Citation Nr: 18151384 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 10-08 443 DATE: November 20, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, is granted Entitlement to service connection for tinnitus is granted. Entitlement to a rating in excess of 10 percent for a right knee disability based upon limitation of flexion is denied. A separate 10 percent rating for a painful limited right knee extension is granted. A separate 10 percent rating for right knee instability is granted. Entitlement to an initial compensable rating for hypertension is denied. REMANDED Entitlement to service connection for flat feet is remanded. Entitlement to an initial compensable rating for pseudofolliculitis barbae (PFB) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is in favor of the finding that Veteran’s acquired psychiatric disorders began during active service, or are otherwise related to an in service injury, event, or disease 2. Affording the Veteran the benefit of the doubt, his tinnitus began during active service; is otherwise related to an in-service injury, event, or disease; or began within one year of separation from service. 3. At worst, the Veteran’s right knee flexion was limited to 75 degrees, with pain. 4. At worst, the Veteran's right knee extension was limited to 5 degrees with pain. 5. The Veteran has slight instability of his right knee. 6. The Veteran does not have diastolic pressure that is predominately 100 or more or systolic pressure at predominately at 160 or more. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD and depression, have been met. 38 U.S.C. §§ 1101, 1112, 1154, 5107, 5108 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 2. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303. 3.307, 3.309 (2018). 3. The criteria for a rating in excess of 10 percent for a right knee disability pursuant to Diagnostic Code 5260 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2018). 4. The criteria for a separate 10 percent rating for a right knee disability pursuant to Diagnostic Code 5261 are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2018). 5. The criteria for a separate 10 percent rating for right knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.71a, Diagnostic Code 5257 (2018). 6. The criteria for an initial compensable rating for the Veteran’s hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7101 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran testified at a hearing before a Veterans Law Judge (VLJ) in June 2013 and a copy of the transcript is of record. The VLJ who held the hearing is no longer employed by the Board. The law requires that the VLJ who conducted the hearing participate in making the final determination of the claims. 38 U.S.C. § 7107(c) (2012); 38 C.F.R. § 20.707 (2018). By an August 2018 letter, the Veteran was given an opportunity to request another hearing. The letter advised him that if he did not respond within 30 days, the Board would assume that he did not want another hearing. The Veteran responded in an August 2018 letter declining an additional hearing. In May 2014, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development. The AOJ was instructed to provide the Veteran an opportunity to receive new VA examinations for his flat feet, psychiatric, and right knee disabilities. Additionally, the AOJ was instructed to send the Veteran a statement of the case (SOC) addressing his tinnitus and PFB claims. Last, the AOJ was instructed to associate the Veteran’s Social Security Administration (SSA) records with the file. The Veteran received new VA examinations in July 2014 for all the aforementioned claims. In addition, addendum opinions and examinations were added from October 2014, March 2017, April 2017, August 2017, and March 2018. An SOC was issued in May 2015 for his tinnitus and PFB claims and he perfected his appeal of those issues to the Board. Finally, the Veteran’s SSA records were added to the file. Accordingly, the Board finds there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Board also notes the Veteran’s service connection claim for a back disability was granted in a November 2017 rating decision and is therefore no longer before the Board. The Board rephrased the Veteran’s claim of entitlement to service connection for PTSD as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). With respect to the Veteran’s right knee and hypertension claims, VA’s duty to notify was satisfied by a January 2005 letter. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2015); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran’s service treatment records, VA medical treatment records, indicated private medical records, and Social Security Administration records have been obtained. The Veteran was afforded VA examinations in July 2008, July 2014, October 2014, and March 2017 to evaluate the severity of his hypertension and right knee disabilities. The VA examinations are adequate because they were based upon consideration of the Veteran’s pertinent medical history, his lay assertions and current complaints, and because they describe his hypertension and right knee disabilities in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. To establish service connection for the claimed disorder, there must be (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) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2018); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Second, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the evidence in light of the entirety of the record. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2018). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Acquired Psychiatric Disorder Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between a veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2018); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). The diagnostic criteria set forth in The American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, (5th ed. 2013) (DSM- 5) for mental disorders have been adopted by the VA. 38 C.F.R. § 4.125 (2018). The Veteran has been diagnosed with PTSD and depression. The Veteran recounted several in-service events that he believed were related to his development of PTSD and depression. First, the Veteran was involved in heated communications with other service members which he thought would escalate to physical violence. Second, he almost had a physical altercation with a new sergeant, which led to the Veteran carrying a gun. Third, the Veteran stated that several service members whom he was close to committed suicide; both suicides occurred near the barracks. The Veteran stated he felt guilty he could not do more to prevent their deaths. In May 2009, the Veteran reported feeling depressed, having problems sleeping, and becoming fatigued easily. The Veteran stated he had these feelings on and off since 2004, but they had worsened in the past 3 months. He also experienced nightmares and flashbacks of boot camp. In March 2013, he reiterated that while in-service he had been around people who had committed suicide or had been killed in combat. Furthermore, in a May 2013 statement, the Veteran stated he did not seek help immediately upon separation from service because he was trying to adjust to civilian life. The Veteran received a VA examination in July 2014. He was diagnosed with PTSD and depressive disorder. The examiner determined the Veteran’s psychiatric disorders were at least as likely as not related to service. The examiner acknowledged the Veteran’s stressors had not been independently verified and based his opinion was on the Veteran’s statements. Nevertheless, based on the Veteran’s statement the examiner found a nexus to service. Moreover, the examiner noted that the Veteran’s depression was aggravated by his service-connected right knee disability because he was no longer able to engage in an active lifestyle. The Veteran received another VA examination in April 2017. Similarly, the examiner opined the Veteran’s psychiatric disorders were due to his reported in service stressors. The examiner noted the Veteran had no psychiatric symptoms prior to service. Thus, the examiner concluded the Veteran’s psychiatric disorders were more liked caused by a reaction to his in-service stressors. In an August 2017 addendum opinion, the examiner clarified that the Veteran’s depression symptoms overlapped with his PTSD, but that he had both disorders. The Board finds the preponderance of the evidence is in favor of the Veteran’s claim. The July 2014 and April 2017 VA examiners concluded the Veteran’s psychiatric disorders were due to his time in service. The Board acknowledges the Veteran’s stressors were not verified. Nevertheless, the Board finds the Veteran’s lay statements competent and credible. The Board assigns high probative value to his statements and to the VA examiners’ opinions. As the evidence of record is for the Veteran’s claim, the Board finds service connection is warranted. See Alemany v. Brown, 9 Vet. App. 518 (1996). 2. Tinnitus The nexus element may be satisfied by evidence a showing of continuity of symptomatology after service to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a), (b), 3.309(a) (2018); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For veterans who served 90 days or more after December 31, 1946, the chronic diseases listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), including tinnitus are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101(3), 1112(a)(1) (2012); 38 C.F.R. §§ 3.307(a), 3.309(a) (2018). As a lay person the Veteran is competent to self-diagnose tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002). The Veteran received a VA examination in June 2008. He reported he began experiencing constant, buzzing tinnitus after using firearms on the firing range during service. The examiner considered his statements but noted the Veteran’s hearing was normal and there were no significant threshold shifts for either ear upon separation. The Veteran’s service records also contained no complaints or treatment for tinnitus. The examiner also noted that according to medical journals, tinnitus rarely occurs without accompanying hearing loss. Further, tinnitus rarely results when noise exposure does not cause permanent hearing loss. The Veteran’s records failed to show cochlear change or damage to account for tinnitus as a symptom of auditory dysfunction. The Veteran has provided lay assertions that his tinnitus began in service and persisted since that time. He is competent to make this observation. There is nothing in the record that renders his statements not credible. The lay assertions and the VA examiner’s opinion are in relative equipoise. Affording the Veteran the benefit of the doubt, service connection for tinnitus is granted based upon continuity of symptoms. Increased Rating Disability ratings are determined by applying the criteria established in VA’s Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20 (2018). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2018). 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). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection in March 2008 for a right knee disability and hypertension. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Right Knee The Veteran’s right knee disability is rated under Diagnostic Code, 5260 for limitation of flexion of the leg. Under this Diagnostic Code, a noncompensable rating is warranted when flexion is limited to 60 degrees. A 10 percent rating is warranted when flexion of the leg is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a (2018). Normal flexion is 140 degrees. 38 C.F.R. § 4.71, Plate II (2018). The Board will also consider Diagnostic Code 5261 for limitation of extension of the leg. Under this Diagnostic Code, a noncompensable rating is warranted when extension is limited to 5 degrees. A 10 percent rating is warranted when extension of the leg is limited to 10 degrees. A 20 percent rating is warranted when extension is limited to 15 degrees. A 30 percent rating is warranted when extension is limited to 20 degrees. A 40 percent rating is warranted when extension is limited to 30 degrees. A 50 percent rating is warranted when extension is limited to 50 degrees. 38 C.F.R. § 4.71a (2018). Normal extension is 0 degrees. 38 C.F.R. § 4.71, Plate II (2018). Diagnostic Codes 5260 and 5261 are for limitation of motion. They provide criteria for limitation of flexion and extension of the leg. When a rating of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have sustained by virtue of other factors. Those factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. 38 C.F.R. §§ 4.40, 4.45 (2018); DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40 (2017); Johnston v. Brown, 10 Vet. App. 80 (1997). A claimant who has arthritis as shown by x-ray of the knee may be rated separately under Diagnostic Codes 5003. VAOPGCPREC 23-97 (1997); 62 Fed. Reg. 63,604 (1997). Under Diagnostic Code 5003, the disability is rated based upon limitation of motion of the affected joint. When limitation of motion is noncompensable, a 10 percent rating is warranted when there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent rating is warranted where there is x-ray evidence of the involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a (2018). The Board finds the Veteran is appropriately rated for his limitation of motion under Diagnostic Code 5260. Diagnostic Code 5003 is less favorable to the Veteran because there is no evidence of record to show that he has incapacitating exacerbations of his arthritis, which is required for a 20 percent rating. The Veteran has not stated that he has incapacitating exacerbations and the medical evidence does not support this conclusion. The Veteran does not have ankylosis, a meniscus condition, or genu recurvatum. Therefore, Diagnostic Codes 5256, 5258, 5259, and 5263 do not apply. 38 C.F.R. § 4.71a (2018). In July 2008, the Veteran received a VA examination. He reported constant knee pain, with occasional swelling, particularly with weight-bearing activities. The Veteran did not use assistive aids for walking or have incapacitating episodes. He did not have any deformities, giving way, stiffness, weakness, dislocation, locking episodes, effusion, or flare ups. The Veteran subjectively reported instability, but it was not found during testing. The Veteran’s active range of motion was flexion to 120 degrees and passive range of motion was flexion to 130 degrees, with pain. Hist extension for both active and passive was 90 to 0 degrees. He did not have any additional loss after repetition. His knees impacted his ability to play basketball and climb stairs. He was able to walk one to three miles. He did not have a meniscus abnormality. In a February 2013 VA record, he complained of pain, but denied locking, buckling, or instability. In April 2013, he stated he used a cane and had to stop working at his old job because it required too much walking and lifting. At his June 2013 hearing, he reiterated that his right knee limited his ability to play sports. He also reported problems with prolonged walking, prolonged sitting, climbing stairs, and lifting and bending his knee. He stated his knee had swelled up at least 10 times in the past year and sometimes it hurt so bad it was hard to get out of bed in the morning. The Veteran stated his knee had worsened since his last examination. The Veteran’s next examination was in July 2014. He reported occasional buckling and weakness, but denied flare ups. His flexion was to 130 degrees with no pain, and he had normal extension, also without pain. Pain, weakness, fatigue, and lack of endurance caused no change in his flexion or extension after repetition. He experienced functional loss in the form of less movement than normal, but there was no impact on his functional ability. There was no dislocation. He was limited in his ability to run, kneel, stand, squat, walk, or climb for prolonged periods. His muscle strength was normal at 5/5. He did not have a meniscus condition. In October 2014, the Veteran had another VA examination. His knee continued to hurt when standing and he experienced flare ups where he felt aching pain. His flexion was to 100 degrees and his extension was normal. The examiner noted the Veteran’s abnormal range of motion impacted his ability to bend, twist, and turn. After repetitive testing, the Veteran’s flexion decreased to 85 degrees but his extension remained normal. The examiner noted that functional loss in the form of less movement than normal, excess fatigability, pain on movement, swelling, and interference with standing and sitting caused the Veteran to lose an additional 10 degrees of flexion and 5 degrees of extension. Muscle strength was normal at 5/5. He did not report history of instability or subluxation. Instability was not reported or noted on clinical testing. He did not have a meniscus condition. The Veteran’s most recent examination was in March 2017. He continued to experience flare ups after squatting, running, and playing sports. His flexion was to 90 degrees and his extension was 90 to 0 degrees. The examiner noted the Veteran’s abnormal range of motion did not cause functional loss and after repetitive testing he did not experience any functional loss. He also did not experience functional loss due to the DeLuca factors after repetitive use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The pain he experienced during a flare up did not impact his functional ability. He had no instability, effusion, or subluxation. He used a brace in the past, but was currently not using one. Muscle strength was normal at 5/5. He did not have a meniscus condition. Separate ratings are available for limitations of flexion and extension under Diagnostic Codes 5260 and 5261. VAOPGCREC 9-2004 (2004). At worst, the Veteran is unable to flex his right knee beyond 85 degrees as noted by his October 2014 examination. However, the examiner also reported that the Veteran experienced an additional loss of 10 degrees of flexion under certain conditions, which would put the Veteran’s flexion at 75 degrees. This range of motion is more closely described by the criteria for a noncompensable rating. At no point during the appeal period has the Veteran’s flexion been limited to 60 degrees. Nevertheless, it is clear from the Veteran’s description of his symptoms that there is limited motion and painful motion. The provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to at least the minimum compensable evaluation for motion that is accompanied by pain. See Burton v. Shinseki, 25 Vet. App. 1 (2011). As a result, the RO assigned a 10 percent rating for painful flexion under Diagnostic Code 5260. However, evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40 (2018). The medical evidence of record does not support a finding that the Veteran has some functional loss in his knees due to pain such that his flexion is limited to 45 degrees. The Board considers the Veteran’s report of increased right knee pain during flare ups, but he also reported no additional loss in function. The VA examiners specifically considered functional loss in the form of painful motion, weakness, stiffness, swelling, decreased endurance, and fatigability in the evaluation of the Veteran’s knee disabilities. The October 2014 VA examiner described how those factors impacted the Veteran’s flexion and extension. Nevertheless, even considering the decrease in range of motion the Veteran experienced, his range of motion was still not contemplated by a 20 percent rating, which requires that flexion be limited to 30 degrees. For the following reasons, the Board grants a separate rating for painful limited extension under Diagnostic Code 5261. The evidence of record indicates that the Veteran has painful limited extension. At his July 2008, July 2014, and March 2017 VA examinations, his extension was normal without pain. At his October 2014 VA examination, his extension was normal. But the October 2014 VA examiner estimated that his extension would be limited to 5 degrees after repetitive use over time due to factors such as pain. At his June 2013 hearing, the Veteran credibly testified that it hurt to bend his knee and walk. This implies that he experiences painful extension as well as flexion. Under Diagnostic Code 5261, limitation of extension to 5 degrees warrants a noncompensable rating. However, a separate 10 percent rating under Diagnostic Code 5261 is warranted based on painful extension. 38 C.F.R. § 4.59. However, even when considering functional loss, his limitation of extension does not approach 15 degrees, which is required for a 20 percent rating. For the following reasons, the Board grants a separate 10 percent rating for slight instability under Diagnostic Code 5257. At his July 2008 VA examination, the Veteran reported that his right knee was unstable, but instability was not detected upon clinical testing. At his July 2014 VA examination, three types of stability tests were administered: anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability. His posterior and medial-lateral stability tests were normal. However, his anterior instability was 1+ (0-5 millimeters). Because the Veteran reported instability and instability was found on clinical testing, a separate 10 percent rating under Diagnostic Code 5257 is granted. Under Diagnostic Code 5257, a 10 percent evaluation is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent evaluation is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent evaluation is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a (2015). Diagnostic Code 5257 is based upon instability and subluxation, not limitation of motion, as a result, the criteria set forth in DeLuca do not apply. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Veteran’s credible lay assertion of instability and the presence of a single 1+ anterior instability test result at his July 2014 VA examination is indicative of slight instability and not moderate instability. The anterior instability test has four possible results: Normal, 1+ (0-5 millimeters), 2+ (5-10 millimeters), and 3+ (10-15 millimeters). 1+ is the least severe result of the test outside of a normal finding. Additionally, the posterior and medial-lateral tests conducted at the July 2014 examination were normal. Further, all clinical testing at three other VA examinations was also normal. Although the Veteran described instability at his July 2008 and July 2014 VA examinations, he did not report it at his October 2014 or March 2017 VA examinations. The Board emphasizes that the rating criteria contemplate “recurrent” instability, and in this case, normal clinical testing at four VA examinations (except for the one 1+ result in July 2014 for one of the three tests conducted) indicates that the instability is not recurrent. 2. Hypertension Hypertension is rated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent evaluation is warranted for diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more; or, as the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted for diastolic pressure predominantly 110 or more; or, systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted for diastolic pressure predominantly 120 or more. A 60 percent evaluation is warranted for diastolic pressure predominantly 130 or more. For VA compensation purposes, the term hypertension means that diastolic blood pressure is predominantly 90 or greater, and isolated systolic hypertension means that systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Board considers the complete history of the Veteran’s treatment records and VA examinations. The evidence of record includes blood pressure readings from 2008 to 2018. The Veteran’s blood pressure readings fluctuate over time, but at no time do the Veteran’s readings show consistent diastolic pressure at 100 or more. Further, the Veteran’s blood pressure readings do not show consistent systolic pressure at 160 or more. The Board acknowledges that at the July 2008 VA examinations the Veteran’s diastolic pressure was recorded as over 100. Based on the previous readings from that same day, however, it appears the examiner flipped the diastolic and systolic numbers when recording the Veteran’s blood pressure. Accordingly, even at that examination the Veteran’s diastolic pressure was under 100. Furthermore, the Board acknowledges that the Veteran is on medication to control his hypertension, a fact which is considered in the Diagnostic Code. Consequently, to qualify for a compensable rating the Veteran must show that he has a history of diastolic pressure predominately 100 or more in combination with controlling his hypertension on medication. As previously noted, the Veteran does not have a history of diastolic pressure over 100. Moreover, the Veteran has consistently reported at his VA examinations that he no longer takes his medication and prefers to control his blood pressure through diet and exercise. Thus, the evidence of record is against the Veteran’s claim and the reasonable doubt standard is not applicable. See 38 C.F.R. § 4.3 (2018). Therefore, the Board concludes a compensable rating is not warranted. REASONS FOR REMAND 1. Flat feet Service connection is warranted if a preexisting disorder was aggravated by a veteran’s active service. A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306(a) (2018). The Veteran’s flat feet were noted on his April 1998 entrance examination as mild and asymptomatic. At his June 2013 Board hearing, the Veteran testified that he experienced pain wearing his boots in service, complained about the pain, and was given different boots. The Veteran is competent to report observable symptoms such as foot pain in service. His hearing testimony is also credible. The Board finds that his flat feet disability increased in severity during service based upon his hearing testimony. The next step of the inquiry is whether that increase in severity was clearly and unmistakably due to the natural progression of the disease. The Board finds that an addendum opinion is needed. The March 2018 opinion is inadequate because it does not address the Veteran’s credible lay descriptions of an increase in severity of the disability in service. Additionally, the examiner relied on an absence of treatment for flat feet from separation from service until 2009 to conclude that no aggravation occurred. However, this is not permissible because there were no treatment records available for the time between his separation from service in 2004 and 2009. 2. Pseudofolliculitis Barbae The Veteran was service connected for PFB in August 2008 at a noncompensable rating. This rating was based on the Veteran’s July 2008 VA examination, over 10 years ago. The Veteran has not received a VA examination since that date. The Board finds a VA examination is necessary to determine the current severity of the Veteran’s disability. 3. TDIU In the above decision, the Board service-connected the Veteran’s PTSD and depression. The rating assigned when the AOJ implements the grant may impact the adjudication of the Veteran’s TDIU claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a veteran’s claim for the second issue). Thus, the Board finds a remand is necessary so the Veteran’s PTSD and depression can be rated by the AOJ. The matters are REMANDED for the following action: 1. Provide the Veteran’s claims file to an appropriate clinician so a supplemental opinion may be provided for his flat feet. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination is only required if deemed necessary by the clinician. The clinician is advised that the Board has accepted as credible the Veteran’s statement that he had bilateral foot pain in service due to the boots he wore, and that this represents an increase in severity during service. The examiner must provide an opinion as to whether the pre-existing flat feet disability was aggravated beyond its natural progression by the Veteran’s period of service. If so, provide an opinion as to whether any such increase was clearly and unmistakably (obviously, manifestly, or undebatably) due to the natural progress of the disease. 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 to determine the current severity of his PFB disability. 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 all findings, along with a complete rationale for any opinions provided. 3. Assign a rating for the Veteran’s psychiatric disorder. 4. Then readjudicate the Veteran’s claims, including the TDIU claim. If the decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Brunot, Associate Counsel