Citation Nr: 18146360 Decision Date: 11/01/18 Archive Date: 10/31/18 DOCKET NO. 16-40 607 DATE: November 1, 2018 ORDER Entitlement to service connection for vision loss is denied. Entitlement to service connection for left ear hearing loss is granted. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a liver condition is denied. Entitlement to service connection for a bilateral testicular condition is denied. Entitlement to an initial rating in excess of 20 percent for right rotator cuff strain is denied. Entitlement to an initial compensable rating for right ankle strain prior to February 20, 2015, and in excess of 20 percent since that date is denied. REMANDED Entitlement to service connection for a left upper arm disability is remanded. Entitlement to service connection for a right ear disability is remanded. Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. Refractive error of the eye is not a disability for which service connection may be granted, and a preponderance of the evidence is against a finding that the Veteran has a superimposed disease or injury that had its onset in service or that is otherwise associated with service. 2. The Veteran’s left ear hearing loss is as likely as not related to his active service. 3. The Veteran’s right ear does not meet the criteria for a hearing loss disability for VA purposes. 4. The claims file is void of any competent evidence linking a disability manifested by elevated liver enzymes to the Veteran’s active service. 5. The Veteran does not have a diagnosed bilateral testicular condition. 6. Range of motion testing does not reveal that the Veteran’s right shoulder results in limitation of motion to 25 degrees from the side; the right shoulder disability is not manifested by impairment of the humerus or nonunion or dislocation of the clavicle or scapula. 7. Prior to February 20, 2015, the Veteran was shown to experience pain on movement of the right ankle, but the range of motion was not shown to be so functionally limited as to be classified as marked. 8. Since February 20, 2015, the range of motion of the right ankle was manifested by marked limitation of motion; ankylosis of the right ankle was not present. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral eye disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 4.9 (2018). 2. The criteria for service connection for a left ear hearing loss disability have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2018). 3. The criteria for service connection for a right ear hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1133, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2018). 4. The criteria for service connection for a liver condition have not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 5. The criteria for service connection for a bilateral testicular condition have not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 6. The criteria for entitlement to an initial rating in excess of 20 percent for right rotator cuff strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code 5201 (2018). 7. The criteria for a 10 percent rating for right ankle strain were met prior to February 20, 2015. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2018). 8. The criteria for a rating in excess of 20 percent rating for right ankle strain since February 20, 2015, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code 5271 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1987 to April 2014. He served in Southwest Asia from July 2004 to February 2005 and from August 2009 to April 2010. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In a July 2016 Statement of the Case (SOC), the RO styled the issue pertaining to the right ankle as entitlement to an effective date prior to February 20, 2015, for the award of a 20 percent rating. However, as the rating decision which granted the initial claim for service connection was not a final decision and the Veteran was clearly seeking an increased rating for this issue, the Board has styled the issue as entitlement to increased initial ratings as noted above. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for certain chronic diseases, including arthritis, when such disability is manifested to a degree of 10 percent or more within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112(a); 38 C.F.R. §§ 3.307, 3.309 (2018). When chronic diseases are at issue, the second and third elements for service connection may alternatively be established by showing continuity of symptomatology. See Walker v. Shinseki, 701 F.3d 1331 (Fed. Cir. 2013). The Veteran’s service records show that he was stationed in Southwest Asia for the purposes of 38 U.S.C. § 3.317. However, none of the issues decided herein are implicated by the regulations pertaining to service in Southwest Asia. Vision Loss Historically, the Veteran submitted a claim for entitlement to service connection for vision loss in December 2013. The claim was denied in a June 2014 rating decision from which the Veteran appealed. Refractive errors of the eyes are congenital or developmental defects and not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. Id. Thus, VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990) (cited at 55 Fed. Reg. 45,711) (Oct. 30, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). A review of the Veteran’s service treatment reports reflects that the Veteran reported blurry vision and underwent a foreign body removal of the right eye in February 1994. He was assessed with a corneal abrasion. In March 1994, the corneal abrasion was noted to be resolved. The Veteran underwent an optometry examination in April 2007. He was assessed with refractive error – hypermetropia. The Veteran was reported to have a normal ophthalmologic examination in February 2012. He was assessed with refractive error – hypermetropia and presbyopia. The Veteran’s retirement examination dated in December 2013 revealed a normal clinical evaluation of the eyes. At a December 2013 VA eye examination, the Veteran reported blurred vision beginning in 2000 which began when computers were introduced into the workspace. He reported that he used computers as a maintenance supervisor. The examiner conducted an eye examination and indicated that the Veteran did not have any diagnosed eye disability. His corrected distance and near vision was 20/40 or better. The examiner concluded that the Veteran did not have any diagnosis related to a vision loss condition because there is no pathology to render a diagnosis. The examiner concluded that the Veteran has bilateral presbyopia, an age-related refractive error which account for blurred vision. In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for a bilateral eye disability. In this case, the Veteran has not pointed to any specific injury or physical trauma in service. The Board acknowledges the removal of a foreign body in February 1994 and diagnosis of a corneal abrasion. However, the records reflect that the eye healed after that incident. Thereafter, the only report of any condition of the eyes includes a diagnosis of refractive error – hypermetropia and presbyopia. Furthermore, there is no indication of hypermetropia or presbyopia with any superimposed disease or injury in service. Moreover, while the Veteran was diagnosed with bilateral presbyopia at the VA examination in 2013, there was no evidence of vitreous/retinal disease at the VA examination. The VA examiner acknowledged the Veteran’s report of blurred vision and indicated that it was a symptom of his refractory error. Due to a lack of evidence of refractive error with superimposed disease or injury in service, service connection for presbyopia based on in-service incurrence or aggravation must be denied. The Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for a bilateral eye disability must be denied. Hearing Loss Historically, the Veteran submitted a claim for entitlement to service connection for hearing loss in December 2013. The claim was denied in a June 2014 rating decision from which the Veteran appealed. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The provisions of 38 C.F.R. § 3.385 do not require that hearing loss be shown as defined in that regulation at the time of separation from service, if there is sufficient evidence to demonstrate a relationship between a veteran’s service and his current disability. Hensley v. Brown, 5 Vet. App. 155 (1993). A review of the Veteran’s service treatment reports reflects that the Veteran’s January 1987 enlistment examination revealed puretone thresholds of 10, 10, 5, 20, and 15 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 5, 5, 10, 10, and 15 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. The Veteran underwent audiograms on numerous occasions during service. An audiogram dated in February 1991 revealed puretone thresholds of 15, 10, 10, 20, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 10, 5, 10, 15, and 15 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In June 1994, an audiogram revealed puretone thresholds of 15, 5, 5, 15, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 5, 0, 10, 5, and 30 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In June 1998, an audiogram revealed puretone thresholds of 15, 15, 0, 5, and 10 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 0, 0, 5, 10, and 25 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In September 2000, an audiogram revealed puretone thresholds of 15, 15, 5, 10, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 5, 5, 10, 0, and 30 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In May 2005, an audiogram revealed puretone thresholds of 15, 15, 0, 5, and 10 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 10, 10, 15, 20, and 45 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In June 2006, an audiogram revealed puretone thresholds of 20, 20, 0, 10, and 15 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 15, 15, 10, 10, and 40 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In April 2007, an audiogram revealed puretone thresholds of 15, 10, 5, 10, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 10, 10 10, 15, and 40 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In January 2012, an audiogram revealed puretone thresholds of 15, 20, 5, 10, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 5, 10, 10, 20, and 35 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. In February 2013, an audiogram revealed puretone thresholds of 15, 20, 5, 15, and 25 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 10, 10, 15, 25, and 40 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. A review of the records reflect that the Veteran was assessed with sensorineural hearing loss on several occasions during service. The Veteran’s December 2013 retirement examination included audiometric testing which revealed puretone thresholds of 10, 15, 5, 10, and 20 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 0, 15, 15, 25, and 45 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. The Veteran reported hearing loss on a report of medical history form prepared in conjunction with the retirement examination. At a December 2013 VA audiological examination, the Veteran reported exposure to weapons and engines during service. He indicated that when he was conversing, he had to have other people repeat themselves to understand what was being said to him. Audiometric testing revealed puretone thresholds of 10, 20, 10, 15, and 15 decibels in the right ear, at 500, 1000, 2000, 3000, and 4000 Hertz, and 5, 20, 10, 25, and 25 decibels for the left ear, at 500, 1000, 2000, 3000, and 4000 Hertz. Speech recognition scores were 100 percent in the right ear and 96 percent in the left ear. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss in the frequency range of 6000 Hertz or higher frequencies. The examiner opined that the Veteran’s hearing loss was at least as likely as not related to service due to military noise. However, the diagnosis of sensorineural hearing loss in the frequencies of 6000 Hertz or higher was noted to reveal impaired hearing that does not meet the criteria for a disability for VA purposes. Right Ear In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for right ear hearing loss. The Veteran’s right ear hearing thresholds did not meet the criteria for hearing loss pursuant to VA regulations at any time during service or since that time. As such, there is no medical evidence showing that hearing loss was diagnosed for VA purposes either during service or within a year of service. To the extent the Veteran would be competent to report diminished hearing acuity, he would not be competent to diagnose hearing loss for VA purposes as such a determination would require both objective audiometric and speech recognition testing, which the Veteran could not perform on himself. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Furthermore, there is no evidence of the Veteran having met the criteria for a compensable rating for hearing loss within one year after service. 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges that lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465 (1994). For example, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. As such, the Veteran is considered competent to describe his perception of diminished hearing acuity. Yet, aside from statements that he was exposed to military noise during service, the Veteran has not provided any extensive descriptions of any changes in hearing acuity during service. The Board acknowledges that the VA examiner determined that the Veteran had right ear sensorineural hearing loss in the frequency range of 6000 Hertz or higher frequencies and opined that the Veteran’s hearing loss was at least as likely as not related to service due to military noise. However, the diagnosis of sensorineural hearing loss in the frequencies of 6000 Hertz or higher was noted to reveal impaired hearing that does not meet the criteria for a disability for VA purposes. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for right ear bilateral hearing loss and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. Left Ear In this case, service connection for left ear hearing loss is warranted. At times during service and at his separation from service, the Veteran had hearing loss for VA purposes in the left ear at 4000 Hertz. When examined by VA in December 2013, prior to his separation from service, audiometric testing did not reveal hearing loss for VA purposes in either ear. Similarly, speech recognition testing did not reveal hearing loss for VA purposes. However, the VA examiner conceded that the Veteran was exposed to acoustic trauma in service. Moreover, there is medical evidence showing that left ear hearing loss was diagnosed for VA purposes within a year of service. Resolving all reasonable doubt in the Veteran’s favor, the competent and credible evidence creates a nexus between the Veteran’s current left ear hearing loss and active duty service. Therefore, service connection for left ear hearing loss is granted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Liver Condition A review of the Veteran’s service treatment reports reflects that hepatic function panels were performed in January 2011, March 2011, and April 2011 and revealed elevated alanine aminotransferase. Protein was also elevated at the time of the May 2011 hepatic function panel. No reference to any liver conditions was included in the voluminous service treatment reports of record. At a VA liver conditions examination in February 2016, the Veteran was noted to have undergone a hepatic function panel in December 2014 which did not reveal any elevated blood tests. No disability of the liver was diagnosed. This evidence notwithstanding, the Veteran does not meet the preliminary requirement for service connection, namely showing of a current “disability”. Elevated liver function tests are a laboratory finding are not a ratable disability for VA compensation purposes. The term “disability,” as used for VA purposes, refers to impairment of earning capacity and Congress specifically limits entitlement to service connection for diseases or injuries that have resulted in a disability. See 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439, 448. Simply stated, elevated liver function tests are test results, not disabilities. In this case, there is no evidence showing that the Veteran’s elevated liver function tests have resulted in disabilities. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Court of Appeals for Veterans Claims (Court) has held that where the law is dispositive of the claim, the claim should be denied because of lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Therefore, as there is no basis in the law to grant the Veteran’s appeal, the claim for service connection for a liver condition must be denied. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection for a liver condition and service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. Here, however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert; supra. Bilateral Testicular Condition The Veteran contends that service connection is warranted for a bilateral testicular condition. A review of the Veteran’s service treatment reports reflects that the Veteran was treated for a varicocele and painful ejaculation during service. However, the Board notes that the Veteran has been granted service connection for both of these conditions. A review of the claims file does not reflect any complaints, findings, or treatment for any other disabilities of the testicles. In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is not entitled to service connection for a bilateral testicular condition. The evidence of record does not include a diagnosis of a bilateral testicular condition (except, as noted, for the varicocele and painful ejaculation for which service connection has been established). In all claims for service connection, the threshold requirement is evidence of a currently diagnosed disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The competent evidence of record does not establish any symptoms of or a currently diagnosed bilateral testicular condition. Consequently, the objective findings do not support the finding of a diagnosis of a currently diagnosed testicular condition. Consequently, entitlement to service connection for a testicular condition is denied. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service connected disability exhibits symptoms that would warrant different ratings. See 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. It is essential that the examination upon 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 the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating 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. 38 C.F.R. § 4.59. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The shoulder and ankle are major joints. 38 C.F.R. § 4.45. The Board notes that during the course of the appeal, the Court of Appeals for Veterans’ Claims (Court) held, in Correia v. McDonald, 28 Vet. App. 158 (2016), that 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. Right Rotator Cuff Strain In a June 2014 rating decision, the Veteran was granted service connection for right rotator cuff strain and a 10 percent rating was assigned effective May 1, 2014, the day following his separation from active service. In a July 2016 Statement of the Case (SOC), the RO assigned a 20 percent rating effective May 1, 2014. The Veteran seeks a rating in excess of 20 percent for his right rotator cuff strain. At a December 2013 VA examination, the Veteran was assessed with right rotator cuff strain. He was noted to be right hand dominant. The Veteran reported muscle atrophy in the right arm and shoulder. The Veteran reported that he had limitation of motion and strength in the right upper arm and shoulder during flare-ups. Range of motion testing revealed flexion of the right and left shoulder to 180 degrees with pain in the right shoulder beginning at 140 degrees and right and left shoulder abduction to 180 degrees with pain in the right shoulder beginning at 140 degrees. The examiner also reported that the Veteran had right shoulder external and internal rotation that ends at 90 degrees with pain at 70 degrees of both external and internal rotation. The Veteran had 90 degrees of external and internal rotation of the left arm with no pain. Repetitive use testing revealed no change in flexion or abduction for either arm but pain on movement of the right arm. For the right shoulder, the examiner reported that the Veteran had pain, weakness, fatigability, and/or incoordination but no additional limitation of functional ability of the right shoulder during flare-ups or with repeated use over time. There was pain on palpation of the right shoulder and guarding of the right shoulder. There was clicking of the right shoulder but no recurrent dislocation of the glenohumeral joint. There was no tenderness on palpation of the acromioclavicular joint and no ankylosis. At an April 2015 VA examination, the Veteran was assessed with right shoulder strain. Range of motion testing of the right shoulder revealed flexion to 115 degrees, abduction to 110 degrees, external rotation to 25 degrees, and internal rotation to 90 degrees and range of motion of the left shoulder revealed flexion to 140 degrees, abduction to 130 degrees, external rotation to 50 degrees, and internal rotation to 55 degrees. The examiner indicated that the right arm decreased motion affects his ability to perform activities. There was no evidence of pain with weight bearing but there was objective evidence of crepitus. Following three repetitions of motion the Veteran had flexion of the right arm to 130 degrees, abduction to 100 degrees, external rotation to 30 degrees, and internal rotation to 90 degrees. Following three repetitions of motion the Veteran had flexion of the left arm to 140 degrees, abduction to 140 degrees, external rotation to 45 degrees, and internal rotation to 55 degrees. The Veteran endorsed moderate to severe daily flare-ups of the right shoulder which resulted in flexion limited to 105 degrees, abduction limited to 95 degrees, external rotation limited to 30 degrees, and internal rotation to 90 degrees. The examiner indicated that there was less movement than normal of the right shoulder. The Veteran also had instability, dislocation, or labral pathology and mechanical symptoms such as clicking or catching of the right shoulder. There was no ankylosis of the right shoulder. The Veteran reported that his condition has continued to worsen with decreased range of motion and right shoulder pain at rest and with movement. He adjusted his activity of the right upper extremity and has developed right elbow pain. Two courses of physical therapy have not alleviated his symptoms. The Veteran’s right shoulder disability is rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5201. Diagnostic Code 5201 pertains to limitation of motion of the arm and provides that a 20 percent rating is warranted for limitation of motion of the dominant or non-dominant arm at shoulder level. A 30 percent rating is warranted for limitation of motion of the dominant arm midway between side and shoulder level. A 40 percent rating is appropriate for limitation of motion of the dominant arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. As an initial matter, the Board notes that the medical evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his right shoulder is considered his major or dominant extremity. 38 C.F.R. § 4.69. Normal forward elevation of a shoulder (flexion) and normal abduction is to 180 degrees. Normal internal and external rotation is to 90 degrees. 38 C.F.R. § 4.71, Plate 1 (2018). The Board finds that the Veteran’s right shoulder disability does not warrant a rating in excess of 20 percent at any time during the relevant time period on appeal. The Veteran had some limitation of motion of his right (dominant) shoulder, with pain. However, there is no evidence to indicate that there was limitation of motion of the arm midway between side and shoulder level at any time during the relevant time period at issue. Accordingly, the Veteran is not entitled to a rating in excess of 20 percent at any time during the relevant time period on appeal. The Board has also considered other diagnostic codes for possible application. However, the evidence of record does not indicate ankylosis or impairment of the scapula, humerus, or clavicle. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, 5203. Thus, the Veteran is not entitled to a rating in excess of 20 percent under any other diagnostic codes. The evidence of record shows reports of pain on use and at rest (at the most recent examination). However, there was no evidence of fatigue, weakness, lack of endurance, instability, or incoordination on examination. The findings on examination do not suggest weakened movement, excess fatigability, incoordination, swelling, deformity or atrophy of disuse equated to what is necessary for the award of a rating in excess of 20 percent. Even accounting for the report of pain on movement and loss of motion noted at the most recent VA examination, the findings are simply not consistent with a higher rating as the ranges of motion found on examination do not equate to any rating in excess of 20 percent. 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Right Ankle Strain In a June 2014 rating decision, the Veteran was granted service connection for right ankle strain effective May 1, 2014, the day following his separation from active service. The Veteran submitted a VA Form 21-526EZ in February 2015 and requested an increased rating for his right ankle. This claim was received before the June 2014 rating decision became final and as such it was accepted as a statement indicating that his right ankle had increased in severity. In a May 2015 rating decision, a 20 percent rating was granted effective February 20, 2015, the date of a statement indicating that his right ankle increased in severity was received. The Veteran submitted a notice of disagreement in January 2016 and indicated that he believed that the 20 percent rating should be awarded effective May 1, 2014, the date that service connection was established. As noted above, the Board has recharacterized the issue as a claim for initial increased ratings for the right ankle. The Veteran’s service-connected right ankle strain is rated pursuant to Diagnostic Code 5271. 38 C.F.R. § 4.71a. Diagnostic Code 5271 states that a 10 percent evaluation is warranted for moderate limitation of motion of the ankle, whereas a 20 percent evaluation is in order for marked limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board notes that words such as moderate and marked are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Because the rating schedule offers no further guidance on the issue, the Board will rely on Webster’s definitions of the terms used. “Marked” means noticeable, Webster’s II New College Dictionary, 670 (1995). “Moderate” means of average or medium quantity. Id. at 704. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. At a December 2013 VA examination, the Veteran was assessed with right ankle musculoskeletal strain. Range of motion testing of the right and left ankle revealed flexion to 45 degrees or greater with pain at 40 degrees and dorsiflexion to 20 degrees or greater with pain at 15 degrees. The Veteran was able to perform repetitive use testing with no loss of range of motion of either ankle but pain on motion bilaterally. There was no localized tenderness or pain on palpation or either ankle. There was normal muscle strength and no joint laxity of either ankle. The Veteran ambulated without the use of any assistive devices. Diagnostic tests revealed small calcaneal spurs of the bilateral ankles. The examiner indicated that there was no additional limitation of functional ability of either ankle during flare-ups or repeated use over time. At an April 2015 VA examination, the Veteran was assessed with right ankle strain. Range of motion testing revealed dorsiflexion of the right and left ankle from 0 to 20 degrees and plantar flexion from 0 to 10 degrees. The examiner reported that the Veteran had pain with plantar flexion of the right ankle and no evidence of pain with weight-bearing or objective evidence of crepitus. The examiner noted that the Veteran’s reduced range of motion resulted in difficulty with ambulation, especially during flares. The Veteran was able to perform repetitive use testing with at least three repetitions for both ankles. There was no additional loss of function or range of motion of either ankle after three repetitions. The examiner indicated that pain limited dorsiflexion of the right ankle to 25 degrees and plantar flexion to 10 degrees with repeated use over a period of time. The Veteran reported occasional flare-ups of moderate severity lasting one hour. For the right ankle, the examiner indicated that during flare-ups pain, fatigue, and weakness resulted in dorsiflexion limited to 20 degrees and plantar flexion limited to 0 degrees. The examiner reported that the Veteran’s right ankle was manifested by less movement than normal, disturbances of locomotion, and interference with standing. The examiner noted that the Veteran also had right ankle instability. There was no ankylosis of either ankle. Prior to February 20, 2015 Here, at the examination performed in 2013, the Veteran had pain on movement in both ankles. Inexplicably, the Veteran was granted a 10 percent rating for the left ankle (not on appeal) but a noncompensable rating was assigned for the right ankle. While the ankles have generally functioned normally, the medical professional at the 2013 examination documented pain on examination. As such, pursuant to 38 C.F.R. § 4.59, a 10 percent rating should be assigned for the Veteran’s right ankle prior to February 20, 2015. It is noted that the 10 percent rating is the equivalent of the rating that would be assigned for moderate limitation of motion. As such, the issue becomes whether the Veteran has been shown to have marked limitation of motion for the period prior to February 20, 20115. Again, “Marked” means noticeable, Webster’s II New College Dictionary, 670 (1995). Having reviewed the evidence, the Board notes that the Veteran had full range of motion of the right ankle prior to February 20, 2015. In addition, while pain was present, neither pain nor repetitive motion was shown to additionally limit the Veteran’s range of motion. Looking at other factors as well, x-rays of the ankles revealed calcaneal spurs of the ankles but no arthritis was documented. As such, there is no evidence which suggests that there is marked or noticeable limitation of motion. In reaching these conclusions, the Board has considered whether an increased disability rating is warranted on the basis of functional loss or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Here, as noted, repetitive motion did not cause additional limitation of motion, nor did pain. Moreover, a 10 percent rating has been granted for pain on movement. As such, a rating in excess of 10 percent is not warranted for the relevant time period on appeal. The Board has also considered whether any higher ratings are available under any other Diagnostic Codes pertaining to the ankle. However, the Veteran’s right ankle strain is not manifested by ankylosis of the ankles (Diagnostic Code 5270), ankylosis of the subastragalar or tarsal joints (Diagnostic Code 5272), malunion of the os calcis or astragalus (Diagnostic Code 5273), or astragalectomy. Consequently, a higher rating is not warranted under any of these Diagnostic Codes. Since February 20, 2015 In considering the evidence of record and the applicable laws and regulations, the Board concludes that the Veteran is entitled to a rating in excess of 20 percent for right ankle strain since February 20, 2015. The Veteran is receiving the maximum schedular rating for a limitation of motion of the ankles pursuant to Diagnostic Code 5271. 38 C.F.R. § 4.71. As such, the Board considered whether any higher ratings are available under any other Diagnostic Codes pertaining to the ankle. However, the Veteran’s right ankle strain is not manifested by ankylosis of the ankle (Diagnostic Code 5270), ankylosis of the subastragalar or tarsal joints (Diagnostic Code 5272), malunion of the os calcis or astragalus (Diagnostic Code 5273), or astragalectomy. Consequently, a higher rating is not warranted under any of these Diagnostic Codes. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Duty to Assist There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, examinations in this case have been undertaken and medical opinions were obtained with regard to the claims for vision loss, hearing loss, right rotator cuff strain and right ankle strain. Regarding records, VA must obtain “records of relevant medical treatment or examination” at VA facilities. 38 U.S.C. § 5103A(c)(2). All records pertaining to the condition at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has indicated no such records exist and all pertinent records have been obtained. With regard to the liver condition and bilateral testicular condition decided herein, while VA medical opinions were not provided, the Federal Circuit Court of Appeals (Federal Circuit) has recognized that there is not a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary’s obligation under 38 U.S.C. § 5103A(d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). In this case, there is no evidence of a diagnosis of a liver disability or a bilateral testicular condition (except for those which service connection has already been established). As such, VA’s duty to provide an examination with an opinion is not triggered with regard to this matter. See Waters, 601 F.3d 1274. Under these circumstances, VA is not required to provide examinations in connection with these claims. REASONS FOR REMAND A review of the claims file reveals that a remand is necessary before a decision on the merits of the remaining claim can be reached. Left Upper Arm Disability The Veteran contends that his left upper arm disability is either directly related to service or is secondary to service-connected cervical or lumbar spine disabilities. The Veteran was afforded a VA examination in January 2015 and in February 2016. The January 2015 examiner was requested to provide an opinion as to whether the claimed left upper arm disability was secondary to his service-connected cervical and lumbar spine disabilities. The examiner diagnosed the Veteran with paresthesia of unknown etiology and also diagnosed compression neuropathy of the brachial complex. The examiner indicated that the Veteran’s disability was less likely than not related to his symptoms in service but failed to address whether the disability was caused or aggravated by the service-connected cervical or lumbar spine disabilities. The February 2016 provided a negative nexus on the basis of the Veteran’s service in Southwest Asia. Consequently, a remand is necessary to address whether service connection is warranted on a secondary basis. Right Ear Disability The Veteran contends that service connection is warranted for a right ear disability. A review of the service treatment reports reflects that the Veteran was treated for a right ear eustachian tube dysfunction on several occasions during service including in February 2013. On a report of medical history form prepared in July 1998, the Veteran reported that he underwent a surgical procedure where tubes were placed in his ears in when he was a child. The Veteran was afforded a ear VA examination in December 2013. Following a physical examination, the examiner indicated that there was evidence of a healed tympanic membrane perforation of the right side and he also diagnosed bilateral tympanosclerosis. However, the examiner then concluded that there was no pathology to render a diagnosis. The conclusion that there was no pathology to render a diagnosis conflicts with the diagnosis of tympanosclerosis. No opinion was offered as to the etiology of the diagnosed bilateral tympanosclerosis. The Veteran also underwent a VA examination in February 2016 for the claimed right ear disability. The examiner specifically found that the Veteran does not have a Eustachian tube disorder but also concluded that an association between service in Southwest Asia and the development of a Eustachian tube disorder has not been clearly defined. However, once again, no opinion was offered as to the diagnosed bilateral tympanosclerosis. In order to properly adjudicate the claim for a right ear disability, an addendum opinion with etiology opinion should be obtained. Sleep Apnea A review of the Veteran’s service treatment reports notes reports of snoring. The Veteran underwent a polysomnogram in February 2013. The study did not demonstrate significant obstructive sleep apnea due to low apnea hypopneas per hour. There was slightly reduced sleep efficiency, increased arousals, and awakenings with mild reductions in the deeper stages of sleep. The examiner noted that the findings appeared to be due to position dependent apnea. The Veteran was recommended to avoid sleep in the supine position, raising of the head of the bed, weight loss, possible use of CPAP but only after repeated polysomnography in the supine position with a sleep aid, and the use of a dental oral appliance. The Veteran was afforded a VA examination in February 2016. Although the examiner initially noted that the Veteran had been diagnosed with sleep apnea in 2013, he ultimately concluded that the there was no diagnosis of sleep apnea and as such no etiological opinion could be offered. The report indicates that a sleep study was canceled. In light of the conflicting VA examination report which suggests both that the Veteran had sleep apnea diagnosed in 2013 and that there was no diagnosis of sleep apnea, the Board has determined that a remand is necessary in order to obtain a sleep study to determine whether a diagnosis of sleep apnea is appropriate and the etiology of any such diagnosed sleep apnea. The matter is REMANDED for the following action: 1. Submit the Veteran’s claims file to the examiner who conducted the January 2015 VA examination or to an examiner with similar expertise and request an addendum opinion. The claims file should be provided to the examiner for review prior to the examination and such review should be noted in the examination report. The VA examiner is requested to provide an opinion as to whether it is as likely as not (50 percent probability or greater) that a left upper arm disability was caused or aggravated by the service-connected lumbar or cervical spine disabilities. A complete rationale should be provided for any opinion expressed. If the examiner determines that another examination is necessary, the Veterans should be scheduled for such. 2. Submit the Veteran’s claims file to the examiner who conducted the December 2013 VA examination or to an examiner with similar expertise and request an addendum opinion. The claims file should be provided to the examiner for review prior to the examination and such review should be noted in the examination report. The VA examiner is requested to provide an opinion as to whether it is as likely as not (50 percent probability or greater) that the diagnosed bilateral tympanosclerosis was incurred in or caused by the Veteran’s service, including treatment for a right Eustachian tube dysfunction. A complete rationale should be provided for any opinion expressed. If the examiner determines that another examination is necessary, the Veteran should be scheduled for such. 3. Schedule the Veteran for an appropriate VA examination for his claim for service connection for sleep apnea. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. Any necessary tests, including a polysomnography (sleep study) should be conducted. A complete history should be obtained from the Veteran. The examiner should include a diagnosis for any diagnosed sleep disorder. If the examiner determines that the Veteran has current sleep apnea, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s claimed sleep apnea was incurred in or caused or aggravated by service or is otherwise related thereto. A complete rationale for all opinions expressed should be included. (Continued on the next page)   4. Then, readjudicate the claims. If action remains adverse to the Veteran, issue a supplemental statement of the case, allow the appropriate time for response, and then return the case to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Cryan, Counsel