2008 VA treatment note indicated a clinical assessment of right knee pain with instability. A July 2009 VA Orthopedic Note indicates mild laxity with valgus stress and no varus laxity. The treatment records occasionally continue to indicate some, mild laxity and/or instability, but not lateral instability (or laxity) or recurrent subluxation that would warrant a rating in excess of 10 percent disabling. The Veteran's functional limitations relate primarily to the painful motion which is separately rated at 20 percent and that rating is not at issue in this appeal. Any additional rating for the laxity based on the pain, other symptoms, and associated functional limitations relating to the chondromalacia and related limitation of motion is not warranted on this record. 38 C.F.R. § 4.14. The evidence is not in equipoise, rather the weight of the evidence is against entitlement to any rating in excess of 10 percent for right knee laxity. Gilbert, 1 Vet. App. at 53-56; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5257. V. Increased Rating: Low Back The Veteran currently has a 20 percent rating for his low back disability and a separate 10 percent rating for right lower extremity radiculopathy. The legal criteria for and the application of those criteria to the radiculopathy claim will be discussed in the section below; however, the VA examinations will be summarized in a discussion of the evidence here. Disabilities of the thoracolumbar spine are to be rated under the General Rating Formula for Diseases and Injuries of the Spine (the "Formula"). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2017). The Formula provides, in relevant part, the following ratings: A 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of height. A 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Id. Finally, a maximum 100 percent evaluation is warranted where there is unfavorable ankylosis of the entire spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Id., Note (2). The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. Ranges of motion are to be rounded to the nearest five degrees. Id., Note (4). "Unfavorable ankylosis" is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dislocation; or neurologic symptoms due to nerve root stretching." See id., Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See id., Note (5). The rating criteria are to be applied irrespective of symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. See 38 C.F.R. § 4.71a, Introductory Note to General Rating Formula for Diseases and Injuries of the Spine; see also 68 Fed. Reg. at 51,455 (Supplementary Information). Notes appended to the new General Rating Formula for Diseases and Injuries of the Spine specify that associated objective neurologic abnormalities are to be evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1). Intervertebral Disc Syndrome (IVDS), subject to rating under Diagnostic Code 5243, is evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining, under 38 C.F.R. § 4.25, separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. The criteria contained in Diagnostic Code (DC) 5243 provides for a 20 percent evaluation where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent evaluation contemplates incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent evaluation is assigned when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Id., Note (2). The Veteran has undergone several VA examinations to evaluate his back disability during the appeal period. At a February 2008 VA examination, the Veteran reported constant back pain (6/10) that was sharp but did not radiate to the lower extremities. The Veteran had no weakness, numbness, tingling, or bowel or bladder incontinence. On physical examination, there was no evidence of warmth, erythema, or swelling. The Veteran reported tenderness with light touch along his paraspinous muscle. There was "no appreciable" spasm. Flexion was to 50 degrees and combined range of motion was 120 degrees. The Veteran reported pain on all ranges of motion. There was evidence of pain, weakness, fatigability, and lack of endurance associated with repetitive motion. The examiner noted normal straight leg raises and the absence of pain or other symptoms radiating down the lower extremities. Muscle tone, bulk, and strength were normal. Reflexes were normal except for 1+ measurements at the ankles bilaterally. Sensation testing showed decreased light touch in the stocking/glove distribution. Pain was noted as the Veteran's primary component limiting his range of motion and causing functional impairment. In July 2010, A VA examiner documented the Veteran's complaints of pain (7/10) and denial of any radicular components of the condition. He also denied any episodes requiring bed rest. The Veteran reported flare-ups three times a week requiring rest and characterized by stiffness, fatigue, spasms, weakness, decreased motion, and numbness in his back. The Veteran denied bladder or bowel complaints. The examiner measured forward flexion to 50 degrees (with pain beyond 50 degrees) and combined range of motion of 140 degrees. Repetitive motion testing resulted in increased pain but no weakness, fatigability, or additional limitation of function. The examiner noted decreased range of motion of 15 degrees after repetitive use testing (resulting in forward flexion of 35 degrees and combined range of motion of 125 degrees). Strength and reflexes were normal. The sensory examination revealed "decreased glove-like pattern in both of his feet." The examiner diagnosed lumbar degenerative joint disease with moderate to severe functional impairment with pain being the primary component resulting in limited motion. The April 2013 VA examination revealed forward flexion to 80 degrees and combined range of motion of 220 degrees. The examiner noted a mixed motor exam, normal deep tendon reflexes, and negative straight leg raise testing on the right lower extremity. The examiner noted excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. There was localized tenderness or pain to palpation as well as guarding or muscle spasm. The examiner indicated the Veteran had subjective light touch deficits in the lateral cutaneous nerve of the thigh and the superficial peroneal nerve groups of the right lower extremity. He opined that the Veteran had incomplete paralysis of the sciatic nerve of mild severity. The examiner noted there were no other neurologic abnormalities. The examiner noted the Veteran did not have IVDS. The examiner diagnosed lumbar spondylosis with right lower extremity radiculopathy. In August 2017, the Veteran underwent a VA examination in which he was diagnosed with a lumbar strain and lumbar spondylosis. The Veteran reported intermittent inability to get out of bed and occasional visits to his primary care provider for treatment. He indicated that, at worst, his back pain was a seven on a ten-point scale. The Veteran reported flare-ups that occur as often as three times per month where "he can't do anything." The Veteran indicated that, due to his back condition, he sometimes has to lay down and he is unable to ambulate long distances. Objective testing revealed forward flexion of 90 degrees and combined range of motion of 240 degrees. There was no evidence of pain with weight-bearing nor objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissues of the back. The Veteran was able to perform repetitive use testing. The examiner noted that he was unable to say, without resorting to speculation, whether pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability with repeated use over a period of time or during flare-ups. The examination was neither medically consistent nor inconsistent with the Veteran's statements regarding flare-ups and limitations associated with repetitive use over time. There was no guarding or muscle spasm and no additional contributing factors of disability. Muscle strength was normal throughout, as were reflexes and sensation. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis nor any other neurologic abnormalities or findings related to the back condition. The Veteran did not have IVDS of the thoracolumbar spine (back). With respect to the Veteran's ability to work, the examiner opined that the Veteran's back condition may limit his ability to ambulate or run. The Veteran's treatment records do not reveal ranges of motion, symptoms, or functional limitations that warrant a rating in excess of 20 percent or significantly more severe than the findings of the VA examinations summarized above. The greater weight of the evidence establishes that, throughout the appeal period, the Veteran has not had ankylosis, that his forward flexion has been limited to, at most, 35 degrees, and his combined range of motion has been 120 degrees or more. These ranges of motion meet, but do not exceed, the criteria for a 20 percent rating. The Board has considered the Veteran's reports of flare-ups and weakness, pain, and fatigability, but finds his subjective reports, in light of the objective findings by VA examiners, do not warrant a rating in excess of 20 percent. A higher rating (40 percent) would be warranted where the Veteran had forward flexion of less than 30 degrees or ankylosis of the thoracolumbar spine. His symptoms, including considering his subjective reports of flare-ups, do not meet or more closely approximate these criteria. The greater weight of the evidence is against finding that the Veteran meets or more closely approximates the criteria for any rating in excess of 20 percent disabling for his service-connected back disability. The claim is denied. VI. Increased Rating: Radiculopathy of the Right Lower Extremity The Veteran currently has a 10 percent rating for right lower extremity radiculopathy. He seeks a higher rating. Diseases of the peripheral nerves are evaluated under the Schedule of Ratings for Diseases of the Peripheral Nerves. See 38 C.F.R. § 4.124a, DCs 8510-8540, 8610-8630, and 8710-8730. As discussed below, the disability associated with the sciatic nerves are evaluated under DC 8520. Under DC 8520, a 10 percent evaluation is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent evaluation is assigned for moderate incomplete paralysis; a 40 percent evaluation is assigned for moderately severe incomplete paralysis; a 60 percent evaluation is assigned for severe incomplete paralysis with marked muscular atrophy; and an 80 percent evaluation is assigned for complete paralysis: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. In addition, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. A Note at the beginning of 38 C.F.R. § 4.124a indicates that disability from neurological disorders is rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function, and that with partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The words mild, moderate, moderately severe, and severe as used in the various diagnostic codes 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. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration and that, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; see also 38 C.F.R. § 4.123 (indicating neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated with a maximum equal to severe, incomplete paralysis); 38 C.F.R. § 4.124 (indicating neuralgia characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated with a maximum equal to moderate incomplete paralysis). Radiculopathy was diagnosed on only one of the four most recent VA examinations. At that April 2013 VA examination, the examiner noted the radiculopathy resulted in incomplete paralysis of the sciatic nerve of mild severity. This meets, but does not exceed, the criteria for a 10 percent rating. The findings on all the other VA examinations, including the most recent August 2017 VA examination, indicate that the Veteran does not have radiculopathy. The available treatment records also do not support finding radiculopathy of more than mild severity or otherwise warranting any rating higher than 10 percent disabling. A higher rating would be warranted for symptoms comparable to incomplete paralysis of the sciatic nerve of moderate severity. The greater weight of the evidence is against any such finding. The Veteran's claim of entitlement to a rating in excess of 10 percent disabling for radiculopathy of the right lower extremity is denied. VII. Duties to Notify and Assist The Veteran has not raised any specific 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). Further, the Veteran has not alleged any deficiency with the conduct of his two Board hearings as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. ORDER Entitlement to service connection for hearing loss is denied. Entitlement to service connection for a foot disability other than flat feet, including plantar fasciitis, is denied. Entitlement to a rating in excess of 10 percent for laxity of the right knee is denied. Entitlement to an increased rating for recurrent low back pain with history of muscle strain, currently evaluated as 20 percent disabling is denied. Entitlement to an increased rating for right lower extremity radiculopathy, evaluated as 10 percent disabling, is denied. REMAND The VA has a duty to assist the Veteran in obtaining records in the custody of a federal agency until such a search becomes futile. See, e.g., 38 C.F.R. § 3.159(c)(2). To the extent they exist, treatment records created since the Board's most recent, August 2016 remand should be obtained and associated with the claims file. As the August 2016 remand indicated, the Veteran is entitled to additional assistance obtaining records verifying his alleged stressors and the Joint Services Records Research Center (JSRRC) failed to conduct searches for time periods specified by the AOJ and indicated in the prior remands. The prior searches were detailed in the Board's August 2016 remand. After that remand, a May 2017 memo from the JSRRC was added to the claims file detailing the research conducted to corroborate the Veteran's claimed stressors. The memo details searches related to the U.S.S. L.Y. Spear (AS-36) for the year 1974, though the Veteran has repeatedly alleged the incident occurred in 1975. Likewise, the memo details searches related to the U.S.S. Saratoga only for the year 1975, but the AOJ requested a search of the years from 1975 to 1976 and the Veteran has indicated that the incident occurred in 1976. This memo and the JSRRC searches do not comply with the Board's prior remand instructions, so remand is required to again determine whether information related to the alleged stressors is present in the available records. The VA Adjudication Procedure Manual M21-1 (M21-1) outlines the information that JSRRC requires in order to conduct a meaningful search. Specifically, M21-1MR, Part IV, subpart ii, Ch.1, ¶ D.3.d. requires at a minimum: the veteran's full name and social security number; a description of the claimed stressor(s); the month and year when the stressful event occurred; the units of assignment (battalion or company level) at the time of the stressful events; and geographic location. The Board reiterates that the Veteran has provided descriptions of the claimed stressors including with respect to the recovery of the civilian body while aboard the U.S.S. L.Y. Spear and the ejection seat incident while aboard the U.S.S. Saratoga. Although the Veteran has only indicated a year for each of those incidents, that does not relieve VA from submitting a request for records searches. Where a period of time identified by the Veteran is longer than the two month period required by JSRRC, "the duty to assist require[s] VA to submit multiple 60-day record searches." Gagne v. McDonald, 27 Vet.App. 397, 404 (Oct. 19, 2015). In addition, the nexus opinion by the VA examiner in June 2017, although favorable, is inadequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). First, the opinion indicates that the Veteran does not meet the criteria for a current diagnosis of PTSD. If the examiner's opinion is that the Veteran has not had PTSD at any point during the appeal period (despite treatment for the condition in the past), that opinion should be stated and the basis for the opinion explained. Second, the examiner's opinion assumes that the U.S.S. Saratoga incident is "well documented and occurred in 1975." This statement is ambiguous as there are two alleged stressors involving the U.S.S. Saratoga. One is, as noted in the Board's August 2016 remand, a minor collision with the U.S.S. Missisinewa that involved no fatalities (though the Veteran has claimed otherwise, including retrieving the bodies). The collision is well-documented and coincides with the Veteran's time aboard the U.S.S. Saratoga (late 1975), but his version of events (particularly deaths) conflicts with the documentation of that incident. The second incident involved an ejector seat accident that allegedly resulted in the death of a captain. This second incident has not been documented. The updated nexus opinion in August 2017 is negative, but is again inadequate. The request for the opinion indicates that there was no collision involving the U.S.S. Saratoga in 1975-1976. As noted above, there was a collision but the record indicates there were no deaths resulting from the minor collision. The Board also notes that the examiner recited the history of the U.S.S. Spear (AM-322) which was decommissioned in 1946, rather than the U.S.S. L.Y. Spear (AS-36) which was active during the 1970s and on which the Veteran served for several years in the 1970s until roughly April 1975. The factual basis for the negative opinion is in error, so the opinion has no probative value. Because the reasoning of both the favorable and unfavorable opinions are inadequate for the Board to evaluate the conclusions in light of the facts of this case, the Board will direct that the AOJ seek clarification or, if the original examiner is unavailable, obtain an updated nexus opinion from another qualified VA examiner. See 38 C.F.R. § 19.9 and 20.901(a); Tyrues v. Shinseki, 23 Vet.App. 166, 182 (2009). While the AOJ must obtain an updated nexus opinion, a new examination need not be scheduled unless deemed necessary by the VA examiner whose opinion is sought. The June 2017 VA examiner's nexus opinion with respect to diabetes is ambiguously stated and inadequate for lack of any rationale. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The examiner's opinion, as stated, indicates the Veteran had diabetes during service in 1996. The Veteran was discharged in January 1992 and was first diagnosed with diabetes in July 1996. Remand is required to obtain an adequate opinion. The Veteran's claim of entitlement to service connection for a disability characterized by vision loss is inextricably intertwined with the diabetes claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (claims "are inextricably linked together" where a favorable decision on one "could have a significant impact" the other); September 2017 VA Examination (opining that the Veteran's diagnosed eye disability is related to his diabetes). The vision loss claim must be remanded as well. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's more recent treatment records (since August 2017) from the San Diego, Atlanta, and Tampa VAMCs and associated facilities. All such records should be associated with the electronic claims folder. 2. Then, submit research requests to the Joint Services Records Research Center (JSRRC) based on the information included in the claims file and any updated information provided by the Veteran. The requests should seek, at least, information (1) regarding the alleged recovery of a civilian body while the Veteran was aboard the U.S.S. L.Y. Spear (AS-36) and should cover the time periods specified by the Veteran including all of 1975 and 1976 (except for any portion of that period for which records conclusively indicate the Veteran was not aboard the U.S.S. L.Y. Spear); and (2) regarding the alleged ejector seat incident while he was aboard the U.S.S. Saratoga (CV-3) and should cover the time periods specified by the Veteran including all of 1976. Where searches have already been conducted for a particular time period, searches with respect to those time periods need not be replicated. Where a period of time identified by the Veteran is longer than the two month period required by JSRRC, the AOJ should submit multiple 60-day record searches. 3. Only after completion of the above, then the entire claims file should be reviewed by the examiner who examined the Veteran in June 2017 with respect to his PTSD for the purpose of obtaining an addendum opinion (or another medical professional if that person is no longer available). A new examination is not required, unless it is deemed needed. After reviewing the record and performing any examination and/or testing of the Veteran deemed necessary, the examiner should address the following: a. If the opinion is obtained from the June 2017 VA examiner, the examiner should provide a more complete explanation regarding his conclusion that the Veteran does not meet the criteria for a diagnosis of PTSD. Specifically, the examiner should discuss, based on a review of the medical record, whether the Veteran has had PTSD at any point during the appeal period. See, e.g., VA examination reports from 1999 and 2004 versus reports from VA psychiatrist W.G. Currently, the following alleged stressors have not been verified: (1) combat in Vietnam, (2) witnessing deaths when the U.S.S. Saratoga collided with the U.S.S. Mississinewa, (3) witnessing the death of a captain during an ejector seat incident while aboard the U.S.S. Saratoga, and (4) the recovery of a dead body while aboard the U.S.S. L.Y. Spear. If any of those currently unverified stressors have been verified by development pursuant to this Remand, the AOJ should notify the examiner of that fact and the examiner should consider the cumulative effect of all verified stressors. OR b. If the opinion is obtained from a new examiner, that individual should provide an opinion as to whether the Veteran meets the diagnostic criteria for PTSD (or any other acquired psychiatric condition) at any point during the appeal period - please see above discussion. c. For each acquired psychiatric disorder the Veteran had during the appeal period, is the acquired psychiatric disorder at least as likely as not (50 percent or greater probability) related to any specific verified stressor or cumulative effect of verified stressors - please see above discussion. 4. Only after obtaining updated VA treatment records, then the entire claims file should be reviewed by the examiner who examined the Veteran in June 2017 with respect to his diabetes for the purpose of obtaining an addendum opinion (or another medical professional if that person is no longer available). A new examination is not required, unless it is deemed needed. After reviewing the record and performing any examination and/or testing of the Veteran deemed necessary, the examiner should address the following: a. If the opinion is obtained from the June 2017 VA examiner, the examiner should provide a more complete explanation regarding his conclusion that the Veteran's diabetes is less likely than not related to his active service. It would be helpful if the examiner provided an opinion if the medical records support the Veteran's assertion of a continuity of symptomatology such that diabetes was present in service or within one year after service, but was not diagnosed until July 1996. OR b. If the opinion is obtained from a new examiner, that individual should provide an opinion as to whether the Veteran diagnosed diabetes mellitus is at least as likely as not (50 percent or greater probability) related to his active service. It would be helpful if the examiner provided an opinion if the medical records support the Veteran's assertion of a continuity of symptomatology such that diabetes was present in service or within one year after service, but was not diagnosed until July 1996. 5. After undertaking any other development deemed appropriate, re-adjudicate the issues remaining on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case (SSOC) and afford them an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs