Citation Nr: 18149754 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 15-37 679 DATE: November 13, 2018 ORDER The reduction in rating from 20 percent to 10 percent, effective from November 1, 2015, for lumbar spine disability was improper and the 20 percent rating is restored. A rating in excess of 20 percent prior to April 5, 2018 and in excess of 40 percent thereafter for a lumbar spine disability with degenerative joint disease is denied. An initial disability rating in excess of 20 percent for radiculopathy of the right lower extremity is denied. Service connection for chronic fatigue syndrome is denied. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hypertension, to include as due to PTSD or sleep apnea or as secondary to a service-connected disability, is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected lumbar spine disability, is remanded. Entitlement to service connection for bilateral foot arthritis, to include as secondary to service-connected plantar warts of the bilateral feet and/or degenerative changes of the right fifth metatarsophalangeal joint, is remanded. Entitlement to service connection for sleep apnea, to include as due to PTSD, is remanded. Entitlement to service connection for radiculopathy of the bilateral hands (claimed as bilateral hand numbness), to include as due to cervical spine disability or as secondary to service-connected lumbar spine disability, is remanded. FINDINGS OF FACT 1. The reduction in the rating for lumbar spine disability from 20 percent to 10 percent, effective from November 1, 2015, did not result in a reduction or discontinuance of compensation payments that were being made; therefore, the notice provisions of the regulation governing compensation rating reductions do not apply. 2. The 20 percent rating for lumbar spine disability was in effect for more than five years, but less than 20 years, at the time of the October 2015 rating decision that decreased the evaluation to 10 percent, effective November 1, 2015. 3. The October 2015 rating decision does not consider or make findings of whether the evidence shows it is reasonably certain that the material improvement found will be maintained under the ordinary conditions of life. 4. During the appeal period prior to April 5, 2018, the Veteran’s lumbar spine disability manifested, at worst, in forward flexion to 70 degrees, extension to 10 degrees, no ankylosis, and pain on motion. 5. As of April 5, 2018, the Veteran’s lumbar spine disability manifests, at worst, in forward flexion to 25 degrees, extension to 15 degrees, and no ankylosis. 6. For the entire initial appeal period, the Veteran’s radiculopathy of the right lower extremity manifests moderate incomplete paralysis of the sciatic nerve. 7. The Veteran served in the Southwest Asia theater of operations, in Saudi Arabia, from February 1990 to May 1991 and is a Persian Gulf Veteran. 8. The probative medical evidence of record does not establish a diagnosis of chronic fatigue syndrome during the appeal period and his symptoms of fatigue have been attributed to diagnosed PTSD and sleep apnea. CONCLUSIONS OF LAW 1. The reduction in rating from 20 percent to 10 percent, effective from November 1, 2015, for lumbar spine disability was improper. 38 U.S.C. §§ 1155, 5112 (2012); 38 C.F.R. §§ 3.150(e), 3.344, 4.2, 4.10, 4.71a, Diagnostic Code 5237 (2018). 2. The criteria for entitlement to a rating in excess of 20 percent prior to April 5, 2018 and in excess of 40 percent thereafter for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.27, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2018). 3. The criteria for entitlement to an initial disability evaluation in excess of 20 percent for radiculopathy of the right lower extremity have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.14, 4.124a, Diagnostic Code 8520 (2018). 4. The criteria for entitlement to service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 101(33), 1110, 1117, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.317 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1979 to October 1999. Generally, the propriety of a rating reduction is a separate issue from a claim for an increased evaluation. See Dofflemeyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992); see also Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991) (“This is a rating reduction case, not a rating increase case.”). However, in this case, in response to the Veteran’s disagreement with the October 2015 rating decision which reduced his disability rating for disability, the Regional Office (RO) issued a Statement of the Case (SOC) in November 2017 and a Supplemental Statement of the Case (SSOCs) in April 2018 that adjudicated his claim as if it were one for an increased rating. By consistently treating a claim as if it is part of a timely filed substantive appeal, VA effectively waives all objections to the procedural adequacy of the appeal with respect to that issue. See Percy v. Shinseki, 23 Vet. App. 37, 46 (2009). The Board finds that the RO led the Veteran to believe that the issue of entitlement to an increased rating for disability was on appeal and has therefore taken jurisdiction of that issue, as listed above. The Veteran filed a VA Form 9, Substantive Appeal, to the Board of Veterans’ Appeals in October 2015 and requested a hearing. In March 2016, the Veteran indicated that he wished to withdraw his request to appear at a hearing before a Veterans Law Judge. Thus, the Board deems the request for a hearing withdrawn. 38 C.F.R. § 20.704(e) (2018) (providing that a request for a hearing may be withdrawn by an appellant at any time before the date of the hearing). Neither the Veteran nor his representative have raised any other 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). A total disability rating based on individual unemployability (TDIU) is not for consideration because the Veteran does not contend, and the evidence does not show, that his service-connected disabilities on appeal render him unemployable. Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). Increased and Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Ratings are assigned based on the average impairment of earning capacity resulting from a service-connected disability. 38 C.F.R. § 4.1. Where two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected lumbar spine disability in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s disability should be viewed in relation to its history. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Given the nature of the present claim for a higher initial evaluation for service-connected radiculopathy of the right lower extremity, the Board has considered all evidence of severity since the effective date for the award of service connection on October 5, 2015. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to a disability rating in excess of 20 percent prior to April 5, 2018 and in excess of 40 percent thereafter for a lumbar spine disability with degenerative joint disease, to include consideration of the propriety of the reduction from 20 percent to 10 percent, effective from November 1, 2015 The Veteran’s lumbar spine disability with degenerative disc disease is evaluated under Diagnostic Code 5242-5237. 38 C.F.R. § 4.71a. Under the General Rating Formula for Diseases and Injuries of the Spine, a 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. Note (5) provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a. Under current provisions, intervertebral disc syndrome (IVDS) is evaluated either under the General Rating Formula for Diseases and Injuries of the Spine as noted above, or under the Formula for Rating IVDS, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. In this case, the medical evidence of record does not show the Veteran’s service-connected lumbar spine disability has been manifested by IVDS at any time during the appeal period, thus consideration for higher ratings under the Formula for Rating IVDS will not be discussed below. When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A. Propriety of the Reduction from 20 percent to 10 percent effective from November 1, 2015 A rating reduction is the result of a course of action taken by VA, and not a claim by the Veteran. When the propriety of a rating reduction is at issue, the focus is on the actions of the RO in effectuating the reduction, both in terms of compliance with the special due process considerations applicable to reductions, and in terms of whether the evidence at the time of the decision reducing the evaluation supported the reduction. In most cases, violations of the set of due process considerations applicable to rating reductions, or failure of the evidence to meet the standards for reducing an evaluation, render the underlying reduction void ab initio, rather than merely voidable. The burden is on VA to justify a reduction in a rating. See Brown v. Brown, 5 Vet. App. 413 (1993) (finding that the Board is required to establish, by a preponderance of the evidence and in compliance with 38 C.F.R. § 3.344, that a rating reduction is warranted). In an October 2015 rating decision, the Veteran’s existing 20 percent disability rating for a lumbar spine disability with degenerative joint disease was reduced from 20 percent to 10 percent, effective November 1, 2015. The Board notes that there are specific procedural requirements applicable to rating reductions. If a reduction in the evaluation is considered warranted and the lower evaluation would result in a reduction or discontinuance of the compensation payments currently being made, the RO must issue a rating proposing the reduction and setting forth all material facts and reasons. 38 C.F.R. § 3.105(e). In the present case, the Board notes that the rating reduction for lumbar spine disability with degenerative joint disease, effective November 1, 2015, did not result in a change to the Veteran’s combined disability rating. Accordingly, the requirements of 38 C.F.R. § 3.105(e) do not apply. As to rating reductions, the United States Court of Appeals for Veterans Claims (Court) has held that several general regulations are applicable to all rating reduction cases, without regard for how long a particular rating has been in effect. Specifically, the Court has stated that certain regulations “impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon a review of the entire history of the Veteran’s disability.” Brown, 5 Vet. App. at 420 (referring to 38 C.F.R. §§ 4.1, 4.2, 4.13). A rating reduction requires an inquiry as to “whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations.” Id. at 421. Thus, in any rating-reduction case, not only must it be determined that an improvement in a disability had actually occurred, but also that the improvement reflects an improvement under the ordinary conditions of life and work. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. There are more stringent evidentiary requirements for reducing ratings that have been at the same level for more than 5 years, such as in the current appeal. 38 C.F.R. § 3.344(c). The relevant period for this purpose is calculated from the effective date of the establishment of the former rating to the effective date of the reduction. See Brown, 5 Vet. App. 413. By a June 2008 rating action, the RO granted an increased 20 percent rating to the service-connected lumbar spine disability, effective January 30, 2008. By the appealed October 2015 rating action, the RO reduced the Veteran’s lumbar spine disability from 20 to 10 percent, effective November 1, 2015. Hence, the 20 percent rating assigned to the lumbar spine disability had remained in effect for more than 5 years, but less than 20 years. Pursuant to 38 C.F.R. § 3.344(a), if a rating has been in effect for more than 5 years, then rating agencies will handle cases of changes of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. 38 C.F.R. § 3.344(a). It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Id. Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction. Id. Ratings on account of diseases subject to temporary or episodic improvement will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Id. Moreover, though material improvement in the physical or mental condition is clearly reflected the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. Id. By regulation, the RO must observe the provisions of 38 C.F.R. § 3.344(a) when reducing a disability rating that has been in place for more than 5 years. Greyzck v. West, 12 Vet. App. 288, 292 (1999). It is well established that failure of the RO to consider and apply the applicable provisions of 38 C.F.R. § 3.344 in such cases, renders a rating decision void ab initio. See Id.; see also Hayes v. Brown, 9 Vet. App. 67, 73 (1996); Dofflemyer, 2 Vet. App. at 277. The law provides that where a rating reduction was made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, in a rating reduction case the erroneous reduction must be vacated and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Indeed, in Schafrath, the Court found the reduction in that case void ab initio because the reduction was made without observance of 38 C.F.R. § 3.344(a), among other regulations. Id. In the instant case, relevant documents show that the RO reduced the disability rating assigned to the Veteran’s lumbar spine disability without taking 38 C.F.R. § 3.344(a) into consideration. The Board has reviewed the October 2015 rating decision, wherein the RO reduced the Veteran’s lumbar spine disability from 20 to 10 percent. In reducing the Veteran’s lumbar spine disability from 20 to 10 percent in the appealed October 2015 rating action, the RO indicated that VA examinations, notably those conducted in April 2010 and October 2015, had showed “sustained improvement.” The RO, however, failed to consider and discuss whether any material improvement would be maintained under the ordinary conditions of life. In addition, the lack of a reference to 38 C.F.R. § 3.344, or a recitation of the language therein, in the October 2015 rating action indicates that the due process provisions of section 3.344 were not properly considered. There is no reference to 38 C.F.R. § 3.344(a) or language indicating that the RO considered 38 C.F.R. § 3.344(a), aside from a cursory statement that there was “sustained improvement” on two consecutive VA examinations in the appealed. Further, there was no discussion as to whether the April 2010 and October 2015 examinations were as full and complete as the June 2008 examination, on which the 20 percent rating was based. Again, while the October 2015 rating action notes that the Veteran’s lumbar spine disability had demonstrated “sustained improvement” on two VA examinations, there is no reference of whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. The Board cannot glean from the October 2015 rating decision that the RO considered whether the improvement would be maintained under the ordinary conditions of life. Clear from the cases discussed above, when the RO reduces a rating without observance of the law, its action was without authority and the reduction is void ab initio. Therefore, the appeal as to this issue must be granted and the 20 percent rating for a lumbar spine disability is restored, effective November 1, 2015. B. Rating in excess of 20 percent prior to April 5, 2018 The Veteran’s lumbar spine disability was evaluated in a VA thoracolumbar spine disabilities examination on October 5, 2015. At the October 2015 VA examination, the Veteran reported re-occurring sharp pain and lower back spasms. The Veteran also reported two episodes where he was immobilized by lower back pain. The examiner diagnosed the Veteran with mechanical lower back pain with degenerative joint disease. Range of motion was found to be flexion of 70 degrees, extension of 10 degrees, lateral flexion in each direction of 20 degrees, lateral rotation in each direction of 20 degrees. There was pain on motion throughout the movements but no additional limitation of motion with repetition. The examiner noted the Veteran’s lumbar spine manifested in interferences with standing, sitting, disturbances of locomotion, and less movement than normal. The examiner noted there was no ankylosis present or neurologic abnormalities such as bladder or bowel problems. The Veteran also did not exhibit IVDS. The Veteran reported wearing a lumbar brace for support. The VA examiner reported there were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran’s lumbar spine disability. As noted above, the next-higher rating of 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The Board has considered whether a disability rating higher than 20 percent is warranted for this period of appeal based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, 8 Vet. App. at 206-07. The October 2015 VA examiner indicated that the Veteran was observed after repetitive use testing of at least three repetitions, and that there was no additional loss of function or range of motion after repetitive use. The examiner also noted that pain may increase loss of function or range of motion after repeated use over time; however, the examiner noted a similar range of motion measurements as discussed above. Thus, any additional limitation due to pain cannot be established to more nearly approximate a finding of forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. §§ 4.45, 4.59, 4.71a, Diagnostic Code 5237; DeLuca, 8 Vet. App. at 202; Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Even when considering the Veteran’s pain and functional loss, his disability is not more closely described as limitation of forward flexion to 30 degrees or less or favorable ankylosis. He does not have ankylosis because he retains motion in his thoracolumbar spine. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). In sum, the Board finds that the 20 percent rating contemplated functional loss due to pain, excess fatigability, and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination during this period of appeal. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07. The Veteran’s representative contends that the Veteran’s claim for an increased disability rating should be referred for extraschedular consideration. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peak, 22 Vet. App. 111 (2008), aff’d, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. The Veteran’s representative asserts that the schedular criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5237 does not adequately reflect the Veteran’s functional loss in occupational and daily activities, and does not adequately contemplate his total disability picture. In support of assertion, the Veteran’s representative highlights that the October 2015 VA examination notes that the Veteran reported sharp pain during simple motions like walking, sitting, and standing. The Veteran’s representative also states the October 2015 examiner reported that due to the Veteran’s lumbar spine pain, the Veteran may note intolerance to full forward flexion and prolonged walking. The Board finds that the rating criteria under Diagnostic Code 5237 contemplates the Veteran’s symptoms and manifestations of his service-connected lumbar spine disability. As noted above, a 20 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. This rating criteria specifically considers the limitation of forward flexion. Further, as noted above, the Board has also considered the Veteran’s pain on motion in evaluating his disability. In addition, the October 2105 examination notes only that the Veteran may note intolerance to full forward flexion and prolonged walking. The October 2015 examination does not state these limitations are certain to occur, nor does the examination establish an exceptional or unusual disability picture, such as marked interference with employment. For these reasons, remand for referral for extraschedular consideration is not warranted. C. Rating in excess of 40 percent since April 5, 2108 The Veteran’s lumbar spine disability was re-evaluated at a VA thoracolumbar spine examination on April 5, 2018. At the April 2018 VA examination, the Veteran reported aching pain with stiffness and spasms. The Veteran also reported daily flare-ups. The examiner diagnosed the Veteran with mechanical lower back pain with degenerative joint disease. Range of motion was found to be flexion of 25 degrees, extension of 15 degrees, lateral flexion in each direction of 20 degrees, right lateral rotation of 15 degrees, and left lateral rotation of 20 degrees. There was pain on motion throughout the movements. The examiner noted additional range of motion loss after repetitive-use testing. After repetitive use, range of motion was found to be flexion of 15 degrees, extension to 5 degrees, lateral flexion in each direction of 10 degrees, right lateral rotation of 5 degrees, and left lateral rotation of 10 degrees. The examiner noted that there may be additional function loss with repeated use over time but could not say without resorting to speculation. The examiner noted there was no ankylosis present or neurologic abnormalities such as bladder or bowel problems. The Veteran also did not exhibit IVDS syndrome. The Veteran did not report using an assistive device for support. The VA examiner reported there were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran’s lumbar spine disability. As noted above, the next-higher rating of 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a. The April 2018 VA examiner indicated that the Veteran was observed after repetitive use testing of at least three repetitions, and noted additional range of motion loss. The examiner also noted that pain may increase loss of function or range of motion after repeated use over time; however, the examiner stated that range of motion measurements could not be speculated without resorting to speculation. The Board finds that any additional limitation due to pain cannot be established to more nearly approximate a finding of unfavorable ankylosis of the entire thoracolumbar spine. Even when considering the Veteran’s pain and functional loss, his disability is not more closely described as unfavorable ankylosis of the entire thoracolumbar spine. He does not have ankylosis because he retains motion in his thoracolumbar spine. See Dinsay, 9 Vet. App. at 81; Lewis, 3 Vet. App. at 259. As a result, the Board finds that a rating in excess of 40 percent for the service-connected lumbar spine disability at any time during the appeal period since April 5, 2018 is not warranted in this case. See 38 C.F.R. § 4.71a, Diagnostic Code 5237. Given that the Veteran is already in receipt of the schedular maximum for limitation of motion of the thoracolumbar spine, inquiry into the DeLuca factors is moot for the appeal period since April 5, 2018. DeLuca, 8 Vet. App. at 206; Johnston v. Brown, 10 Vet. App. 80, 87 (1997). Lastly, as noted above, the Veteran’s representative contends that the Veteran’s claim for an increased disability rating should be referred for extraschedular consideration. See 38 C.F.R. § 3.321; Thun, 22 Vet. App. at 111, aff’d, Thun, 572 F.3d at 1366. The Veteran’s representative asserts that the schedular criteria under Diagnostic Code 5237 does not adequately reflect the Veteran’s functional loss in occupational and daily activities, and does not adequately contemplate his total disability picture. In support of assertion, the Veteran’s representative highlights that the April 2018 VA examination notes that the Veteran’s lumbar spine disability manifests in pain and weakness that causes the Veteran to have difficulty standing, walking, and sitting/driving for long periods. The VA examiner further noted, “as a food service technician, these functional deficits cause him to move slower with less efficiency, thereby decreases his productivity levels.” The Board has carefully compared the level of severity and symptomatology of the Veteran’s lumbar spine disability with the established criteria found in the rating schedule. The Board, the Veteran’s symptomatology is fully addressed by the rating criteria under which the Veteran’s lumbar spine disability is rated. There are no additional symptoms that are not addressed by the rating schedule. The Veteran has not described any exceptional or unusual features of lumbar spine disability. The symptomatology of the Veteran’s lumbar spine disability centers on complaints of pain, weakness, fatigability, and limited range of motion. These symptoms are specifically contemplated under the assigned ratings criteria. Therefore, the Board finds that the rating criteria reasonably describe the Veteran’s disability level and symptomatology for her service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran’s disability picture. In addition, the Board finds that some level of decreased productivity at work is not the equivalent of marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). D. Additional Considerations With regard to the entire appeal period, the Board considered whether a separate evaluation may be warranted for any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate Diagnostic Code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (1). At the outset, the Board notes that service connection for radiculopathy of the right lower extremity was granted as secondary to service-connected lumbar spine disability in an October 2015 VA rating decision. With regard to any other associated neurological abnormalities associated with the service-connected lumbar spine disability, the record is silent for any additional findings. In fact, the October 2015 and April 2018 VA examination reports included indications of “no” for the Veteran having any other objective neurological abnormalities or findings associated with the thoracolumbar spine. As a result, the Board finds a separate evaluation for any associated objective neurological abnormality (other than radiculopathy of the right lower extremity) associated with the service-connected lumbar spine disability is not warranted in this case. The Board considered other potentially applicable Diagnostic Codes. See Schafrath, 1 Vet. App. at 589. In this case, the evidence does not reflect that there are any other musculoskeletal disorders of the lumbar spine that the Veteran’s lumbar spine disability is more properly rated under another Diagnostic Code. See 38 C.F.R. § 4.71a, Diagnostic Code 5237. Accordingly, higher ratings under alternate Diagnostic Codes is not warranted. The Board considered the Veteran’s reported history of symptomatology related to the service-connected lumbar spine disability. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for higher ratings for his lumbar spine disability have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran’s disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board also considered the possibility of staged ratings and finds that the scheduler ratings for the service-connected disability on appeal have been in effect for appropriate periods on appeal. Accordingly, additional staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. 2. Entitlement to an initial disability rating in excess of 20 percent for radiculopathy of the right lower extremity The Veteran claims entitlement to an initial disability rating in excess of 20 percent for radiculopathy of the right lower extremity. In an October 2015 rating decision, the Veteran was granted service connection for radiculopathy of the right lower extremity and assigned an initial 20 percent disability rating effective from October 5, 2015. The Veteran’s radiculopathy of the right lower extremity is evaluated under Diagnostic Code 8520. 38 C.F.R. § 4.124a. In accordance with Diagnostic Code 8520, disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. Id. During the appeal period since October 5, 2015, the Veteran’s radiculopathy of the right lower extremity was evaluated in two VA examinations. In an October 2015 VA thoracolumbar spine examination, the VA examiner noted that the Veteran experienced radiculopathy that manifested in moderate, constant pain and mild numbness in the right lower extremity. In an April 2018 VA thoracolumbar spine examination, the VA examiner noted that the Veteran experienced radiculopathy that manifested in moderate, constant pain, moderate numbness, and moderate paresthesias in the right lower extremity. Accordingly, the Board finds that the criteria for a 20 percent disability rating most closely represents the Veteran’s symptoms of radiculopathy of the right lower extremity. The next-higher 40 percent disability rating is not warranted because the Veteran’s symptom of radiculopathy of the right lower extremity do not rise to the level of moderately severe. As such, the Board finds that an initial rating in excess of 20 percent for the service-connected radiculopathy of the right lower extremity is not warranted in this case. See 38 C.F.R. § 4.124a, Diagnostic Code 8520. The Board acknowledges the Veteran’s statements that his radiculopathy is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno, 6 Vet. App. at 469. The Board finds, however, that neither the Veteran’s statements nor medical evidence demonstrates that the criteria for an initial disability evaluation in excess of 20 percent have not been met. The Board also acknowledges that the Veteran’s VA treatment and private medical records note complaints of and treatment for radiculopathy of the right lower extremity; however, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered the possibility of staged ratings and finds that the proper rating has been in effect for the entire initial appeal period. Accordingly, staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. Lastly, the Veteran’s representative also contends that the Veteran’s claim for a higher initial disability rating for radiculopathy of the right lower extremity should be referred for extraschedular consideration. See 38 C.F.R. § 3.321; Thun, 22 Vet. App. at 111, aff’d, Thun, 572 F.3d at 1366. The Veteran’s representative asserts that the schedular criteria of 38 C.F.R. § 4.124a, Diagnostic Code 8520 does not adequately reflect the Veteran’s functional loss in occupational and daily activities, and does not adequately contemplate his total disability picture. In support of assertion, the Veteran’s representative highlights that the October 2015 VA examination notes that the Veteran’s radiculopathy may cause feeling of instability while walking. The Board finds that the rating criteria under Diagnostic Code 8520 contemplates the Veteran’s symptoms and manifestations of his service-connected radiculopathy of the right lower extremity. As noted above, a 20 percent disability rating is warranted for moderate, incomplete paralysis of the sciatic nerve. While instability is not specifically addressed by the rating criteria, it stands to reason that moderate, incomplete paralysis of the sciatic nerve may result in some amount of instability. In addition, the October 2105 examination notes only that the Veteran’s radiculopathy may cause feelings of instability while working. The October 2015 examination note does not establish an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. For these reasons, remand for referral for extraschedular consideration is not warranted. Service Connection 3. Entitlement to service connection for chronic fatigue syndrome Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A “qualifying chronic disability” for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). The Veteran claims entitlement to service connection for chronic fatigue syndrome. In this case, the Board finds that the Veteran is a Persian Gulf Veteran as his service personnel records reflect that he served in the Southwest Asia theater of operations, specifically Saudi Arabia, from February 1990 to May 1991. See 38 U.S.C. § 101(33); 38 C.F.R. § 3.317(e)(2). Nevertheless, as discussed below, the Veteran is currently diagnosed with PTSD and sleep apnea attributable to his complaints of fatigue. These diagnoses are known clinical diagnoses and, therefore, not qualifying chronic disabilities. As such, the undiagnosed illness presumptive provisions of 38 U.S.C. § 1117 do not apply and other provisions of a qualifying chronic disability do not provide an exception for a diagnosed fatigue or muscle or joint pain disability. The claim on appeal will be discussed on a direct basis below. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). At present, the most probative evidence of record does not establish a diagnosis of chronic fatigue syndrome during the appeal period. In a January 2012 VA chronic fatigue syndrome examination, the examiner noted that the Veteran’s symptoms of fatigue and sleep disturbances were attributable to his PTSD and sleep apnea, and not chronic fatigue syndrome. The examiner did not diagnose the Veteran with chronic fatigue syndrome. The Veteran’s VA treatment records also do not contain a diagnosis of chronic fatigue syndrome. The medical evidence of record does not support the Veteran’s claim on a direct basis. The existence of a current disability is the cornerstone of a claim for VA disability compensation, and without a current disability, service connection is not warranted. 38 U.S.C. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (In the absence of proof of a present disability, there can be no valid claim). The Board acknowledges the Veteran’s contentions that he has chronic fatigue syndrome. However, the Veteran’s statements alone are not sufficient to constitute a current diagnosis. The Veteran is competent to describe symptoms he has experienced, whether in service or during the years since discharge, based on his personal knowledge. Layno, 6 Vet. App. at 469. However, the diagnosis of chronic fatigue syndrome is a complex condition which the Veteran in this case is not competent to address due to his lack of medical training and/or expertise. See Davidson v. Nicholson, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, the probative value of the Veteran’s lay statements regarding chronic fatigue syndrome are low. Without objective evidence of a diagnosis of chronic fatigue syndrome, the claim must be denied. For these reasons, the Board finds that the preponderance of the probative evidence of record weighs against the claim of service connection for chronic fatigue syndrome. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for PTSD The Veteran claims entitlement to service connection for PTSD. The Board acknowledges that the Veteran served during Desert Storm and earned a Kuwait Liberation for his service. Following an initial VA examination for PTSD in June 2012, the VA examiner opined that the Veteran did not meet the criteria for a diagnosis of PTSD pursuant to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV) criteria. In July 2012, the VA examiner provided an addendum opinion stating that the Veteran’s claimed in-service stressor event did not meet the criteria for a combat-related stressor event. The VA examiner did not discuss why the Veteran’s claimed stressor of serving in a war zone, hearing incoming explosions and small arms fire, or feeling physically threatened by present landmines does not meet the criteria for an in-service stressor, particularly the fear of hostile military or terrorist activity. See 38 C.F.R. § 3.304(f)(3) (2018). Review of subsequent VA treatment records shows diagnoses of unspecified trauma and stressor related disorder pursuant to the DSM-5 in June 2014 and PTSD symptoms/combat stress reaction in November 2016, as well as continued treatment for PTSD. Moreover, VA implemented usage of the DSM-5, effective August 4, 2014, and as this case was initially certified to the Board in November 2017, the DSM-5 is for application in this case. As a result, the Board finds that an addendum VA opinion is necessary to determine if the Veteran has a current diagnosis of PTSD, and if so, is the Veteran’s PTSD is related to his period of active service. 2. Entitlement to service connection for hypertension, to include as due to PTSD or sleep apnea or as secondary to a service-connected disability The Veteran claims entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. Specifically, the Veteran contends that his hypertension is caused or aggravated by his sleep apnea, PTSD, and/or other disabilities resulting in chronic pain. At present, the Veteran’s VA treatment records establish that the Veteran has a diagnosis of hypertension during the appeal period. Currently, the probative evidence of record does not contain a medical opinion addressing the Veteran’s claim that his current hypertension is caused or aggravated by his sleep apnea, PTSD, and/or other service-connected disabilities. As a result, a VA examination and medical opinion is necessary to address the etiology of the Veteran’s hypertension, to include as secondary to chronic pain from his service-connected disabilities. 3. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected lumbar spine disability The Veteran claims entitlement to service connection for a cervical spine disability. Specifically, the Veteran contends that his current cervical spine disability was caused or aggravated by his service-connected lumbar spine disability. Service connection can be established for disabilities caused or aggravated by service-connected disabilities. 38 C.F.R. § 3.310. The Board acknowledges that the Veteran has a current cervical spine disability. In a January 2012 VA neck conditions examination, the VA examiner noted a diagnosis of degenerative joint disease and degenerative disc disease of the cervical spine. The VA examiner opined that the Veteran’s current cervical spine disability was less likely than not related to his service-connected lumbar spine disability. The VA examiner reasoned: [Degenerative joint disease] and [degenerative joint disease] of the spine in one area does not cause the same pathologic process to occur in another area. It is all related to wear on the discs and joints of the spine from biomechanical forces. The Board finds that the January 2012 opinion is inadequate for purposes of determining secondary service connection because the opinion fails to address the element of aggravation. Further, the January 2012 opinion does not provide a comprehensive rationale and analysis for its conclusion that Veteran’s service-connected lumbar spine disability did not cause his current cervical spine disability. An addendum medical opinion and comprehensive rationale is required to determine if the Veteran’s service-connected lumbar spine disability caused or aggravated his current cervical spine disability beyond its natural progression. 4. Entitlement to service connection for bilateral foot arthritis, to include as secondary to service-connected plantar warts of the bilateral feet and/or degenerative changes of the right fifth metatarsophalangeal joint The Veteran claims entitlement to service connection for bilateral foot arthritis. Specifically, the Veteran contends that his bilateral foot arthritis was caused or aggravated by his service-connected degenerative changes of the right fifth metatarsophalangeal joint and/or walking with an abnormal gait due to service-connected bilateral foot plantar warts. The Veteran has a current diagnosis of bilateral foot arthritis of the first metatarsophalangeal joint. VA feet examinations conducted in September 2010 and July 2011 note a diagnosis of bilateral foot arthritis of the first metatarsophalangeal joint; however, neither medical opinion provided addresses the Veteran’s contention that his bilateral foot arthritis of the first metatarsophalangeal joint was caused or aggravated by his service-connected bilateral foot plantar warts and/or degenerative changes of the right fifth metatarsophalangeal joint. Accordingly, an addendum opinion is required to address the Veteran’s claim for secondary service connection. 5. Entitlement to service connection for sleep apnea, to include as due to PTSD 6. Entitlement to service connection for radiculopathy of the bilateral hands (claimed as bilateral hand numbness), to include as due to cervical spine disability or as secondary to service-connected right knee, left knee, and/or lumbar spine disability Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. The Veteran seeks entitlement to service connection for sleep apnea, to include as due to PTSD. At present, the Veteran contends that his sleep apnea is caused or aggravated by his PTSD. The Board acknowledges that the Veteran has a current diagnosis of sleep apnea. As noted above, the Veteran’s claim of entitlement to service connection for PTSD is remanded for an additional VA opinion. The Board finds that the Veteran’s claim for entitlement to sleep apnea is inextricably intertwined with the PTSD claim being remanded at this time, as development of the evidence and the outcome of the pending service connection claim may impact the outcome of the sleep apnea claim. A grant of service connection, and recognition of the Veteran’s disabilities as related to his claimed PTSD may be pertinent to the intertwined sleep apnea claim on appeal. Thus, the Board must defer final adjudication of the sleep apnea issue until the directed development necessary for determining the Veteran’s service connection for PTSD has been accomplished. The Veteran also seeks entitlement to service connection for radiculopathy of the bilateral upper extremities. Most recently, the Veteran contends that his radiculopathy of the bilateral upper extremities is caused or aggravated by his cervical spine disability. As noted above, the Veteran’s claim of entitlement to service connection for a cervical spine disability is remanded for a VA addendum medical opinion. The Board finds that the Veteran’s claim for entitlement to radiculopathy of the bilateral upper extremities, to include as secondary to a cervical spine disability is inextricably intertwined with the cervical spine disability claim being remanded at this time, as development of the evidence and the outcome of the pending service connection claim may impact the outcome of the radiculopathy of the bilateral extremities claim. A grant of service connection, and recognition of the Veteran’s disabilities as related to his claimed cervical spine disability may be pertinent to the intertwined radiculopathy of the bilateral upper extremities claim on appeal. Thus, the Board must defer final adjudication of the issue of service connection for radiculopathy of the bilateral hands until the directed development necessary for determining the Veteran’s service connection for a cervical spine disability has been accomplished. The Court has held that two issues are “inextricably intertwined” when they are so closely tied together that a final decision cannot be rendered unless both issues have been considered. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the matters are REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the June 2012 initial VA examination for PTSD so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether: (a.) The Veteran has a current psychiatric disability, to include PTSD under the DSM-5 criteria. (b.) If so, it is at least as likely as not (50 percent or greater probability) that the Veteran’s psychiatric disability, to include PTSD, began during active service or is related to an incident of service. The examiner should specifically discuss the Veteran’s claimed stressors and how they do or do not meet the criteria for fear of hostile military or terrorist attack. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Schedule the Veteran for an examination with an appropriate clinician for his hypertension. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide an opinion as to whether: (a.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s current hypertension began during active service, is related to an incident of service, or began within one year after discharge from active service. (b.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s current hypertension was caused by a service-connected disability, PTSD, or sleep apnea. (c.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s current hypertension was aggravated beyond its natural progression by a service-connected disability, PTSD, or sleep apnea. The examiner should discuss the Veteran’s contention that chronic pain from his service-connected disabilities has caused or aggravated his current hypertension. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Return the Veteran’s claims file to the examiner who conducted the January 2012 VA examination for neck conditions so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether: (a.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s cervical spine disability began during active service, is related to an incident of service, or if symptoms of arthritis began within one year after discharge from active service. (b.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s cervical spine disability was caused by his service-connected lumbar spine disability. (c.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s cervical spine disability was aggravated beyond its natural progression by his service-connected lumbar spine disability. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Return the Veteran’s claims file to the examiner who conducted the July 2011 VA foot conditions examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether: (a.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral foot disability began during active service, is related to an incident of service, or if symptoms of arthritis began within one year after discharge from active service. (b.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral foot disability was caused by his service-connected bilateral foot plantar warts and/or degenerative changes of the right fifth metatarsophalangeal joint. (c.) It is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral foot disability was aggravated beyond its natural progression by his service-connected bilateral foot plantar warts degenerative changes of the right fifth metatarsophalangeal joint. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 5. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. 6. After the above required development is completed, the AOJ should also conduct any additional development necessary for adjudicating the issues of service connection for sleep apnea as secondary to PTSD and for radiculopathy of the bilateral hands as secondary to cervical spine disability. 7. After all completed development, the AOJ should then readjudicate the claims. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a SSOC and afforded the requisite opportunity to respond before the case is returned to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Riordan, Associate Counsel