Citation Nr: 18155964 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-45 302 DATE: December 6, 2018 ORDER Entitlement to an initial rating in excess of 10 percent for hypertension (also claimed as high blood pressure) is dismissed. Entitlement to an initial rating in excess of 10 percent for status post right hand index finger injury with residual numbness is dismissed. Entitlement to an initial rating in excess of 10 percent for tinnitus is dismissed. Entitlement to an initial rating in excess of 10 percent for temporomandibular joint (TMJ) disorder (also claimed as a dental condition) is dismissed. Entitlement to an initial compensable rating for hemorrhoids is dismissed. Entitlement to an initial compensable rating for erectile dysfunction (also claimed as hypogonadism and a penile condition) is dismissed. Entitlement to an initial rating in excess of 10 percent for lumbar spine scar is denied. Entitlement to an initial compensable rating for scars of the bilateral hands and posterior trunk is denied. REMANDED Entitlement to service connection for status post rib fractures is remanded. Entitlement to service connection for a left foot condition, including pes cavus is remanded. Entitlement to service connection for a right foot condition, including pes cavus is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for residuals of an eye injury (previously claimed as status post right eye orbital fracture) is remanded. Entitlement to service connection for traumatic brain injury (TBI), residuals of orbital fracture is remanded. Entitlement to service connection for headaches, residuals of orbital fracture is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to an initial compensable rating for right knee patellofemoral syndrome is remanded. Entitlement to an initial rating in excess of 20 percent for right shoulder tendonitis is remanded. Entitlement to an initial rating in excess of 10 percent for lumbar spinal fusion with implantation is remanded. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy associated with lumbar spinal infusion with implantation is remanded. Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy associated with lumbar spinal fusion with implantation is remanded. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD) is remanded. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD) (also claimed as hiatal hernia in stomach) is remanded. Entitlement to automobile or other conveyance and adaptive equipment, or for adaptive equipment only is remanded. FINDINGS OF FACT 1. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial rating in excess of 10 percent for hypertension (also claimed as high blood pressure). 2. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial rating in excess of 10 percent for status post right hand index finger injury with residual numbness. 3. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial rating in excess of 10 percent for tinnitus. 4. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial rating in excess of 10 percent for TMJ disorder (also claimed as a dental condition). 5. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial compensable rating for hemorrhoids. 6. On November 21, 2017, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial compensable rating for erectile dysfunction (also claimed as hypogonadism and a penile condition). 7. The Veteran’s scars are manifested by one painful linear scar of the lumbar spine and two linear scars of the bilateral hands that are neither painful nor disabling; none of the scars were deep, nonlinear, or resulted in any disabling effect of lumbar spine or bilateral hands. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial rating in excess of 10 percent for hypertension. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 2. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial rating in excess of 10 percent for status post right hand index finger injury with residual numbness. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 3. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial rating in excess of 10 percent for tinnitus. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 4. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial rating in excess of 10 percent for TMJ disorder. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 5. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial compensable rating for hemorrhoids. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 6. The criteria for withdrawal of a substantive appeal have been met as to the issue of entitlement to an initial compensable rating for erectile dysfunction. 38 U.S.C. § 7105 (b)(2), (d)(5) (2012); 38 C.F.R. §§ 20.202, 20.204. 7. The criteria for an initial rating in excess of 10 percent for lumbar spine scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7804. 8. The criteria for an initial compensable rating for scars of the bilateral hands and the posterior trunk have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2002 to July 2013. Withdrawn Claims In written correspondence dated November 21, 2017, prior to the promulgation of a decision in the appeal, the Board received written notification from the Veteran expressing his desire to no longer appeal the issues concerning entitlement to increased ratings for hypertension, right hand index finger injury with residual numbness, tinnitus, TMJ disorder, hemorrhoids, and erectile dysfunction. VA regulations provide for the withdrawal of an appeal to the Board by the submission of a written request at any time before the Board issues a final decision on the merits. See 38 C.F.R. § 20.204. After an appeal is transferred to the Board, an appeal withdrawal is effective the date it is received by the Board. Id. Appeal withdrawals must be in writing and must include the name of the Veteran, the Veteran’s claim number, and a statement that the appeal is withdrawn. Id. The Veteran’s notification containing his request to withdraw the above-stated issues on appeal has been reduced to writing, and it contains his name and claim number. The Board has not yet issued a decision concerning these claims, thus the criteria are met for withdrawal of the claims. When pending appeals are withdrawn, there are no longer allegations of factual or legal error with respect to the issue that had been previously appealed. In such an instance, dismissal of the pending appeal is appropriate. See 38 U.S.C. § 7105(d) (2012). Accordingly, further action by the Board on these issues is not appropriate and the appeal should be dismissed. Id. Increased Ratings Entitlement to an initial rating in excess of 10 percent for a painful lumbar spine scar, and to a compensable rating for scars of the bilateral hands and posterior trunk is denied. The Veteran contends that he deserves a higher rating than he is currently assigned for the scars of his painful lumbar spine, and his bilateral hands and posterior trunk. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating 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. See 38 U.S.C.§ 1155; 38 C.F.R. § 4.1. Staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The relevant time period for consideration in a claim for an increased initial disability rating is the period beginning on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). The Veteran has been assigned an initial 10 percent rating for a painful back scar, status post surgery pursuant to Diagnostic Code 7804. He has also been assigned a separate initial noncompensable evaluation for scars of his bilateral hands and posterior trunk pursuant to Diagnostic Code 7805. Diagnostic Code 7804 (scar(s), unstable or painful) provides that one or two scars that are unstable or painful are rated 10 percent disabling. Three or more scars that are unstable or painful are rated 20 percent disabling. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides 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, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118. Diagnostic Code 7805, covering other scars, including linear scars, and other effects of scars, provides that any disabling effect(s) that are not considered in a rating provided under Diagnostic Codes 7800 through 7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Veteran underwent a VA examination in June 2013. On examination, the examiner diagnosed the Veteran with bilateral hand laceration scars and lumbar surgical scars. There was one scar that was painful, which was located on the lower back. The Veteran described it as very painful to touch and wearing clothing, taking showers, or bathing caused irritation. There were no unstable scars and no scars that were both painful and unstable. None of the scars were due to burns. There were bilateral hand knife laceration scars that were linear and each measured 4 x 1 cms. There was a scar on the posterior trunk located in the lower back that was linear and measured 10 x 1 cms. There were no superficial or deep non-linear scars. The scars did not result in limitation of function and there were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with any scar. The scars did not impact the Veteran’s ability to work. VA treatment records are negative for treatment related to any of the Veteran’s scars; however, a physical examination in November 2014 noted tenderness along the Veteran’s back scar. Based on the evidence of record, the Veteran’s painful lumbar spine scar does not meet the criteria for an initial rating in excess of 10 percent, and the scars of the bilateral hands and posterior trunk do not meet the criteria for an initial compensable rating for the period on appeal. Indeed, only one of the Veteran’s service-connected scars has been shown to be painful or tender—namely, his service-connected lumbar spine scar. A rating higher than 10 percent for this scar is not warranted, as the evidence shows the scar is not unstable and is not of a size warranting a higher rating under another diagnostic code. With respect to the Veteran’s other service-connected scars, the evidence does not show, nor does the Veteran assert that his scars of the hands and posterior trunk are painful or tender. They too are not large enough to warrant a compensable rating, and they have not been shown to cause functional impairment such that a compensable rating under a different code pertaining to the hands or back would be appropriate. Finally, as the scars were not deep; or were not deep and nonlinear, Diagnostic Codes 7801 (scars, not of the head, face, or neck that are deep and nonlinear) and 7802 (scars not of the head, face, or neck, that are superficial and nonlinear) are inapplicable. See June 2013 VA examination. As such, an initial rating in excess of 10 percent for lumbar spine scar and a compensable rating for scars of the bilateral hand and posterior trunk are not warranted. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Status Post Rib Fractures The Veteran contends that he is entitled to service connection for a current disability status post rib fractures. At a June 2013 VA examination, the Veteran reported that he participated in combat, and fractured his ribs when he was hit with an IED in 2006. He indicated that his condition has stayed the same since his injury in that he had flare-ups that were precipitated by physical activity and alleviated by rest. He reported that the flare-ups resulted in functional impairment during sex, and having weakness and stiffness. He claimed that he had localized pain in the ribs. The June 2013 VA examiner stated that physical examination of the ribs and x-rays were within normal limits. The examiner determined that there was no pathology to render a diagnosis, and indicated that the Veteran’s condition does not affect his usual occupation or daily activities. The Board is cognizant of the holding of Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018). In that decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. Although the examiner appeared to find that there was no functional impairment caused by the Veteran’s rib pain, the examiner did not reconcile this opinion with the Veteran’s lay statements to the contrary made at the examination. On remand, the Veteran should be afforded another examination of his ribs, so that an examiner can clarify any current disability, and indicate whether such is a residual of the in-service injury claimed by the Veteran. 2. Left and Right Foot Conditions, including Pes Cavus The Veteran asserts he has a bilateral foot condition, to include pes cavus, that had onset during his period of active duty service. As pointed out by the Veteran’s attorney, although a VA examiner in June 2013 identified no current disability, the examiner did not reconcile this conclusion with the fact that bilateral mild asymptomatic pes cavus was noted on his separation examination just one month earlier in May 2013. The Veteran has since been treated for chronic foot pain. See a September 2, 2018 VA treatment report listing “chronic foot pain” as part of the Veteran’s medical history. On remand, the Veteran should be afforded a VA foot examination specifically addressing whether the Veteran has current disabilities that can be related to service, to include in-service documentation of pes cavus upon separation from service. 3. Bilateral Hearing Loss On October 2015 VA hearing loss DBQ, the examiner acknowledged that there was a permanent positive threshold shift between 500 and 6000 Hz in the bilateral ears and that hearing loss did not exist prior to service. Also, VA has conceded a high probability of hazardous noise exposure associated with the Veteran’s combat engineer military occupational specialty (MOS) and a moderate probability of hazardous noise exposure associated with his unmanned aerial vehicle (UAV) operator MOS. Although the Veteran had normal hearing at the time of the October 2015 VA examination, in a statement associated with his September 2016 Form 9, the Veteran reported that he was unable to maintain the seal in his right ear during testing, which compromised the results. Also, October 2017 VA treatment records for a TBI consult indicated that the Veteran had severe hearing loss. Therefore, as the record remains unclear as to whether or not the Veteran has a current hearing loss disability by VA standards, a new VA examination is warranted. See 38 C.F.R. § 3.385. 4. Residuals of an Eye Injury, Headaches, and TBI The Board notes that throughout the appeal period, the Veteran as well as the RO, in the July 2016 statement of the case, erroneously referred to the May 2008 in-service eye injury as impacting the right eye, when clearly the record shows that the Veteran’s left eye was injured while boxing. In a September 2016 statement associated with his VA Form 9 and in December 2016 correspondence, the Veteran referred to the eye injury in service during which he complained of pressure in his head and a headache and clarified that he was seeking development for all residuals that could stem from the in-service injury, including headaches, concussion, and TBI. Additionally, VA treatment records document complaints of pressure in both of his eyes in conjunction with his headaches. In light of the Veteran’s contentions seeking all possible residuals from his in-service eye injury, the RO misstating that the Veteran injured his right eye in service, and post service VA treatment records indicating that the Veteran had problems with both of his eyes associated with his headaches, the Board has broadened and recharacterized the Veteran’s claim from entitlement to service connection for status post right eye orbital fracture to entitlement to service connection for residuals of an eye injury. The Veteran’s claims for service connection for headaches and TBI will continued to be developed on a direct basis. The Veteran has not appeared for a VA examination regarding any eye disability, and he failed to report for a VA examination scheduled in December 2016 for his headaches and TBI. The record reflects that the Veteran did attend his appointments for VA treatment around the same time. In a February 2018 statement along with his notice of disagreement, the Veteran and his attorney reported that he did not receive notifications of his scheduled VA examinations and that he was committed to attending rescheduled examinations. There is no documentation in the Veteran’s file confirming that the Veteran was notified of his scheduled examinations. On remand, he should be rescheduled. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claims. 38 C.F.R. § 3.655. 5. Left Knee Disability With regard to the Veteran’s claim for service connection for a left knee disability, the Board notes that the claim was previously denied because the evidence failed to show that the Veteran had a diagnosed left knee condition. The June 2013 VA examiner found that the Veteran did not have a current left knee diagnosis and thus did not provide a nexus opinion. As discussed above, in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the United States Court of Appeals for the Federal Circuit held that where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. During the June 2013 VA examination, the Veteran reported that he had flare-ups of knee symptoms that impacted his ability to walk, stand, or sit. The examiner indicated that the Veteran had a meniscus condition that was manifested by frequent episodes of joint pain in both knees. Given the Federal Circuit’s holding in Saunders, and because the June 2013 examiner did not comment on whether the Veteran's left knee condition caused any functional impairment, the Board finds it necessary to remand the service-connection claim to afford the Veteran a new VA examination, assessing whether the Veteran's left knee pain can be considered a disability for compensation purposes. The Board adds that on his September 2016, VA Form 9, the Veteran claimed that his left knee disability was secondary to his service-connected right knee disability. If a current disability is shown, an opinion addressing secondary service connection is necessary. 6. Lumbar Spinal Fusion with Implantation and Associated Bilateral Lower Extremity Neurological Symptoms, Right Shoulder Tendonitis, Right Knee Patellofemoral Syndrome. Regarding the claim for a higher rating for the Veteran’s lumbar spine, right shoulder and right knee disabilities, a new VA examination must be provided that complies with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Correia mandates that orthopedic examinations include the testing described in 38 C.F.R. § 4.59, or an explanation as to why such testing is not warranted or not possible. The June 2013 VA examinations of the shoulder, knee, and thoracolumbar spine do not specify that such testing was performed, including passive range of motion, or whether such testing was considered not warranted or not possible. Sharp requires VA examiner to obtain information from the Veteran as to the severity, frequency, and duration of flare-ups, as well as precipitating and alleviating factors, and the extent of functional impairment. It also requires that VA examiners estimate the additional loss of range of motion during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. If an estimate cannot be provided without resort to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. In this case, the June 2013 VA examinations of the shoulder, knee, and thoracolumbar spine do not provide the necessary information regarding flare-ups, as specified above. During his examination, the Veteran reported that he had flare-ups of his shoulder, in which he could not raise his arm above his head and could not push open doors. He indicated that flare-ups impacted the function of his knee making it difficult to walk, stand, or sit. He also reported that flare-ups impacted the function of his thoracolumbar spine and indicated that he could not walk and flare-ups impacted his sex life and quality of life. The examiner failed to ascertain adequate information—i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. VA treatment records document the Veteran’s complaints of lumbar back pain with numbness in his legs. See November and December 2014 VA treatment records. Also on October 2015 VA examination for hypertension, the examiner noted a history of the Veteran being seen by VA for acute spine pain and neuropathy episodes. However, the current extent of the Veteran’s neurological symptoms in his bilateral lower extremities associated with radiculopathy and/or the lumbar spine disability remains unclear. During the June 2013 VA back (thoracolumbar spine) conditions disability benefits questionnaire (DBQ), the examiner indicated that the Veteran did not exhibit radiculopathy or constant pain, paresthesias and/or dysesthesias, and numbness in his bilateral lower extremities. However, on June 2013 peripheral nerves conditions DBQ, the examiner found severe constant pain and severe paresthesias and/or dysesthesias, in his bilateral lower extremities. The Veteran also had moderate numbness in the right lower extremity. As the Veteran’s lumbar spine disability will be evaluated on remand, which will include consideration of neurological symptoms in the bilateral lower extremities, the examiner should clarify the nature and extent of all neurological symptoms associated with the Veteran’s service-connected radiculopathy and lumbar spinal infusion with implantation. 7. PTSD The Veteran did not appear for his scheduled PTSD examination. In a February 2018 statement, the Veteran and his attorney reported that he did not receive notifications of his scheduled VA examination and that he was committed to attending a rescheduled examination. There is no documentation in the Veteran’s file confirming that the Veteran was notified of his scheduled examination. On remand, he should be rescheduled. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claims. 38 C.F.R. § 3.655. 8. GERD The Veteran was last afforded a VA esophageal conditions DBQ in June 2013. Since that time, the Veteran underwent an endoscopy for dysphagia in December 2015, a symptom that was not present at the time of the June 2013 VA examination. A remand is necessary in order to afford the Veteran another VA examination or examinations that accurately assess the current severity of his GERD. 9. Entitlement to Automobile or Other Conveyance and Adaptive Equipment or Adaptive Equipment Only. The Board finds that the Veteran’s claim for entitlement to automobile and adaptive equipment or adaptive equipment only is intertwined with the pending appeals being remanded herein for additional evidentiary development. Therefore, a decision on this claim is being deferred pending completion of the development ordered on remand to avoid piecemeal adjudication. The matters are REMANDED for the following action: 1. Obtain any outstanding VA (since October 2018) and private treatment records. 2. Schedule the Veteran for a VA examination with a physician with appropriate expertise to assess whether the Veteran has a current rib disability that is related to his period of service. The Veteran’s claims file should be sent to, and reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his claimed disability. Upon review of the file, interview and examination of the Veteran, the examiner should respond to each of the following: a) Does the Veteran have a current rib disability? If functional impairment due to pain exists, even without an underlying diagnosis, the examiner should consider this to be a disability for the purposes of this examination. b) If a current disability exists, is it at least as likely as not that the disability had onset in, or is otherwise related to injury sustained during his period of active duty service, to include an in-service rib fracture as described by the Veteran? If there is a medical reason to call into question the Veteran’s reported history of fracturing his rib in service, please make this clear. All opinions should be supplemented with a clinical explanation or rationale. 3. Schedule the Veteran for a VA examination with a physician with appropriate expertise to assess whether the Veteran has a current bilateral foot disability that is related to his period of service. The Veteran’s claims file should be sent to, and reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his claimed disability. Upon review of the file, interview and examination of the Veteran, the examiner should respond to each of the following: a) Does the Veteran have a current bilateral foot disability? If functional impairment due to pain exists, even without an underlying diagnosis, the examiner should consider this to be a disability for the purposes of this examination. The examiner should specifically address whether the Veteran has pes cavus. If not, the examiner should reconcile this finding with the Veteran’s May 2013 Report of Medical Examination upon separation, which specifically noted the presence of mild asymptomatic pes cavus. b) If a current disability exists, is it at least as likely as not that the disability had onset in, or is otherwise related to his period of active duty service, to include an in-service inversion injury in 2007, and notation of pes cavus on his separation examination. All opinions should be supplemented with a clinical explanation or rationale. 4. Schedule the Veteran for a VA audiological examination to determine the nature, extent, and etiology of any diagnosed bilateral hearing loss. The examiner is requested test the Veteran’s hearing, and indicate whether a current hearing loss disability exists for VA purposes. If so, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnosed bilateral hearing loss had its onset in service or is related to the Veteran’s military service. The examiner should consider the October 2015 VA examiner’s findings that there was a permanent positive threshold shift between 500 and 6000 Hz in the bilateral ears during service and that VA has conceded a high probability of hazardous noise exposure associated with the Veteran’s combat engineer MOS and a moderate probability of hazardous noise exposure associated with his UAV operator MOS. All opinions must be supported by a detailed rationale. 5. Schedule the Veteran for a VA examination(s) with an appropriate professional to determine the nature and etiology of any current residuals of an eye injury, headaches, and TBI. The claims folder, to include a copy of this remand, must be provided to and reviewed by the examiner in conjunction with the examination. a) Residuals of an Eye Injury. i. Identify all eye conditions present from August 2013; ii. Determine whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed eye condition is related to the Veteran's active duty service, including a left eye injury and headache in May 2008. iii. The examiner must provide a rationale for all opinions expressed, and consider VA treatment records documenting complaints of pressure in the eyes during headaches and episodes of blurry vision. b.) Headaches i. Identify all headache conditions present from August 2013; ii. Determine whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed headache condition is related to the Veteran's active duty service, including a left eye injury and headache in May 2008. iii. The examiner must provide a rationale for all opinions expressed, and consider the Veteran’s contentions indicating that his headaches began in service when he was hit in the eye while boxing in May 2008 and he felt pressure in his head and had a headache. c) Traumatic Brain Injury i. Clarify whether or not the Veteran has a current diagnosis of traumatic brain injury since August 2013, and if so, identify the Veteran’s symptoms associated with TBI. See October 2017 VA treatment records; ii. Identify all other current residuals of the in-service eye injury (other than an eye condition, headaches, or TBI); iii. Determine whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed TBI and other residuals an eye injury (other than an eye condition, headaches, or TBI) is related to the Veteran's active duty service, including a left eye injury and headache in May 2008. iv. The examiner must provide a rationale for all opinions expressed and consider the Veteran’s contentions indicating that his TBI and other residuals of an eye injury began in service when he was hit in the eye while boxing in May 2008 and he felt pressure in his head and had a headache. 6. Schedule the Veteran for a VA examination(s) with appropriate physicians to determine the extent and severity of his service-connected right shoulder, right knee, and lumbar spine disabilities, and radiculopathy of the bilateral lower extremities, as well as the nature and etiology of any left knee disability. The claims folder, to include a copy of this remand, must be provided to and reviewed by the examiner in conjunction with the examination. a) Thoracolumbar Spine Disability. i. All indicated tests should be performed, including range of motion findings expressed in degrees and in relation to normal range of motion; ii. The examination must include testing results of joint pain on both active and passive motion, and in weight-bearing and non-weight bearing in the thoracolumbar spine. If such testing cannot be completed, an explanation should be provided as to why this is so. See Correia v. McDonald, 28 Vet. App. 158 (2016). iii. The examiner must also estimate any functional loss in terms of additional degrees of limited motion the thoracolumbar spine experienced during flare-ups and repetitive use over time. If the examiner cannot provide this estimate without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). iv. The examiner must report whether the Veteran experiences incapacitating episodes (physician-prescribed bed rest) and the frequency and total duration of such episodes over the course of a year. v. The examiner should also assess the severity of all neurologic manifestations of the Veteran’s service-connected thoracolumbar spine disability, to include left and right lower extremity radiculopathy. b) Right Shoulder Disability i. All indicated tests should be performed, including range of motion findings expressed in degrees and in relation to normal range of motion; ii. The examination must include testing results of joint pain on both active and passive motion, and in weight-bearing and non-weight bearing in both shoulders. If such testing cannot be completed, an explanation should be provided as to why this is so. See Correia v. McDonald, 28 Vet. App. 158 (2016). iii. The examiner must also estimate any functional loss in terms of additional degrees of limited motion the right shoulder experienced during flare-ups and repetitive use over time. If the examiner cannot provide this estimate without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). c) Right Knee Disability i. All indicated tests should be performed, including range of motion findings expressed in degrees and in relation to normal range of motion; ii. The examination must include testing results of joint pain on both active and passive motion, and in weight-bearing and non-weight bearing in both knees. If such testing cannot be completed, an explanation should be provided as to why this is so. See Correia v. McDonald, 28 Vet. App. 158 (2016). iii. The examiner must also estimate any functional loss in terms of additional degrees of limited motion the right knee experienced during flare-ups and repetitive use over time. If the examiner cannot provide this estimate without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). iv. The examiner should also indicate whether the Veteran has instability and/or subluxation and, if so, the extent of any such instability (e.g., mild, moderate, severe). The examiner should consider the Veteran’s statements in conjunction with his September 2016 Form 9, indicating that he does experience instability in his right knee. d.) Left Knee Disability i. The examiner should first identify any left knee disability. If functional impairment due to pain exists, even without an underlying diagnosis, the examiner should consider this to be a disability for the purposes of this examination. ii. Then, as to each disability, the examiner should indicate whether it is at least as likely as not (50 percent probability or more) that the disability had its onset in or is otherwise related to the Veteran’s active duty service. An opinion should also be provided as to whether any service-connected disability, including the Veteran’s right knee disability, has caused or aggravated the Veteran’s left knee disability beyond its natural progression. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached. 7. Schedule the Veteran for a VA psychiatric examination to determine the current nature and severity of his PTSD. The claims file should be made available to the examiner in conjunction with the examination, and the examiner should indicate that the claims file was reviewed. All tests deemed necessary by the examiner should be performed, and all findings set forth in detail. 8. Schedule the Veteran for new VA examination with an appropriately qualified health care professional to determine the current nature and severity of his GERD. The entire claims file should be made available to, and reviewed by, the examiner. Once the examination and review is complete, the examiner should report the symptoms and severity of the Veteran’s GERD. 9. With respect to all examinations scheduled, advise the Veteran that it is his responsibility to report for his scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. § 3.655. In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that proper notice of the scheduled examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. (Continued on Next Page) 10. Then, review all the evidence of record, and readjudicate the Veteran’s claims, to include entitlement to automobile and adaptive equipment or for adaptive equipment only. If the claims remain denied, issue to the Veteran and his attorney a Supplemental Statement of the Case. Afford them the appropriate period of time within which to respond thereto. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Crohe, Counsel