Citation Nr: 18157856 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 16-27 762 DATE: December 14, 2018 ORDER Entitlement to a disability rating higher than 10 percent for tinnitus is denied. The Board having determined a separate 10 percent rating is warranted for hypertension throughout the period of the claim, the benefit sought on appeal is granted to this extent, subject to the criteria applicable to the payment of monetary benefits. Entitlement to a rating higher than 60 percent for kidney disease is denied. Entitlement to a compensable rating for bilateral foot scars is denied. Entitlement to an effective date earlier than May 8, 2008, for the award of service connection for hypertension, is denied. Entitlement to an effective date earlier than May 8, 2008, for the award of service connection for kidney disease, is denied. Entitlement to a temporary total disability rating for a bilateral foot disability is denied. REMANDED Entitlement to a disability rating higher than 30 percent for bilateral pes planus and hallux valgus is remanded. Entitlement to service connection for a lower back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right foot disability other than pes planus or hallux valgus is remanded. Entitlement to service connection for a left foot disability other than pes planus or hallux valgus is remanded. Entitlement to service connection for an eye disability, claimed as blurred vision and/or “a blow to the right eye,” is remanded. Entitlement to service connection for bilateral lower extremity scars is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran is in receipt of a 10 percent rating for tinnitus, which is the maximum allowable rating under VA regulations. 2. Throughout the period of the claim, the Veteran has had hypertension with diastolic pressure of predominantly 100 or more; he has not had diastolic pressure of predominantly 110 or more or systolic pressure of predominantly 200 or more. 3. Throughout the period of the claim, the Veteran’s chronic kidney disease has caused renal dysfunction with definite decrease in kidney function; it has not caused persistent edema and albuminuria with BUN 40 to 80mg%, or creatinine 4 to 8mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion; it has not required regular dialysis or precluded more than sedentary activity from one of the following: persistent edema and albuminuria, or BUN more than 80mg%, or creatinine more than 8mg%, or markedly decreased function of kidney or other organ systems, especially cardiovascular. 4. The Veteran’s post-bunionectomy foot scars have not been unstable or painful; they do not have a total area of 39 square centimeters or greater. 5. Following expiration of the appeal period for a May 2004 denial of the Veteran’s claim for service connection for hypertension, VA did not receive any claim for service connection for hypertension prior to May 8, 2008. 6. VA did not receive any claim for service connection for kidney disease prior to May 8, 2008. 7. The Veteran’s October 2003 surgery for ingrown toenails was unrelated to any service-connected condition. CONCLUSIONS OF LAW 1. There is no legal basis for the assignment a rating higher than 10 percent for tinnitus; thus, the criteria for a rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §1155 (2012); 38 C.F.R. § 4.87, Diagnostic Code (DC) 6260 (2017). 2. Throughout the period of the claim, the criteria for a separate 10 percent rating, but not higher, for hypertension, have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.104, DC 7101 (2017). 3. The criteria for a rating higher than 60 percent for chronic kidney disease have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.115a (2017). 4. The criteria for a compensable rating for post-bunionectomy foot scars have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, DCs 7801, 7802, and 7804 (2017). 5. The criteria for entitlement to an effective date prior to May 8, 2008, for the grant of service connection for hypertension, have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.400, 3.816 (2017). 6. The criteria for entitlement to an effective date prior to May 8, 2008, for the grant of service connection for kidney disease, have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.400, 3.816 (2017). 7. The criteria for a temporary total rating for a period of convalescence following October 2003 ingrown toenail surgery have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.30 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty in the United States Army from June 1974 to June 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of rating decisions issued by the Department of Veterans Affairs (VA) Regional Offices (ROs). In this case, the Board has issued decisions and/or remands affecting various of the Veteran’s claims (listed in the ORDER and REMANDED sections above) in July 1987, May 1991, November 1992, January 1998, March 2011, and August 2012. The Veteran’s claims have now been returned to the Board for further appellate consideration. In a November 2012 rating decision, the RO granted service connection for hypertension and a kidney disorder, and assigned an effective date of November 28, 2008, for the awards of service connection. The Veteran subsequently perfected an appeal of the effective date assigned. During the pendency of the appeal, in an April 2016 decision, the RO changed the effective dates to May 8, 2008. The Veteran has not indicated he is satisfied with the effective dates assigned, and, as such, the issues remain on appeal. The Veteran’s claims for service connection for a lower back, bilateral knee, and bilateral ankle disabilities were denied in an October 2010 rating decision on the basis that the conditions were unrelated to service. The October 2010 decision became final because the Veteran did not submit a Notice of Disagreement or new evidence in connection with the claim within the appeal period. See 38 C.F.R. § 3.156(b) (2017). Subsequently, the Veteran asserted his lower back, bilateral knee, and bilateral ankle disabilities were secondary to his service-connected bilateral foot disability. In a January 2017 correspondence, he indicated his bilateral foot disability had recently worsened. Under these circumstances, the Board finds that new and material evidence has been received sufficient to reopen the Veteran’s previously denied claims. See 38 C.F.R. § 3.156(a) (2017); Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010); Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran asserted a claim for service connection for an eye condition, to include “blurred vision,” in February 1983. He stated the condition was the result of an injury he received while playing basketball in service. The claim was denied in a March 1983 decision on the basis that no condition had been diagnosed. The March 1983 decision became final because the Veteran did not submit a Notice of Disagreement or new evidence in connection with the claim within the appeal period. See 38 C.F.R. § 3.156(b) (2017). Subsequently, the Veteran submitted a claim for service connection for a “blow to the right eye” in March 2013. The record shows the Veteran has continued to complain of light sensitivity. The Board observes that at the time of the March 1983 decision, the Veteran had not described his in-service injury as involving a blow to the eye. Under these circumstances, the Board finds that new and material evidence has been received sufficient to reopen the Veteran’s previously denied claim. See 38 C.F.R. § 3.156(a) (2017); Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010); Justus v. Principi, 3 Vet. App. 510, 513 (1992). General Legal Criteria Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2017). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Background and Analysis At the outset, the Board notes it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to the Veteran’s claims. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s claims. Increased rating for tinnitus In a February 1999 rating decision, the RO granted the Veteran’s claim for service connection for tinnitus, and assigned an initial 10 percent rating pursuant to 38 C.F.R. § 4.87, DC 6260. The Veteran filed a claim for an increased rating in October 2006, and the RO continued the 10 percent rating in an April 2007 decision. The RO again continued the 10 percent rating in an April 2016 decision. The Veteran ultimately perfected an appeal regarding this issue. According to VA regulations, a 10 percent evaluation is the maximum schedular rating allowed for tinnitus. 38 C.F.R. § 4.87, DC 6260. Thus, the Veteran’s service-connected tinnitus has already been assigned the maximum schedular rating available. Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). As there is no legal basis upon which to award a higher schedular evaluation, the appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Increased rating for foot scars The record shows the Veteran underwent right and left bunionectomies for his service-connected hallux valgus in June 1983 and May 1984, respectively. He is service-connected for the scars associated with these surgeries. He is assigned a noncompensable rating for the scars. The Veteran’s scars may be rated under 38 C.F.R. § 4.118, DCs 7801, 7802, or 7804. Under DC 7801, compensation may be warranted for scars associated with underlying soft tissue damage. Specifically, a 10 percent rating is warranted for scars with an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). A 20 percent rating is warranted for scars with an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating is warranted for scars with an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating is warranted for scars with an area or areas of 144 square inches (929 sq. cm.) or greater. Under DC 7802, a 10 percent rating is warranted for scars that are not associated with underlying soft tissue damage, where the scars have an area or areas of 144 square inches (929 sq. cm.) or greater. Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. The Veteran was afforded VA examinations in October 2013 and October 2015. Both examiners indicated the Veteran’s post-bunionectomy scars were not painful or unstable. Both examiners indicated the scars did not have a total area of 39 square centimeters or greater. The Board has thoroughly reviewed the entire record, to include all post-service treatment notes. There is no evidence showing the Veteran’s post-bunionectomy scars are unstable or painful, or that they have a total area of at least 39 square centimeters. Accordingly, the Board finds a compensable rating for the Veteran’s bilateral post-bunionectomy scars is not warranted. Increased ratings for hypertension and kidney disease By way of background, service connection for hypertension and kidney disease was granted in an August 2012 Board decision. In a November 2012 rating decision implementing the Board’s decision, the RO assigned a 10 percent initial rating for the Veteran’s hypertension, and a 60 percent initial rating for his kidney disease. As explained above, both awards have been assigned an effective date of May 8, 2008. In April 2016, the RO assigned a single 60 percent rating for the Veteran’s hypertension and kidney disease. It is unclear why the RO combined the Veteran’s ratings. Regarding the Veteran’s hypertension, the Board notes that under 38 C.F.R. § 4.104, DC 7101, a 10 percent rating is warranted for hypertension with diastolic pressure predominantly 100 or more; or systolic pressure predominantly 160 or more; or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more; or systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A 60 percent rating is warranted for diastolic pressure predominantly 130 or more. A review of the Veteran’s VA outpatient treatment records shows that between November 2008 and September 2012, the following blood pressure readings were taken: 138/80, 135/74, 152/91, 157/102, 160/93, 147/90, 143/88, 160/92, 128/88, 138/89, 152/92, 138/88, 152/99, 159/98, 139/97, 124/76, 138/89, 127/86, 121/75, 142/88, 155/89, and 147/90. The Veteran was afforded a VA examination in October 2013. Blood pressure readings were 166/104, 156/111, and 158/99. The examiner indicated the Veteran’s treatment plan included taking continuous medication. Based on the foregoing, and having resolved reasonable doubt in favor of the Veteran, the Board finds the Veteran has diastolic pressure predominantly of 100 or more. In addition, the foregoing shows that the Veteran’s hypertension has required continuous medication for control. Again, it unclear why the RO has combined the Veteran’s hypertension rating with his rating for kidney disease. The Board finds a separate 10 percent rating for the Veteran’s hypertension is warranted throughout the period of the claim. A review of the foregoing, and of the entire record, however, does not show the Veteran’s diastolic pressure has been predominantly 110 or more or that his systolic pressure has been predominantly 200 or more at any time during the period of the claim. Accordingly, the Board finds a rating higher than 10 percent for hypertension is not warranted. Regarding the Veteran’s kidney disease, the Board notes that under 38 C.F.R. § 4.115a, a 60 percent rating is warranted for renal dysfunction with constant albuminuria with some edema; or with definite decrease in kidney function; or with hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is warranted for renal dysfunction with persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. The record shows the Veteran was diagnosed with chronic kidney disease at least as early as December 2006. He was afforded a VA examination in October 2015. The examiner indicated the Veteran had renal dysfunction with recurring proteinuria and transient edema. The Board observes that in its November 2012 rating decision, the RO assigned a 60 percent initial rating for the Veteran’s kidney disease based on its finding that the record showed a definite decrease in kidney function. The Board does not disagree with this finding, or that the record supports assignment of a 60 percent rating for the Veteran’s kidney disease. However, the Board has thoroughly reviewed the record, and observes the evidence does not show persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The record does not show renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. For the foregoing reasons, the Board finds a rating higher than 60 percent for the Veteran’s kidney disease is not warranted. Earlier effective date for the award of service connection for hypertension and/or a kidney condition Generally, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2017). The Veteran’s claims for service connection for hypertension was denied in a May 2004 rating decision. The Veteran filed a claim for service connection for kidney problems which was received by VA on May 8, 2008. The claim was denied in a November 2008 rating decision. The Veteran filed a claim to reopen his claim for service connection for hypertension in November 2008. As noted above, the Board granted service connection for hypertension and kidney disease in an August 2012 decision. The RO implemented the decision in November 2012 and assigned a November 2008 effective date for service connection for both conditions. In an April 2016 decision, the RO changed the effective dates to May 8, 2008, the date the Veteran filed his initial claim for service connection for kidney problems. Upon a thorough review, the record does not show the Veteran filed any correspondence, after the initial denial of his claim for service connection for hypertension in May 2004, which could be construed as a formal or informal claim for service connection for hypertension, prior to May 8, 2008. In addition, the record does not show the Veteran filed any correspondence which could be construed as a formal or informal claim for service connection for kidney disease prior to May 8, 2008. See 38 C.F.R. § 3.155(a) (as in effect prior to March 24, 2015) (defining an informal claim as “[a]ny communication or action, indicating an intention to apply for one or more benefits.... Such informal claim must identify the benefit sought”); Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009) (the essential elements of a claim are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing”); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed.Cir.2006) (holding that the plain language of the regulations requires a claimant to have an intent to file a claim for VA benefits); Rodriguez v. West, 189 F.3d 1351, 1354 (Fed.Cir.1999) (noting that even an informal claim must be in writing). Based on the foregoing, the Board finds effective dates prior to May 8, 2008, for the awards of service connection for hypertension and kidney disease, are not warranted. Temporary total rating for bilateral foot disability The record shows the Veteran underwent right and left bunionectomies for his service-connected hallux valgus in July 1983 and May 1984, respectively. He was awarded temporary total ratings for convalescence following these surgeries for the periods from June 3, 1983, to July 31, 1983, and May 25, 1984, to July 31, 1984, respectively. In May 2004, the Veteran filed a claim for a temporary total rating for “an operation [he] had on [his] feet [on] October 2, 2003.” The record shows the Veteran underwent a procedure to remove portions of ingrown toenails of the right and left great toes on October 2, 2003. In a May 2004 decision, the RO denied the Veteran’s claim, noting the procedure in question was unrelated to the Veteran’s service-connected pes planus and hallux valgus. In March 2013, the Veteran filed a claim for a temporary total rating for surgery on his right and left big toes. A thorough review of the record does not show the Veteran has undergone any surgeries for his service-connected pes planus or hallux valgus subsequent to the procedures performed in 1983 and 1984. In addition, the Board notes the Veteran has not contended that his ingrown toenails, the condition for which his October 2003 surgery was performed, have any relation to his service-connected foot conditions. There is no medical evidence in the record associating the conditions. In sum, because the October 2003 surgery which forms the basis of the Veteran’s claim for a temporary total rating was not performed in relation to any service-connected condition, the claim must be denied. See 38 C.F.R. § 4.30 (“Total ratings will be assigned under this section” for treatment of “a service-connected disability. . . .”) (Emphasis added). REMAND The Board finds additional development is required before the Veteran’s remaining claims are decided. The Board initially notes that VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease, or injury is a low threshold. McLendon, 20 Vet. App. at 83. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Furthermore, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). In addition, where the evidence indicates that a service-connected disability has worsened since the last VA examination, and that examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2017); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Regarding the Veteran’s claim for an increased rating for his service-connected bilateral pes planus and hallux valgus, the Veteran was last afforded a VA examination to address the severity of these conditions in October 2015, more than three years ago. In a January 2017 correspondence, the Veteran indicated his bilateral pes planus and hallux valgus had worsened since the October 2015 examination. Under these circumstances, the Board finds a remand is warranted for a VA examination to assess the current severity of the Veteran’s service-connected bilateral foot disability. Regarding the Veteran’s claims for service connection for lower back, bilateral knee, and bilateral ankle disabilities, the Veteran has contended these conditions were caused by or have been aggravated by his service-connected bilateral foot disability. The Veteran was afforded ankle, knee, and back examinations in October 2013, and additional examinations in October 2015, to address these contentions. Ultimately, the VA examiners opined that the Veteran’s lower back, bilateral knee, and bilateral ankle disabilities were unrelated to his service-connected bilateral foot disability. Upon review, the examiners’ opinions were supported primarily by findings that the severity of the Veteran’s pes planus was relatively minor. As noted above, however, the Veteran has contended his bilateral foot symptoms have worsened since October 2015. Under these circumstances, the Board finds a remand is warranted for additional VA examinations to determine whether the Veteran’s lower back, bilateral knee, and bilateral ankle disabilities are causally related to his service-connected bilateral foot disability. Regarding the Veteran’s claim for service connection for a bilateral foot disability other than pes planus and hallux valgus, the Board notes that in a January 2014 rating decision, the RO denied service connection for bilateral talipes valgus. The Veteran perfected an appeal of the decision and the claim has been certified to the Board. Upon review, the record shows the Veteran has been diagnosed with conditions related to his feet other than pes planus and hallux valgus, such as plantar fasciitis and arthritis. VA examination reports of record, however, do not include any opinion as to whether the Veteran’s non-service-connected foot conditions are etiologically related to his service-connected pes planus and hallux valgus. Under these circumstances, the Board finds that a remand is warranted for a VA examination. Regarding his claim for service connection for an eye disability, variously claimed as blurred vision and/or a “blow to the right eye,” the Veteran has contended he has experienced blurred vision since he suffered an injury involving a blow to the eye while playing basketball during service. To date, the Veteran has not been afforded a VA examination to address this contention. Under these circumstances, the Board finds the low threshold contemplated in McLendon has been satisfied such that a remand is warranted for a VA examination. Regarding the Veteran’s claim for service connection for bilateral lower extremity scars, the record is unclear as to the facts underlying these claims. It appears likely that the Veteran’s claimed lower extremity scars are related to his bilateral knee conditions, to include left knee surgery performed in 1987. Accordingly, the Board finds these claims must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The Veteran has asserted entitlement to a TDIU. Because entitlement to a TDIU is contingent on the disposition of the service connection claims being remanded, the Board finds the claim for a TDIU must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Afford the Veteran a VA examination to determine the current severity of his service-connected bilateral pes planus and hallux valgus. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. The examiner should also identify all right and/or left foot disabilities other than pes planus and hallux valgus that have been present during the period of the claim, to include plantar fasciitis and arthritis. If the examiner determines no foot disability other than pes planus and hallux valgus has been present during the period of the claim, he or she should provide a medical explanation in support of his or her finding. Then, with respect to each identified right and/or left foot disability other than pes planus and hallux valgus, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected bilateral pes planus and/or hallux valgus. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of each identified right and/or left foot disability other than pes planus and hallux valgus found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected pes planus and/or hallux valgus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Afford the Veteran a VA examination to determine the nature and etiology of his lower back disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all lower back disabilities present during the period of the claim. Then, with respect to each identified lower back disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. If not, the examiner should state, with respect to each identified lower back disability, whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected bilateral pes planus and/or hallux valgus. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s lower back disability found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected pes planus and/or hallux valgus. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Afford the Veteran a VA examination to determine the nature and etiology of his right and/or left knee disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all right and/or left knee disabilities present during the period of the claim. Then, with respect to each identified right and/or left knee disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. If not, the examiner should state, with respect to each identified right and/or left knee disability, whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected bilateral pes planus and/or hallux valgus. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s right and/or left knee disabilities found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected pes planus and/or hallux valgus. The examiner should also identify all scars associated with the Veteran’s right and/or left knee disabilities, and complete an examination report assessing the severity of any present scars. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Afford the Veteran a VA examination to determine the nature and etiology of his right and/or left ankle disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all right and/or left ankle disabilities present during the period of the claim. Then, with respect to each identified right and/or left ankle disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. If not, the examiner should state, with respect to each identified right and/or left ankle disability, whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s service-connected bilateral pes planus and/or hallux valgus. If aggravation is found, the examiner should provide an opinion, to the extent possible, as to: a) The baseline manifestations of the Veteran’s right and/or left ankle disabilities found prior to aggravation; and b) The increased manifestations which, in the examiner’s opinion, are proximately due to his service-connected pes planus and/or hallux valgus The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Afford the Veteran a VA examination to determine the nature and etiology of any eye disability present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all eye disabilities present during the period of the claim (claimed as blurred vision and/or “a blow to the right eye”). If the examiner determines no eye disability has been present during the period of the claim, he or she should provide a medical explanation in support of his or her finding. Then, with respect to each identified eye disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s contention that he has experienced blurred vision ever since he was injured while playing basketball during service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Undertake any other development determined to be warranted. 8. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel