Citation Nr: 18149070 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-25 776 DATE: November 8, 2018 ORDER Entitlement to service connection for hemihypertrophy is denied. Entitlement to service connection for viral syndrome disorder is denied. Entitlement to service connection for sickle cell anemia disorder is denied. Entitlement to an initial compensable rating for pseudofolliculitis barbae is denied. REMANDED 1. Entitlement to service connection for bilateral hearing loss is remanded. 2. Entitlement to service connection for tinnitus is remanded. 3. Entitlement to service connection for hypertension is remanded. 4. Entitlement to an initial compensable disability rating for residuals of injury, is remanded. 5. Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative arthritis, is remanded. 6. Entitlement to an initial compensable disability rating for left hip sprain with degenerative arthritis, is remanded. 7. Entitlement to a rating in excess of 10 percent for residuals of left knee injury is remanded. 8. Entitlement to an initial compensable disability rating for right knee sprain with degenerative joint disease, is remanded. 9. Entitlement to an initial compensable disability rating for residuals of left foot ingrown toenails disorder is remanded. 10. Entitlement to service connection for a left ankle disorder is remanded. 11. Entitlement to service connection for substance abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. 12. Entitlement to service connection for tobacco abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. 13. Entitlement to service connection for insomnia, to include as secondary to service-connected left knee disorder or other musculoskeletal disorders, is remanded.   FINDINGS OF FACT The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of hemihypertrophy. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of viral syndrome disorder. The Veteran’s current sickle cell trait is a congenital or hereditary defect and the Veteran is not shown to have current disability that is superimposed on the sickle cell trait that was incurred during active service. The Veteran’s pseudofolliculitis barbae covers less than 5 percent of his body, requires no medication, and is unaccompanied by scarring. CONCLUSIONS OF LAW 1. The criteria for service connection for hemihypertrophy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for viral syndrome disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for sickle cell anemia disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for an initial compensable disability rating for pseudofolliculitis barbae have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1–4.14, 4.118, Diagnostic Code 7813-7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1987 to June 1994. A hearing was not requested. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for hemihypertrophy Regarding hemihypertrophy, the first element of service connection is not met. The Veteran has submitted no medical evidence of hemihypertrophy. This disorder is not noted in the March 2013 VA knee examination and is not noted in any of the four VA musculoskeletal examinations conducted in August 2014. The second element is also not met. Hemihypertrophy is not mentioned in the Veteran’s pre-service medical records, his entrance examination, or any of his later service treatment records. Because the preponderance of the evidence is against the existence of a current disorder or an in-service event or injury, the Veteran’s claim of entitlement to service connection for hemihypertrophy must be denied. Entitlement to service connection for viral syndrome disorder Regarding a viral syndrome disorder, the first element of service connection is not met. An August 2014 VA infectious diseases examination indicates that the Veteran does not have an infectious disease. During the examination, the Veteran states that he “ha[s] no recollection of viral illness during the service” and “[h]e denies any treatment for viral illnesses in the service and after the service.” The Veteran has submitted no medical evidence suggesting the existence of a current diagnosis of a viral syndrome disorder. Because the preponderance of the evidence is against the existence of a current diagnosis of a viral syndrome disorder, the Veteran’s claim must be denied. Entitlement to service connection for sickle cell anemia disorder “Sickle cell trait alone, without a history of directly attributable pathological findings, is not a ratable disability.” 38 C.F.R. § 4.118, Diagnostic Code 7714, Note (1). The term “disability” as used for VA purposes refers to impairment in earning capacity. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Neither the Veteran’s January 1987 report of medical history (received 7/15/94, page 37 of 171) nor his March 1987 entrance examination (received 7/15/94, pages 32–33 of 130) indicate sickle cell anemia. Consistent with this, a January 1987 private medical record in the Veteran’s personnel file (received 7/13/94, page 25 of 130) states that the Veteran has no history of sickle cell. The first evidence of sickle cell trait is a January 1990 in-service blood test (received 7/15/94, page 159 of 171) which states: “Pattern consistent with sickle cell trait (Heterozygous).” The Veteran’s August 2014 VA infectious diseases examination makes no mention of a sickle cell disorder. The Veteran has presented no lay or medical evidence to suggest that he has ever suffered from, been diagnosed with, or been treated for a sickle cell disorder. There is also no evidence that the Veteran’s sickle cell trait causes an impairment in earning capacity or results in any disability for which service connection could be granted. There is also no evidence that another disability is superimposed over the Veteran’s sickle cell trait. Since the Veteran’s sickle cell trait alone is not a current disability for which service connection may be granted, the Board concludes that the preponderance of the evidence is against the claim for service connection for sickle cell anemia disorder or of a chronic disability manifested by sickle cell trait, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55–56 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to an initial compensable rating for pseudofolliculitis barbae On May 3, 2013, the Veteran filed a claim of entitlement to service connection for pseudofolliculitis barbae (PFB). In October 2014, the RO granted service connection at an initial noncompensable rating under Diagnostic Code 7806-7813 from the date of the claim. The Veteran is appealing the rating aspect of that decision. Because the claim is an initial claim, the Board will consider evidence of symptomatology from the date that the claim was filed. 38 C.F.R. § 3.400(o). Rating Schedule Effective August 13, 2018, the schedule of ratings for the skin was amended. 83 Fed. Reg. 32664 (July 13, 2018) (codified at 38 C.F.R. § 4.118). Claims pending prior to the effective date will be considered under both the old and new schedules, and whatever schedule is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new schedule will be applied. Because the Veteran’s claim was filed on May 3, 2013, the Board will consider both schedules. Under the new schedule, “systemic therapy” refers to treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin. 38 C.F.R. § 4.118(a). “Topical therapy” refers to treatment that is administered through the skin. Id. Two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of the skin are involved. 38 C.F.R. § 4.118(b). Only the highest evaluation shall be used if two or more skin conditions involve the same area of skin. Id. Topical corticosteroids, such as skin creams, do not categorically constitute “systemic therapy” under 38 C.F.R. § 4.118, but may constitute “systemic therapy” if administered on a large enough scale to affect the body as a whole. Johnson v. Shulkin, 862 F.3d 1351, 1355–56 (Fed. Cir. 2017). In other words, some topical treatments may constitute “systemic therapy,” depending on the facts of the case. Burton v. Wilkie, No. 16-2037, 2018 U.S. App. Vet. Claims LEXIS 1314, at *9–10 (Vet. App. Sep. 28, 2018). In addressing whether a topically-applied corticosteroid is a systemic therapy, the Board must consider two questions. First, “whether a topical treatment operates by affecting the body as a whole in treating the veteran’s skin condition.” Id. at *12 (emphasis omitted). Second, “whether a given treatment is ‘like’ a corticosteroid or other immunosuppressive drug....” Id. at *20. Neither question categorically requires a medical opinion to be answered. Burton only applies to claims filed prior to August 13, 2018. Diagnostic Code 7800 provides compensation for disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. The rating criteria and Notes of Diagnostic Code 7800 were not changed by the recent amendments. A 10 percent rating is provided for a skin disorder with one characteristic of disfigurement of the head, face, or neck. Id. A 30 percent rating is provided for a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. Id. A 50 percent rating is provided for a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with four or five characteristics of disfigurement. Id. An 80 percent rating is provided for a skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with six or more characteristics of disfigurement. Id. Note (1) to Diagnostic Code 7800 provides that the eight characteristics of disfigurement are: 1) scar is 5 or more inches (13 or more cm) in length; 2) scar is at least one-quarter inch (0.6 cm) wide at the widest part; 3) surface contour of scar is elevated or depressed on palpation; 4) scar is adherent to underlying tissue; 5) skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm); 6) skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm); 7) underlying soft tissue is missing in an area exceeding six square inches (39 sq. cm); and 8) skin is indurated and inflexible in an area exceeding six square inches (39 sq. cm). 38 C.F.R. § 4.118. Note (2) to Diagnostic Code 7800 provides that tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle), and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), as appropriate. 38 C.F.R. § 4.118. Note (3) provides that unretouched color photographs are to be taken into consideration when rating under these criteria. Id. Note (4) provides that disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, are evaluated under the appropriate diagnostic code(s) and combined under section 4.25 with the evaluation assigned under this diagnostic code. Id. Under Note (5), the characteristic(s) of disfigurement may be caused by one scar or by multiple scars, and need not be caused by a single scar in order to assign a particular evaluation. Id. Diagnostic Code 7801 provides compensation for burn scar(s), other than on the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118. Prior to August 13, 2018, a 10 percent evaluation is provided for scars exceeding 6 square inches (39 sq. cm.) in area but less than 12 square inches (77 sq. cm.) in area. Id. A 20 percent evaluation is provided for scars exceeding 12 square inches (77 sq. cm.) in area but less than 72 square inches (465 sq. cm.) in area. Id. A 30 percent evaluation is provided for scars exceeding 72 square inches (465 sq. cm.) in area but less than 144 square inches (929 sq. cm.) in area. Id. A 40 percent evaluation is provided for scars exceeding 144 square inches (929 sq. cm.) in area. Id. Note (1) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Note (2) provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or the trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. Effective August 13, 2018, Diagnostic Code 7801 provides compensation for burn scar(s), other than on the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118. The rating criteria for Diagnostic Code 7801 were not changed by the recent amendments but the Notes have been amended. Note (1) now states that the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. Id. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) states that a separate evaluation may be assigned for each affected zone of the body under Diagnostic Code 7801 if there are multiple scars, or a single scar, affecting multiple zones of the body. Id. Under such circumstances, separate evaluations are to be combined under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under Diagnostic Code 7801. Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118. Prior to August 13, 2018, a 10 percent evaluation is provided for scars of 144 square inches (929 sq. cm.) or greater in area. Id. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damages. 38 C.F.R. § 4.118. Note (2) provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or the trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. Effective August 13, 2018, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. The rating criteria for Diagnostic Code 7802 were not changed by the recent amendments but the Notes have been amended. Note (1) now states that the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. Id. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) provides that a separate evaluation may be assigned for each affected zone of the body under Diagnostic Code 7802 if there are multiple scars, or a single scar, affecting multiple zones of the body. 38 C.F.R. § 4.118. Under such circumstances, separate evaluations are to be combined under § 4.25. Id. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under Diagnostic Code 7802. Id. Diagnostic Code 7803 was eliminated from the rating criteria before August 13, 2018. 38 C.F.R. § 4.118 (effective from October 23, 2008). Diagnostic Code 7804 provides compensation for painful or unstable scars. 38 C.F.R. § 4.118. The rating criteria and Notes of Diagnostic Code 7804 were not changed by the recent amendments. A 10 percent rating is provided for one or two scars that are unstable or painful. Id. A 20 percent rating is provided for three or four scars that are unstable or painful. Id. A 30 percent rating is provided for five or more scars that are unstable or painful. Id. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. Note (2) states that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Id. Note (3) states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. Id. Prior to August 13, 2018, Diagnostic Code 7805 provides that disabling effects of scars (including linear scars) not considered in a rating under Diagnostic Codes 7800 to 7804 are evaluated under other appropriate diagnostic codes. 38 C.F.R. § 4.118. Effective August 13, 2018, Diagnostic Code 7805 contains essentially identical language, except that it does not specifically reference linear scars. Diagnostic Code 7806 provides compensation for service-connected dermatitis or eczema. 38 C.F.R. § 4.118. Prior to August 13, 2018, a 0 percent rating is provided where less than 5 percent of the entire body or less than 5 percent of exposed areas is affected and no more than topical therapy was required during the past 12-month period. Id. A 10 percent rating is provided where: 1) 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected; or 2) systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 30 percent rating is provided where: 1) 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected; or 2) systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A 60 percent rating is provided where: 1) more than 40 percent of the entire body or more than 40 percent of exposed areas are affected; or 2) constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. Id. Also under this Diagnostic Code, scars may be rated under Diagnostic Codes 7800 to 7805, depending on the disability. Effective August 13, 2018, dermatitis or eczema are evaluated under the General Rating Formula for the Skin. 38 C.F.R. § 4.118. A 0 percent rating is provided for no more than topical therapy required over the past 12-month period and at least one of the following: (i) characteristic lesions involving less than 5 percent of the entire body affected; or (ii) characteristic lesions involving less than 5 percent of exposed areas affected. Id. A 10 percent rating is provided for at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 38 C.F.R. § 4.118. A 30 percent rating is provided for at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118. A 60 percent rating is provided for at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118. Alternatively, dermatitis or eczema can be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. The General Rating Formula for the Skin does not apply to Diagnostic Code 7824. Id. Prior to August 13, 2018, Diagnostic Code 7813 provides compensation for service-connected dermatophytoses, including ringworm of the body (tinea corporis), head (tinea capitis), feet (tinea pedis), beard area (tinea barbae), nails (tinea unguium), and inguinal area (jock itch, tinea cruris). 38 C.F.R. § 4.118. Such disorders are to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. Id. Effective August 13, 2018, Diagnostic Code 7813 provides compensation for service-connected dermatophytoses, including ringworm of the body (tinea corporis), head (tinea capitis), feet (tinea pedis), beard area (tinea barbae), nails (tinea unguium, onychomycosis), and inguinal area (jock itch, tinea cruris), and for tinea versicolor. 38 C.F.R. § 4.118. Such disorders are to be evaluated under the General Rating Formula for the Skin. Application of the Rating Schedule The October 2014 VA skin examination states that the Veteran develops a neck rash “approximately 2 times per year (usually when he shaves in a different direction, with an electric razor, or has a ‘close shave’)” but that “[o]therwise he does not experience the rash or any symptoms.” There is no scarring, no disfigurement, no neoplasms, no oral treatment, and no topical treatment. The skin disorder covers less than five percent of his entire body and does not impact his ability to work. The preponderance of the evidence is against the existence of any symptomatology that would support a compensable rating for PFB. There are no characteristics of disfigurement so as to support a compensable rating under Diagnostic Code 7800. There are no scars exceeding an area of 6 square inches, whether nonlinear or associated with underlying soft tissue damage, so as to support a compensable rating under Diagnostic Code 7801. There are no scars of 144 square inches or greater in area so as to support a compensable rating under Diagnostic Code 7802. There are no painful or unstable scars so as to support a compensable rating under Diagnostic Code 7804. Finally, the Veteran’s PFB does not cover an area of the body of 5 percent or greater or require the use of any medication so as to support a compensable rating under Diagnostic Code 7805 or the General Rating Formula For The Skin. For these reasons, the preponderance of the evidence is against a compensable rating. Rather, the Veteran’s symptoms more nearly approximate a noncompensable rating under Diagnostic Code 7805. The evidence does not support additional staged ratings for any time period on appeal. For no period would the Veteran be entitled to a higher rating under a different Diagnostic Code. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. An October 2014 VA examiner opines that the Veteran’s current bilateral hearing disorder is less likely than not related to service. In rendering this opinion, the examiner notes that the Veteran displayed normal hearing in his March 1987 entrance examination (received 7/13/94, pages 32–33 of 130) and his May 1994 exit examination (received 7/13/94, pages 112–13 of 130). But the examiner does not address the slight shifts in pure tone thresholds for the right ear at 3000 Hz and 6000 Hz. An addendum opinion is required. 2. Entitlement to service connection for tinnitus is remanded. The hearing loss addendum opinion described above could potentially provide evidence that is relevant to the Veteran’s claim of entitlement to service connection for tinnitus. Since this issue is intertwined with the hearing loss claim, a decision on the tinnitus claim at this time would be premature. 3. Entitlement to service connection for hypertension is remanded. The Board cannot make a fully-informed decision on the issue of service connection for hypertension because no VA examiner has opined whether the current diagnosis is related to service. The Veteran’s service treatment records include blood pressure readings as follows: Date Blood Pressure 3/5/1987 136/80 1/5/1989 122/70 2/3/1989 128/70 5/22/1989 144/96 6/21/1989 102/80 3/15/1990 134/72 11/26/1990 128/80 5/28/1991 130/80 2/23/1994 120/80 5/25/1994 130/84 These readings do not represent readings taken two or more times on at least three different days as required for a diagnosis under VA’s rating schedule. See 38 C.F.R. § 4.104, DC 7101, Note (1). However, they are consistent with elevated blood pressure as defined by the American Heart Association. See Health Topics, High Blood Pressure, Understanding Blood Pressure Readings (Nov. 30, 2017) available at http://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. These blood pressure readings therefore indicate a possible relationship to service. 4. Entitlement to an initial compensable disability rating for residuals of left thumb injury is remanded. 5. Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative arthritis is remanded. 6. Entitlement to an initial compensable disability rating for left hip sprain with degenerative arthritis is remanded. 7. Entitlement to a rating in excess of 10 percent for residuals of left knee injury is remanded. 8. Entitlement to an initial compensable disability rating for right knee sprain with degenerative joint disease is remanded. 9. Entitlement to an initial compensable disability rating for residuals of left foot ingrown toenails disorder is remanded. While the record contains contemporaneous VA examinations regarding disabilities 4-9, the examinations do not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). New examinations are therefore required. 10. Entitlement to service connection for a left ankle disorder is remanded. The musculoskeletal examinations described above could potentially provide evidence that is relevant to the Veteran’s claim of entitlement to service connection for a left ankle disorder. Since this issue is intertwined with the musculoskeletal claims remanded for further development, a decision on the left ankle claim at this time would be premature. 11. Entitlement to service connection for substance abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. Service connection may not be granted for substance abuse on the basis of service incurrence or aggravation. 38 U.S.C. §§ 105, 1131; 38 C.F.R. § 3.301(a); VAOPGCPREC 2-98 (explaining that direct service connection for disability resulting from a claimant’s own drug or alcohol abuse is precluded for all VA benefit claims filed after October 31, 1990). However, secondary service connection is available for drug and alcohol abuse if such abuse is found to be secondary to a service-connected disability. See Allen v. Principi, 237 F.3d 1368, 1381–82 (Fed. Cir. 2001). Compensation may be awarded only “where there is clear medical evidence establishing that alcohol or drug abuse is caused by a veteran’s primary service connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing.” Id. at 1381. The October 2014 VA mental disorders examination does not address substance abuse. A new examination is required. 12. Entitlement to service connection for tobacco abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. For claims filed after June 9, 1998, as here, Congress has prohibited the grant of service connection for a disability due to the use of tobacco products during active duty service. 38 U.S.C. § 1103(a). This does not bar a finding of secondary service connection for a disability related to use of tobacco products after service. See VAOPGCPREC 6-03 (Service Connection for Cause of Disability or Death, 69 Fed. Reg. 25178 (2004)). The October 2014 VA mental disorders examination does not address tobacco use. For this reason also a new examination is required. 13. Entitlement to service connection for insomnia, to include as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. The musculoskeletal examinations described above could potentially provide evidence that is relevant to the Veteran’s insomnia claim, in that he is claiming insomnia as secondary to at least one musculoskeletal disorder. Also, the mental disorder examination described above could potentially provide evidence that is related to the Veteran’s insomnia claim. Since these issues are intertwined, a decision on the insomnia claim at this time would be premature. Additionally, on Remand the RO should obtain all relevant VA treatment records dated from September 2012 to the present before the issues on appeal are decided on the merits. Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain all VA treatment records from September 2012 to the present. If no records are available, the claims folder must indicate this fact. Any additional records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a hearing impairment. The examiner must opine: (a.) Whether it is at least as likely as not (a 50 percent or better probability) that any current hearing loss disorder was incurred in the Veteran’s service. (b.) Whether it is at least as likely as not (a 50 percent or better probability) that any current tinnitus disorder was incurred in the Veteran’s service. In reaching these opinions, the examiner should consider the October 2014 VA examination. The examiner should also consider the Veteran’s March 1987 entrance examination (received 7/13/94, pages 32–33 of 130) and his May 1994 exit examination (received 7/13/94, pages 112–13 of 130) and comment upon the shifts in pure tone thresholds for the right ear at 3000 Hz and 6000 Hz. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of hypertension. The examiner must address the following: (a.) Whether hypertension at least as likely as not (1) began during active service, (2) manifested within 1 year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) , is otherwise related to an in-service injury, event, or disease. (b.) Whether hypertension is at least as likely as not (1) proximately due to a different medical condition, or (2) aggravated beyond its natural progression by a different medical condition. If so, the examiner should identify the primary medical condition. 4. Schedule the Veteran for an examination of the current severity of his residuals of left thumb injury, lumbar strain with degenerative arthritis, left hip sprain with degenerative arthritis, residuals of left knee injury, right knee sprain with degenerative joint disease, and residuals of left foot ingrown toenails disorder disabilities. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups and after repeated use over time, and the degree of functional loss during flare-ups and after repeated use over time. To the extent possible, the examiner should identify any symptoms and functional impairments due to the disability alone and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement or an opinion regarding flare-ups and after repeated use over time, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. After obtaining any additional records to the extent possible, provide an examination and obtain a medical opinion regarding the nature and etiology of any current or previously-diagnosed left ankle disorder. The examiner should address the following: (a.) Whether the Veteran has any current or previously-diagnosed left ankle disorder; (b.) Whether a left ankle disorder at least as likely as not (1) began during active service, (2) manifested within 1 year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) , is otherwise related to an in-service injury, event, or disease. (c.) Whether a left ankle disorder (i) is proximately due to a service-connected musculoskeletal disorder or (ii) was aggravated by a service-connected musculoskeletal disorder. 6. Provide an examination and obtain a medical opinion regarding the nature and etiology of any acquired psychiatric disorder, including but not limited to substance abuse, alcohol abuse, and insomnia. The examiner should review the entire claims file, conduct all necessary tests and studies, and provide the requested opinions. (a.) Identify all acquired psychiatric disorders currently present, including substance abuse, alcohol abuse, and insomnia. (b.) Offer an opinion as to whether it is at least as likely as not that a current acquired psychiatric disorder, including insomnia but not including substance abuse or alcohol abuse, had its onset in service or was otherwise caused by an in-service disease or injury. (c.) Offer an opinion as to whether it is at least as likely as not that a current acquired psychiatric disorder had its onset within one year of the Veteran’s discharge from his period of active service. (d.) Whether the Veteran has any current or previously-diagnosed acquired psychiatric disorder, including substance abuse, alcohol abuse, and insomnia, that (i) is proximately due to a service-connected musculoskeletal disorder or (ii) was aggravated by a service-connected musculoskeletal disorder. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cannon, Associate Counsel