Citation Nr: 18156122 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 18-31 251 DATE: December 11, 2018 ORDER Entitlement to an initial rating of 20 percent prior to March 27, 2018 and 30 percent thereafter for cervical strain, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an increased rating for status post lumbar strain with degenerative disc disease (DDD) and spondylosis L5-S1, rated as 20 percent disabling is denied. Entitlement to a 20 percent rating, but no higher, from May 27, 2015 for right forearm injury with laceration repair with peripheral neuropathy is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an increased rating for instability of the left knee, currently rated as 10 percent disabling, is denied. Entitlement to a 20 percent initial rating for lateral collateral ligament sprain, right ankle, is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an increased rating for bilateral pes planus, currently rated as 30 percent disabling, is denied. Entitlement a separate, initial 10 percent rating for Morton’s neuroma of the right foot is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to an initial compensable rating for scar, status post right knee arthroscopic surgery is denied. Entitlement to an initial compensable rating for scar status post left knee arthroscopic surgery is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a headache disorder, to include as secondary to service-connected cervical strain, is remanded. FINDINGS OF FACT 1. Prior to March 27, 2018, the Veteran’s service-connected cervical strain more nearly approximated forward flexion to 30 degrees with consideration to functional impairment; forward flexion of the cervical spine to 15 degrees or less has not been approximated, even with consideration to functional impairment. 2. From March 27, 2018, the Veteran’s service-connected cervical strain more nearly approximated forward flexion to 15 degrees with consideration to functional impairment; ankylosis is not shown. 3. The Veteran’s service-connected lumbar spine strain with DDD more nearly approximated forward flexion to 60 degrees with consideration to functional impairment; forward flexion of the lumbar spine to 30 degrees or less has not been approximated, even with consideration to functional impairment. 4. From May 27, 2015, the Veteran had mild incomplete paralysis of the radial nerve in the right upper extremity; moderate incomplete paralysis for any right upper extremity nerve is not more nearly approximated. 5. The Veteran’s instability of the left knee more nearly approximated slight instability; moderate instability is not more nearly approximated. 6. The evidence is at least evenly balanced as to whether symptoms of the Veteran's lateral collateral ligament sprain, right ankle, more nearly approximated marked limitation of motion of the right ankle; ankylosis has not been shown or more nearly approximated. 7. The preponderance of the evidence shows that the Veteran's bilateral pes planus more closely approximated severe acquired flat feet; but it did not more nearly approximate pronounced acquired flat feet. 8. The evidence shows that the Veteran developed a symptomatic right foot Morton’s neuroma associated with service-connected bilateral pes planus. 9. The Veteran's service-connected hypertension requires the regular use of prescribed medications with a history of increased blood pressure readings; symptoms did not more nearly approximate predominant diastolic blood pressure of 100 or more, or a predominant systolic blood pressure of 160 or more. 10. The Veteran's right knee scar is linear, but has not been shown to be painful, unstable, or productive of limited motion. 11. The Veteran's left knee scars are linear, but have not been shown to be painful, unstable, or productive of limited motion. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for cervical strain initial ratings of 20 percent prior to March 27, 2018 and 30 percent thereafter, but no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. 2. The criteria for a rating in excess of 20 percent for service-connected status post lumbar strain with DDD and spondylosis L5-S1, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, DC 5242. 3. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent rating, but no higher, from May 27, 2015 for right forearm injury with laceration repair with peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8513, 8514, 8515. 4. Resolving reasonable doubt in the Veteran's favor, the criteria for a rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.71a, DC 5257. 5. Resolving reasonable doubt in the Veteran’s favor, the criteria for an initial 20 percent rating, but no higher, for lateral collateral ligament sprain, right ankle have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, DC 5271. 6. The criteria for rating in excess of 30 percent for bilateral pes planus are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.71a, DC 5276. 7. Resolving reasonable doubt in the Veteran’s favor, the criteria for a separate 10 percent rating for right foot Morton’s neuroma as associated with bilateral pes planus are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.71a, DC 5279. 8. The criteria for an initial compensable disability rating for service-connected hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.104, DC 7101. 9. The criteria for an initial compensable disability rating for a right knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.118, DCs 7801-7805. 10. The criteria for an initial compensable disability rating for left knee scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.118, DCs 7801-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1980 to July 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2016 and February 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2016, the Veteran appointed the private attorney listed on the title page as his representative. The Board recognizes this change in representation. The issue of a higher initial rating for cervical strain was developed separately and was not certified for appeal. However, the timely June 2018 substantive appeal indicated the Veteran wanted to appeal all issues listed on the statement of the case (SOC) and specifically referenced the April 2018 SOC. It did not reference the May 2018 SOC for the cervical strain disability. In October 2018 correspondence, the representative clarified that the Veteran wanted the June 2018 substantive appeal to encompass the May 2018 SOC for cervical strain. Given this background, the Board accepts jurisdiction for the issue of a higher initial rating for cervical strain. See Percy v. Shinseki, 23 Vet. App. 37, 45 (2009); 38 C.F.R. § 20.200. The Board also notes that service connection for headaches was not adjudicated in the above rating decisions. The subsequent evidence raises the issue of a separate rating for headaches secondary to the service-connected cervical strain disability. See 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237, Note 1. The Board has added this issue to the appeal. It is addressed in the Remand section. Additional private medical records, VA treatment records and an updated VA right ankle examination report have been received since the April 2018 and May 2018 SOCs. For the private medical records, the automatic waiver provision of 38 U.S.C. § 7105(e) applies. See 38 U.S.C. § 7105(e) (providing for initial review by the Board "if the claimant or the claimant's representative . . . submits evidence"). For the VA treatment records, the updated records are either cumulative of previously considered evidence or not relevant to the claims decided in the instant decision. 38 C.F.R. § 20.1304(c). Then, the instant decision awards the maximum schedular rating for right ankle motion loss and the November 2018 VA ankle examination is cumulative of previous evidence. Id. The Veteran is not prejudiced by consideration of the newly received evidence. I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. In this case, these claims originate from an August 2015 Fully Developed Claim (FDC) filed on VA Form 21-526EZ. The notice attached to the FDC claims form satisfies the duty to notify. Neither the Veteran, nor his attorney representative have identified any notification deficiency and none has been identified by the Board. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). For the duty to assist, VA obtained identified and available evidence needed to substantiate the claims. For his service-connected disabilities, he was furnished VA examinations for his bilateral pes planus, left knee disability, scars, lumbar spine and right arm peripheral neuropathy in December 2015. He received updated VA examinations for service-connected hypertension in December 2016, cervical spine in March 2018, and right ankle disability in November 2018. He has not asserted a material change in severity in any service-connected disability since the most recent VA examinations and additional examination is not warranted. The Board notes that the representative’s October 2016 objection that the VA orthopedic examinations did not adequate consider functional impairment. However, his assertion is generalized and does not identify any specific deficiency for this particular case. To the extent any portion of the orthopedic VA examinations are not totally complaint with the most recent holding regarding the adequacy of VA orthopedic examinations, the instant decision results in an award of the maximum schedular rating on the basis of motion loss for the right ankle and higher ratings for the lumbar and cervical spine. For the back disability and neck disability prior to March 27, 2018, the Veteran has demonstrated range of motion (ROM) significantly greater than next higher rating criteria and additional motion loss was not found upon repetitive ROM testing. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of 38 C.F.R. § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The Veteran’s flare-up or repetitive use reports concern generalized joint pain as opposed to significant, additional motion loss from that recorded upon examination. Notably, for the back, the VA examiner specifically estimated motion loss during flare-ups. For his neck disability, the Veteran indicated a worsening occurred following the January 2016 VA examination and this report implies that he had less functional impairment in the past. The record does not include any indication that any passive motion or comparison studies would assist in the substantiation any of these claims. Passive movement (i.e. assisted motion) would inherently reflect greater mobility than active movement. The Veteran does not identify any specific problem with passive motion or assert a comparison study is needed for any claimed joint. For the above reasons, the Board concludes that a remand for additional notice or development would result in additional delay without any benefit flowing to the Veteran. Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) ("[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant"); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott in the duty to assist context). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of his claims. II. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). For ratings based upon limitation of motion of the affected joint, the Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that 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 (38 C.F.R. § 4.40), as well as 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 (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to a higher initial rating for cervical strain, currently rated as 10 percent disabling The Veteran has a 10 percent initial rating for service-connected cervical strain under DC 5237. 38 C.F.R. § 4.71a, DC 5237. DC 5237 provides ratings pursuant to the General Rating Formula for General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). Briefly, the Board notes alternative rating under DC 5243 for Intervertebral Disc Syndrome (IVDS). 38 C.F.R. § 4.71a, DC 5243. However, the evidence does not indicate that the Veteran has IVDS of the cervical spine. To the extent he reports incapacitating episodes at the March 2018 VA examination, he has not detailed a severity that would result in more beneficial application of this alternative rating criteria and further discussion of it is not warranted. The General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, provides the ratings for cervical spine disability. A 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. Id. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. Id. Note 2 provides that normal forward flexion, extension, and left and right lateral flexion of the cervical spine are all zero to 45 degrees and left and right lateral rotation of the cervical spine are both zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. July 2015 private chiropractic records showed that the Veteran complained of mid to low back discomfort from travelling. Palpation revealed areas of spasm, hypomobility and end point tenderness at C2 and C5, among other areas. The chiropractor included a cervical spine range of motion (ROM) report. He listed cervical flexion and extension to 45 degrees, right and left lateral flexion to 45 degrees and right and left rotation to 80 degrees. In January 2016, the Veteran was afforded a VA-contract examination for this claim. The examiner diagnosed cervical strain. She indicated the Veteran had flare-ups and functional loss, but could not describe them. Cervical spine range of motion (ROM) forward flexion was to 40 degrees, right lateral flexion was to 40 degrees, and left lateral rotation was to 45 degrees. Extension, left lateral flexion and right lateral flexion had normal motion. Pain was noted for forward flexion, extension and right lateral flexion, but did not cause additional functional loss. Tenderness of the midline lower cervical spine was observed. Repetitive use did not cause further motion loss. The examiner declined to estimate additional motion loss during repeated use over time or during flare-ups. She cited the absence of objective evidence to make such a finding. Localized tenderness was noted, but did not result in abnormal gait or spinal contour. Muscle strength and reflexes were normal. Right upper extremity sensation was decreased in forearm and hand/fingers. The examiner attributed the sensory disturbance to separate arm injury. Radiculopathy was not reported. The examiner noted the Veteran missed approximately two days of work due to chiropractic care. She noted that he worked in a relatively sedentary job. In the October 2016 NOD, the representative noted reports of headaches and left arm pain that were associated with cervical strain. He requested separate ratings for these disabilities. In March 2018, the Veteran had another VA-contract examination. The examiner diagnosed cervical strain. The Veteran reported having intermittent neck pain that had worsened in the past 18 months. He sought chiropractic care. The pain caused frequent headaches. He had occasional tingling in his left hand and fingers during the past 18 months. Although he had an unrelated right arm injury, he also noticed additional tingling and numbness in his right lower arm and hand as well. The examiner summarized the current symptoms as intermittent 5-8/10 neck pain with tingling of hands and headaches with blurry vision. For flare-ups, the Veteran described excruciating neck pain with headaches that required bed rest. These episodes happened once or twice a month and lasted for two days. The Veteran described functional impairment as limitations with neck mobility and headaches that required rest. He was limited in his ability to perform yard work and exercise. Cervical spine ROM showed that flexion and extension were to 30 degrees. Right and left lateral flexion was to 20 degrees. Right lateral rotation was to 30 degrees. Left lateral rotation was to 50 degrees. Pain was noted with forward flexion and extension. Tenderness was noted at C2-3 and listed as a 5-6/10 severity. Repetitive use testing did not show additional motion loss. The examiner declined to estimate motion loss during repeated use over time or flare-ups due an inability to observe the Veteran. Muscle spasm and guarding was noted, but not deemed to result in an abnormal gait or spinal contour. Muscle strength and reflexes were normal. Moderate sensory impairment of both upper extremities was noted. The examiner assessed mild bilateral radiculopathy. She noted occupational impairment of travel difficulties. The Veteran worked as a logistic management specialist for the Navy and had lost one to two weeks of work over the past twelve months. Based upon the above, the Board resolves reasonable doubt to find the Veteran’s cervical strain more nearly approximates the 20 percent rating criteria prior to March 16, 2018 and the 30 percent criteria thereafter. 38 C.F.R. § 4.71a, DC 5237. Prior to March 16, 2018, the ROM study is limited to the January 2016 VA-contract examination report. It confirmed cervical flexion to 40 degrees with pain. On its face, this report does not more nearly approximate the 20 percent cervical strain criteria. However, the examiner noted flare-ups and functional loss but declined to describe them. In the subsequent examination, the Veteran specified reported limited neck mobility as a functional impairment that interfered with activity. The ROM from the January 2016 VA examination for cervical flexion is not far from the listed 30 degrees cervical flexion for the next higher 20 percent rating criteria. Thompson, 815 F.3d at 785; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5237. Based on the limited evidence, it would reasonable to infer additional degrees of cervical spine motion loss with repetitive use or activity. The Board acknowledges that it cannot be stated with certainty as to the precise limitation of motion experienced from repetitive use. However, the record is reasonably clear that the Veteran had flare-ups and functional loss in January 2016 with likely additional motion loss during repetitive activity. See English v. Wilkie, No. 17-2083 (Vet. App. Nov. 1, 2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); Id. To account for additional motion loss during periods of activity, flare-ups and the like, the Board grants a 20 percent rating for estimated motion loss based upon the available evidence. From March 16, 2018, the evidence showed the cervical strain disability more nearly approximated the 30 percent rating criteria. 38 C.F.R. § 4.71a, DC 5237. The Veteran had another VA-contract examination on this date. It included the first report of increased neck disability and showed cervical flexion decreased to 30 degrees. The Veteran specifically reported having limitation with neck mobility during activities such as yard work and exercise. He also described incapacitating episodes of neck pain. Again, the Board acknowledges that it cannot be stated with certainty as to the precise limitation of motion experienced during activity. However, the record is reasonably clear that the Veteran had developed increased flare-ups and functional loss by March 2018 with additional motion loss as compared to January 2016. To account for additional motion loss during periods of during periods of activity, flare-ups and the like, the Board grants a 30 percent rating from March 16, 2018 for estimated motion loss based upon the available evidence. The Board finds that a rating in excess of 30 percent for cervical strain is not warranted. 38 C.F.R. § 4.71a, DC 5237. As noted above, an initial rating in excess of 30 percent for cervical strain contemplates ankylosis. There is no evidence suggesting ankylosis of the cervical spine. Moreover, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited functional loss regulations are not for application. See id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). An initial cervical spine disability rating greater than 30 percent under 38 C.F.R. § 4.71a, DC 5270 is not for further consideration. Id. The Board notes that associated neurological manifestations are to be considered. 38 C.F.R. § 4.71a, DC 5242, Note 1. Associated neurological manifestations for the upper extremities are raised by the record. However, the procedural background in this case includes April 2018 separate rating awards for bilateral upper extremity peripheral neuropathy. The Veteran has not specifically disputed these initial ratings and they are not before the Board. The issue of a separate rating for headaches as raised by the representative in the October 2016 NOD is addressed in the Remand section. For the foregoing reasons, an initial 20 percent rating prior to March 27, 2018 and 30 percent thereafter, but no higher, is granted for cervical spine strain. As the preponderance of the evidence is against higher initial ratings than the ones granted above, the benefit of the doubt doctrine is not for application and the claim for higher initial ratings than the ones assigned herein must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to increased rating for status post lumbar strain with degenerative disc disease (DDD) and spondylosis L5-S1, rated as 20 percent disabling The Veteran has a 20 percent rating for service-connected status post lumbar strain with DDD and spondylosis under DC 5242. 38 C.F.R. § 4.71a, DC 5242. As noted above, DC 5242 provides ratings pursuant to the General Rating Formula. The record does not raise the issue of incapacitating episodes due to lumbar spine IVDS. Further discussion of this alternative rating criteria is not warranted. Under the General Rating Formula for lumbar spine disability, such disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. As relevant, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, DC 5242. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). Any associated neurological abnormalities are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a. July 2015 private chiropractor records showed that the complained about low back discomfort associated with frequent travel. Lumbar ROM study showed a full flexion motion. In December 2015, the Veteran had a VA-contract examination. The examiner maintained the established diagnosis. The Veteran reported the disability had worsened. He described flare-ups as low back pain and shooting pain down the legs. He described functional impairment as caution with any weights and bending activity. Lumbar spine ROM showed forward flexion to 85 degrees. No pain was found. The examiner noted mild tenderness to palpation (ttp) over the lower lumbar spine and paraspinal muscles. Repetitive motion did not cause additional loss. The examiner did not find additional functional impairment from repeated use over time. As to flare-ups, the examiner estimated that pain would limit forward flexion to 50 degrees. She listed additional factors contributing to disability as disturbance of locomotion, interference with sitting and interference with standing. Lower extremity muscle strength was complete, but reflexes were diminished bilaterally. Sensory findings were normal bilaterally. Radiculopathy was not found. The examiner noted that the Veteran was unable to work during flare-ups. In his October 2016 NOD, the representative reported that the Veteran recently visited the emergency room on two occasions due to back pain. April 2017 private chiropractor records showed that the Veteran complained about increased low back pain following yard work and from bending this morning. He reported 5/10 pain. ROM showed lumbar spine forward flexion to 90 degrees. May 2018 private chiropractor records showed that the Veteran continued to have chronic low back pain, but experienced improvements with chiropractic adjustments. ROM showed lumbar spine forward flexion to 80 degrees. Upon review, the Board finds that a rating in excess of 20 percent for lumbar spine strain with DDD is not warranted. 38 C.F.R. § 4.71a, DC 5242. The medical and lay statements do not indicate that the flare-ups are so severe as to more nearly approximate the 40 percent rating criteria. The December 2015 VA examination report included motion loss estimated during flare-ups. This estimate does not more nearly approximate the next higher 40 percent rating criteria. Sharp, 29 Vet. App. at 33; Thompson, 815 F.3d at 785; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5242. The Veteran does not contend the estimates are inaccurate. Then, the private chiropractor ROM studies from April 2017 and May 2018 weigh against additional lumbar spine motion loss. The Veteran does not otherwise specifically identify motion loss during flare-ups or repetitive suggestive of lumbar spine ROM flexion to 30 degrees or less. Id. For these reasons, even considering functional impairment, a rating in excess of 20 percent is denied. Id. For the foregoing reasons, a rating in excess of 20 percent for lumbar spine strain with DDD is denied. As the preponderance of the evidence is against higher ratings, the benefit of the doubt doctrine is not for application and the claim for an increased rating for lumbar strain with DDD must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative have raised any other issues with the above rating, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to an increased rating for right forearm injury with laceration repair with peripheral neuropathy and radiculopathy of the right upper extremity The Veteran is service-connected for this right upper extremity disability with a 10 percent rating prior to March 27, 2018 and 20 percent rating thereafter pursuant to 38 C.F.R. § 4.71a, DC 8513-8515. In the April 2018 rating decision, the RO assigned a 20 percent rating based on a determination of moderate incomplete paralysis of the median nerve under DC 8515 and a 20 percent rating for mild incomplete paralysis based upon right upper extremity radiculopathy of the major extremity under DC 8513. It interpreted these ratings as encompassing the same symptoms and assigned a single 20 percent rating. 38 C.F.R. § 4.14. Under DC 8513, for paralysis of all radicular groups, a 20 percent rating is assigned for mild incomplete paralysis of the minor and major upper extremity. A 30 percent rating is assigned for moderate incomplete paralysis of the minor upper extremity and a 40 percent rating is assigned for moderate incomplete paralysis of the major upper extremity. A 60 percent rating is warranted for severe incomplete paralysis of the minor upper extremity and a 70 percent rating is warranted for severe incomplete paralysis of the major upper extremity. Complete paralysis is rated 80 percent for the minor upper extremity and 90 percent for the major upper extremity. 38 C.F.R. § 4.124a, DC 8513. Under DC 8515, for paralysis of the median nerve, 10 percent rating is warranted for mild incomplete paralysis of the median nerve, a 30 percent rating is warranted for moderate incomplete paralysis of the major side and 20 percent of the minor side, a 50 percent rating is warranted for severe incomplete paralysis of the major side and 40 percent of the minor side, and a 70 percent rating is warranted for complete paralysis of the major side and 60 percent of the minor side. 38 C.F.R. § 4.124a, DC 8515. In addition, DC 8514 applies to paralysis of the radial nerve. For the minor (non-dominant) extremity, 20, 20, and 40 percent ratings are warranted for mild, moderate, or severe incomplete paralysis. For the major (dominant) extremity, 20, 30, and 50 percent ratings are warranted for mild, moderate, or severe incomplete paralysis. A 60 percent rating for the minor extremity and a 70 percent rating for the major extremity is warranted for complete paralysis of the radial nerve. 38 C.F.R. § 4.124a, DC 8514. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. See 38 C.F.R. § 4.69. Here, as the evidence shows that the Veteran is either right arm dominant or ambidextrous; his right arm is his dominant extremity for rating purposes. Words such as "severe," "moderate," and "mild" are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. In applying the schedular criteria for rating peripheral nerve conditions, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. The note preceding § 4.124a provides that when the involvement is wholly sensory, the rating should be for the mild or, at most, the moderate degree. In Miller v. Shulkin, 28 Vet. App. 376, the United States Court of Appeals for Veterans Claims (Court) interpreted the note preceding § 4.124a as providing for "a maximum disability rating for wholly sensory manifestations of incomplete paralysis of a peripheral nerve." The Court further added that the "note contains no mention of non-sensory manifestations," and "decline[d] to read into the regulation a corresponding minimum disability rating for non-sensory manifestations." Id. Turning to the evidence, the Veteran had a December 2015 VA neurology examination. The examiner diagnosed right forearm injury with laceration repair and peripheral neuropathy. The Veteran reported periodic worsening symptoms when the nerve knot was bumped or from pressure carrying an object with shooting pain forcing him to drop the object. He also reported a weak hand grip. He was right hand dominant. No peripheral nerve symptoms were found. Muscle strength testing was normal. Right upper extremity reflexes were diminished. Decreased sensation was found for right inner/outer forearm. The examiner assessed mild incomplete paralysis of the radial nerve. In the October 2016 NOD, the representative noted the Veteran’s reports that excess tissue in his hand caused extreme pain with certain activities. The Veteran had difficulties with lifting and grabbing activities. In March 2018, the Veteran was afforded a VA-contract examination for his cervical strain disability. As relevant, the Veteran reported having more upper right extremity tingling and numbness. The Veteran reported being ambidextrous. Pertinent clinical findings showed full strength for the right upper extremity. Reflexes were normal. Light touch sensation was decreased for the right hands and fingers. The examiner assessed moderate paresthesias and/or dysesthesias and numbness for the right upper extremity. She assessed mild cervical radiculopathy. For the following reasons, the Board finds that a 20 percent initial rating from May 27, 2015, the date of the service connection claim, for the service-connected right upper extremity disability is warranted. 38 C.F.R. §§ 3.400, 4.124a, DC 8514. A rating in excess of 20 percent is not warranted. 38 C.F.R. § 4.124a. The December 2015 VA examination included an assessment of mild incomplete paralysis of the right upper extremity radial nerve. This report clearly satisfies the criteria for a 20 percent rating under DC 8514. 38 C.F.R. §§ 3.400, 4.124a, DC 8514. Although the RO has not provided a rating under DC 8514, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). The facts in this case warrant the DC change from DC 8513-8515 to DC 8514 from May 27, 2015 to maximize available benefits. The Board also finds that the evidence does not show right upper extremity neurological disturbances more nearly approximating the criteria for a rating in excess of 20 percent under DCs 8513, 8514, or 8515. 38 C.F.R. §§ 4.1-4.10, 4.124a, DCs 8513, 8514, 8515. The evidence primarily suggests right upper extremity numbness and weakness, which do not more nearly approximate those of at least the moderate degree. There was no atrophy or loss of motor strength from clinical observation. Diminished reflexes were noted in December 2016, but not in the March 2018 clinical evaluation. Sensory disturbances did not suggest unusual impairment of the affected area or affected a larger area in the nerve distribution. Given this background, the Board finds the evidence does not more nearly approximate moderate partial paralysis for any right upper extremity nerve. Id.; 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.124a, DCs 8513, 8514, 8515. In sum, a 20 percent rating for right upper extremity forearm injury with laceration repair with peripheral neuropathy is warranted from May 27, 2015. 38 C.F.R. § 3.400. The preponderance of the evidence is against the claim for a rating in excess of 20 percent in all other respects, and the benefit of the doubt doctrine is therefore not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative have raised any other issues with the above rating, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 4. Entitlement to an increased rating for instability of the left knee, current rated as 10 percent disabling. The Veteran is service connected for left knee instability with a 10 percent rating pursuant to 38 C.F.R. § 4.71a, DC 5257. DC 5257 provides a 10 percent rating for slight impairment, a 20 percent rating is warranted for moderate impairment, and a 30 percent rating is warranted for severe impairment. 38 C.F.R. § 4.71a, DC 5257. The Veteran had a VA-contract examination for this claim in December 2015. The examiner diagnosed status post left knee injury with arthroscopic surgery and anterior ligament reconstructive surgery with degenerative arthritis. The examiner noted a history of knee instability. As relevant, left knee joint stability testing was normal. In the October 2016 NOD, the representative requested a higher evaluation. He noted the Veteran was service-connected for his right, but the left knee was more symptomatic. Upon review, the evidence does not more nearly approximate findings for moderate left knee instability. 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5257. The Veteran has not provided any details as to the nature, frequency and severity of his left knee instability. The reports and clinical findings from the December 2015 VA left knee examination do not more nearly approximate the next higher 20 percent rating under DC 5257 for moderate impairment. Id. For the foregoing reasons, a rating in excess of 10 percent for left knee instability is denied. As the preponderance of the evidence is against an increased rating, the benefit of the doubt doctrine is not for application and the claim for an increased rating for left knee instability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative have raised any other issues with the above rating, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to an initial rating in excess of 10 percent for lateral collateral ligament sprain, right ankle The Veteran's service-connected lateral collateral ligament sprain, right ankle is currently rated as 10 percent disabling, exclusive of a temporary total rating, under 38 C.F.R. § 4.71a, DC 5271, for limitation of motion of the ankle. The medical and lay evidence does not suggest the service-connected right ankle sprain has manifested in the malunion or ankylosis of any right lower extremity joint and additional DCs 5262, 5270, 5272 or 5283 are not for further consideration. 38 C.F.R. § 4.71a, DCs 5262, 5270, 5272, 5283. Under DC 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum, 20 percent rating is warranted for marked limited motion of the ankle. Normal range of motion of the ankle includes dorsiflexion from zero to 20 degrees, and plantar flexion from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. The terms "marked" and "moderate" are not defined in DC 5271, and the question of whether a particular degree of disability is moderate or marked is ultimately a legal rather than a medical one. 38 C.F.R. § 3.100(a) (delegating the Secretary's authority "to make findings and decisions . . . as to the entitlement of claimants to benefits" to, inter alia, VA "adjudicative personnel"); 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination . . . so that the current rating may accurately reflect the elements of disability present’). In December 2015, the Veteran was afforded a right ankle examination. The examiner diagnosed right lateral collateral ligament sprain. Currently, the Veteran reported swelling and increased pain in his right ankle that flared-up when walking. The examiner noted flare-ups as swelling and pain that impacted walking and ability to perform some physical activity. During flare-ups, the Veteran limited physical activity. He elevated his right leg and used to medication to control the swelling and pain. Range of motion (ROM) of the right ankle dorsiflexion was to 10 degrees and plantar flexion was to 35 degrees, both without pain. There was mild tenderness to palpation and crepitus. Repetitive ROM testing did not cause further motion loss. The examiner identified functional impairment for the right ankle as pain. He estimated right ankle repeated use over time ROM as dorsiflexion to 5 degrees and plantar flexion to 20 degrees. Additional factors contributing to disability were swelling, disturbance of locomotion and interference with standing. Muscle strength was normal. Ankylosis was not found. Stability or dislocation was suspected. The examiner noted that the Veteran occasionally used a brace with activity to manage right ankle pain. In October 2016, the representative asserted that there was a bone fragment in the joint that interfered with its function. October 2017 private medical records showed that the Veteran sought treatment for bilateral foot and ankle pain. It had gradually developed over time and was of a 4/10 severity. It was aggravated by routine activity. The Veteran tried to treat it with an ankle brace and shoe inserts. X-rays confirmed arthritic changes at the ankles. Orthopedic examination showed full muscle strength and ROM for the right ankle. November 2017 private medical records showed that the Veteran experienced extreme right ankle swelling after moving sideways while mowing grass on a hill. Clinical evaluation revealed an edematous and mildly erythematous right ankle joint, both medial and lateral. The right ankle was mildly tender. There was minimal pain on the medial deltoid ligament. The clinician assessed ankle sprain. She ordered a magnetic resonance imaging study based upon the reported sensation of something moving inside the ankle joint. December 2017 private medical records included an assessment of lateral right ankle instability and osteochondral defect. In March 2018, the Veteran underwent private surgery for lateral ankle instability and osteochondral defect of the right ankle. No surgical complications were noted. As noted, the Veteran had a November 2018 VA right ankle examination as part of a subsequent temporary total rating based upon convalescence claim. The findings from this report are substantially similar to previous clinical findings. For the following reasons, the Board finds that the evidence is evenly balanced as to whether the service-connected lateral collateral ligament sprain, right ankle more nearly approximated marked motion loss. 38 C.F.R. § 4.71a, DC 5271. The December 2015 VA examination report showed that the Veteran had right ankle dorsiflexion to 10 degrees without pain. However, the examiner estimated that with repeated use over time right ankle dorsiflexion would be to 5 degrees. See English v. Wilkie, No. 17-2083 (Vet. App. Nov. 1, 2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. §§ 4.40, 4.45, 4.59. Although the Veteran did not specifically describe motion loss during flare-ups or repetitive use, he reported swelling and pain that interfered with activity. He is competent to report additional impairment during flare-ups or repetitive use and the Board considers his report credible. Jandreau v. Nicholson, 492 F.3d 1372, 1376, n. 4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). Thus, the evidence from December 2015 indicates right ankle disability that more nearly approximates marked right ankle plantar flexion. As noted above, an initial rating in excess of 20 percent for ankle disability contemplates ankylosis. There is no evidence suggesting ankylosis of the right ankle. As noted in Johnston, 10 Vet. App. at 85, the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. See id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). An initial right ankle disability rating greater than 20 percent under 38 C.F.R. § 4.71a, DC 5270 is not for further consideration. Id. For the above stated reasons, the Board finds that the Veteran's service-connected lateral collateral ligament sprain, right ankle warrants an initial 20 percent rating, but no higher, from the date of the service connection claim. As the preponderance of the evidence is against a higher initial rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor prior representative has raised any other issues with the above rating, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 6. Entitlement to an increased rating for bilateral pes planus, currently rated as 30 percent disabling and a separate rating right foot Morton’s neuroma as associated with bilateral pes planus The Veteran is in receipt of a 30 percent rating for bilateral pes planus pursuant to DC 5276. 38 C.F.R. § 4.71a, DC 5276. Under DC 5276, a 30 percent rating is assigned for pes planus with severe symptomatology, objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities is rated 30 percent for both feet. The maximum schedular rating of 50 percent is assigned for pes planus with pronounced symptomatology shown by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances affecting both feet. Id. Also for consideration is DC 5279 for Metatarsalgia, anterior (Morton’s disease) that provides a maximum 10 percent rating. 38 C.F.R. § 4.71a, DC 5279. In December 2015, the Veteran was afforded a VA podiatry examination. The examiner listed bilateral pes planus with a history of plantar warts as the diagnosis. He also identified Morton’s neuroma of the right foot as an associated condition. He identified bilateral pes planus with hind foot valgus with a history of plantar warts. The Veteran reported having pain in both feet and occasional burning gout type sensations. These symptoms were also described as occurring during flare-ups. Clinical examination showed the Veteran to have bilateral foot pain on use and accentuated on use. In addition, the examiner noted bilateral foot pain on manipulation and accentuated by manipulation. There was no swelling or characteristic calluses. The examiner noted arch support use that did not relieve symptoms in either foot. Extreme tenderness of the plantar surface was not found for either foot. Decreased longitudinal arch height was found for both feet. Objective evidence of marked deformity and marked pronation were noted for both feet. The weight-bearing line feel over or medial to the great toe bilaterally. Inward bowing of the Achilles’ tendon was noted for both feet, however marked inward displacement and severe spasm of the Achilles’ tendon was not found. The examiner found right foot Morton’s neuroma. He reported that the bilateral foot pain caused instability of station. He further described pain and instability in both feet during flare-ups. He noted that the Veteran used a right ankle brace with activity. He described the occupational impact as of pain with walking and standing for long periods of time. In his October 2016, the representative asserted that the Veteran had pronounced bilateral pes planus. The Veteran reported flare-ups of foot pain in the mornings and had to manage severe bilateral foot pain to complete daily activities. For the following reasons, the Board finds that a rating in excess of 30 percent for service-connected bilateral pes planus is not warranted. However, a separate 10 percent rating for Morton’s neuroma of the right foot is granted. As to an increased rating for pes planus, the weight of the evidence does not show symptoms more nearly approximating the 50 percent rating criteria under DC 5276. A 50 percent rating for bilateral pes planus requires pronounced symptomatology contemplated as marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. The December 2015 VA examination report did not show extreme tenderness of the plantar surface, marked inward displacement and severe spasm of the Achilles tendon on manipulation for either foot. It showed marked pronation and indicated that these symptoms were not relieved by arch supports. The Board observes that the description of pronounced flatfoot symptoms of marked pronation, extreme tenderness, marked inward displacement and severe spasm are listed in the conjunctive. 38 C.F.R. § 4.71a, DC 5276. The clinical findings from the December 2015 did not include most of the symptoms enumerated by the pronounced flat foot rating criteria. It does not otherwise indicate the presence of additional symptoms more nearly approximating the contemplated symptoms. As to functional impairment, the examiner described it as pain with walking and standing for long periods of time. The representative describes the Veteran has having severe bilateral foot pain with daily activities, particularly in the morning. The Board considers severe bilateral foot pain from these reports to be contemplated by the 30 percent rating criteria under DC 5276 and not more nearly approximating the 50 percent rating criteria for pronounced flat feet. Overall, the evidence does not suggest the Veteran’s bilateral pes planus more nearly approximates the pronounced disability contemplated by the 50 percent rating. Regarding Morton’s neuroma, the December 2015 VA examiner identified Morton’s neuroma of the right foot as a disorder associated with service-connected bilateral pes planus. The Board observes that Morton’s disease and Morton’s neuroma are akin to each other. https://medical-dictionary.thefreedictionary.com/Morton%27s+disease. Although not specified, it is reasonable to infer from the December 2015 VA examination report that the right foot Morton’s neuroma caused foot pain. Accordingly, the Boards find that a separate 10 percent rating is warranted for Morton’s neuroma of the right foot. 38 C.F.R. § 4.71a, DC 5279. For these reasons, the Board finds that a separate 10 percent rating is warranted for Morton’s neuroma of the right foot, but that a rating in excess of 30 percent for bilateral pes planus is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 7. Entitlement to an initial compensable rating for hypertension The Veteran's hypertension has been assigned a noncompensable percent rating under 38 C.F.R. § 4.104, DC 7101. Under that DC, a 10 percent evaluation is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent evaluation is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent evaluation is warranted where diastolic blood pressure is predominantly 130 or more. 38 C.F.R. § 4.104; see also McCarroll v. McDonald, 28 Vet. App. 267, 273 (2016) (ameliorative effects of medication are contemplated in the DC 7101 criteria). The Board finds that a compensable initial rating is not warranted. The December 2015 VA examination showed that the Veteran had hypertension manifesting in service and currently took medication. Blood pressure readings were listed as 140/88, 140/86 and 140/88. In October 2016, the representative reported that the Veteran took four different medications for hypertension and requested that his blood pressure readings be considered for a higher evaluation. In December 2016, the Veteran had another VA hypertension examination. The examiner confirmed a hypertension diagnosis and noted the three medications used for treatment. Blood pressure readings were reported as 140/92, 144/98 and 148/96. VA treatment records and private chiropractic records included blood pressure readings that did not suggest the presence of diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. Notably, the blood pressure readings from April 2017 and May 2018 private medical records were 120/80 and 110/88, respectively. The Veteran has not provided any lay report specifically asserting an increase in disability or higher blood pressure readings than reflected in the available medical records. For the foregoing reasons, the preponderance of the evidence is against an initial compensable disability rating for hypertension. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 8. Entitlement to an initial compensable rating for scar, status post right knee reconstructive surgery and scars, status post left knee arthroscopic surgery The Veteran is service-connected for right and left knee postoperative scars with noncompensable initial ratings under 38 C.F.R. § 4.118, DC 7805. As a preliminary matter, the Board notes that the scars are located on the Veteran’s knees and are linear. As such, DC 7800 (scars of the head, face, or neck), DC 7801 and 7802 are not applicable. 38 C.F.R. § 4.118, DC 7800-7802. Under DC 7805, scars, including linear scars, and other effects of scars, are to be evaluated under DC 7800-7802 and 7804. In addition, any disabling effect(s) not considered in a rating provided under DC 7800-7804 is to be evaluated under an appropriate diagnostic code. Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. In December 2015, the Veteran was afforded a VA scar examination. The examiner assessed multiple scars, bilateral knees status post surgery. He noted reports of pain associated with a right forearm scar. None of the scars were unstable. For the right knee, the examiner reported a 9 cm linear scar. For the left knee, the examiner reported separate 7 cm and 2 cm linear scars. He reported that the scars did not result in limitation of function. In October 2016, the representative asserted a compensable rating was warranted since the Veteran reported numbness associated with these scars. There is no evidence that the Veteran's linear postoperative scars for either knee are painful or unstable. At best, the representative asserts the Veteran’s reported numbness associated with these scars. The Veteran does not otherwise provide any detail as to the numbness or otherwise assert pain is present for either postoperative knee scar. Hence, this assertion of numbness is vague and does not suggest functional impairment to more nearly approximate the painful criteria for a compensable rating under DC 7804. He does not detail any limitation of function for a rating under DC 7805. Overall, the weight of the evidence is against a finding that any knee scar more nearly approximates a compensable rating. 38 C.F.R. § 4.118, DCs 7804-7805. Therefore, the Board finds that a compensable rating for any right and left knee scars under the applicable diagnostic codes is not warranted. There is no reasonable doubt to be resolved as to these issues, and these claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND Entitlement to service connection for sleep apnea is remanded. An additional medical opinion as to the etiology of the Veteran’s sleep apnea is needed. While the Veteran and other lay observers are competent to report his weight gain, snoring and fatigue in service, the issue of a military nexus in this case is complex. The complex medical issue designation for the nexus is appropriate because sleep apnea was initially diagnosed over a decade after service and there are numerous possible causes. Thus, the Veteran and other lay reporters are not competent to provide nexus reports regarding sleep apnea in this particular case. Jandreau, 492 F.3d at 1376, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). The competent medical evidence regarding direct service connection is limited to the March 2018 medical opinion by a VA contract examiner. However, this medical opinion is inadequate for adjudication purposes as it did not fully address the lay reports and contentions. The March 2018 VA contract examiner only specifically considered lay reports of snoring in service and mainly relied on an absence of complaints in service treatment records to reject a nexus. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In this case, the Veteran was diagnosed with severe sleep apnea in 2014, which implies it may have existed for some time. Then, the Veteran asserted he had additional symptoms of daytime fatigue, hypertension and weight gain in military service that may be associated with sleep apnea. (See May 2015 and January 2016 lay statements; October 2016 representative statement; March 2016 Mayo Clinic medical article). Thus, the rationale supporting the March 2018 VA contract medical opinion is not responsive to the facts in this particular case. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An additional medical opinion as to the etiology of the sleep apnea that considers the lay reports of daytime fatigue, weight gain and associated hypertension and characterization of sleep apnea as severe upon its initial diagnosis in 2014. Entitlement to a separate rating for headaches as associated with service-connected cervical strain. The Veteran asserts he has headaches attributable to his service-connected cervical strain. The applicable disability rating criteria contemplate associated objective neurologic abnormalities as potentially separately ratable disabilities. See 38 C.F.R. § 4.71a, DC 5237, Note 1. Given the medical complexity of this issue, a medical opinion is needed. Jandreau, supra. The matter is REMANDED for the following action: 1. Contact an appropriate clinician for a sleep apnea medical opinion. The electronic claims file and a copy of this Remand must be made available to and reviewed by the examiner. A clinical evaluation is only required if the examiner deems one necessary. The examiner is directed to answer the following question: Is it at least as likely as not that sleep apnea is related to reported in-service weight gain, snoring, fatigue or associated with the development of elevated blood pressure in service? The examiner is advised that the Veteran and other lay observers are competent to report his loud snoring, fatigue, weight gain and history, and such reports must be specifically acknowledged and considered in formulating any opinions. (See May 2015 reports from the Veteran’s wife and K.W.; December 2015 reports from G.H.; October 2016 reports of military weight gain). If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The examiner must also address the “severe” characterization of the Veteran’s sleep apnea in September 2014 and the Mayo Clinic medical article received in October 2016 that identified hypertension as a complication of sleep apnea. All opinions expressed must be accompanied by a complete rationale with specific consideration of the lay reports and medical evidence suggesting a nexus. 2. Schedule the Veteran for a VA examination to determine the etiology of his headaches. The entire electronic claims file must be reviewed by the examiner in conjunction with the examination. The examiner is requested to opine as to the following: (a) Is it at least as likely as not (i.e., 50 percent or greater probability) that headaches are an objective neurologic abnormality associated with the service-connected cervical strain? A complete rationale for all opinions should be provided. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. D. Simpson, Counsel