Citation Nr: 18143677 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 11-16 759 DATE: October 19, 2018 ORDER Entitlement to service connection for mild degenerative changes of the thoracic spine is granted. Entitlement to service connection for left knee patellofemoral syndrome is granted. Entitlement to service connection for laboratory results during service, to include the following: homocysteine 9.8 range, high cholesterol, Tbil at 1.5, RBC low, low lymphocytes, high glucose, high globulin, low HGB, low HCT, leukocystosis and impaired fasting glucose, high PT, high WBC, low MPV, low VLDL, high nitrate positive, high INR, high IgE, low INR, hyperlipidemia, and high potassium, is denied. Entitlement to an initial evaluation of 100 percent for service-connected coronary artery disease (CAD) is granted. Entitlement to an initial evaluation of 10 percent for service-connected right knee degenerative joint disease (right knee disability) is granted. Entitlement to an initial evaluation of 10 percent for service-connected residuals of a partially ruptured left achilles tendon with residuals of a chronic left ankle sprain (left ankle disability) is granted. Entitlement to an initial evaluation of 10 percent, but no higher, for service-connected right finger degenerative joint disease (right finger disability) is granted. REMANDED The claim of entitlement to service connection for residuals of a left hamstring strain is remanded. The claim of entitlement to service connection for a right shoulder disorder is remanded. The claim of entitlement to service connection for a neck/cervical spine disorder is remanded. The claim of entitlement to service connection for left ear hearing loss is remanded. The claim of entitlement to service connection for an enlarged prostate is remanded. The claim of entitlement to service connection for tinea pedis, bilateral feet, with hyperhidrosis and onychomycosis on the bilateral great toes, is denied. The claim of entitlement to service connection for a rash of the lower extremities is denied. The claim of entitlement to an initial evaluation in excess of 10 percent for service-connected hypertension is remanded. The claim of entitlement to an initial evaluation in excess of 10 percent for service-connected right knee disability is remanded. The claim of entitlement to an initial evaluation in excess of 10 percent for service-connected left ankle disability is remanded. The claim of entitlement to an initial compensable evaluation for service-connected right ear hearing loss is remanded. The claim of entitlement to an initial evaluation in excess of 20 percent for service-connected deep venous thrombosis (DVT) is remanded. The claim of entitlement to an initial evaluation in excess of 30 percent for service-connected gastritis with gastroesophageal reflux disorder (GERD) is remanded. The claim of entitlement to an initial compensable evaluation for a service-connected colon polyp is remanded. The claim of entitlement to an initial compensable evaluation for service-connected simple bilateral kidney cysts with a right punctuate nephrolith in the right kidney is remanded. The claim of entitlement to an initial compensable evaluation for service-connected residuals of melanoma in the right foot is remanded. FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, degenerative changes of the thoracic spine are related to active service. 2. Left knee patellofemoral syndrome had onset during the Veteran’s service. 3. The Veteran’s claimed homocysteine 9.8 range, high cholesterol, Tbil at 1.5, RBC low, low lymphocytes, high glucose, high globulin, low HGB, low HCT, leukocytoses and impaired fasting glucose, high PT, high WBC, low MPV, low VLDL, high nitrate positive, high INR, high IgE, low INR, hyperlipidemia, and high potassium, are laboratory results and not actual disabilities for which VA compensation benefits are payable. 4. Resolving all doubt in favor of the Veteran, CAD results in workload of 3 METs or less and results in dyspnea, fatigue, angina, dizziness, and syncope. 5. For the entire appeal, the Veteran’s service-connected right knee, right index finger, and left ankle disorders have been manifested by pain on use. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative changes of the thoracic spine have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303 (2018). 2. The criteria for service connection for left knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303 (2018). 3. The criteria for service connection for lab results during service, to include homocysteine 9.8 range, high cholesterol, Tbil at 1.5, RBC low, low lymphocytes, high glucose, high globulin, low HGB, low HCT, leukocytoses and impaired fasting glucose, high PT, high WBC, low MPV, low VLDL, high nitrate positive, high INR, high IgE, low INR, hyperlipidemia, and high potassium, have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018). 4. The criteria for entitlement to an initial evaluation of 100 percent for CAD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.21, 4.104, Diagnostic Codes (DC) 7005, 7017 (2018). 5. The criteria for an initial 10 percent evaluation for right knee degenerative joint disease have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.59, 4.71a, DC 5003 (2018). 6. The criteria for an initial 10 percent evaluation for residuals of a partially ruptured left achilles tendon with residuals of a chronic left ankle sprain have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.59, 4.71a, DCs 5311-5271 (2018). 7. The criteria for an initial 10 percent evaluation, but no higher, for right finger degenerative joint disease have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.59, 4.71a, DC 5229 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1981 to January 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a May 2018 hearing. A transcript of the hearing is of record. Duties to Notify and Assist For any issues decided herein, neither the Veteran nor his attorney has raised any 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). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The threshold question in any claim seeking service connection is whether there is a current disability at any point during the appeal period. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In the absence of proof of a current disability, service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44. 1. Entitlement to service connection mild degenerative changes of the thoracic spine The Veteran claims he has a thoracolumbar disorder that is a result of wear and tear sustained during his military service. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In making this finding, the Board is aware that x-rays of the lumbar spine were normal at the September 2009 VA examination and that disability of the thoracolumbar spine was not found. However, December 2006 Tricare records show a diagnosis of mild degenerative changes of the thoracic spine on CT scan. September 2006 radiographic images of the chest similarly showed degenerative changes of the thoracic spine. The Board finds the Veteran’s records of treatment from his service are highly probative sources of evidence that tend to show the presence of a thoracolumbar disability. Second, the Board finds that there was in-service disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In general, the Veteran attributes his low back disorder to in-service wear and tear. See May 2018 hearing transcript. September 2006 and December 2006 CT scan studies show degenerative changes of the thoracic spine. Third, the Board finds that the evidence of record supports a finding that the degenerative changes of the thoracolumbar spine is related to active service. A September 2009 VA examination did not provide any nexus statement, as an x-ray found there was no arthritis. In an April 2018 statement, however, Dr. SSK opined that the degenerative changes were more likely than not related to stress incurred during service. Dr. SSK noted that the Veteran was subjected to a direct injury through axial load trauma while in service. Specifically, the Veteran loaded and unloaded equipment from military aircraft, trucks, and warehouses for a long duration. The continuous and prolonged handling of heavy equipment increased the down-bearing trauma, imposing altered body posture. This would put a strain on the cervical and thoracic spine. The carrying of heavy loads likely caused the Veteran to move and carry loads in an unnatural position and continual trauma of this kind could result in permanent injury. The Board finds this opinion probative as it is based upon a review of medical records and interview with the Veteran and provided a supporting explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). As such, the Board finds that service connection for a thoracolumbar disorder, diagnosed as degenerative changes of the thoracic spine, is warranted. 2. Entitlement to service connection for a left knee disorder The Veteran claims he has a left knee disorder that is a result of wear and tear sustained during his military service. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). At the September 2009 VA examination, the examiner diagnosed left knee patellofemoral syndrome. Second, the Board finds that there was an in-service injury. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In general, the Veteran attributes his left knee disorder to in-service wear and tear due to over 25 years of active service. See May 2018 hearing transcript. In a May 2018 statement submitted at the hearing, the Veteran indicated that he constantly experienced pain and swelling in his knees. Third, the Board finds that the evidence of record supports a finding that left knee patellofemoral syndrome is related to active service. Although the VA examination conducted in September 2009 does not provide a nexus statement, the Veteran has a diagnosis of patellofemoral syndrome within 8 months of his service. He submitted his claim in response to left knee symptoms at separation, and thus, continuity of his symptoms may be presumed. Accordingly, all three elements of service connection have been met. Based on the foregoing, the Board concludes the Veteran’s current patellofemoral knee syndrome of the left knee began during active service. Service connection is thus warranted.   3. Entitlement to service connection for lab results during service, to include the following: homocysteine 9.8 range, high cholesterol, Tbil at 1.5, RBC low, low lymphocytes, high glucose, high globulin, low HGB, low HCT, leukocytoses and impaired fasting glucose, high PT, high WBC, low MPV, low VLDL, high nitrate positive, high INR, high IgE, low INR, hyperlipidemia, and high potassium The Veteran claims that he is entitled to service connection for a series of laboratory results found during his military service. When asked to clarify his claim, the Veteran explained that he was claiming service connection for things noted in his service treatment records (STRs) that he was not advised about by his doctors. However, laboratory results and are not, in and of themselves, disabilities for compensation purposes. See Schedule for Rating Disabilities: Endocrine System Disabilities, 61 Fed. Reg. 20.440, 20.445 (May 7, 1996). The term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2018). The evidence does not show nor has the Veteran contended that his laboratory findings are manifestations of an underlying disease, and there is no evidence to suggest that the Veteran’s laboratory findings during service resulted in any impairment of earning capacity or other disability for which service connection may be granted. See Allen v. Brown, 7 Vet. App. 439 (1995). Thus, as a matter of law, there is no basis for awarding service connection for the claimed laboratory findings, and the appeal for this issue is denied. This denial is grounded solely on the legal determination that laboratory findings is not itself a disability for VA purposes, based on the absence of legal merit, or lack of entitlement under the law, with respect to the claim. Sabonis v. West, 6 Vet. App. 426, 430 (1994). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2017). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). 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 (2017). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2017). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). 4. Entitlement to an initial evaluation in excess of 30 percent for service-connected CAD Coronary artery disease is rated under Diagnostic Code 7005. Under the applicable criteria, a 30 percent rating is assigned for documented coronary artery disease resulting in a workload of greater than 5 METs (metabolic equivalents of task) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005. A 60 percent rating is granted for coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Finally, a 100 percent (total) rating is assigned for coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. In-service Tricare records in January 2007 shows the Veteran undergoing a stress test for coronary artery disease. The test showed left ventricular ejection fraction of 47 percent. On initial VA examination in September 2009, the Veteran complained of dyspnea on exertion, chest tightness, and frequent coughing at morning. The Veteran had no chest pain, dizziness, papulation, hemoptysis, and sputum. An examination revealed coronary artery disease. Although chest X-rays were normal, an echocardiogram showed mild left atrium enlargement and trivial to mild MR and trivial TR. Left ventricular function was normal. There was a left ventricular relaxation abnormality, however. The examination did not include testing or an estimate for METs. The Veteran submitted an April 2018 private opinion from Dr. SSK. The doctor had reviewed the Veteran’s medical records and the history of his treatment and had conducted a phone interview with the Veteran. Dr. SSK opined that the Veteran’s METs had been limited to the 2 to 4 METs range since service, based upon the telephone interview, medical records, and lay statements from the Veteran and his family. The doctor based the estimate, in part, on the Veteran’s reports on interview that he was unable to keep up with his wife and daughter when walking and experiencing shortness of breath after one to two flights of stairs. The doctor listed the Veteran’s symptoms as dyspnea, shortness of breath, fatigue, angina, and dizziness. The Board grants a 100 percent evaluation for the Veteran’s coronary artery disease for the duration of the appeal period because the April 2018 opinion from Dr. SSK persuasively demonstrates a METs level of less than 3 METs that resulted in dyspnea, shortness of breath, fatigue, angina, and dizziness. The September 2009 VA examination does not address the relevant diagnostic criteria. Thus, the Board finds that a 100 percent evaluation is warranted. No higher evaluation is warranted. 5. Entitlement to compensable evaluations for right knee, right finger, and left ankle disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint). Furthermore, painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute functional loss and is just one fact to be considered when evaluating functional impairment). Section 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). Rather, section 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, 28 Vet. App. at 354. The Board finds that 10 percent ratings are warranted for the Veteran’s right knee, right finger, and left ankle disorders for the duration of the appeal. The Board bases this finding on the noncompensable ratings for musculoskeletal disabilities and complaints of pain on motion. See 38 C.F.R. § 4.59; Burton, 25 Vet. App. 1. The evidence shows that the Veteran’s consistent reports of right knee, right finger, and left ankle pain. See May 2018 hearing. At the September 2009 VA examination, the Veteran reported a history of pain in the DIP joint of the right index finger. An objective examination showed mild tenderness. The Veteran similarly reported pain on the medial and lateral aspect of the left ankle, and an objective examination showed mild tenderness in the same locations. The contemporaneous examination of the right knee also discussed a history of bilateral anterior knee pain. Thus, with consideration of the holdings of Burton and Southall-Norman, the Board finds that at initial 10 percent ratings are warranted for the right knee, right finger, and left ankle conditions. 38 C.F.R. § 4.59. The issues of entitlement to increased ratings in excess of 10 percent for the Veteran’s right knee and left ankle disorders are addressed in the remand. Evaluations in excess of the 10 percent ratings regarding the right knee and left ankle are remanded herein. Regarding the Veteran’s right finger, the Board finds that a 10 percent disability rating is warranted throughout the appeal period, but no higher. In making this finding, the Board has considered the various diagnostic codes used to rate disability of the fingers. 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. DC 5225 contemplates both favorable and unfavorable ankylosis of the index finger and provides for a 10 percent disability rating. DC 5226 contemplates favorable and unfavorable ankylosis of the long/middle finger and provides for a 10 percent disability rating. 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. The Veteran does not have any service-connected disabilities in his other fingers. As such, DC 5223 is inapplicable. Further, the maximum schedular evaluations provided in DCs 5225 and 5226 are 10 percent. Thus, they do not provide for higher ratings and are inapplicable to this case. Under DC 5229, currently used to evaluate the Veteran’s right index finger degenerative joint disease, the maximum schedular benefit is also 10 percent. In short, there is no basis for a disability rating higher than 10 percent for the Veteran’s right index finger. In conclusion, the Board grants a 10 percent evaluation for the Veteran’s right index finger degenerative joint disease. A disability rating in excess of 10 percent for right index finger degenerative joint disease is not warranted, however. REASONS FOR REMAND For all claims remanded herein, remand is required to obtain outstanding records of private and VA treatment. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2018). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records, VA medical records, records from facilities with which the VA has contracted, and records from Federal agencies such as the Social Security Administration. 38 C.F.R. § 3.159(c)(2). VA will end its efforts to obtain records only where it concludes that the records sought do not exist or that further efforts to obtain those records would be futile, such as where the Federal department or agency advises VA that the requested records do not exist or the custodian does not have them. 38 C.F.R. § 3.159(c)(2). In addition, this includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). On at least one occasion during the May 2018 hearing, the Veteran’s attorney referred to the Veteran receiving medical advice from his private and VA doctors. There are no records of treatment documenting treatment of any service-connected disorders past 2009. On remand, outstanding records of treatment should be obtained. More specific reasons for remand are discussed below. 1. Entitlement to service connection for residuals of a left hamstring strain Remand is required for an adequate VA examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA examination was conducted in September 2009. No opinion was provided regarding whether the Veteran currently experiences residual complications from his left hamstring injuries during service. A June 1986 STR documents the Veteran receiving treatment after sustaining a strained left hamstring. The Veteran asserts he sustained another left leg injury in 2003. The Veteran related this history during the May 2018 hearing and noted that he still experienced pain in his hamstring when walking. The Veteran’s representative also asserted that the Veteran experienced swelling in his left hamstring as a result of his service-connected deep vein thrombosis. As such, an examination should be provided to determine the nature and etiology of any disorder found. 2. Entitlement to service connection for a right shoulder disorder 3. Entitlement to service connection for a cervical spine/neck disorder Remand is required for an examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. VA provided an examination in September 2009. At that time, the examination showed no cervical spine or right shoulder disabilities. The examiner noted suspected right shoulder supraspinatus tendinitis. Pain alone, however, can serve as a disability for VA compensation purposes if the pain results in functional impairment that affects earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). In May 2018, VA received an April 2018 opinion from Dr. SSK. The doctor found that the Veteran had cervical spine and right shoulder symptoms of pain and limitation of motion and found that these symptoms were etiologically related to wear and tear and injuries sustained during his service. However, there was no finding of whether right shoulder or neck pain resulted in functional impairment of earning capacity. In light of the lack of disability shown in the September 2009 VA examination but Dr. SSK’s finding of pain, the Board finds that a remand for another examination is warranted for an examiner to assess first whether an underlying pathology exists in the neck and right shoulder, and if not, whether the Veteran’s pain results in functional impairment that affects the Veteran’s earning capacity pursuant to Saunders. 4. Entitlement to service connection for left ear hearing loss Remand is required to provide a current examination for the Veteran’s claim of entitlement to service connection for left ear hearing loss. The Veteran’s claim was denied based on the absence of a present disability shown in the Veteran’s service treatment records and the September 2009 VA examination. However, at the May 2018 hearing, the Veteran testified that his left ear hearing had worsened, suggesting that there may now be left ear hearing loss for VA purposes. Because the Veteran may now have hearing loss in the left ear, the Board finds that remand is appropriate for a new examination. The Veteran’s right ear hearing loss is service-connected due to favorable evidence linking his diminished hearing to his service-connected hypertension. As such, a secondary opinion should be obtained as well. 5. Entitlement to service connection for an enlarged prostate Remand is required for an examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. The Veteran claims he has benign prostatic hyperplasia as a result of his service-connected CAD and DVT. See May 2018 hearing. Alternatively, at his hearing he claimed that he has an enlarged prostate that was caused by his exposure to aviation fuels and other chemicals over the course of his lengthy career experience with aircrafts. As a result, he reportedly suffers from voiding and urinary dysfunction. The Veteran indicated that he was receiving treatment from a urologist. The September 2009 VA examination indicated that a rectal examination had shown no hemorrhoid, palpable lump, and a normal prostate. At the 2018 Board hearing, however, the Veteran took issue with this finding asserting that he never received a rectal examination at the September 2009 VA examination. In an accompanying statement and submission, the Veteran cited to two studies purporting to show a link between benign prostatic hyperplasia and hypertension and pulmonary embolism. The Veteran is service-connected for hypertension and DVT. Considering his submissions and his credible disagreement with the findings of the September 2009 VA examination, the Board finds that an examination is warranted on remand. 6. Entitlement to service connection for tinea pedis, bilateral feet, with hyperhidrosis and onychomycosis on the bilateral great toes 7. Entitlement to service connection for a rash of the lower extremities Remand is required for an examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr, 21 Vet. App. at 311. At the September 2009 VA examination, a skin examination did not reveal a rash of the lower extremities. A skin disease examination report focused further on demodicidosis or rosacea on the face as a result of the Veteran’s CPAP use. The Veteran claims he has rashes of the lower extremities and tinea pedis with hyperhidrosis and onychomycosis of the bilateral feet and great toes that had onset during his active service. The Veteran’s STRs document treatment in November 1994 and August 1995 for a rash on his bilateral thighs. In January 1995, the Veteran received treatment for tinea pedis, bilateral feet, with hyperhidroses and onychomycosis. At the May 2018 hearing, the Veteran’s attorney indicated that the Veteran had expressed his belief that his rash issues had resolved, and he was unsure whether any of his claimed disorders were a “ratable condition”. The attorney indicated that they were investigating any plausible etiologies for why the Veteran experienced these episodic breakouts which did manifest in service. Despite this history, remand is nevertheless required for a new examination. 8. Entitlement to an initial evaluation in excess of 10 percent for service-connected hypertension Remand is necessary to obtain an updated VA examination. VA’s duty to assist includes obtaining evidence necessary to substantiate the claim, which may include a thorough and contemporaneous medical examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The only examination of record for the Veteran’s hypertension was conducted in September 2009. Due to the lack of contemporaneous records showing the severity of the Veteran’s disorder, the Board finds that remand is appropriate for an updated VA examination. 9. Entitlement to an initial evaluation in excess of 10 percent for service-connected right knee disability 10. Entitlement to an initial evaluation in excess of 10 percent for service-connected left ankle disability Remand is required for the Veteran’s claims of entitlement to initial evaluations in excess of 10 percent for the Veteran’s right knee and left ankle disorders in order to provide adequate examinations. In increased evaluation claims, VA examinations for musculoskeletal conditions must 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. 38 C.F.R. § 4.59 (2018); Correia v. McDonald, 28 Vet. App. 158 (2016). In addition, in increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. For example, a VA examination report is not adequate when the VA examiner failed to elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record- including the veteran’s lay information-or explain why she or he could not do so. Sharp, 29 Vet. App. at 34-35. The only examination conducted for the Veteran’s right knee and left ankle was in September 2009. The examination does not comply with the Court’s holdings in Correia and Sharp. Accordingly, remand is appropriate for a new examination for these disorders. 11. Entitlement to an initial compensable evaluation for service-connected right ear hearing loss Remand is required to obtain a current VA examination for the Veteran’s right ear hearing loss. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). During the May 2018 hearing, the Veteran testified that his hearing is getting worse, and his representative suggested that a new examination would help to ascertain the present severity of his disorder. Remand is thus warranted to provide a current examination. 12. Entitlement to an initial evaluation in excess of 20 percent for service-connected DVT 13. Entitlement to an initial evaluation in excess of 30 percent for service-connected gastritis with GERD 14. Entitlement to an initial compensable evaluation for a service-connected colon polyp 15. Entitlement to an initial compensable evaluation for service-connected simple bilateral kidney cysts with a right punctuate nephrolith in the right kidney VA’s duty to assist includes obtaining evidence necessary to substantiate the claim, which may include a thorough and contemporaneous medical examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Green v. Derwinski, 1 Vet. App. 121, 124 (1991). During the May 2018 hearing, the Veteran indicated that his examination conducted in September 2009 was flawed because the examiner spoke partial English and was unable to elicit the Veteran’s symptoms for his multiple disorders. The examination report, which is a translation, does not contain findings that are relevant to the diagnostic codes used for rating the disabilities, including service-connected DVT, gastritis with GERD, colon polyp residuals, and simple bilateral kidney cysts with right punctuate nephrolith in the right kidney. Accordingly, new examinations that address the severity of his disabilities consistent with the criteria for their respective diagnostic codes.   16. Entitlement to an initial compensable evaluation for service-connected residuals of melanoma in the right foot A June 2009 in-service treatment note from a private oncology clinic indicated that the Veteran had been diagnosed in the early spring of 2008 with stage II-A malignant melanoma of the right foot. The Veteran underwent multiple surgical excisions for evidence of residual disease at the time of the June 2009 exam. The Veteran reported that he appeared to be completely healed and described the process as asymptomatic. He denied any specific pigmentary changes or nodularities of the skin. During the May 2018 hearing, however, the Veteran testified as to several residual complications of the right foot melanoma. In particular, he testified that there is significant scarring located behind the big toe, describing it has hard, thick, skin covering the surgical area. He indicated there was pulling and adhesion, affecting the Veteran’s ability to move his toes and causing them to curl slightly. He also described shooting pain, intermittent numbness, tingling, and throbbing. The Veteran is in receipt of a noncompensable rating for residuals of melanoma in the right foot under DC 7818, which evaluates malignant skin neoplasms. Under DC 7818, the malignant skin neoplasms and their residuals are to be rated as disfigurement of the head, face, or neck, scars, or impairment of function. As the Veteran complaints he has residual symptoms of scarring behind his right big toe, application of the diagnostic codes for rating scars is raised. However, the Veteran’s representative also asserts that the Veteran’s residuals result in foot impairment. As such, the Board finds that remand is warranted for an examination to ascertain the present residuals of his service-connected right knee disorder. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his claimed left hamstring disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must identify and discuss any left hamstring disorder identified during the pendency of this claim. If no diagnosis is present, the examiner must determine whether any left hamstring pain reaches the level of a functional impairment of earning capacity. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed left hamstring disorder, to include any finding of pain that results in functional impairment of earning capacity, had onset in, or is otherwise related to, active military service. Third, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed left hamstring disorder, to include any finding of pain that results in functional impairment of earning capacity, was caused or aggravated by service-connected DVT. The examiner must specifically address the STRs documenting left hamstring injuries in 1986 and 2003 and the Veteran’s assertions of present symptoms in the left hamstring when walking. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his claimed cervical spine/neck disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must identify and discuss any neck disability identified during the pendency of this claim. If no diagnosis is present, the examiner must determine whether any neck pain reaches the level of a functional impairment of earning capacity. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed neck disorder, to include any finding of pain that results in functional impairment of earning capacity, had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of an in-service wear and tear on his cervical spine and continuing symptomatology since then and an April 2018 opinion from Dr. SSK that links present neck symptoms to his service. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his claimed right shoulder disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must identify and discuss any right shoulder disability identified during the pendency of this claim. If no diagnosis is present, the examiner must determine whether any right shoulder pain reaches the level of a functional impairment of earning capacity. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed right shoulder disorder, to include any finding of pain that results in functional impairment of earning capacity, had onset in, or is otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of an in-service wear and tear and injury on his right shoulder and continuing symptomatology since then and an April 2018 opinion from Dr. SSK that links present neck symptoms to his service. 6. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his claimed prostate disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner should indicate whether the Veteran has had a prostate disorder during the pendency of his appeal. The examiner should address the Veteran’s competent statements regarding urinary frequency made during his May 2018 hearing. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed prostate disorder, to include benign prostatic hyperplasia, had onset in, or is otherwise related to, active military service. In rendering this opinion, the examiner must specifically address the Veteran’s assertions of a lengthy history of an enlarged prostate prior to his separation from service. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that any diagnosed prostate disorder was caused or aggravated by a service-connected disorder, including hypertension, DVT, or CAD. 7. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected hypertension. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 8. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected right ear hearing loss and the etiology of any left ear hearing loss. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. If left ear hearing loss is diagnosed, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the hearing loss had onset in, or is otherwise related to, active military service. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the left ear hearing loss is caused or aggravated by the service-connected hypertension. In rendering this opinion, the examiner must address the September 2009 VA examiner’s opinion that the Veteran’s right ear hearing loss is caused by either noise exposure or hypertension. 9. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected right knee and left ankle disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must test the range of motion and pain of the right knee and left ankle in active motion, passive motion, weight-bearing, and non-weight-bearing. The examiner must also conduct the same testing on the opposite joints. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. In addition, describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. 10. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected DVT. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. The examiner should address the Veteran’s credible statements describing his symptoms of deep vein thrombosis during the May 2018 hearing. 11. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected gastritis with GERD. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 12. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected residuals of colon polyp. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 13. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected residuals of simple bilateral kidney cyst with a right punctuate nephrolith in the right kidney. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 14. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected residuals of melanoma of the right foot. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. The examiner must ascertain whether the residual scarring from the Veteran’s melanoma of the right foot results in functional impairment of the foot. 15. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel