Citation Nr: 18151549
Decision Date: 11/19/18	Archive Date: 11/19/18

DOCKET NO. 13-14 704
DATE:	November 19, 2018
ORDER
Entitlement to service connection for a right shoulder disability is denied.
Entitlement to service connection for a cervical disability is denied.
Entitlement to service connection for flat feet/foot pain problems is denied.
Entitlement to service connection for residuals of pseudomonas external ear infection is denied.
Entitlement to service connection for cardiac arrhythmia/abnormal electrocardiogram (EKG), including as due to exposure to herbicide is denied.
Entitlement to service connection for prostatitis and benign prostatic hypertrophy, including as due to exposure to herbicides is denied.
Entitlement to a compensable rating for hemorrhoids is denied.
Prior to May 17, 2017, a 10 percent evaluation for a chronic left ankle injury with degenerative joint disease is granted.  
On and after May 17, 2017, a disability rating in excess of 20 percent for a chronic left ankle injury with degenerative joint disease is denied.  
Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), is granted from February 26, 2008, to November 25, 2014, based on the Veteran’s service-connected coronary artery disease alone, subject to the law and regulations governing the award of monetary benefits.    
Special monthly compensation at the housebound rate under 38 U.S.C. § 1114 (s) is granted, effective January 13, 2009 to November 25, 2014, subject to the law and regulations governing the award of monetary benefits.
REMANDED
The claim of entitlement to service connection for a lumbar spine disorder is remanded.
The claim of entitlement to service connection for a thoracic spine disorder is remanded.
The claim of entitlement to service connection for irritable bowel syndrome (IBS) is remanded.
The claim of entitlement to an increased rating for residuals of a hiatal hernia, evaluated as noncompensable prior to May 17, 2017, and as 10 percent disabling on and after that date is remanded.
FINDINGS OF FACT
1. The most probative evidence weighs against a finding that the Veteran's right shoulder disorder had onset during active service, manifested within one year of service discharge, or is otherwise related to active service.
2. The most probative evidence weighs against a finding that the Veteran’s cervical spine disorder had onset during active service, manifested within one year of service discharge, or is otherwise related to active service.
3.  A bilateral foot disorder, diagnosed as plantar fasciitis, did not manifest during active service and is not otherwise related to active service.
4. A disability manifested by ear infections, claimed as residuals of pseudomonas external ear infection, did not manifest during active service and is not otherwise related to active service.  
5. The evidence does not demonstrate present cardiac arrhythmia or abnormal EKG results.  
6. A prostate disorder, diagnosed as benign prostatic hypertrophy and prostatitis, did not manifest during active service and is not otherwise related to active service.
7. For the entire appeal period, the Veteran’s hemorrhoids manifested in mild to moderate symptoms.
8. Prior to May 17, 2017, the Veteran’s left ankle has been manifested by pain on use but not marked limitation of motion.  
9. The Veteran does not have ankylosis of the left ankle. 
10. From September 26, 2008, to November 25, 2014, the Veteran’s coronary artery disease prevented him from securing or following substantially gainful employment.  
11. In addition to the Veteran’s service-connected coronary artery disease, the Veteran has separate additional service-connected disabilities ratable as 60 percent or more from January 13, 2009, to November 25, 2014. 
12. From September 26, 2008, to January 12, 2009, the Veteran is not permanently housebound as a result of service-connected disabilities.  
CONCLUSIONS OF LAW
1. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018).
2. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018).
3. The criteria for service connection for a bilateral foot disorder, claimed as flat feet/foot pain and diagnosed as bilateral plantar fasciitis, are not met.  38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018).
4. The criteria for service connection for a disability manifested by ear infections, claimed as residuals of pseudomonas external ear infection, have not been met.  38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018).
5. The criteria for service connection for cardiac arrhythmia or abnormal EKG results, including as due to exposure to herbicides, have not been met.  38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018).
6. The criteria for service connection for a prostate disorder, diagnosed as benign prostatic hypertrophy and prostatitis, including as due to exposure to herbicides have not been met.  38 U.S.C. §§ 1110, 1116 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018).
7. The criteria for a compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7336 (2018).
8. Prior to May 17, 2017, the criteria for a 10 percent rating, but no more, for a chronic left ankle injury with degenerative joint disease are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5271 (2018).
9. On and after May 17, 2017, the criteria for a disability rating in excess of 20 percent for a chronic left ankle injury with degenerative joint disease have not been met.  38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5271 (2018).
10. The criteria for a TDIU, based solely on the Veteran’s coronary artery disease, have been met from February 26, 2008, to November 25, 2014.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2018).
11. The criteria for special monthly compensation at the housebound rate have been met from January 13, 2009, to November 25, 2014. 38 U.S.C. § 1114 (s) (2012); 38 C.F.R. § 3.350 (2018).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from June 1966 to May 1987.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 
In September 2014, the Veteran testified during a hearing at the RO before a Veterans Law Judge. A transcript of the hearing is of record.  The Veterans Law Judge who conducted the hearing is no longer employed by the Board.  The Veteran was notified of this in an August 2018 correspondence and provided another opportunity to present testimony before a different judge.  In September 2018, the Veteran indicated that he did not wish to appear at another Board hearing.  
The Board remanded these issues in April 2015.  Also remanded at that time were claims of entitlement to service connection for hypertension, nerve damage due to a vasectomy, chronic left foot synovial cyst, and a claim of entitlement to TDIU.  
In a March 2018 rating decision, service connection was garneted for chronic kidney disease with hypertension, nerve damage due to a vasectomy, a scar, status post left foot synovial cyst removal, and removal of left testicle.  These appeals are thus satisfied in full.  See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997).
The claim of entitlement to a TDIU has been recertified to the Board as a claim of entitlement to a TDIU prior to January 13, 2009.  On and after that date, the Veteran is in receipt of a combined schedular rating of 100 percent.  On and after November 26, 2014, the Veteran is in receipt of special monthly compensation (SMC) due to the Veteran’s receipt of a total disability rating for his coronary artery disease and additional service-connected disability ratings combining for at least 60 percent.  38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i).  On and after November 26, 2014, the issue of entitlement to a TDIU is moot because the Veteran is in receipt of SMC at the housebound rate.  For the period prior to that date, the award of a 100 percent rating does not necessarily render moot a claim of entitlement to a TDIU. See Bradley v. Peake, 22 Vet. App. 280 (2008).  A separate TDIU predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation (SMC) under 38 U.S.C. § 1114 (s). Bradley, at 293-94.  Thus, it might benefit the Veteran to retain or obtain the TDIU even where a 100 percent combined schedular rating also has been granted. Bradley, at 293-94.  Indeed, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C. § 1114 (s) if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating. Bradley, at 293-94.  The Board notes that a June 2016 rating decision granted a TDIU from August 31, 2010.  However, this grant appears to be based on multiple service-connected disorders.  The Board will reconsider whether a TDIU may be individually attributed to one service-connected disorder prior to November 26, 2014, for the purposes of addressing whether SMC at the housebound rate is also warranted prior to that date.   The Board will also address whether a TDIU is warranted prior to January 13, 2009, as this issue was recertified to the Board and the Veteran’s increased rating claim (hemorrhoids), of which the Veteran’s TDIU claim is part and parcel, was submitted in September 2008.  
Duties to Notify and Assist
Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).
Service Connection
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018).  To establish a right to compensation for a present disability, a Veteran must show:  (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement.  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).  Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d) (2018).
In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service.  38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015).  Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time.  38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a).
Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time.  If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim.  38 C.F.R. §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310 (2018).
The Board further notes that the Veteran’s exposure to herbicide agents during service has been conceded.  See April 2015 Board decision.  
For veterans presumed to have been exposed to herbicides, certain enumerated diseases shall be service connected even though there is no record of such disease during service, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied.  38 C.F.R. § 3.309(e).  The enumerated diseases which are deemed to be associated with herbicide exposure include coronary artery disease and prostate cancer, but not cardiac arrhythmias, benign prostatic hypertrophy, or prostatitis. 38 C.F.R. § 3.309(e).
Regardless of whether a claimed disability is recognized under 38 U.S.C. § 1116, pertaining to herbicide agent exposure presumptive diseases, a claimant is not precluded from presenting evidence that a claimed disability was due to or the result of herbicide exposure. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999).
The threshold question in any claim seeking service connection is whether the veteran, in fact, has the disability for which service connection is sought. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).  In the absence of proof of a current disability, service connection is not warranted.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44.
1. Entitlement to service connection for a right shoulder disability.
The Veteran alleges that a right shoulder injury was incurred during service and has existed since that time.  See January 2009 claim.  In a January 2009 private treatment evaluation, the Veteran’s treating physician documented the Veteran’s report of recurrent shoulder issues after serving as a gunner in the military.  
First, the Board finds that there is a current disability.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  A May 2017 VA examination diagnoses right rotator cuff tendonitis.  Private treatment records from January 2009 document a diagnosis of osteoarthritis affecting multiple levels, including the neck, thoracic spine, lumbar spine, and shoulders.  
Second, the Board finds that there was an in-service event, injury or disease.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  The Veteran’s statements provide little specificity regarding the nature of his in-service right shoulder injury.  However, a 1974 Report of Medical History indicates that the Veteran had high shoulder pain in 1972 after lifting heavy objects.  The 1974 report documented no recent problems.  The STRs are otherwise silent for right shoulder complaints.  The Board concedes that an in-service injury occurred based on the 1974 medical history report.  
Third, the Board finds that the evidence of record does not support a finding a right shoulder disorder is related to active service.  
On VA examination in May 2017, the Veteran related that he initially injured his shoulder in service, but he was unable to recall the nature of the injury.  He reported that he did require surgery on the shoulder approximately 20 years earlier, and he indicated that this was due to the presence of arthritis and bone fragments.  The Veteran denied any current pain and reported fair range of motion.  The examiner diagnosed rotator cuff tendonitis.  In the opinion, the examiner noted that the only reference to shoulder pain in the Veteran’s service is from a 1974 physical which indicates the Veteran had high shoulder pain in 1972.  The Veteran had reported being hospitalized for a week of treatment, although the examiner was unable to find any records of this treatment in the Veteran’s STRs.  The remainder of the STRs were silent for any right shoulder complaints, diagnoses, or treatment.  Post-service, no treatment was required or sought until 1994.  Given the evidence of record, the examiner opined that it was less likely than not that the Veteran’s current right shoulder disability is related to the Veteran’s service, to include an injury sustained in 1972.
The May 2017 opinion is highly probative because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions).  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts).  
The Board finds that the May 2017 VA opinion supports a finding that the Veteran’s right shoulder disorder did not have onset in service and is not otherwise related to service.  Further, to the extent the evidence may suggest that the Veteran suffers from osteoarthritis in the right shoulder, there is no evidence to suggest it manifested within one year of the Veteran’s separation from active duty.  
The Veteran does not accord a January 2009 assessment from the Veteran’s private treatment provider, which notes the Veteran’s report of shoulder symptoms since serving as a gunner in service any probative weight.  After diagnosing multiple disorders, the doctor expressed his belief that with more than 51 percent likelihood, “many of these issues” were directly related to the Veteran’s military service.  This opinion is not supported by any rationale and does not provide any specificity as to which disorder the doctor is addressing.  
To the extent the Veteran claims that his right shoulder disorder is etiologically related to service, his contentions are not competent lay evidence.  Although it is error to categorically reject a lay person as competent to provide a diagnosis, not all such questions are subject to non-expert opinion. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).  Whether a layperson is competent to provide a medical opinion depends on the facts of the particular case. “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  Lay witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994).  But here, the etiology of an underlying pathology that is productive of a musculoskeletal disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied on a direct basis and on a presumptive basis for chronic diseases.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
2. Entitlement to service connection for a cervical disability
The Veteran alleges that a cervical spine injury was incurred during service and have existed since that time.  See January 2009 claim.  
First, the Board finds that there is a current disability.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  Private treatment records from January 2009 document a diagnosis of osteoarthritis affecting multiple levels, including the neck, thoracic spine, lumbar spine, and shoulders.  May 2017 VA examinations of the cervical and thoracolumbar spines show a diagnosis of cervical spine degenerative disease.  A present disability is shown.  
Second, the Board finds that there were injuries to the Veteran’s spine during service.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  In February 1979, the Veteran presented for treatment for neck pain with a steady, dull headache. The STRs are otherwise silent for any neck symptoms.  In any event, an in-service injury or event is shown.  
However, the Board finds that a nexus is not shown between the Veteran’s present cervical spine disorder and his in-service injuries.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  
A May 2017 VA examination was provided.  The examiner opined that it was less likely than not that the Veteran’s cervical spine disorder was related to military service.  Explaining, the examiner noted that the Veteran’s STRs showed no treatment, diagnosis, or complaint of neck pain with the single exception of some neck discomfort noted in association with a headache in February 1979.  No further complaints or references to neck issues were seen, and subsequent routine physicals did not mention any neck pain.  No cervical spinal related issues were noted until 2009, over 21 years post-discharge.  As such, the examiner opined that it was less likely than not that the Veteran’s degenerative disease of the cervical spine is related to military service.  The examiner also indicated that a review of the Veteran’s current service-connected disabilities did not reveal any conditions that would cause degenerative disease of the cervical spine.  
The May 2017 opinion is corroborated by the evidence of record.  That is, the evidence is silent for cervical spine complaints until 2009, when private treatment records document osteoarthritis affecting multiple levels, including the thoracolumbar and cervical spines.  They do not provide any causal link between the Veteran’s current complaints and his military service.  
Accordingly, the Board accords the May 2017 opinion significant probative weight because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Because of its probative value, the Board finds that the May 2017 VA opinion supports a finding that the Veteran’s cervical spine disorder did not have onset in service and is not otherwise related to service.  Further, there is no evidence to suggest the disorder manifested within one year of the Veteran’s separation from active duty.  
The Veteran does not accord a January 2009 assessment from the Veteran’s private treatment provider, in which the doctor expressed his belief that, with more than 51 percent likelihood, “many of these issues” were directly related to the Veteran’s military service.  One of the issues seemingly identified was the Veteran’s cervical spine degenerative disease.  This opinion is not supported by any rationale and does not provide any specificity as to which disorder the doctor is addressing.  
Further, and as noted above, the etiology of an underlying pathology that is productive of a musculoskeletal disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  As such, the Veteran’s lay statements that purport to link his cervical spine disorder to service are non-competent lay statements.  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied on a direct basis and on a presumptive basis for chronic diseases.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
3. Entitlement to service connection for flat feet/foot pain problems
The Veteran alleges that a bilateral foot disorder, claimed as flat foot, was incurred during service and have existed since that time.  See January 2009 claim.  
First, the Board finds that there is a current disability.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  Private treatment records from January 2009 document a diagnosis of osteoarthritis affecting multiple levels including the feet. The report did not specify further, however.  A May 2017 VA examination of the feet shows a diagnosis of bilateral plantar fasciitis. Accordingly, a present disability is shown.  
Second, the Board notes that there were no injuries to the Veteran’s feet during service.  STRs are silent for any foot pain or complaints.  The Veteran did report during a May 2017 VA examination that he was issued shoes that were too small and that he experienced resulting foot pain during service that was severe enough to impair PT testing.  The Board concedes that there was bilateral foot pain in service and finds that the in-service element of service connection is met.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  
However, the Board finds that a nexus is not shown between the Veteran’s present bilateral foot disorder and his in-service injuries.  See Holton, 557 F.3d at 1366; 
Post- service, the Veteran did report pain in both feet which was noted to have an unclear etiology in a March 1994 private treatment record.  The Veteran reported that he had been told his bilateral foot pain may be due to tarsal tunnel syndrome.  Based on his report, that diagnosis was rendered.  
VA provided an examination in May 2017.  At that time, the Veteran reported that he had only been diagnosed with flat feet recently.  After conducting an examination, the examiner opined that it was less likely than not that the Veteran’s bilateral foot condition, claimed as flat foot, was related to service.  The examiner noted that the Veteran had sought care in 1994 for foot problems that were diagnosed as tarsal tunnel syndrome right foot, bilateral equinus deformity, and bilateral plantar fasciitis.  This is documented in private treatment records, as noted above.  However, in 1994, noted the examiner, there was no flat foot.  The current examination did show trophic changes and decreased sensation, but these were related to other service-connected conditions, explained the examiner.  Pes planus was not identified at present time.  The examiner continued, noting that the Veteran’s STRs did not indicate any complaints or treatment any foot specific issue other than an ankle sprain and a ganglion cyst of the left ankle.  The Veteran had also denied foot problems on his personal history questionnaires.  Given the silence of the medical record with respect to the presence of pes planus and the absence of this condition on current examination, the examiner opined that it was less likely than not that the Veteran’s claimed pes planus was due to service or service-related conditions.  The examiner also explained that plantar fasciitis and spurs were noted on X-rays in 2009.  The examiner explained that there are some arch and foot deformities related to diabetes, a service-connected condition, but these conditions were not evident on the current examination.  The examiner indicated that plantar fasciitis could be related to multiple issues, but this was present well before the Veteran’s diabetes.  The examiner also indicated that the literature does not suggest either that peripheral vascular disease is causally related to plantar fasciitis.  
The Board accords the May 2017 opinion significant probative weight because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Because of its probative value, the Board finds that the May 2017 VA opinion supports a finding that the Veteran’s bilateral foot disorder, diagnosed as plantar fasciitis, did not have onset in service and is not otherwise related to service.  The examination also supports a finding that the Veteran does not have flat feet, or pes planus.  Indeed, the most probative source of evidence regarding the diagnosis of any foot disorder and that condition’s etiology is the May 2017 VA examination.  
The Veteran does not accord a January 2009 assessment from the Veteran’s private treatment provider, in which the doctor expressed his belief that, with more than 51 percent likelihood, “many of these issues” were directly related to the Veteran’s military service.  One of the issues seemingly identified was osteoarthritis, which was summarily attributed to the Veteran’s feet.  This opinion is not supported by any rationale and does not provide any specificity as to which disorder the doctor is addressing.  In addition, the Veteran is service-connected for a left ankle disorder which has associated arthritis.  
Further, and as noted above, the etiology of an underlying pathology that is productive of a musculoskeletal disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  As such, the Veteran’s lay statements that purport to link his bilateral foot disorder to service are non-competent lay statements.  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied on a direct basis.  The May 2017 VA examination raised a secondary theory of entitlement when the examiner opined that the Veteran’s bilateral foot disorder is not caused by a service-connected condition.  The Veteran does not assert service connection on a secondary basis, and there is no indication that his disorder may be associated with a service-connected condition.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
4. Entitlement to service connection for a disability manifested by ear infections, claimed as residuals of pseudomonas external ear infection
The Veteran alleges that a bilateral ear disorder, claimed as residuals of pseudomonas external ear infection, was incurred during service and have existed since that time.  See January 2009 claim.  
First, the Board finds that there is a current disability.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  A May 2017 VA examination of the ears shows a diagnosis of chronically ruptured tympanic membranes and chronic otitis media.  These diagnoses are confirmed in July 2009 VA treatment records.  March 2003 private records document left otitis media with the Veteran’s reports of recurrent infections. Accordingly, a present disability is shown.  
Second, the STRs show treatment for ear difficulties. The STRs did show otitis externa in August 1978 that required several weeks of treatment in 1978.  Ultimately, cultures were done that showed pseudomonas as the cause of the infection, which was limited to the left ear.  The examiner noted that this resolved with appropriate treatment, and a review of the STRs did not show any further diagnosis or treatment for otitis externa.  The Veteran was noted ot have a visit in 1987 for Eustachian tube dysfunction.   The in-service element of service connection is met.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  
However, the Board finds that a nexus is not shown between the Veteran’s present bilateral diagnoses and his in-service events.  See Holton, 557 F.3d at 1366; 
VA provided an examination in May 2017.  The Veteran was noted to have a prior history of acute otitis externa that had resolved.  The Veteran reported that he had a ruptured ear drum in service that was treated with antibiotics.  Since then, he had not undergone any surgery or treatment.  He did report having an episode of mastoiditis in 1995 that resulted in surgery.  He also reported having chronic external ear infections, his last treatment being a few years earlier.  He finally reported a history of drainage requiring treatment three to four times per year.  A physical examination revealed erythema of both EACs and bilateral perforated tympanic membranes.  The examiner reviewed the Veteran’s medical records, noting that private treatment records showed chronic otitis media, not chronic otitis externa.  The STRs did show otitis externa in 1978 that required several weeks of treatment in 1978.  Ultimately, cultures were done that showed pseudomonas as the cause of the infection, which was limited to the left ear.  The examiner noted that this resolved with appropriate treatment, and a review of the STRs did not show any further diagnosis or treatment for otitis externa.  The Veteran was noted to have a visit in 1987 for Eustachian tube dysfunction.  However, this was a temporary condition unrelated to his earlier infection, noted the examiner.  The examiner noted that the Veteran was service-connected for rhinitis and that Eustachian tube dysfunction often results from failure of pressure equilibration due to congestion related to the allergies.  The Veteran’s STRs did not document any notes or visits indicating ruptured tympanic membranes.  The examiner noted that the private treatment records showed current bilateral chronic otitis media and chronically ruptured bilateral tympanic membranes.  This condition is unrelated to the external ear infection in service that only affected the left ear and resolved.  The Veteran’s exit examination showed no ear abnormalities, and the personal history questionnaire completed by the Veteran indicated a negative response to any ear problems.  Given this history, the examiner opined that it was less likely than not that the Veteran’s current chronically ruptured tympanic membranes and chronic otitis media were related to a single event of otitis externa of the left ear in 1978.  
The Board accords the May 2017 opinion significant probative weight because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Because of its probative value, the Board finds that the May 2017 VA opinion supports a finding that the Veteran’s bilateral ear diagnoses, diagnosed as bilateral perforated tympanic membranes and chronic otitis media, did not have onset in service and are not otherwise related to service.  
Further, and as noted above, the etiology of a chronic ear disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  As such, the Veteran’s lay statements that purport to link his bilateral ear disorders to service are non-competent lay statements.  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied on a direct basis.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
5. Entitlement to service connection for cardiac arrhythmia/abnormal electrocardiogram (EKG), including as due to exposure to herbicide agents
The Veteran claims entitlement to service connection for cardiac arrhythmia or abnormal EKG results.  See January 2009 claim.  The Board ordered that an examination be conducted to ascertain the nature and etiology of this claimed condition.  The Board notes that the Veteran is already service-connected for coronary artery disease.  
An examination was provided in May 2017.  The Veteran was diagnosed with a history of myocardial infarction and arteriosclerotic heart disease.  No other diagnosis was rendered.  The examiner discussed the Veteran’s medical history, including the Veteran’s first heart attack in 1990 and all subsequent events and treatment.  The examiner specifically found that the Veteran has not had cardiac arrhythmia, a heart valve condition, an infectious heart condition, or pericardial adhesions.  In the opinion, the examiner cited to a thorough review of the Veteran’s claims file and all medical records, including private records.  The examiner noted that on one occasion the Veteran underwent an EKG that showed what was felt to be a conduction delay.  However, follow-up revealed that the Veteran’s results were a normal variant.  No arrhythmia was diagnosed.  Review of more current records, including private treatment records, make no mention of arrhythmia, noted the examiner.  Currently, noted the examiner, the heart demonstrated regular rate and rhythm and no irregularity was detected on physical examination.  As such, the examiner concluded that it was less likely than not that the Veteran has arrhythmia that was related to service.  The examiner provided direct and secondary opinions that addressed the Veteran’s claim.  However, they were all predicated on the finding that the Veteran did not have cardiac arrhythmias and that the evidence did not demonstrate that he ever did.  
The Board finds that service connection for arrhythmia, or abnormal EKG results, is not supported by the evidence of record.  Service connection requires a showing of a current disability. See Brammer, 3 Vet. App. at 225.  A current disability is shown if the claimed condition is demonstrated at the time of the claim or while the claim is pending. McClain, 21 Vet. App. at 321.  Here, the evidence simply does not support a finding that the Veteran has cardiac arrhythmia.
In making this finding, the Board accords the May 2017 VA examination significant probative weight because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Further, the diagnosis of a heart disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  As such, the Veteran’s lay statements that purport to diagnose a heart disorder are non-competent lay statements.  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied because a present disability is not shown.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
6. Entitlement to service connection for prostatitis, including as due to exposure to herbicide agents
The Veteran alleges that a prostate disorder was incurred during service and has existed since that time.  See January 2009 claim.  
First, the Board finds that there is a current disability.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).  A May 2017 VA examination shows benign prostatic hypertrophy and prostatitis.  Private treatment records from the appeal period similarly document these diagnoses.  A present disability is shown.  
Second, an in-service event is shown.  See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d).   A July 1972 STR shows an impression of prostatitis after the Veteran presented with groin pain that could be reproduced by prostate palpation.  February 1987 STR shows the Veteran’s a complaint of penile discharge with bowel movements in 1987.  There was noted to be prostatic secretions with bowel movements but no underlying pathology.  In light of these records, the in-service element of service connection is met.  
However, the Board finds that a nexus is not shown between the Veteran’s present bilateral diagnoses and his in-service events.  See Holton, 557 F.3d at 1366.  First, benign prostatic hypertrophy and prostatitis are not recognized as disorders presumed to be related to exposure to herbicide agents during the Vietnam Era.  As such, service connection on a presumptive basis is not warranted under 38 C.F.R. § 3.307(d) and 38 C.F.R. § 3.309(e).  
Post-service, private treatment records document benign prostatic hypertrophy with prior episodes of urinary retention as early as February 1998.  The Veteran reported a history of chronic complaints of prostatitis in April 2002.  See April 2002 private treatment record.  However, an examination did not result in an actual diagnosis of prostatitis or an enlarged prostate.  A January 2009 private treatment record documents prostatitis and a history of this condition.  The Veteran was noted to have benign prostatic hyperplasia, previously treated by transurethral 
On VA examination in May 2009, an examination revealed an indented prostate bed with no prostate tissue palpable.  The examiner explained that this was apparently related to a history of a transurethral resection prostatectomy performed for benign disease.  
On VA examination in May 2017, the VA examiner opined that it was less likely than not that the Veteran had prostatitis that was related to active military service.  The examiner also opined that it was less likely than not that the Veteran’s episode of acute prostatitis in service or his current prostatic issues were related to Agent Orange exposure.  The examiner referred to an examination of the Veteran and a review of the Veteran’s claims file, in addition to a review of medical literature regarding chronic prostatitis, benign prostatic hypertrophy, and overactive bladder.  The examiner acknowledged that the Veteran was diagnosed with an acute episode of prostatitis in 1972, during service.  This resolved with treatment, and the examiner found no further episodes of prostatitis in the remainder of the Veteran’s STRs.  The examiner did note that the Veteran had a complaint of penile discharge with bowel movements in 1987 and that this was noted to be prostatic secretions.  However, the examiner explained that this was not otherwise related to prostatitis because it was a normal physiologic response to pressure on the prostate.  The examiner explained that the maneuver of the prostatic massage can be used as a means of expressing prostatic fluid for diagnostic purposes.  Therefore, the pressure of stool in the rectal vault can easily result in expression of prostatic fluid and is not a pathologic response.  Otherwise, continued the examiner, the Veteran’s STRs did not show the typical symptoms of chronic prostatitis, such as chronic urinary frequency, pain with urination, and dribbling of urine.  Post-service, the Veteran had remained asymptomatic regarding prostatitis for the following 15 years.  The examiner acknowledged that the Veteran had another episodes of prostatitis in 2009.  However, the Veteran had since been diagnosed with significant benign prostatic hypertrophy and overactive bladder, which would be considered the chief contributing factors in the second episode of prostatitis.  The development of these conditions was unrelated to the first episode, opined the examiner, as intervening pathology had occurred to cause the second episode.  
Further, opined the examiner, prostatitis and benign prostatic hypertrophy are also unrelated to the vasectomy complications.  The complications of the vasectomy were related to the Veteran’s left testicle only, and the involved nerve that was considered entrapped does not serve the bladder or prostate area.  The examiner further explained that there was no supportive evidence suggesting that a vasectomy and complicating orchialgia and nerve entrapment are causally related to prostatic problem.  As such, the examiner concluded that it was less likely than not that the episode of prostatitis in service is related to current prostatic and lower urinary tract issues, including the second episode of prostatitis, benign prostatic hypertrophy, and overactive bladder.  
Regarding Agent Orange, the examiner cited to a thorough search of the medical literature, which indicated that he only prostatic issue related to exposure to Agent Orange is prostate cancer.  Because the Veteran was not diagnosed with prostate cancer, it was less likely than not that the Veteran’s prostatitis experienced in service, the second episode in 2009, and related prostatic issues were related to Agent Orange exposure.  
The May 2017 opinion is highly probative because it is premised on an interview with the Veteran, a comprehensive review of the Veteran’s medical records, and is supported by an adequate rationale.  Particularly, the examiner addressed the in-service events and post-service treatment for prostate disorders and why they were not related.  The rationale was very thorough.  Accordingly, the Board finds that the May 2017 VA opinion supports a finding that the Veteran’s prostate conditions did not have onset in service and are not otherwise related to service, to include exposure to Agent Orange.  
Further, and as noted above, the etiology of a prostate disorder, which is an internal medical process not capable of lay observation, is clearly distinguishable from ringing in the ears, a broken leg, or varicose veins. See Jandreau, 492 F.3d at 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002).  As such, the Veteran’s lay statements that purport to link his prostate disorders to service are non-competent lay statements.  Regardless, the Veteran’s assertions are outweighed by the medical evidence of record, which is more probative as it is based upon medical expertise.
Accordingly, service connection is denied on a direct basis.  In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
Increased Rating
Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018).  The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service.  The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations.  38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018).  Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018).  When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor.  38 C.F.R. § 4.3 (2018).
In considering the severity of a disability, it is essential to trace the medical history of the Veteran.  38 C.F.R. §§ 4.1, 4.2, 4.41 (2018).  Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending.  Powell v. West, 13 Vet. App. 31, 34 (1999).
Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.”  Fenderson v. West, 12 Vet. App. 119, 126 (1999).  In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time.  Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings).  When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim.  Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009).  When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed.  Hart, 21 Vet. App. at 509. 
7. Entitlement to a compensable rating for hemorrhoids
The Veteran submitted a claim for an increased rating for his hemorrhoids on September 24, 2008.
The Veteran’s hemorrhoids are rated pursuant to 38 C.F.R. § 4.114, Diagnostic Code (DC) 7336.  Under DC 7336, a noncompensable rating is warranted where the hemorrhoids are found to be mild or moderate in nature.  A 10 percent rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences.  The maximum rating of 20 percent is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Id.
On VA examination in May 2009, the Veteran reported having problems with hemorrhoids with local pain and small amounts of bleeding.  He reported satisfactory passage of stools, although he had occasional swelling in the anal area.  He generally used rectal suppositories or Preparation H with reasonably good results.  A rectal examination showed some external hemorrhoid tags.  Anal sphincter tone appeared to be within normal limits.  The examiner diagnosed external hemorrhoids, status post surgical excision without sequelae.  
VA provided an examination in May 2017.  On clinical interview, the Veteran denied having any current issues.  An examination showed a small amount of redundant tissue and peri-anal scarring, mild.  There was no active hemorrhoidal disease.  
The evidence is otherwise silent regarding the severity of the Veteran’s hemorrhoids.  
Based on the medical evidence of record, the Board finds that the Veteran’s hemorrhoids during the instant claim, while present at times, did not amount to any severity other than mild.  Neither the medical evidence nor the Veteran’s lay statements indicate that the Veteran’s hemorrhoids are currently, or ever were during the claim, large or thrombotic, irreducible, with excessive redundant tissue, with anal fissure, or with persistent bleeding with secondary anemia.  In short, the evidence does not show that the Veteran’s hemorrhoids more nearly approximate the criteria corresponding to a compensable rating pursuant to DC 7336. 
A compensable rating for service-connected hemorrhoids pursuant to DC 7336 is not warranted.  38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.114.
8. Entitlement to an increased rating for a chronic left ankle injury with degenerative joint disease, evaluated as noncompensable prior to May 17, 2017, and as 20 percent disabling on and after that date.
Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 
38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements.  Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint).
Furthermore, painful motion is an important factor of disability.  Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint.  38 C.F.R. § 4.59.  Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint.  38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis).  Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute functional loss and is just one fact to be considered when evaluating functional impairment).  In increased evaluation claims, VA examinations for musculoskeletal conditions must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.  38 C.F.R. § 4.59 (2018); Correia v. McDonald, 28 Vet. App. 158 (2016).
Section 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under diagnostic codes predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016).  Rather, section 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the diagnostic code under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman, 28 Vet. App. at 354.
Prior to May 17, 2017, the Veteran is in receipt of a noncompensable disability rating for his left ankle.  On and after that date, the disorder is evaluated as 20 percent disabling.
The Veteran’s left ankle disability has been evaluated under DC 5271, which addresses limited ankle motion.  Limitation of motion of the ankle may be rated under Diagnostic Code 5271.  Under Diagnostic Code 5271, a 10 percent evaluation is assigned for moderate limitation of the ankle, and a maximum 20 percent evaluation is assigned for marked limitation of motion. 38 C.F.R. § 4.71a. 
Normal ankle dorsiflexion is from 0 to 20 degrees, and normal ankle plantar flexion is from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II.
	Factual History
VA provided an examination in May 2009.  The Veteran reported having increased ankle pain in more recent years, and recent X-rays had suggested a problem with degenerative joint disease in the left ankle.  He indicated he could tolerate walking on a level surface for short distances, or up to 100 yards.  However, noted the examiner, the Veteran presented with a series of multiple medical issues which likely contributed to the Veteran’s functional disability, including significant peripheral arterial insufficiency.  The examiner explained that the limitation strictly related to arthritis was difficult to assess due to the multiple disabilities.  At a minimum, however, the examiner acknowledged that the left ankle disability caused some intermittent local pain.  On examination, dorsiflexion was from zero to 15 degrees, plantar flexion was from zero to 40 degrees, inversion was from zero to 10 degrees, eversion was from zero to 15 degrees.  These measurements did not change on repetitive motion.  The examiner diagnosed left ankle injury associated with local degenerative joint disease and recurrent local pain with moderate weightbearing activity.  
VA provided an examination in May 2017.  At that time, a diagnosis of degenerative arthritis of the left ankle was rendered.  The Veteran reported that, with respect to his left ankle alone, he was not experiencing any specific issues at this time.  On examination, dorsiflexion was zero to zero degrees.  Plantar flexion was zero go 35 degrees.  No pain was noted on examination, and there was no evidence of pain with weight bearing.  The examiner also conducted range of motion testing in nonweight-bearing passive motion, but no pain was noted.  The examiner noted no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.  There was no evidence of crepitus, either.  The Veteran also did not experience flare-ups or instability in his left ankle.  
Other than showing that the Veteran has residual complications left ankle injury with degenerative joint disease, the other evidence of record does not provide insight into the severity of the Veteran’s service-connected left ankle disorder.  The Board notes that the Veteran suffers from multiple disorders, some service-connected, in his lower extremities.  While the Veteran is significantly impaired in his ability to walk distances, for instance, it is unclear what level of this impairment is attributable to his left ankle disorder.  
	Analysis
The Board finds that a 10 percent rating is warranted for the Veteran’s left ankle disorder prior to May 17, 2017.  The Board bases this finding on the noncompensable ratings for musculoskeletal disabilities and complaints of pain on motion. See 38 C.F.R. § 4.59; Burton, 25 Vet. App. 1.  
On examination in May 2009, the examiner clearly identified recurrent local pain in the left ankle.  Thus, with consideration of the holdings of Burton and Southall-Norman, the Board finds that an initial 10 percent ratings is warranted for the left ankle disorder.  38 C.F.R. § 4.59.  
Prior to May 17, 2017, the date on which the VA examination conducted for the Veteran’s left ankle was conducted, the evidence does not demonstrate marked limitation of motion.  The Veteran had dorsiflexion of zero to 15 degrees.  As noted above, normal dorsiflexion is zero to 20 degrees.  The Veteran had plantar flexion from zero to 40 degrees.  Normal plantar flexion is zero to 45 degrees.  The examination did not indicate that pain, weakened movement, excess fatigability, and incoordination limited the Veteran’s left ankle disability to such an extent that additional functional limitation was marked in nature.  Accordingly, a disability rating in excess of 10 percent prior to May 17, 2017, is not warranted.  
On and after May 17, 2017, the Board finds that a disability rating in excess of 20 percent is not warranted.  A 20 percent evaluation is the maximum schedular benefit for limited ankle motion.  A higher disability rating is not available for the Veteran’s disorder.  In any event, the Veteran was not able to dorsiflex his ankle.  This approximates marked limitation of motion.  Accordingly, a 20 percent disability rating is appropriate given the level of disability shown.
The Board has considered whether higher ratings are warranted under different diagnostic codes.  However, the evidence does not demonstrate ankylosis of the ankle.  38 C.F.R. § 4.71a, DC 5270.  As this is the only potentially relevant diagnostic code providing for a higher rating than 20 percent, no other code is applicable.  See 38 C.F.R. § 4.71a, DCs 5272-52774.  
TDIU
As noted above, the Board will consider whether a TDIU is warranted for any one disorder prior to November 26, 2014, for the purposes of determining whether SMC at the housebound rate is warranted.  The Veteran’s claim for an increased rating for hemorrhoids was initially raised in a statement received on September 26, 2008.  On and after November 26, 2014, the issue of entitlement to a TDIU is moot.  
From September 26, 2008 until November 26, 2014, the Board grants a TDIU based on the Veteran’s service-connected coronary artery disease, alone.  
VA will grant TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience.  38 C.F.R. §§ 3.340, 3.341, 4.16.  TDIU is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment.  If there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability.  38 C.F.R. § 4.16(a).  If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more.  38 C.F.R. § 4.16(a).
Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment.  38 C.F.R. §§ 3.340, 3.341, 4.16.  The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.”  Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).
Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran’s background including his employment and educational history.  38 C.F.R. §§ 3.321(b), 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance.  Bowling v. Principi, 15 Vet. App. 1 (2001).  Rather, the issue must be referred to the Director of Compensation Service for such assessment in the first instance.  Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015).  Thereafter, the Board has jurisdiction to review the entirety of the Director’s decision denying or granting an extraschedular rating and is authorized to assign an extraschedular rating when appropriate.  Kuppamala, 27 Vet. App. at 457.
For VA purposes, the term unemployability is synonymous with inability to secure and follow a substantially gainful occupation.  VAOPGPREC 75-91, 57 Fed. Reg. 2,317 (Jan. 21, 1992).  Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993).  A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment.  Van Hoose, 4 Vet. App. at 363.
The ability to work sporadically or obtain marginal employment is not substantially gainful employment.  38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991).  Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment.  38 C.F.R. § 4.16(a).
Prior to November 26, 2014, the Veteran is in receipt of a 60 percent evaluation for coronary artery disease.  On and after November 26, 2014, the heart disorder is evaluated as 100 percent disabling, serving as the threshold basis for the Veteran’s receipt of SMC at the housebound rate.  Prior to November 26, 2014, the percentage requirements for a TDIU are met based on coronary artery disease alone, without regard for any other service-connected disabilities.  38 C.F.R. § 4.16 (a).  Thus, the percentage requirements for a TDIU are met because the Veteran has one service-connected disability which is rated as 60 percent disabling.  38 C.F.R. § 4.16 (a).  
The only remaining consideration is whether the Veteran’s coronary artery disease, alone, rendered the Veteran unable to secure or follow substantially gainful employment.  The Board resolves reasonable doubt in the Veteran’s favor and finds in the affirmative.  
First, though records of the Veteran’s claim are not available, the Veteran is in receipt of Social Security Administration disability benefits.  At the September 2014 hearing, the Veteran credibly testified that he received these benefits in 1992 after suffering his first heart attack.  When questioned, the Veteran affirmed that his coronary artery disease was the reason the benefits were granted.  Also at the hearing, the Veteran described having an occupational history consisting of manual labor and driving.  This is corroborated by VA audiological examinations of record. 
Second, the Veteran’s heart disorder has been productive of severe occupational limitations.  In a March 2009 statement, the Veteran’s private treatment provider, Dr. MC, opined that the Veteran’s peripheral artery disease and coronary artery disease left the Veteran totally disabled.  The coronary artery disease resulted in chronic angina.  
On VA examination for his heart in January 2016, the Veteran indicated that his ability to work in civilian life was terminated by his cardiac disease with a coronary occlusion in September 1990.  The Veteran had not worked since that time on the advice of his cardiologist.  The Veteran had suffered a second heart attack in 1998 and undergone a stent placement.  The Veteran had experienced chest pain and a third catheter was placed in 2014.  The Veteran reported that he had been hospitalized for his heart almost 30 times.  The examiner indicated that the Veteran’s heart condition would prevent heavy work.  Notably, this examination was provided after November 26, 2014, the effective date for the total disability rating for the Veteran’s coronary artery disease.  A May 2017 VA examination indicated that the Veteran’s heart condition would prevent the Veteran from functioning adequately in most work settings.  The Veteran suffered from chronic angina, which required medications to control.  Notwithstanding the dates of the VA examinations, the Board notes that the examiners’ comments on the functional impact of the Veteran’s coronary artery disease were not solely addressing his present limitations.  
All of the above leads the Board to find that the Veteran is and has been unemployable as a result of his heart disorder.  The Veteran’s previous work history involves the sort of physical labor that is precluded by the Veteran’s heart disease.  There is nothing to suggest he possesses the transferrable skillsets from his prior occupations that would be possible in different occupations.  Further, the evidence clearly indicates that the Veteran suffered from severe functional limitations as a result of his heart disease prior to November 26, 2014.  The Veteran’s credible statements indicate that he had been advised by treatment providers to cease employment.  
Thus, with reasonable doubt resolved in the Veteran’s favor, the Board finds that a TDIU is warranted from September 26, 2008, to November 25, 2014.  The Board has selected the September 26, 2008, effective date because this was the date the Veteran submitted his claim for an increased rating for hemorrhoids, of which the Veteran’s TDIU claim is part and parcel.  See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009).
SMC
Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i).
Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute.  Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling.
The Court has held that although a TDIU may satisfy the “rated as total” element of section 1114(s), a TDIU based on multiple underlying disabilities cannot satisfy the section 1114(s) requirement of “a service-connected disability” because that requirement must be met by a single disability.
In this case, the Veteran is assigned a TDIU based solely due to his service-connected coronary artery disease from September 26, 2008, to November 25, 2014. Although coronary artery disease was not rated as 100 percent, for SMC purposes this disability satisfied the requirement of a “service-connected disability rated as total.” See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008).  The Veteran has met the minimum threshold for the entire appeal period; he had a single service-connected disability rated as total (i.e. his coronary artery disease) form September 26, 2008, to November 25, 2014.
Between January 13, 2009, and November 25, 2014, the Veteran is also service-connected for chronic kidney disease with hypertension, evaluated as 60 percent disabling.  This disability, alone, satisfies the requirement for additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems.  The Veteran has several other disabilities rated between this period.  However, for the purposes of SMC at the housebound rate, the Veteran’s chronic kidney disease with hypertension, alone, satisfies the second criteria.  
Thus, the Veteran has a single service-connected disability rated as 100 percent by way of his TDIU predicated on his service-connected coronary artery disease, and has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems.  Therefore, the criteria for SMC at the housebound rate are met from January 13, 2009, to November 25, 2014.  
From September 26, 2008, to January 12, 2009, the Veteran is service-connected for the following disorders other than coronary artery disease: 1) tinnitus, rated as 10 percent disabling; 2) bilateral hearing loss, rated as 10 percent disabling; 3) residuals of right second, third, and fourth fingers, rated as noncompensable; and 4) hemorrhoids, rated as noncompensable.  These disorders do not combine to equal at least 60 percent.  Accordingly, SMC is not warranted at the housebound rate under 38 U.S.C. § 1114 (s) on the basis of the Veteran’s disability ratings.  
SMC may nevertheless be awarded from September 26, 2008, to January 12, 2009, if the Veteran was permanently housebound by reason of his service-connected disabilities.  The Board finds that the Veteran was not permanently housebound from September 26, 2008, to January 12, 2009.  Though the evidence clearly demonstrates that the Veteran was severely impaired as a result of his coronary artery disease, it does not demonstrate that he was substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises.  There is nothing of record to suggest that the Veteran was permanently housebound from September 26, 2008, to January 12, 2009.  Accordingly, there is no basis to grant SMC at the housebound rate during this time period.  
REASONS FOR REMAND
1. Entitlement to service connection for thoracic and lumbar spine disorders.  
Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993).
On VA examination conducted in May 2017, the Veteran was diagnosed with a lumbar strain and thoracic spine degenerative joint disease.  Regarding the thoracolumbar spine, the Veteran reporting that he sustained an injury to his back in 1971 during service.  Since then, he had experienced chronic pain managed by medication.  After conducting the examination, the examiner opined that it was less likely than not that the Veteran’s thoracic and lumbar spine conditions were first manifest in service.  While acknowledging the Veteran’s report of a significant back injury early in service, the examiner noted that the available records do not document the extent of treatment.  The STRs were also silent for any complaint, treatment, or diagnosis related to the thoracic spine.  The examiner acknowledged that the Veteran did have a brief episode of back pain in 1972, but there was no further mention of a lumbar area issue until 1980, at which point the Veteran reported back pain that had been present for a week and located in the thoracic area.  The STRs were silent for back treatment other than these records, explained the examiner.  The examiner then pointed to a 2009 diagnosis of some degenerative changes in the thoracic spine, but the lumbar spine was normal.  The examiner explained that there continued to have no evidence of significant degenerative changes on current examination.  The examiner concluded that the incidents noted in the STRs, given their brief treatment records and the limited number of events over a 20-year service record, supported that these events of back pain were acute and transitory with interval resolution.  The Veteran’s current disease is mild and not unusual for his age, explained the examiner.  As such, it was less likely than not that the Veteran’s current thoracic and lumbar conditions are related to those reports noted in service.  
The May 2017 VA opinion is inadequate because it is premised, in part, on the Veteran’s back complaints starting in 2009.  That is, there is no mention of back symptoms between the Veteran’s service and his current complaints.  The Board notes that private cardiology treatment records from August 1991 to February 1992 document that the Veteran underwent a right lumbar sympathectomy to treat right foot symptoms.  The procedure did not relieve right foot symptoms, and the Veteran developed back pain that radiated down his leg shortly thereafter.  Subsequent records from the cardiologist do not document back complaints.  A February 1992 internal medicine consultation from the Department of Social Services Disability Evaluation Division documents normal neck and back examinations.  However, aa June 2004 assessment from Dr. SB indicated that the Veteran had a many year history of chronic back pain resulting in a lumbar sympathetectomy in 1992.  A past medical history of back pain from lumbar disc disease was noted.  
This history is not discussed by the May 2017 examiner.  However, it bears directly on the question of whether back symptoms could have existed since service and are corroborative of the Veteran’s credible statements.  Therefore, the Board finds that remand is required for an adequate examination.
2. Entitlement to service connection for irritable bowel syndrome (IBS)
Remand is required to reconcile conflicting opinions of record.  
VA provided an examination in October 2017.  The examiner opined that the Veteran’s IBS was at least as likely as not incurred in or caused by the Veteran’s service.  The examiner explained that the Veteran was exposed to Agent Orange during service and was provided a chlorine pill for water purification.  The examiner explained that these toxins damage the normal function of the intestines.  As such, the examiner opined that IBS is due to toxic exposure.  In a March 2018 opinion, however, a VA examiner opined that IBS was less likely than not incurred in service or aggravated by service.  The examiner cited to STRs from May 1985, June 1972, 1973, and 1984 with recurrence throughout active service or post-service, suggesting that the Veteran’s current IBS is unrelated to active service.  The examiner acknowledged that that the Veteran reported having been treated for IBS, but there were no clinical follow-ups of gastrointestinal issues since discharge other than mentions in “past medical history” portions of VA treatment records.  
Clearly, these opinions conflict, and the evidence does not resolve the difference in opinions.  As such, the Board finds that remand is appropriate for an addendum opinion.  
3. Entitlement to an increased rating for residuals of a hiatal hernia, evaluated as noncompensable prior to May 17, 2017, and as 10 percent disabling on and after that date 
Remand is required for a clarifying examination for the Veteran’s claim of entitlement to an increased rating for a hiatal hernia.  
The Veteran’s disability is evaluated under Diagnostic Code 7346.  Diagnostic Code 7346 concerns hiatal hernia and provides a 10 percent rating for two or more of the symptoms for the 30 percent evaluation of less severity, a 30 percent rating for “[p]ersistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health,” and a 60 percent rating for “[s]ymptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health.” 38 C.F.R. § 4.114, Diagnostic Code 7346. The criteria for the higher disability ratings are conjunctive, meaning that the Veteran must demonstrate all of the listed symptoms to be entitled to the rating. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met). “[A] higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria.” Jones v. Shinseki, 26 Vet. App. 56, 63 (2012).
VA provided an examination in May 2017.  The Veteran was diagnosed with GERD and a history of hiatal hernia.  The Veteran reported a previous history of reflux that he treated with counter antacids regularly.  He reported a history of multiple irregular sleeping at night due to frequent burning in the throat, regurgitation, and vomiting.  The examiner noted that the Veteran was taking proton pump inhibitors chronically.  As a result, the Veteran’s symptoms were less severe than prior to the current medication regimen.  Signs and symptoms of the Veteran’s hiatal hernia and GERD included reflux, regurgitation, sleep disturbance, nausea, and vomiting.  Sleep disturbance episodes occurred four times or more per year, each episode lasting less than one day.  The Veteran’s vomiting episodes were similarly frequent.  
It is unclear whether the effects of the medications taken for the Veteran’s disorder were considered in assigning his present evaluation.  The VA examiner indicated that the Veteran had improved symptoms with medication.  Though the examiner did discuss the Veteran’s symptoms prior to his use of medication, it is unclear whether the current severity provided by the examiner reflects the level of symptomatology absent the use of the medications.  In light of the above, the Board finds that the claim must again be remanded to the AOJ to provide an adequate medical examination to assess the severity of service-connected hiatal hernia.  
The matters are REMANDED for the following action:
1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment.  If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file.  Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile.  The non-existence or unavailability of such records must be verified and this should be documented for the record.  Required notice must be provided to the Veteran and his or her representative.
2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records.  Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file.  All information obtained must be made part of the file.  All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative.
3.  After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his thoracic and lumbar spine disorders.  The entire claims file must be made available to and be reviewed by the examiner.  Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis.  An explanation for all opinions expressed must be provided.  
The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the thoracic and lumbar spine disorders had onset in, or is otherwise related to, active military service.  
The examiner must specifically address the Veteran’s assertions of an in-service back injuries, the documents of treatment contained in the Veteran’s STRs, and post-service treatment records from 1991, 1992, and 2004 documenting complaints of and treatment for chronic lumbar spine symptoms.  
4. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the Veteran’s irritable bowel syndrome from a VA examiner.  The entire claims file must be made available to and be reviewed by the examiner.  If an examination is deemed necessary, it shall be provided.  An explanation for all opinions expressed must be provided.  
The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the IBS had onset in, or is otherwise related to, active service.  
The examiner must specifically address the following: 1) an October 2017 VA opinion where the examiner found that toxins from the Veteran’s exposure to Agent Orange and chlorine pills during service caused the Veteran’s IBS; and 2) a May 2018 VA opinion where the VA examiner opined that IBS was less likely than not incurred in service or aggravated by service.  
5. After any additional records are associated with the claims file, provide the Veteran a VA examination to evaluate the severity of his service-connected hiatal hernia, including determining the severity of the Veteran’s condition in an unmedicated state. The claims file must be made available to the examiner for review, and such review should be noted in the examination report. 
The examiner must report all signs and symptoms necessary for evaluating the Veteran’s service-connected disorder under the rating criteria, to include, if possible, without consideration of the ameliorative effects provided by medications.

 
KELLI A. KORDICH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Steve Ginski, Associate Counsel