Citation Nr: 18155177 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-04 109 DATE: December 4, 2018 ORDER Entitlement to service connection for small fiber neuropathy of the bilateral legs is dismissed. For the entirety of the appeal period, entitlement to a 10 percent disability rating for residuals of a left ankle injury is granted. For the entirety of the appeal period, entitlement to a 10 percent disability rating for residuals of a right ankle injury is granted. For the entirety of the appeal period, entitlement to an initial disability of 50 percent for anxiety disorder not otherwise specified (NOS) is granted. Entitlement to an initial disability rating in excess of 10 percent for right shoulder keloid scar status post fibrotic papule excision is denied. Entitlement to service connection for tinnitus is granted. REMANDED Entitlement to an increased disability rating in excess of 10 percent for residuals of a left ankle injury is remanded. Entitlement to an increased disability rating in excess of 10 percent for residuals of a right ankle injury is remanded. Entitlement to an initial disability rating in excess of 50 percent for anxiety disorder NOS is remanded. Entitlement to service connection for a psychiatric disorder other than anxiety disorder NOS, to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, is remanded. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected tinnitus, is remanded. Entitlement to service connection for a low back disorder, to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, is remanded. FINDINGS OF FACT 1. In April 2018, prior to the promulgation of a decision in the appeal, the Veteran requested that his appeal of the issue of entitlement to service connection for small fiber neuropathy of the bilateral legs be withdrawn. 2. During the entire period on appeal, the Veteran’s residuals of a left ankle injury disability has been manifested by actual pain in the left ankle joint. 3. During the entire period on appeal, the Veteran’s residuals of right ankle injury disability has been manifested by actual pain in the right ankle joint. 4. During the entire period on appeal, the Veteran's anxiety disorder NOS has been manifested by occupational and social impairment with reduced reliability and productivity; but not occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 5. During the appeal period, the Veteran’s right shoulder keloid scar status post fibrotic papule excision has been manifested by a single painful scar that covers an area less than 144 square inches in the right shoulder. It has not been unstable or associated with underlying soft tissue damage. 6. The Veteran's tinnitus was at least as likely as not incurred during active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of entitlement to service connection for small fiber neuropathy of the bilateral legs have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. During the entire period on appeal, the criteria for a disability rating of 10 percent for residuals of a left ankle injury have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5271. 3. During the entire period on appeal, the criteria for a disability rating of 10 percent for residuals of a right ankle injury have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5271. 4. During the entire period on appeal, the criteria for an initial disability rating of 50 percent for anxiety disorder NOS have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9413. 5. The criteria for entitlement to an initial disability rating in excess of 10 percent for right shoulder keloid scar status post fibrotic papule excision have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7804 (2017, August 13, 2018). 6. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. § 1101, 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1984 to July 1990, and January 1991 to March 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2018. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. As discussed in greater detail below, the Board is bifurcating the Veteran's increased rating claims for anxiety disorder NOS and his left and right ankle disabilities in order to grant a 50 percent rating for anxiety disorder NOS and 10 percent ratings for the left and right ankle disabilities for the entire period on appeal; and to remand the issue of whether entitlement to a higher disability rating is warranted for these disabilities during the current appeal period. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (determining that the Board can bifurcate a claim and address different theories or arguments in separate decisions). In so doing, the Board is awarding the Veteran the maximum benefit available based on the evidence currently of record without precluding the possibility of an even higher disability rating being awarded in a future decision. As such, there is no prejudice to the Veteran in the bifurcation of these increased rating claims. I. 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). II. Law and Analysis 1. Entitlement to service connection for small fiber neuropathy of the bilateral legs. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the veteran or by his authorized representative. Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204. During the April 2018 Board hearing, the Veteran testified on the record that he wished to withdraw his service connection claim for small fiber neuropathy of the bilateral legs. See April 2018 Board Hearing Transcript (Tr.), page 36-38. Given that there remain no allegations of errors of fact or law for appellate consideration, the Board does not have jurisdiction to review this appeal, and it is dismissed. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, 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. As indicated above, the Veteran is appealing the initially assigned disability ratings for his anxiety disorder NOS and right shoulder scar. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In contrast, as the Veteran is requesting a higher rating for an already established service-connected disability in his increased rating claims for residuals of left and right ankle injuries, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). For both types of increased rating claims, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Such separate disability ratings are known as staged ratings. 2. Entitlement to a compensable disability rating for residuals of a left ankle injury; and entitlement to a compensable disability rating for residuals of a right ankle injury. The Veteran is in receipt of a noncompensable rating for his residuals of a left ankle injury and residuals of a right ankle injury under 38 C.F.R. § 4.71a, Diagnostic Code 5271. As he filed his increased rating claim for these disabilities on August 20, 2010, the appeal period began on August 20, 2009, one year prior to the date of receipt of his increased rating claim. 38 C.F.R. § 3.400(o)(2). 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. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.14 do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the Diagnostic Code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under Diagnostic Code 5271, a 10 percent rating is awarded for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. Under Diagnostic Code 5270, a 20 percent rating is assigned when the ankle is ankylosed in plantar flexion less than 30 degrees; a 30 percent rating is warranted when the ankle is ankylosed in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees; and a maximum 40 percent rating is assigned the ankle is ankylosed in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion, or eversion deformity. The regulations provide that normal range of motion of the ankle is from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5272, a 10 percent rating is assigned where there is ankylosis of the subastragalar or tarsal joint in good weight-bearing position, and a maximum 20 percent rating is warranted where there is ankylosis of the subastragalar or tarsal joint in poor weight-bearing position. Under Diagnostic Code 5273, a maximum 20 percent rating is assigned for malunion of the os calcis or astragalus with marked deformity. Under Diagnostic Code 5274, a 20 percent rating is assigned for astragalectomy. In addition, Diagnostic Code 5003 states that the severity of degenerative arthritis, established by x-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which, in this case, would be Diagnostic Codes 5260 (limitation of flexion of the leg) and 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. After reviewing the evidence from the appeal period, the Board finds that a 10 percent rating, the minimum compensable rating under the applicable diagnostic code, is warranted as the Veteran's left and right ankle disabilities were shown to be actually painful for the entire period on appeal. See Petitti v. McDonald, 27 Vet. App. 415, 428-429; see also Southhall-Norman v. McDonald, 38 Vet. App. 346, 352-54 (2016) (providing that Section 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or maligned joints or periarticular regions, regardless of whether the Diagnostic Code under which that disability is being evaluated is predicated on range of motion measurements). In a September 2010 VA treatment record, the examiner noted the Veteran’s report of chronic bilateral ankle pain that was a 4 to 5 out of 10 in severity. The pain was complicated by his diabetic neuropathy. The pain had not been relieved by the Veteran’s use of Neurontin, Lyrica, or treatment from an outside pain clinic. The objective examination showed that the right ankle had a normal range of motion and mild tenderness over the lateral ankle. The assessment was chronic ankle pain that was likely due to degenerative joint disease, worsened by diabetes mellitus peripheral neuropathy. A subsequent September 2010 addendum stated that the x-ray revealed no degenerative joint disease. In November 2010, a VA treatment record stated that the Veteran’s ankles hurt on the lateral aspect, and he reported that they were swollen. He indicated that this pain had bothered him for 20 years. The pain was worse with increased standing and walking. Rest helped the joint pain, and elevation helped the swelling. The examination showed the Veteran had adequate, pain-free range of motion of all major joints with adequate strength of all major muscle groups. No deformities were present. The tibialis posterior tendon was around the subtalar joint laterally, bilaterally; the ankle had a range of motion to perpendicular; and there was no pain with range of motion of the subtalar joint bilaterally. The impression was subtalar joint pain bilaterally that was secondary to a pronated gait. The Veteran was given supports to use. During a November 2010 VA examination, the Veteran again reported having bilateral ankle pain that was dull and almost constant. He described the pain as mostly mild to moderate, but he experienced increased pain and stiffness with activity. He did not experience significant swelling, and there was no redness or drainage. The Veteran did not require crutches, a brace, a cane, or corrective shoes. He did not have significant flare ups, and the examiner indicated that the Veteran did not experience additional limitations or functional loss secondary to his pain. The Veteran had full range of motion bilaterally with 20 degrees of dorsiflexion and 45 degrees of plantar flexion. No pain was present with passive motion. No varus of valgus angulation was present. The ankle also had a normal appearance a normal appearance without any swelling. The diagnosis was normal left and right ankle. The examiner stated that the physical examination did not suggest an etiology for the pain. Later in December 2015, private x-rays of the right and left ankle were obtained. The impression from the right ankle x-ray noted that there was a well-corticated 8 millimeter density adjacent to the posterior malleolus of the distal tibia that could be secondary to prior trauma. The x-ray also showed mild osteophyte formation. Both x-rays showed no acute radiographic fracture/malalignment. The left ankle x-ray additionally revealed an achilles tendon enthesophyte on the calcaneus. During the subsequent April 2018 Board hearing, the Veteran testified that he continued to experience pain in both ankles. See Tr., page 13. He also described hearing a popping sound when he moved his ankles, symptoms of swelling, and needing to wear special shoes. See Tr., page 13-15. Activities such as climbing stairs and standing aggravated his pain. See Tr. page 16-17. Based on the foregoing, the Board finds that the minimum compensable rating of 10 percent under Diagnostic Code 5271 is warranted for the entire period on appeal for the left and right ankle disabilities. See Petitti, 27 Vet. App. at 428-429; see also Southhall-Norman, 38 Vet. App. at 352-54. As noted above, the Board is remanding the issues of entitlement to a disability rating in excess of 10 percent for residuals of a left ankle injury and entitlement to a disability rating in excess of 10 percent for residuals of a right ankle injury for the entire period on appeal. Consequently, a discussion of whether the current evidence of record warrants a disability rating higher than 10 percent for either disability is not necessary at this time. 3. Entitlement to an initial disability in excess of 10 percent for anxiety disorder NOS. The Veteran's service-connected anxiety disorder NOS has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9413; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. The Veteran's psychiatric disability has been assigned an initial disability rating of 10 percent effective from August 20, 2010. A 10 percent rating contemplates occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is awarded for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran's own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact occupational and social impairment. Vasquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 118. The Board acknowledges that psychiatric examinations frequently include the assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been officially released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, No. 16-1208, Slip opinion at 5 (Vet. App. Feb. 23, 2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. The Court added that it does not hold that the Board commits prejudicial error every time the Board references GAF scores in a decision. As this appeal was certified to the Board after August 4, 2014, the DSM-5 criteria apply to this case. Consequently, the Board will not afford any probative value to the GAF scores that are documented in the record. In September 2010, a private treatment record documented that the Veteran had a flat affect, he was somewhat depressed, and he was not hopeful. This same month, a VA treatment record noted the Veteran’s report that he was experiencing recurrent nightmares and feeling irritable, guarded, and watchful. The Veteran was taking Cymbalta for depression. A subsequent September 2010 VA treatment record noted the Veteran’s report that he felt down most days, had difficulty with motivation, stayed isolated, and had low energy. The Veteran also described having difficulty concentrating and poor short-term memory. In addition, the Veteran was having marital problems. He was contemplating leaving his marriage and moving to a warmer climate to reduce his chronic pain. The Veteran was still close to his ex-wife and his two children. However, he had been isolated since he stopped working 2 years ago due to neurological pain related to his diabetes. The Veteran had enjoyed his work in security and he missed the job as well as his colleagues. The Veteran described feeling very anxious and depressed. During the evaluation, the Veteran’s affect was congruent to his depressed mood. The examiner determined that his memory was grossly intact, and his judgment and insight were adequate. There were no deficiencies in his appearance or speech. The examiner stated the Veteran denied having current suicidal or homicidal ideation. The Axis I diagnosis was major depressive disorder with anxiety. In a November 2010 VA treatment record, the Veteran reported that his depressed mood and anxiety had become prominent issues since the loss of his job. He reported having no fulfillment or joy in his life since going on disability, and he described having no direction with his time over the past two years. The Veteran reported that he was very limited with activities/hobbies he could engage in without risking a loss of benefits. He denied having current suicidal ideation. The record noted that he took Cymbalta for both his mood and anxiety. He described a mild benefit from the medication in terms of mood, but his anxiety persisted. The Veteran reported that his relationship with his wife remained tenuous. The Axis I diagnosis was depression NOS, rule out chronic adjustment disorder versus mood disorder secondary to general medical condition. During a December 2010 VA examination, the examiner noted that the Veteran had a mildly depressed affect, and he reported that his mood was usually irritable. The Veteran complained of a poor appetite and poor motivation to perform activities. He also been dealing with intermittent, moderate depressive symptoms in the last few years that were most likely related to his diabetic neuropathy. The examiner found that the Veteran had a sleep impairment that was mainly attributable to his pain from diabetic neuropathy. In terms of social functioning, the Veteran reported that he had a good marriage and maintained contact with his children and siblings. He also reported having 3 or 4 friends the he socialized with every few months. The Veteran stated that he was limited in his activities due to pain from diabetic neuropathy. The Veteran stayed home during the winter months, but he went to the river in the summer months for a change of scenery. The examiner described the Veteran’s irritability and hypervigilance as mild, noting that the symptoms had not significantly impacted the Veteran’s overall functioning. The Axis I diagnosis was anxiety disorder NOS and depressive disorder NOS. Approximately one week after the examination, a December 2010 VA treatment record stated that the Veteran spent most his psychotherapy session describing how his current marriage was the cause of his unhappiness. He continued to describe a depressed mood with low motivation. The diagnosis was depression NOS. During the April 2018 Board Hearing, the Veteran indicated that he partly avoided crowds due to problems interacting with people. See Tr., page 10. He also reported not having any friends. After reviewing the evidence from this period, the Board finds that the Veteran should be awarded a 50 percent rating for the entirety of the appeal period. 38 U.S.C. § 5107(b). Although the September 2010 VA examiner found that the Veteran’s psychiatric disability had no significant effect on his occupational or social functioning, the Board finds that this determination is inconsistent with the other evidence from this period that documented symptoms reflective of occupational and social impairment with reduced reliability and productivity. Several treatment records from this period indicated that the Veteran’s affect was flat. In addition, the Veteran also repeatedly described disturbances in his motivation and mood. The Veteran’s reported marital problems and lack of friends additionally demonstrates difficulty in establishing and maintaining effective social relationships. Although the Veteran has also received different diagnoses related to depression during this period, the Board does not find that the evidence has clearly indicated whether these symptoms are associated with his depression versus his service-connected anxiety disorder NOS. See Mittleider v. West, 11 Vet. App. 181 (1998). Thus, the Board considers these symptoms as being due to his anxiety disorder NOS. The Veteran displayed some, but not all, of the symptoms listed as examples under the 50 percent rating criteria. Resolving all doubt in favor of the Veteran, the Boards finds that the overall level of impairment during this period is best reflected by a disability rating of 50 percent. 38 U.S.C. § 5107(b). As noted above, the Board is remanding the issue of entitlement to an initial disability rating in excess of 50 percent for anxiety disorder NOS for the entire period on appeal. Consequently, a discussion of whether the current evidence of record warrants a disability rating higher than 50 percent is not necessary at this time. 4. Entitlement to a disability rating in excess of 10 percent for right shoulder keloid scar status post fibrotic papule excision. The Veteran's right shoulder keloid scar status post fibrotic papule excision is rated under 38 C.F.R. § 4.118, Diagnostic Code 7804. He has been assigned an initial 10 percent rating effective from August 20, 2010. The Board notes that on July 13, 2018, VA published a final rule amending its regulations on skin disabilities. 83 FR 32592 (July 13, 2018). The effective date of the final rule is August 13, 2018. However, for this final rule, VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. As the Veteran filed his August 2010 claim before the August 13, 2018 effective date, the Board will consider whether either the old or new rating criteria is more favorable to the Veteran. Under both the old and new rating criteria, Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating for is assigned for one or two such scars. A 20 percent rating is warranted for three to four scars, and a 30 percent disability rating is assigned for five or more scars. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic 7804. The pre-amended Diagnostic Code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2017). In contrast, the amended Diagnostic Code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (August 13, 2018). Both the old and new criteria provide that a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted when the area of the scar(s) covers at least 12 square inches (77 square centimeters) but less than 72 square inches (456 square centimeters). A 30 percent rating is warranted when the area of the scar(s) covers at least 72 square inches (456 square centimeters) but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned when the area of the scar(s) covers at least 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic 7801. Note (1) to the pre-amended Diagnostic Code 7801 stated that a deep scar is one associated with underlying soft tissue damage. Prior to August 13, 2018, Diagnostic Code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic 7802 (2017). The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (August 13, 2018). Both versions state that a 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square centimeters) or greater. Under the old rating criteria, Diagnostic Code 7805 provided that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate Diagnostic Code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2017). The Board notes that this diagnostic code is largely unchanged under the new amendments apart from the replacement of the phrase "(including linear scars)" with "and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804." 38 C.F.R. § 4.118, Diagnostic Code 7805 (August 13, 2018). The Veteran was provided with a VA examination to evaluate his right shoulder scar in September 2011. The diagnosis was right scar condition, fibrosis, keloid. The examiner noted that the Veteran was right hand dominant. The scar had manifested after the Veteran had a benign papule shaved off his shoulder. The scar was located on the superior aspect of the right shoulder. It measured 1 centimeter by 2 centimeters, and its area was less than 6 square inches (39 square centimeters). It was raised about 4 millimeters. During the examination, the Veteran denied experiencing flare ups that impacted the function of his shoulder and/or arm. Range of motion testing revealed that the Veteran had normal right shoulder flexion (180 degrees) and abduction (180 degrees). There was also no objective evidence of painful motion in either plane of motion. There was no change to these findings after repetitive use testing. In addition, these findings were the same for the left shoulder. Muscle strength testing also yielded normal results for the bilateral shoulders. The examiner found that the Veteran did not have any functional loss and/or functional impairment of the shoulder and arm. His scar did not limit the range of motion of his right shoulder. Although the scar was painful, there were no other disabling effects. The examination did not reveal any signs of skin breakdown. The scar was also superficial and without any inflammation, edema, or keloid formation. During the April 2018 Board hearing, the Veteran testified that his scar was still sensitive and painful, but he was unable to recall an instance when he had experienced skin breakdown in his scar. See Tr., page 11-12. Based on the foregoing, the Board finds that a disability rating higher than 10 percent is not warranted. The Veteran’s single painful scar is less than the three or more painful and/or unstable scars that are required for a higher rating under Diagnostic Code 7804. In addition, the scar had an area less than 144 square inches (929 square centimeters) and it was not associated with underyling soft tissue damage to warrant a rating under Diagnostic Code 7801 or 7802. The record also reflects that the scar did not have any other disabling effects to warrant consideration under another Diagnostic Code as directed by Diagnostic Code 7805. The Board additionally notes that Diagnostic Code 7800 is not applicable in this case as it relates to scars or other disfigurement of the head, face, or neck. In summary, the evidence demonstrates that the Veteran is not entitled to an initial disability rating in excess of 10 percent for his right shoulder scar. Although the Veteran is entitled to the benefit of the doubt where evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Entitlement to service connection for tinnitus. 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; 38 C.F.R. § 3.303(a). 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, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service 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). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including tinnitus, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in 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 is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that his tinnitus was incurred during active service. The Veteran has reported receiving in-service noise exposure from his combat service that included explosions and weapons fire with hearing protection. See December 2010 VA examination. The Veteran’s DD Form 214 shows that his military occupational specialty (MOS) during active service was infantryman, and he received the Combat Infantryman Badge. The Department of Defense's Noise Exposure Listing also provides that this MOS has a high probability of noise exposure. Given the circumstances of the Veteran's service, the Board acknowledges the Veteran's assertion of in-service noise exposure as credible and consistent with his service. 38 U.S.C. § 1154(b). Although lay persons are generally not competent to offer evidence which requires medical knowledge, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran is competent to report symptoms such as ringing or buzzing in his ears as this requires only personal knowledge as it comes to him through his senses. See Layno, 6 Vet. App. at 470; Barr, 21 Vet. App. at 309. In addition, the Veteran is competent to identify a disorder such as tinnitus for diagnostic purposes. 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 310; Charles v. Principi, 16 Vet. App. 370, 374 (2002). The Veteran’s service treatment records (STRs) are silent for any complaints, treatment, or diagnoses concerning tinnitus. However, the Veteran has testified that his tinnitus began during service, and the symptoms have continued to be present since service. See Tr., page 34-35. The Board notes that this testimony conflicts with the Veteran’s report from a December 2010 VA examination that his symptoms of recurrent tinnitus began a couple of years before the examination. However, the Board finds that the Veteran’s April 2018 testimony amounts to a clarification of his prior report to the December 2010 VA examiner. Based on the foregoing, the Board finds that the Veteran's reported history of continuous symptoms of tinnitus since service is credible. Consequently, the Veteran's statements support a finding that his tinnitus was incurred during active service. Although the December 2010 VA examiner provided a negative nexus opinion, the rationale reflects that the opinion was solely based on the Veteran’s report that his tinnitus had not manifested until several years after service. As the examiner was unable to consider the Veteran’s competent and credible testimony that his tinnitus symptoms began during service and have continued since that time, the Board does not find the opinion to be probative. Resolving all doubt in the Veteran's favor, the Board finds that the Veteran meets the requirements for a presumption of service connection. Service connection for tinnitus is therefore granted. 38 C.F.R. §§ 3.102, 3.303, 3.303(b), 3.307, 3.309. REASONS FOR REMAND 1. Entitlement to an increased disability rating in excess of 10 percent for residuals of a left ankle injury; and entitlement to an increased disability rating in excess of 10 percent for residuals of a right ankle injury are remanded. The record reflects that the Veteran was last provided with a VA examination concerning his left and right ankle disabilities approximately eight years ago in November 2010. During the April 2018 Board hearing, the Veteran testified that his ankle disabilities had worsened since this VA examination. See Tr., page 20. Consequently, the Board finds that a remand is necessary to obtain a contemporaneous VA examination. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). 2. Entitlement to an initial disability rating in excess of 50 percent for anxiety disorder NOS is remanded. The Veteran’s psychiatric disability was most recently evaluated during a December 2010 VA examination. The Veteran subsequently asserted that severity of his anxiety disorder NOS has increased. See Tr., page 3. Thus, the Board finds that a remand for a new VA examination is warranted. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer, 10 Vet. App. at 403; Caffrey, 6 Vet. App. at 381. 3. Entitlement to service connection for a psychiatric disorder other than anxiety disorder NOS, to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, is remanded. The Veteran was provided with a VA examination in relation to his claim in December 2010. The examiner diagnosed anxiety disorder NOS and depressive disorder NOS. Although the examiner found the Veteran's anxiety disorder to be related to his in-service experiences, he provided a negative nexus opinion for his depressive disorder. The examiner stated that the Veteran's depressive disorder NOS was a non-service connected condition that was secondary to his diabetic neuropathy. In the absence of any further explanation, the Board finds this rationale to be inadequate. As such, an additional medical opinion should be obtained on remand. The Veteran has also indicated that his depressive disorder NOS is secondary to the pain from his left and right ankle disabilities. See Tr., page 39-42. Thus, the opinion should address this theory of entitlement. As the findings from the Veteran’s VA examination for anxiety disorder NOS might impact his service connection claim for a psychiatric disorder other than anxiety disorder NOS, the Board finds that this claim is inextricably intertwined with the increased rating claim for anxiety disorder NOS remanded herein. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Final appellate review of this claim must be deferred until the appropriate actions concerning the Veteran's increased rating claim for his anxiety disorder NOS are completed and the matter is either resolved or prepared for appellate review. 4. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected tinnitus, is remanded. Although the Veteran was afforded a VA examination in connection with his service connection claim for bilateral hearing loss in December 2010, the findings did not demonstrate the presence of a hearing disability for VA compensation purposes under 38 C.F.R. § 3.385. However, the Veteran later testified that his bilateral hearing loss has increased since the December 2010 VA examination. See Tr., page 33. Affording the Veteran every opportunity, the Board finds that an additional VA examination should be obtained to determine the nature and etiology and any hearing loss that might be present. A September 2010 VA treatment record has also raised the theory that the Veteran’s hearing loss is secondary to his service-connected tinnitus. Thus, any nexus opinion provided on remand should address this theory. 5. Entitlement to service connection for a low back disorder, to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, is remanded. In conjunction with a September 2011 VA examination, a VA examiner provided a negative nexus opinion regarding the Veteran’s service connection claim for a low back disorder. Although the diagnosis section of the report only noted lumbar strain and lumbar radiculopathy, the examiner stated elsewhere in the report that an associated lumbar spine x-ray showed mild facet arthropathy at L4-L5 and L5-S1 with relative preservation of the discs. The examiner noted that there were at least 3 discrete/acute injuries described as muscle strains during service, and the Veteran did not have any job injuries or traumas to report. However, his current x-ray findings were consistent with chronic changes that were not likely to have been caused by the muscles strains found in service. The examiner instead found that the findings were related to age and use over time. However, the examiner did not address the Veteran’s assertion that he has experienced low back problems since service. See September 2010 Statement. The Veteran has also since asserted that his low back disorder is secondary to his service-connected left and right ankle disabilities. See Tr., page 28-29. Thus, an additional VA medical opinion should be obtained on remand. 6. Entitlement to service connection for a left shoulder disorder; and entitlement to service connection for a right hip disorder to include as secondary to service-connected residuals of a left ankle injury and/or residuals of a right ankle injury, are remanded. The Veteran has not yet been afforded a VA examination in relation to his service connection claims for a left shoulder and right hip disorder. He contends that these disorders are related to injuries he sustained during service as well as the physical activities associated with his military occupational specialty of infantryman. The Veteran has also asserted that his right hip disorder is secondary to his left and right hip disabilities. See Tr., page 32. The Veteran reported that he carried approximately 80 pounds in the infantry and sometimes fell with this amount of weight. See Tr., page 21-22. He testified that his left shoulder pain had continued to be present since service. The Veteran stated that he injured his right hip when he fell into a ravine and landed on his belt. See Tr., page 29-30. The Veteran has also reported persistent symptoms of a current left shoulder disorder, and he testified that his doctor told him he had right hip arthritis. In light of this evidence, the Board finds that a VA examination and medical opinion must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that when the medical evidence is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his left and right ankle disabilities, anxiety disorder NOS, major depressive disorder, bilateral hearing loss, low back disorder, left shoulder disorder, and right hip disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the VA Northern California Health Care System dated since December 2010. 2. After the preceding development in paragraph 1 is completed, provide the Veteran with a VA examination to ascertain the current severity and manifestations of his service-connected residuals of a left ankle injury and residuals of a right ankle injury. The claims file must be made available to the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. For the Veteran's residuals of a left ankle injury and residuals of a right ankle injury, the examiner should report all signs and symptoms necessary for rating the disabilities under the rating criteria. In particular, the examiner should provide the range of motion in degrees and test the range of motion in (1) active motion, (2) passive motion, (3) weight-bearing, and (4) nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including limitation of motion) due to these factors. In addition, based on examination results and the Veteran's documented history and assertions, the examiner should indicate whether, and to what extent, the Veteran experiences functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. In this regard, even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffers during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record-including the Veteran's lay information-or explain why he or she could not do so. The examiner should also indicate whether the Veteran has marked or moderate ankle limitation of motion; ankylosis of the ankle; ankylosis of the subastragalar or tarsal joint; malunion of the os calcis or astragalus; or astragalectomy of the left and/or right ankle. The examiner is also asked to evaluate any scars associated with the Veteran's residuals of a left ankle injury and/or residuals of a right ankle injury. 3. After completing the preceding development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected anxiety disorder NOS. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's anxiety disorder NOS under the General Rating Formula for Mental Disorders. The findings of the examiner should address the level of social and occupational impairment attributable to the Veteran's anxiety disorder NOS. 4. After completing the preceding development in paragraph 1, obtain a VA medical opinion from a qualified examiner on the etiology of the Veteran's psychiatric disorder other than anxiety disorder NOS. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. First, the examiner must identify all psychiatric disorders other than anxiety disorder NOS that have been present during the appeal period. If depressive disorder NOS is not identified, the examiner should address the prior diagnoses of record. For each identified disorder, the examiner must provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, active service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s residuals of a left ankle injury and/or residuals of a right ankle injury. 5. After completing the preceding development in paragraph 1, provide the Veteran with a VA examination in connection with his service connection claim for bilateral hearing loss. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. 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 Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. For any identified right and/or left ear hearing loss, the examiner must provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder manifested during, or is otherwise related to, active service. In providing this opinion, the examiner should presume that the Veteran sustained some hazardous noise exposure during service as an infantryman. If the examiner determines that it is less likely than not related to service, the examiner should explain why, including why the delayed onset of hearing loss is significant. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s tinnitus. 6. Obtain a VA medical opinion from a qualified examiner on the etiology of the Veteran's low back disorder. The claims file must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. The Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. First, the examiner must identify all low back disorders that have been present during the appeal period. If lumbar strain and facet arthropathy are not identified, the examiner should address the prior diagnoses of record. For each identified disorder, the examiner must provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during, or is otherwise related to, active service, to include the physical activities therein. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s residuals of a left ankle injury and/or residuals of a right ankle injury. In providing an opinion, the examiner should address the following: (1) the Veteran’s April 2018 testimony that he carried approximately 80 pounds in the infantry and sometimes fell with this amount of weight; (2) the Veteran’s April 2018 testimony that he sometimes went on 25 mile road marches; (3) the Veteran’s April 2018 testimony describing a hard landing after dropping 125 feet from a helicopter; and (4) the Veteran’s September 2010 statement that he has experienced low back problems since service. 7. After completing the preceding development in paragraph 1, provide the Veteran with a VA examination in connection with his service connection claim for a left shoulder disorder. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. 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 Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner must identify all current left shoulder disorders. For each identified disorder, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder manifested during, or is otherwise related to, active service, to include the physical activities therein. In providing an opinion, the examiner should address the following: (1) the Veteran’s April 2018 testimony that he carried approximately 80 pounds in the infantry and sometimes fell with this amount of weight; (2) the Veteran’s April 2018 testimony that he sometimes went on 25 mile road marches; and (3) the Veteran’s April 2018 testimony that he has experienced left shoulder problems since service. 8. After completing the preceding development in paragraph 1, provide the Veteran with a VA examination in connection with his service connection claim for a right hip disorder. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. 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 Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner must identify all current right hip disorders. For each identified disorder, the examiner must provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder manifested during, or is otherwise related to, active service, to include the physical activities therein. In providing an opinion, the examiner should address the following: (1) the Veteran’s April 2018 testimony that he carried approximately 80 pounds in the infantry and sometimes fell with this amount of weight; (2) the Veteran’s April 2018 testimony that he sometimes went on 25 mile road marches; and (3) the Veteran’s April 2018 testimony that he injured his right hip during service when he fell into a ravine and landed on his ammunition belt. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that the disorder was caused or aggravated by the Veteran’s residuals of a left ankle injury and/or residuals of a right ankle injury. 9. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel