Citation Nr: 18140650 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 15-42 601A DATE: October 3, 2018 ORDER Entitlement to service connection for a medically unexplained chronic multi-symptom illness is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. For the entire period on appeal, entitlement to a 10 percent rating, but no higher, for fractured right middle and little fingers, is granted. Entitlement to a compensable rating for hemorrhoids is denied. Entitlement to an initial rating of 30 percent, but no higher, for right foot plantar fasciitis and metatarsalgia, is granted. Entitlement to a rating in excess of 20 percent for laceration, right wrist, with paresthesias, is denied. The reduction of the rating for the service-connected posttraumatic stress disorder (PTSD) from 50 percent to noncompensable, effective April 1, 2015, was not proper, and the 50 percent rating is restored. Entitlement to a rating in excess of 50 percent for PTSD is denied. REMANDED Entitlement to service connection for pes planus of the right foot is remanded. Entitlement to a rating higher than 10 percent for degenerative disc disease and spondylosis, status post laminectomy and discectomy of L4-5, for the period prior to August 25, 2015, and in excess of 20 percent thereafter, is remanded. Entitlement to an initial rating in excess of 10 percent for radiculopathy, right lower extremity is remanded. Entitlement to a rating in excess of 10 percent for degenerative joint disease, chondromalacia left knee is remanded. Entitlement to a rating in excess of 10 percent for chondromalacia right knee, with residual degenerative joint disease is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, an undiagnosed illness or medically unexplained chronic multi-symptom illness. 2. Resolving reasonable doubt in the Veteran’s favor, his tinnitus began during active service. 3. Resolving reasonable doubt in the Veteran’s favor, his sleep apnea began during active service. 4. Resolving reasonable doubt in the Veteran’s favor, his GERD is proximately due to his service-connected obstructive sleep apnea. 5. Resolving reasonable doubt in the Veteran’s favor, for the entire period on appeal, his fractured right middle and little finger disability more nearly approximates favorable ankylosis of the long and little fingers. 6. The preponderance of the evidence is against a finding that the Veteran’s hemorrhoids manifested as (1) large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences or (2) with persistent bleeding with secondary anemia or with fissures. 7. Resolving reasonable doubt in the Veteran’s favor, for the entire period on appeal, the Veteran’s right foot plantar fasciitis and metatarsalgia more nearly approximates extreme tenderness of the plantar surfaces of the right foot, and his condition is not improved by orthopedic shoes or appliances. 8. For the entire period on appeal, the Veteran’s laceration, right wrist, with paresthesias, manifested in mild incomplete paralysis of the middle radicular group; moderate incomplete paralysis was not shown. 9. In a rating decision dated May 30, 2013, and notice provided June 5, 2013, the RO proposed to sever service connection for PTSD. In a rating decision dated January 20, 2015, and notice provided January 21, 2015, the RO severed service connection for PTSD, effective April 1, 2015. 10. In a rating decision dated April 3, 2015, and notice provided April 17, 2015, the RO found that the decision to sever service connection for PTSD was clearly and unmistakably erroneous, and re-established service connection with a noncompensable evaluation, effective April 1, 2015. This resulted in a combined rating reduction from 80 percent to 60 percent, effective April 1, 2015. 11. The RO failed to issue a notice of a proposed reduction or notice of the Veteran’s procedural rights under 38 C.F.R. § 3.105(e) to dispute the reduction for PTSD from 50 percent to noncompensable. As the April 2015 rating decision failed to follow the due process provisions of 38 C.F.R. § 3.105(e) prior to reducing the rating, the rating reduction is void ab initio. 12. For the entire period on appeal, the Veteran’s PTSD symptomatology more nearly approximated occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for an undiagnosed illness or medically unexplained chronic multi-symptom illness are not met. 38 U.S.C. §§ 1110, 1111, 1117, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.317 (2017). 2. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 3. The criteria for service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 4. The criteria for secondary service connection for GERD are met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.310(a) (2017). 5. For the entire period on appeal, the criteria for a 10 percent rating, but no higher, for fractured right middle and little fingers are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.2, 4.3, 4.71a, Diagnostic Code (DC) 5223 (2017). 6. The criteria for a compensable disability rating for hemorrhoids are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.114, DC 7336 (2017). 7. For the entire period on appeal, the criteria for an increased rating of 30 percent for right foot plantar fasciitis and metatarsalgia are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.10, 4.71a, DC 5299-5276 (2017). 8. The criteria for a rating in excess of 20 percent for laceration, right wrist, with paresthesias, are not met. U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.124a, DC 7805-8512 (2017). 9. The criteria for restoration of a 50 percent rating for PTSD, effective April 1, 2015, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.105(e), 4.130, DC 9411 (2017). 10. The criteria for rating in excess of 50 percent for the Veteran’s service-connected PTSD are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, DC 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1990 to February 1995. This matter is on appeal from May 2013 (radiculopathy, fingers, wrist, back, knees, hemorrhoids, TDIU), September 2014 (plantar fasciitis, tinnitus, pes planus, GERD, sleep apnea, chronic multi-symptom illness), and April 2015 (PTSD) rating decisions. In January 2016, the Veteran withdrew his prior Board hearing request. As such, the Board may proceed with adjudication of the appeal. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2017). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for a medically unexplained chronic multi-symptom illness The Veteran is seeking service connection for a medically unexplained chronic multi-symptom illness. The Board notes that the Veteran initially claimed this disability as secondary to his service-connected hemorrhoids. See June 2013 claim. The Veteran is a Persian Gulf Veteran within the definition of 38 C.F.R. § 3.317 as a result of his documented service in Southwest Asia (Kuwait) from August 3, 1992, to August 13, 1992. See 38 C.F.R. § 3.2(i). As a Persian Gulf Veteran, the Veteran may be entitled to compensation if he “exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of [38 C.F.R. § 3.317 ]” which have manifested in service or to a compensable degree either or no later than December 31, 2016, and such symptomatology “by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.” 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(a), (b). A qualifying chronic disability means a chronic disability resulting an undiagnosed illness; a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any other illness that the Secretary determines meets the criteria), or any diagnosed illness that the Secretary determines warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). A “medically unexplained chronic multisymptom illness” is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). “Objective indications of chronic disability” include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). By definition, section 1117 only provides compensation for symptoms of a chronic disability that have not been attributed to a “known clinical diagnosis.” 38 C.F.R. § 3.317(a)(1)(ii). The Board finds the probative, competent evidence does not indicate that the Veteran has an undiagnosed illness or other medically unexplained chronic multi-symptom illness. The September 2014 examiner concluded, after a review of medical records, taking a history, performing a physical examination, and a review of the medical literature, that the Veteran did not have signs or symptoms that might represent an undiagnosed illness or a diagnosed medically unexplained chronic multi-symptom illness. As discussed in more detail below, the Veteran’s gastrointestinal symptoms have been attributed to his now service-connected GERD, and his fatigue symptoms have been attributed to his now service-connected sleep apnea. As no indications of chronic disability remain that have not been associated with a diagnosed disability, service connection due to undiagnosed illness is not warranted under 38 C.F.R. § 3.317 for any issues on appeal. In addition, the May 2014 VA examiner provided a negative opinion on secondary service connection to the Veteran’s service-connected hemorrhoids, concluding that a chronic multi-symptom illness could not be found. Entitlement to service connection for tinnitus The Veteran contends that acoustic trauma during service caused his current tinnitus. The Veteran’s Department of Defense Form 214 lists his occupational specialty as “rifleman.” The Veteran has credibly reported that his duties constantly exposed him to acoustic trauma from ear-piercing gunshots and explosions. In the June 2014 VA examination, the Veteran reported an onset of right-sided intermittent ringing since 1995. In a November 2015 statement, the Veteran reported that after shooting, he would hear a loud high-pitched ringing in his ears that would last up to a minute at a time, sometimes longer. He explained that he had continuously experienced this tinnitus since service. The June 2014 VA examiner provided a negative nexus opinion, which was largely based on the lack of any significant threshold change in the Veteran’s hearing during service. However, in June 2016, Dr. P. H. defined tinnitus and noted that the most common cause of tinnitus is prolonged exposure to loud sounds. He explained how military personnel exposed to explosive blasts can develop tinnitus from the explosions’ shock waves. Dr. P. H. opined that because the Veteran’s ear-ringing manifestations occurred after his military service as a rifleman, where he was exposed to daily loud gunfire, explosions, and shock waves, it was more likely than not that the Veteran’s tinnitus is connected to his military service as a rifleman. Given the acoustic trauma in service, the Veteran’s credible reports that his current tinnitus began in service and continued thereafter, and the positive nexus opinion from Dr. P. H., the Board resolves any reasonable doubt in the Veteran’s favor and concludes that the Veteran has a current diagnosis of tinnitus that began during service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Entitlement to service connection for obstructive sleep apnea The Veteran contends that his obstructive sleep apnea symptoms manifested during service. Specifically, he contends that he would wake up choking in the middle of the night; his bunkmates would tell him he was snoring; and his girlfriend would wake him in fear that he stopped breathing and was choking. He also noted that he was so tired during the day that he would self-medicate with No-Doz to stay awake. The Veteran submitted buddy statements from his mother and sibling, which corroborated the Veteran’s statements regarding the absence of symptoms prior to service and the onset of symptoms during service. VA treatment records documented the Veteran’s complaints of loud snoring beginning in or around 2004. The Veteran was diagnosed with obstructive sleep apnea in an October 2012 VA treatment record following a sleep study. Moreover, in June 2016, Dr. P. H. indicated that exposure to organic solvents, environmental pathogens, and smoking increased inflammation and fluid retention in the respiratory tract. Dr. P. H. explained that inflammation promotes the soft tissue structures surrounding the airway to enlarge, causing pharyngeal airway constriction, and partial or complete airway obstruction and sleep apnea. Dr. P. H. noted the Veteran’s exposure to environmental pathogens, toxic chemicals, and contaminated water while serving at Camp Pendleton for over three years; the lay statements by his mother and brother; and the documented medically sound and consistent symptoms of obstructive sleep apnea during service, and opined that it was more likely than not the Veteran’s obstructive sleep apnea is related to his military service. The Board acknowledges that the September 2014 VA examiner provided a negative etiology opinion. However, the examiner only addressed whether the Veteran’s sleep apnea was related to his Gulf War exposures. As such, the Board affords this opinion no probative weight. Given the Veteran’s competent and credible reports of symptomatology consistent with sleep apnea during service, the buddy statements from his mother, sibling, and girlfriend corroborating these symptoms, and the positive nexus opinion from Dr. P. H., the Board resolves any reasonable doubt in the Veteran’s favor and concludes that the Veteran has a current diagnosis of obstructive sleep apnea that began during service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Entitlement to service connection for GERD The Veteran seeks entitlement to service connection for GERD. He claims that his GERD is either related to environmental exposures during service or secondary to his now service-connected sleep apnea. The 2004 VA treatment records and September 2014 VA examination report show the Veteran has a current diagnosis of GERD, and in June 2016, Dr. P. H. opined that it is at least as likely as not secondary to his obstructive sleep apnea. In support of his opinion, Dr. P. H. cited to clinical research showing a causal relationship between obstructive sleep apnea and GERD. He explained that the pathology indicates that the negative intrathoracic pressure generated during obstructive sleep apnea periods elicits reflux, leading to GERD. The Board acknowledges that the September 2014 VA examiner provided a negative etiology opinion. However, the examiner only addressed whether the Veteran’s GERD was related to his Gulf War exposures, and did not provide an opinion on secondary service connection. As such, the Board resolves any reasonable doubt in the Veteran’s favor and concludes that the Veteran has a current diagnosis of GERD that is secondary to his now service-connected obstructive sleep apnea. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.310. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The plain language of § 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under diagnostic codes predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Court held that § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the diagnostic code under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. at 354. Entitlement to a compensable rating for fractured right middle and little fingers The Veteran asserts that his fractured right middle and little finger disability is worse than the currently-assigned noncompensable rating. His right hand is his dominant hand, and he alleges mild functional limitations due to difficulty performing tasks that require carrying, picking up, and gripping objects, which he alleges limit his abilities and activities of daily living. Throughout the increased rating period on appeal, the Veteran is in receipt of a noncompensable rating for his fractured right middle and little finger disability under the provisions of 38 C.F.R. § 4.71a, DC 5223. DC 5223 addresses favorable ankylosis of two digits of one hand. When the index and middle fingers are involved, a 20 percent disability rating is assigned. The highest, 30 percent, disability rating under this code is only assigned when there is favorable ankylosis of the thumb and any other finger. 38 C.F.R. § 4.71a. Other applicable diagnostic codes include DC 5226, DC 5229, and DC 5230. Id. DC 5226 contemplates favorable and unfavorable ankylosis of the long/middle finger and provides for a 10 percent disability rating. Id. DC 5229 contemplates the limitation of motion for the index or long finger and provides for a noncompensable rating with a gap of less than 2.5 centimeters between the fingertip and proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. Under DC 5229, a 10 percent disability rating with a gap of 2.5 centimeters or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Id. DC 5230 provides for a noncompensable rating for any limitation of motion of the ring or little finger. Id. Importantly, under 38 C.F.R. 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, note (2) says, when two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is otherwise not specified in the rating schedule, the evaluation level as assigned will be that which best represents the overall disability, assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. At the outset, the Board finds that the right middle and little finger are most appropriately rated together under DC 5223, which addresses favorable ankylosis of two digits of one hand. 38 C.F.R. § 4.71a. After a review of all the relevant evidence of record, the Board finds that the Veteran’s fractured right middle and little finger disability more nearly approximates the criteria for a 10 percent rating, but no higher, under DC 5223 based on findings of favorable ankylosis of two digits of one hand. In this regard, in June 2016, Dr. P. H. reviewed the VA examination reports of record and indicated that the Veteran’s symptomatology was medically consistent with favorable ankylosis of the right long and little fingers. Dr. P. H. noted that the Veteran presented with post-fracture deformity of the 3rd and 5th metacarpal heads with a protuberance on the radial side. Dr. P. H. explained that the deformity was most likely caused by inflammation and improper bone healing, producing excess scar tissue and ultimately causing the referenced protuberance in the June 2014 VA examination. Dr. P. H. indicated that the protuberance and scar tissue are likely responsible for the stiffness, joint rigidity, pain, and decreased joint mobility experienced by the Veteran. Dr. P. H. found that this symptomatology is medically consistent and synonymous with an ankylosis diagnosis. The Board acknowledges that the December 2011, December 2013, and June 2014 VA examiners indicated that the Veteran did not have ankylosis of the right middle and little fingers. Nonetheless, these examination reports documented limitation of motion due to pain and during flare-ups. The reports also noted significant complaints pertaining to the right middle and little fingers, such as swelling, weakened grip, stiffness, and numbness. Moreover, Dr. P. H. considered the findings in these reports in concluding that the Veteran’s symptomatology was medically consistent with favorable ankylosis of the right middle and little fingers. Therefore, given the June 2016 opinion of Dr. P. H. and resolving reasonable doubt in the Veteran’s favor, the Board concludes that, for the entire period on appeal, the Veteran is entitled to a 10 percent rating, but no higher, for his fractured right middle and little finger disability. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Entitlement to a compensable rating for hemorrhoids The Veteran asserts that his hemorrhoids disability is worse than the currently-assigned noncompensable rating. A noncompensable evaluation is assigned for the Veteran’s service-connected hemorrhoids under DC 7336. Under DC 7336, a noncompensable evaluation is assigned for mild to moderate hemorrhoids. A 10 percent evaluation is assigned for external or internal hemorrhoids, large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent evaluation is assigned for external or internal hemorrhoids, with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336. The Board finds no evidence in the record indicating that the Veteran had more than mild to moderate hemorrhoids during the period at issue. In a December 2011 VA examination, the examiner noted a diagnosis of internal or external hemorrhoids. The Veteran reported that his hemorrhoids were a little bit worse since his last VA examination. He reported irritation with bowel movements and treatment with preparation H. Examination was normal; there were no external hemorrhoids, anal fissures, or other abnormalities. In a May 2014 VA examination, the examiner noted a diagnosis of internal or external hemorrhoids which did not require treatment with continuous medication. Examination revealed small or moderate external hemorrhoids. Moreover, the Board finds no treatment record or other competent evidence of record that the Veteran experienced hemorrhoids meeting the criteria contemplated by a 10 or 20 percent rating under applicable rating criteria during the period at issue. Neither the Veteran nor his representative provided a specific contention or evidence in support of such a finding on appeal. Accordingly, the Board finds that Veteran’s claim for an increased rating for hemorrhoids must be denied as the preponderance of the evidence is against the claim. Entitlement to an initial rating in excess of 20 percent for right foot plantar fasciitis and metatarsalgia The Veteran asserts that his right foot plantar fasciitis and metatarsalgia is worse than the currently-assigned 20 percent rating. Notably, he contends that his right foot disability is severe and painful, and is not completely relieved by orthotics or arch supports. The Veteran’s right foot plantar fasciitis and metatarsalgia has been rated by analogy under the provisions of 38 C.F.R. § 4.71a, DC 5276, pertaining to flatfoot, acquired. Under DC 5276, a 20 percent rating is assigned for severe unilateral pes planus with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. The maximum 30 percent rating is assigned for pronounced unilateral pes planus with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, and not improved by orthopedic shoes or appliances. Resolving reasonable doubt in favor of the Veteran, for the entire period on appeal, the lay evidence of record shows the Veteran’s right foot plantar fasciitis and metatarsalgia has been characterized by extreme tenderness of the plantar surfaces which is not completely improved by orthopedic shoes or appliances. In this regard, in the May 2008 hearing, the Veteran testified that he still had pain and problems with his arches continuing to drop despite the use of arches in his shoes. He testified that he was very limited in how far he could walk in his daily activities even with arch supports. He indicated that he could maybe go a block or two before stopping to rest. In an April 2012 submission, the Veteran’s representative indicated that the Veteran suffered from pain and decreased functioning even using arch supports. In a December 2016 submission, the Veteran’s representative noted that the Veteran reported daily flare-ups. The Veteran’s representative noted that the Veteran reported severe and painful feet that are not completely relieved by orthotics or arch supports, and extreme tenderness on the bottom of both of his feet. In an April 2018 submission, the Veteran’s representative argued that the Veteran had pronounced symptoms of bilateral pes planus requiring the use of a motorized scooter as a main mode of transportation. The August 2014 VA examiner found that the Veteran had pain on use of feet; pain on manipulation of feet, accentuated on manipulation; swelling on use; extreme tenderness of plantar surfaces improved by orthopedic shoes or appliances; decreased longitudinal arch height on weight-bearing; weight-bearing line falling over or medial to great toe; and metatarsalgia. The Veteran had pain on physical examination, which contributed to functional loss as a result of excess fatigability, pain on weight-bearing, swelling, disturbance of locomotion, and interference with standing. With respect to functional loss during flare-ups, the Veteran indicated that he could not stand more than five minutes, or walk on uneven terrain without pain. The August 2015 VA examiner found that the Veteran had pain on use of feet, accentuated on use; pain on manipulation of feet, accentuated on manipulation; characteristic callouses; extreme tenderness of plantar surfaces improved by orthopedic shoes or appliances; decreased longitudinal arch height on weight-bearing; and metatarsalgia. The Veteran had pain on physical examination, which contributed to functional loss as a result of pain on movement and pain on weight-bearing. With respect to functional loss during flare-ups, the Veteran indicated that he could only do one flight of stairs, and had increased right foot pain after standing or walking for 20 to 30 minutes. The Board acknowledges that the August 2014 and August 2015 VA examiners found that the Veteran’s extreme tenderness of the plantar surfaces of the feet was relieved by orthotics. However, the VA treatment records throughout the appeal period show continued complaints of pain despite the use of orthotics. See, e.g., March 2016 VA podiatry note (reporting pain always present in the right foot despite shoes/inserts). The Board finds that the Veteran’s disability picture more nearly approximates the picture contemplated by the 30 percent rating for the entire period on appeal. The Veteran has credibly reported that his symptomatology is not significantly improved by orthopedic shoes or appliances and that he experiences extreme tenderness of the plantar surface. Affording the Veteran the benefit of the doubt, the Board finds that the Veteran’s right foot plantar fasciitis and metatarsalgia disability is pronounced. The Board has considered whether the Veteran may be entitled to a higher rating under any other diagnostic code. However, as the Veteran is in receipt of the schedular maximum rating available for a unilateral foot disability, it would not be advantageous to rate the Veteran under a different diagnostic code. Thus, resolving reasonable doubt in the Veteran’s favor, a rating of 30 percent, the schedular maximum, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Entitlement to a rating in excess of 20 percent for laceration, right wrist, with paresthesias The Veteran asserts that his laceration, right wrist, with paresthesias, is worse than the currently-assigned 20 percent rating. The Veteran is currently in receipt of a 20 percent rating for laceration, right wrist, with paresthesias, under DC 7805-8512. See 38 C.F.R. § 4.118, DC 7805 and 38 C.F.R. § 4.124a, DC 8512. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. This hyphenated diagnostic code may be read to indicate that scars, other (including linear scars) and other effects of scars is the service-connected disorder (right wrist laceration), and it is rated under DC 8512 based on paralysis of the lower radicular group. The Veteran is right hand dominant. Under DC 8512, for the major extremity, a 20 percent rating is warranted for mild symptoms, 40 for moderate symptoms, a 50 percent rating for severe symptoms, and a 70 percent rating for complete paralysis. The regulation further provides 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. The words “mild,” “moderate,” and “severe” are not defined in the Rating Schedule. 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. It should also be noted that use of terminology such as “mild” and “moderate” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Based on review of the evidence, lay and medical, the Board finds that a rating in excess of 20 percent for the laceration, right wrist, with paresthesias, is not warranted at any time during the appeal period. In the December 2011 radiculopathy VA examination report, the examiner noted moderate paresthesias of the right upper extremity and moderate numbness of the right upper extremity. The examiner noted decreased sensation in the right inner/outer forearm. The December 2011 wrist VA examination report indicated that the Veteran reported symptoms of wrist pain medially, stiffness, and a tingling sensation. He denied flares. Range of motion was as follows: palmar flexion to 70 degrees without pain and dorsiflexion to 70 degrees or greater without pain. There was no additional limitation of motion following repetitive use testing. The right wrist strength was 5/5, and there was no ankylosis. The February 2013 peripheral neuropathy VA examination report noted a diagnosis of neuropathy of the right wrist. The Veteran described an area of tingling and numbness at the scar and down the wrist. He had pain with lateral movement of the wrist joint. The examiner noted mild intermittent pain, mild paresthesias, and mild numbness. Grip strength was 4/5 and there was no atrophy. The Veteran had decreased sensation in the right inner/outer forearm. The examiner found mild incomplete paralysis of the right ulnar nerve and mild incomplete paralysis of the right external popliteal nerve. The examiner indicated that the Veteran’s wrist neuropathy was part and parcel due to the laceration to his right wrist. The examiner noted minimal functional limitations as a result of this disability. In the February 2013 wrist VA examination report, the Veteran reported flare-ups with increased activity with a pain rating of 4/10. Range of motion was as follows: palmar flexion to 80 degrees or greater without pain, dorsiflexion was to 70 degrees or greater without pain, and there was no additional loss of motion following repetitive use testing. There was no functional loss. Strength was 5/5 and there was no ankylosis. The June 2014 peripheral neuropathy VA examination report noted the Veteran’s complaints of numbness on the radial aspect of the right forearm. The examiner noted symptoms of mild paresthesias and mild numbness. Strength was 5/5 and there was no atrophy. Sensation was decreased in the right inner/outer forearm. There were no trophic changes. In a June 2016 opinion submitted by the Veteran, Dr. P. H. indicated that based on the findings in the February 2013 VA examination report, the Veteran’s right wrist disability manifested in mild paralysis. Dr. P. H. indicated further that there was a lack of evidence to substantiate increased severity sufficient to warrant a higher evaluation. He opined that the Veteran’s currently-assigned 20 percent evaluation should remain the same. Based on this evidence, the Board finds that the Veteran’s laceration, right wrist, with paresthesias disability was no more than mild during the entire timeframe on appeal. Neither the Veteran nor his representative provided a specific contention or evidence in support of a rating higher than 20 percent on appeal. The Board has considered whether the Veteran may be entitled to a higher or separate rating under any other diagnostic code. However, as there have not been any findings pertaining to ankylosis of the wrist, DC 5214, pertaining to wrist, ankylosis of, is not for application. 38 C.F.R. § 4.71a, DC 5214. Moreover, none of the range of motion findings during the appeal period more nearly approximate limitation of motion of the wrist manifested by palmar flexion limited in line with forearm or dorsiflexion limited to less than 15 degrees, as required for a rating based on limitation of motion of the wrist under DC 5215. 38 C.F.R. § 4.71a, DC 5215 (major extremity). Accordingly, the Board finds that Veteran’s claim for a rating in excess of 20 percent for laceration, right wrist, with paresthesias must be denied as the preponderance of the evidence is against the claim. Whether the reduction of the service-connected PTSD from 50 percent to noncompensable, effective April 1, 2015, was proper The Veteran contends that the reduction of the service-connected PTSD from 50 percent to noncompensable, effective April 1, 2015, was not proper. He contends that VA reduced his rating without observing the applicable laws and regulations set forth in 38 C.F.R. § 3.105(e). See March 2016 brief submitted by the Veteran’s representative. To this point, he contends that VA never issued a reduction proposal or gave him the opportunity to request a predetermination hearing on the proposed reduction. Id. He requested the Board restore his 50 percent rating for PTSD retroactive to the date VA reduced his evaluation. Id. VA regulations provide that where a reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance is to be prepared setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). The beneficiary must be notified at his or her latest address of record of the contemplated action and furnished detailed reasons. The beneficiary must be given 60 days for the presentation of additional evidence. 38 C.F.R. § 3.105(e). Here, there is no evidence that the reduction was first proposed, or that notice regarding the process of how to dispute the proposed reduction was provided to the Veteran. In September 2011, the Veteran requested an increased rating for his service-connected PTSD. He underwent VA examinations in December 2011 and February 2013. In a rating decision dated May 30, 2013, and notice provided June 5, 2013, the RO proposed to sever service connection for PTSD. The Veteran requested a pre-determination hearing. His later request to reschedule his pre-determination hearing was not granted. In a rating decision dated January 20, 2015, and notice provided January 21, 2015, the RO severed service connection for PTSD, effective April 1, 2015. In a rating decision dated April 3, 2015, and notice provided April 17, 2015, the RO found that the decision to sever service connection for PTSD was clearly and unmistakably erroneous, and re-established service connection with a noncompensable evaluation, effective April 1, 2015. This resulted in a combined rating reduction from 80 percent to 60 percent, effective April 1, 2015. Therefore, there was a reduction in the amount of compensation he would receive as a result of this reduction in his PTSD rating. The Board finds that the RO did not satisfy a critical due process requirement under 38 C.F.R. § 3.105(e). A reduction must first be proposed and the beneficiary must be notified at his or her latest address of record, and must be given 60 days for the presentation of additional evidence. See 38 C.F.R. § 3.105(e). The Board notes that although the RO appeared to notify the Veteran with respect to the severance of service connection for PTSD issue, the reduction of the rating for PTSD from 50 percent to noncompensable is a distinct issue that requires separate due process considerations. See 38 C.F.R. § 3.105(d) (severance of service connection) and (e) (reduction in evaluation). Moreover, the Board finds that the RO erred when it did not provide the Veteran with a rescheduled pre-determination hearing with respect to the severance issue. As there was no initial proposal and the Veteran did not receive notice of the proposed reduction, the April 2015 rating reduction violated the due process requirements of 38 C.F.R. § 3.105(e), established to serve as a procedural protection against improper reductions of disability ratings. The United States Court of Appeals for Veterans Claims has consistently held that when an AOJ reduces a Veteran’s disability rating without following the applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). The law provides that where a rating reduction was made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, in a rating reduction case the erroneous reduction must be vacated and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Entitlement to a rating in excess of 50 percent for PTSD The Veteran seeks a rating in excess of 50 percent for his service-connected PTSD. In his September 2011 claim for an increased rating, he asserted that he had experienced significant impulse impairment during his incarceration period and felt his PTSD had increased in severity. As noted above, the RO reduced the Veteran’s rating for PTSD from 50 percent to noncompensable, effective April 1, 2015. However, the Board has restored the Veteran’s 50 percent rating for PTSD. As such, the Board will consider whether the Veteran is entitled to a rating in excess of 50 percent for his service-connected PTSD at any time during the appeal period. PTSD is rated under 38 C.F.R. § 4.130, DC 9411. The rating criteria provide that a 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). The provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. As the Veteran’s claim was certified for appeal to the Board to the Board in March 2017, the amendment is applicable. At the outset, the Board notes that the VA examination reports during this period have questioned the Veteran’s PTSD diagnosis. These examiners have instead diagnosed the Veteran with various other psychiatric disorders, to include anxiety disorder, paranoid personality disorder, and adjustment disorder with mixed anxiety and depressed mood. The examiners opined that these disorders were not related to the Veteran’s service. However, in an October 2013 mental health consultation, his treating VA psychologist diagnosed PTSD based on the Veteran’s reported in-service stressor of a fear of being killed during his service in Kuwait. Given the diagnosis of PTSD during the appeal period and the fact that the examiners could not disassociate the symptomatology from the variously diagnosed psychiatric disorders, the Board will consider all of the Veteran’s psychiatric symptoms. See Mittleider v. West, 11 Vet. App. 181 (1998) (finding that where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran’s service-connected disability). Upon careful review of the evidence of record, the Board finds that the objective medical evidence, and the Veteran’s statements regarding his symptomatology, more nearly approximates symptoms associated with a 50 percent disability evaluation. Similarly, the Board finds that the preponderance of the evidence is against an evaluation in excess of 50 percent for this time period. Neither the lay nor the medical evidence of record during this timeframe more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 70 percent disability evaluation based on occupational and social impairment, with deficiencies in most areas. 38 C.F.R. §§ 4.7, 4.130, DC 9411. The Board has considered the VA treatment records and lay statements by the Veteran regarding the impact of his PTSD on his occupational and social impairment. As contemplated by a 50 percent evaluation, the Veteran’s symptoms reflected occupational and social impairment with reduced reliability and productivity. The Veteran’s commonly reported psychiatric symptoms consisted of depressed mood, anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective relationships, impaired judgment, impaired impulse control, and anger. The Board notes further that the December 2011 VA examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, impairment generally consistent with a 30 percent evaluation. Moreover, the February 2013 and August 2015 VA examiners found occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication, impairment generally consistent with a 10 percent evaluation. However, as explained below, the evidence does not support a 70 percent evaluation at any time during the appeal period. The Board does not find occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, to warrant a 70 percent evaluation. Although not dispositive, the evidence of record reflects the Veteran never suffered from suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and/or the inability to establish and maintain effective relationships. While it is documented that the Veteran struggled with social interactions, there is no indication that the severity of his PTSD has led to an inability to establish and maintain relationships, as accounted for in the criteria for a 70 percent evaluation. While the Veteran’s social relationships have no doubt been impaired by his symptoms of PTSD, the criteria of a 70 percent evaluation describe an “inability” to establish and maintain effective relationships. The evidence suggests that while the Veteran has difficulty establishing and maintaining relationships, there is no evidence he has an inability to do so. As the record reflects, he has established and maintained some relationships with family members and social acquaintances during this timeframe. In his February 2013 VA examination, the Veteran described a “very good relationship” with his mother and sisters. In his August 2015 VA examination, the Veteran reported that he lived with his elderly mother and spent time with his grandkids, who were living with him for the summer. He reported having friends that he talked to on the phone. He described one friend whom he sees occasionally and that he “can talk to, he calms me down.” In terms of the Veteran’s mood, during this time period, the Veteran reported symptoms of depression and anxiety. Nonetheless, a 50 percent evaluation accounts for such effects as displayed by the Veteran during this time period. Moreover, throughout the entire timeframe on appeal, the Veteran’s thought processes were logical and goal-directed. While the February 2013 and August 2015 VA examiners noted impaired impulse control, this appears to be in relation to an incident involving an altercation with his grandchild’s father that occurred prior to the appeal period and resulted in his incarceration for aggravated assault. The Veteran has continued to report anger during this timeframe, but appears to have been successful in avoiding situations and refraining from acting on these feelings. The Board acknowledges that impaired impulse control can be indicative of criteria consistent with a higher evaluation; however, in the Veteran’s case, his anger and impaired impulse control did not manifest with the severity, frequency, and duration consistent with an evaluation higher than 50 percent. In light of the foregoing, the Board finds that a rating in excess of 50 percent for PTSD is not warranted at any time during the appeal period. Thus, the Board finds that the Veteran did not have occupational and social impairment, with deficiencies in most areas. He did have some deficiencies in several areas, but the greater weight of evidence demonstrates that it was to a degree that is contemplated by the assigned 50 percent evaluation. Furthermore, even resolving any reasonable doubt in the Veteran’s favor, the Board finds that he did not meet the requirements for an evaluation greater than the assigned 50 percent schedular evaluation. To the extent that the Veteran had any of the criteria for a 70 percent evaluation or higher, see Mauerhan, 16 Vet. App. at 442, the Board concludes that his overall level of disability did not exceed the criteria for a 50 percent evaluation. In this regard, the Veteran’s disability picture is more in line with the symptoms associated with a 50 percent evaluation. REASONS FOR REMAND While the record contains a contemporaneous VA examination regarding the Veteran’s degenerative disc disease and spondylosis, status post laminectomy and discectomy of L4-5, the examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016) or Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Notably, the August 2015 examination did not include active and passive range of motion measurements. Additionally, while the August 2015 examiner stated that an opinion on whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time could not be provided without resort to speculation because it would “be speculation to attempt to evaluate an un-witnessed subjective report by the veteran,” the examiner did not indicate that the speculation was due to lack of knowledge within the medical community. Additionally, because a decision on the remanded issue of entitlement to an increased rating for the service-connected lumbar spine disability could significantly impact a decision on the issue entitlement to an initial increased rating for the service-connected right lower extremity radiculopathy, the issues are inextricably intertwined. A remand of the claims for an initial increased rating for right lower extremity radiculopathy is required. While the record contains a contemporaneous VA examination regarding the Veteran’s bilateral knee disabilities, in the March 2016 brief, the Veteran’s representative raised several inadequacies with the August 2015 examination report, to include with respect to the findings pertaining to flare-ups. Moreover, the Board finds that the examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016) or Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Notably, the August 2015 examination did not include active and passive range of motion measurements. Additionally, while the August 2015 examiner stated that an opinion on whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time could not be provided without resort to speculation because it would “be speculation to attempt to evaluate an un-witnessed subjective report by the veteran,” the examiner did not indicate that the speculation was due to lack of knowledge within the medical community. Finally, because a decision on the remanded increased rating issues could significantly impact a decision on the issue entitlement to TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for pes planus of the right foot because no VA examiner has opined whether the Veteran’s pes planus, which clearly and unmistakably preexisted service, clearly and unmistakably did not increase in severity beyond the natural progression of the disability in service. In this regard, although the August 2014 VA examiner provided a negative opinion, this opinion did not contain any rationale, to include consideration of the service treatment records (STRs) documenting foot complaints. While on remand, updated VA treatment records should be obtained The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2016 to the present. 2. Schedule the Veteran for an examination of the current severity of his service-connected degenerative disc disease and spondylosis, status post laminectomy and discectomy of L4-5. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the service-connected degenerative disc disease and spondylosis, status post laminectomy and discectomy of L4-5 alone and discuss the effect of the Veteran’s degenerative disc disease and spondylosis, status post laminectomy and discectomy of L4-5 on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Schedule the Veteran for an examination of the current severity of his service-connected bilateral knee disabilities. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the service-connected bilateral knee disabilities alone and discuss the effect of the Veteran’s bilateral knee disabilities on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s pes planus of the right foot, which clearly and unmistakably preexisted service, clearly and unmistakably did not increase in severity beyond the natural progression of the disability in service. The examiner should consider and address the STRs noting mild, asymptomatic pes planus on entrance into service and documenting complaints of, and treatment for, foot pain during service. See, e.g., February 1989 enlistment examination (noting mild asymptomatic pes planus), February 1992 STR, January 1993 STR, August 1993 STRs, January 1994 STR, and February 1994 STR. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to an initial rating in excess of 10 percent for radiculopathy, right lower extremity, and entitlement to TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs