Citation Nr: 1806685 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-36 277 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a gall bladder condition. 2. Entitlement to service connection for a bilateral knee disorder. 3. Entitlement to an initial compensable disability evaluation for bilateral hearing loss. 4. Entitlement to an initial increased disability evaluation for peripheral neuropathy, right upper extremity, rated as 20 percent disabling prior to November 18, 2013; 40 percent disabling from November 18, 2013 to July 7, 2016, and 10 percent thereafter. 5. Entitlement to an initial increased disability evaluation for peripheral neuropathy, left upper extremity, rated as 20 percent disabling prior to November 18, 2013; 30 percent disabling from November 18, 2013 to July 7, 2016, and 10 percent thereafter. 6. Entitlement to an initial increased disability evaluation for peripheral neuropathy, right lower extremity (posterior tibial, musculocutaneous, anterior tibial, and internal popliteal nerve), rated as 10 percent disabling prior to November 18, 2013; as 20 percent disabling from November 18, 2013 to July 7, 2016, and as noncompensable thereafter. 7. Entitlement to an initial increased disability evaluation for peripheral neuropathy, left lower extremity (anterior, crural, and internal saphenous nerve involvement), rated as 20 percent disabling prior to July 7, 2016, and as noncompensable thereafter. 8. Entitlement to an initial increased separate evaluation for peripheral neuropathy, right lower extremity (anterior, crural, and internal saphenous nerve involvement), rated as 20 percent disabling from November 18, 2013 to July 7, 2016, and as noncompensable thereafter. 9. Entitlement to an initial increased separate evaluation for peripheral neuropathy, left lower extremity (posterior tibial nerve involvement), rated as 10 percent disabling from July 7, 2016. 10. Entitlement to an initial separate evaluation in excess of 10 percent for peripheral neuropathy, right lower extremity (posterior tibial nerve involvement), rated as 10 percent disabling from July 7, 2016. 11. Entitlement to an initial separate compensable evaluation for peripheral neuropathy, left lower extremity (obturator nerve involvement), from November 18, 2013. 12. Entitlement to an initial separate compensable evaluation for peripheral neuropathy, right lower extremity (obturator nerve involvement), from November 18, 2013. 13. Entitlement to an initial separate evaluation in excess of 20 percent for peripheral neuropathy, left lower extremity (posterior tibial, musculocutaneous, anterior tibial, and internal popliteal nerve involvement), from November 18, 2013 to July 7, 2016, and a compensable evaluation thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from December 1959 to April 1977. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The matter was before the Board in February 2016, at which time it was remanded for further development. Following the requested development, the Appeals Management Center (AMC), acting on behalf of the RO, in an August 2016 rating determination, reevaluated the Veteran's peripheral neuropathy conditions of the left and right upper and lower extremities, resulting in different disability evaluations being assigned over the appeal period. The Board once again remanded this matter for further development in February 2017. Following the requested development, the AMC acting on behalf of the RO, in a September 2017 rating determination, increased the Veteran's evaluation of peripheral neuropathy, left upper extremity (previously evaluated under DC 8514), from 10 to 20 percent, effective July 7, 2016; the evaluation of peripheral neuropathy, right lower extremity (posterior tibial, musculocutaneous, anterior tibial, and internal popliteal nerves) [previously evaluated under DC 8524]), from noncompensable to 10 percent effective July 7, 2016, and increased the evaluation of peripheral neuropathy, left lower extremity (posterior tibial, musculocutaneous, anterior tibial, and internal popliteal nerve involvement) (previously rated under DC 8524), from noncompensable to 10 percent effective July 7, 2016. As a result of the AMC's actions, the Board has listed the issues as such on the title page of this decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2014). The issue of entitlement to service connection for a bilateral knee disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ) via the AMC. FINDINGS OF FACT 1. Any current gall bladder difficulties are unrelated to service. 2. The Veteran has been shown to have no worse than level II hearing in either ear. 3. For the time period from October 12, 2011, to November 17, 2013, the Veteran had mild incomplete paralysis of the right radial nerve; mild incomplete paralysis of the ulnar nerve, and mild incomplete paralysis of the median nerve; there were no other nerves noted to be involved for this time period. 4. For the time period from November 18, 2013, to July 6, 2016, the Veteran's right upper extremity neurological involvement was most akin to having severe incomplete paralysis of all radicular groups of the right upper extremity. 5. For the time period from July 7, 2016, the Veteran has been found to have mild incomplete paralysis of the median nerve of the right arm; normal findings for the radial (musculospiral nerve), musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves were found. 6. For the time period from October 12, 2011, to November 17, 2013 the Veteran had mild incomplete paralysis of the left radial nerve; mild incomplete paralysis of the left ulnar nerve, and mild incomplete paralysis of the left median nerve; there were no other nerves noted to be involved for this time period. 7. For the time period from November 18, 2013, to July 6, 2016, the Veteran's left upper extremity neurological impairment was akin to that of severe incomplete paralysis of all radicular groups. 8. For the time period from July 7, 2016, the Veteran has been found to have moderate incomplete paralysis of the median nerve of the left upper extremity; normal findings for the radial (musculospiral), musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves have been found. 9. For the left lower extremity, for the time period from October 12, 2011, to November 17, 2013, the Veteran was noted to have mild incomplete paralysis of the left sciatic nerve with normal findings for the femoral nerve (anterior crural nerve); there were no other nerves involved. 10. For the left lower extremity, for the time period from November 18, 2013 until July 6, 2016, normal findings for the left sciatic and external popliteal (common peroneal) nerves were reported; moderate incomplete paralysis for the musculocutaneous (superficial peroneal) nerve; moderate incomplete paralysis for the anterior tibial (deep peroneal) nerve, moderate incomplete paralysis for the internal popliteal (tibial) nerve; moderate incomplete paralysis for the posterior tibial nerve; moderate incomplete for the anterior crural (femoral) nerve; moderate incomplete paralysis for the internal saphenous and obturator nerves, and normal findings for the external cutaneous and ilioinguinal nerves, were present. 11. For the left lower extremity, from July 7, 2016, moderate incomplete paralysis was present for the posterior tibial nerve along with normal findings for the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal, anterior crural (femoral), internal saphenous, obturator, external cutaneous, and ilioinguinal nerves. 12. For the right lower extremity, for the time period from October 12, 2011, to November 17, 2013, the Veteran was noted to have mild incomplete paralysis of the sciatic nerve with normal findings for the femoral nerve (anterior crural nerve); there were no other nerves involved. 13. For the right lower extremity, for the time period from November 18, 2013 until July 6, 2016, there were normal findings for the sciatic and external popliteal (common peroneal) nerves; moderate incomplete paralysis of the musculocutaneous (superficial peroneal) nerve; moderate incomplete paralysis of the anterior tibial (deep peroneal) nerve, moderate incomplete paralysis of the internal popliteal (tibial) nerve; severe incomplete paralysis of the posterior tibial nerve; moderate incomplete of the anterior crural (femoral) nerve; moderate incomplete paralysis of the internal saphenous and obturator nerves, and normal findings for the external cutaneous and ilioinguinal nerves, were present. 14. For the right lower extremity, from July 7, 2016, moderate incomplete paralysis was present for the posterior tibial nerve along with normal findings for the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal, anterior crural (femoral), internal saphenous, obturator, external cutaneous, and ilioinguinal nerves. CONCLUSIONS OF LAW 1. The criteria for service connection for a gall bladder disorder are not met. 38 U.S.C.§§ 1101, 1110, 1131 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria for a compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.85, 4.86, Diagnostic Code (DC) 6100 (2017). 3. The criteria for a 20 percent disability evaluation, and no more, for mild incomplete paralysis of the right radial, ulnar, and median nerves of the right upper extremity from October 12, 2011, to November 17, 2013 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8511, 8512, 8513, 8514, 8515, 8516 (2017). 4. Resolving reasonable doubt in favor the Veteran, the criteria for a 70 percent disability evaluation for all radicular groups of the right upper extremity from November 18, 2013 to July 6, 2016, have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4,7, 4.123, 4.124(a), Diagnostic Codes 8510, 8511, 8512, 8513 (2017). 5. The criteria for a 10 percent disability evaluation for mild incomplete paralysis for the median nerve of the right upper extremity from July 7, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8515 (2017). 6. The criteria for a 20 percent disability evaluation, and no more, for mild incomplete paralysis of the radial, ulnar, and median nerves of the left upper extremity from October 12, 2011, to November 17, 2013 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code 8511, 8512, 8513, 8514, 8515, 8516 (2017). 7. Resolving reasonable doubt in favor of the Veteran, the criteria for a 60 percent disability evaluation for all radicular groups of the left upper extremity from November 18, 2013 to July 6, 2016, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4,7, 4.123, 4.124(a), Diagnostic Codes 8510, 8511, 8512, 8513 (2017). 8. The criteria for a 20 percent disability evaluation for moderate incomplete paralysis of the median nerve of the left upper extremity from July 7, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8515 (2017). 9. The criteria for a 10 percent disability evaluation, and no more, for mild incomplete paralysis for the sciatic nerve of the left lower extremity from October 12, 2011, to November 17, 2013 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). 10. The criteria for a 20 percent evaluation, and no more, for moderate incomplete paralysis of the musculocutaneous (superficial peroneal), internal popliteal (tibial), and anterior tibial (deep peroneal) nerves of the left lower extremity, from November 18, 2013 to July 6, 2016 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8522, 8523, 8524 (2017). 11. The criteria for a 20 percent evaluation, and no more, for moderate incomplete paralysis of the anterior crural (femoral) nerve and moderate incomplete paralysis of posterior tibial nerve of the left lower extremity from November 18, 2013 to July 6, 2016 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8525, 8526 (2017). 12. For the left lower extremity, the criteria for a compensable disability evaluation for neurological impairment of the internal saphenous and obturator nerves have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Codes 8527, 8528 (2017). 13. For the left lower extremity, the criteria for a 10 percent disability evaluation, and no more, for posterior tibial nerve impairment from July 7, 2016 have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Codes 8525 (2017). 14. For the right lower extremity, the criteria for a 10 percent disability evaluation, and no more, for mild incomplete paralysis for the sciatic nerve from October 12, 2011, to November 17, 2013, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). 15. The criteria for a 20 percent evaluation, and no more, for moderate incomplete paralysis of the musculocutaneous (superficial peroneal), the internal popliteal (tibial), and the anterior tibial (deep peroneal) nerves of the right lower extremity, from November 18, 2013, to July 6, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8522, 8523, 8524 (2017). 16. The criteria for a 20 percent evaluation, and no more, for moderate incomplete paralysis of the anterior crural (femoral) nerve and severe incomplete paralysis of posterior tibial nerve of the right lower extremity from November 18, 2013 to July 6, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8525, 8526 (2017). 17. For the right lower extremity, the criteria for a compensable disability evaluation for neurological impairment of the internal saphenous and obturator nerves have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Codes 8527, 8528 (2017). 18. For the right lower extremity, the criteria for a 10 percent disability evaluation, and no more, for neurological impairment of the posterior tibial nerve from July 7, 2016, have been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Codes 8525 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Other specifically enumerated disorders, including calculi of the gall bladder, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2017). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. A review of the Veteran's service treatment records reveals that he was seen with complaints of digestive discomfort. (The Board notes that service connection is currently in effect for GERD). A cholecystogram performed in March 1977 was normal, with no diagnosis of gall bladder disease being rendered at that time. There were no complaints or findings of gallbladder difficulties in the years immediately following service or for many decades thereafter. An ultrasound performed upon the Veteran in April 2010 revealed normal findings. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against the conclusion that any current gall bladder disorder had its onset in service. While the Board notes that the Veteran was treated for digestive difficulties in service, normal findings were reported on a March 1977 cholecystogram with no diagnosis of gall bladder disease being rendered at that time. There were also no findings of gall bladder difficulties in the years immediately following service. The Veteran has asserted that he has experienced gall bladder difficulties since service. Such recent assertions, however, are inconsistent with, and outweighed by, other lay and medical evidence of record, including the normal cholecystectomy findings in March 1977. The Veteran also did not report having gall bladder difficulties for many years following service, with normal gall bladder findings being reported on an April 2010 ultrasound. This contemporaneous evidence outweighs and is more probative than are his assertions voiced years later and in connection with a claim for disability benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (noting that contemporaneous evidence has greater probative value than history as reported by a veteran). See also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor to consider as evidence against a claim of service connection). For these reasons, the Board concludes that the assertions of gall bladder symptoms since service are not credible. The Veteran has related any current gall bladder difficulties to his active service. While the Veteran, as a lay person, is competent to describe observable symptoms such as pain and while lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, an opinion as to the etiology and onset of gall bladder disease falls outside the realm of common knowledge of a lay person. The Veteran's lay statements on the question of relating any current gall bladder trouble to service are not competent in the present case. See Davidson, 581 F.3d at 1316 (Fed. Cir. 2009); Kahana, 24 Vet. App. at 433, n. 4 (2011). Such diagnoses require clinical or diagnostic testing that the Veteran is not competent to address. Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. The Veteran was afforded the opportunity to provide competent medical evidence or a competent opinion relating his any current gall bladder difficulties to his period of service. He has not provided either medical evidence or an opinion to support that proposition.. In this case, any current gall bladder disease was not shown during active service or for many years thereafter, including no chronic symptoms during service, no manifestation to a compensable degree within one year of service separation, and no continuous post service symptoms. The weight of the competent evidence demonstrates that any current gall bladder disease was neither incurred in nor related to active service. For these reasons, the Board finds that service connection for a gall bladder disease is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Hearing Loss The Veteran has been assigned a noncompensable evaluation under Diagnostic Code 6100 for his service-connected bilateral hearing loss. He contends that the severity of his condition more closely reflects the severity required for a higher disability rating. The VA rating scheme for the evaluation of hearing loss provides ratings from noncompensable to 100 percent based on the results of controlled speech discrimination tests together with the results of puretone audiometry tests which average puretone thresholds at 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85 (2017). The evaluation of hearing impairment applies a formula which is essentially a mechanical application of the VA Schedule for Rating Disabilities to numeric designations after audiology evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85(a) (2017). Using Table VI in 38 C.F.R. § 4.85, the puretone average and speech recognition score are combined to give each ear a numeric designation for use on Table VII to determine the correct disability level. Alternatively, Table VIA uses only the puretone averages to give each ear a numeric designation. The regulations have two provisions for evaluating veterans with certain patterns of hearing impairment that cannot always be accurately assessed under § 4.85 because the speech discrimination test may not reflect the severity of communicative functioning that veterans experience. 38 C.F.R. § 4.86(a) provides that if puretone thresholds in the specified frequencies of 1000, 2000, 3000, and 4000 Hertz are each 55 decibels or more, an evaluation can be based either on Table VI or Table VIA, whichever results in a higher evaluation. This provision corrects the fact that with a 55-decibel threshold level (the level at which speech becomes essentially inaudible) the high level of amplification needed to attempt to conduct a speech discrimination test would be painful to most people, and speech discrimination tests may therefore not be possible or reliable. See 64 Fed. Reg. 25209 (May 11, 1999). Additionally, 38 C.F.R. § 4.86(b) provides that if the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, an evaluation can be based on either Table VI or Table VIA, whichever results in a higher numeric designation, and that designation will then be elevated to the next higher Roman numeral. This provision compensates for a pattern of hearing impairment that is an extreme handicap in the presence of any environmental noise, and a speech discrimination test conducted in a quiet room with amplification of sound does not always reflect the extent of impairment experienced in the ordinary environment. The Veteran has not been shown to have either of these exceptional patterns at any time. The Veteran has argued that his hearing loss is more severe than is reflected by his assigned evaluations. Although the Veteran is competent to attest to his observations and laypeople may, in some circumstances, opine on questions of diagnosis and etiology, in this case, the Veteran is not competent to diagnose himself with a particular level of hearing impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159(a)(1) (2017) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Specifically, while the Veteran is clearly competent to describe what he experiences (diminished hearing), he is unable to provide competent evidence as the audiometry or measured level of his hearing loss to support a higher disability rating. In conjunction with his claim, the Veteran was afforded a VA examination in January 2013. At the time of the examination, the Veteran reported that his hearing loss was getting worse. Audiological evaluation revealed pure tone thresholds, in decibels, as follows: right ear 10, 40, 85, and 90, and left ear 15, 45, 85, and 85, at 1000, 2000, 3000, and 4000 Hertz, respectively. Speech audiometry testing revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The examiner rendered diagnoses of bilateral sensorineural hearing loss. Using Table VI in 38 C.F.R. § 4.85, the Veteran's right ear corresponded with Level I hearing loss, the left ear corresponded with Level II hearing loss. These levels correspond with a noncompensable evaluation. In October 2014, the Veteran was fitted for hearing aids. In conjunction with the February 2016 Board decision, the Veteran was afforded an additional VA examination in July 2016. Audiological evaluation revealed pure tone thresholds, in decibels, as follows: right ear 10, 45, 80, and 95, and left ear 15, 55, 80, and 85, at 1000, 2000, 3000, and 4000 Hertz, respectively. Speech audiometry testing revealed speech recognition ability of 96 percent in the right ear and of 98 percent in the left ear. The examiner rendered a diagnosis of bilateral sensorineural hearing loss. The examiner indicated that the Veteran's hearing loss impacted the ordinary conditions of life, including his ability to work in that Veteran reported that he could not hear well in woman's voice range and that he could not hear well about 1/2 the time. Using Table VI in 38 C.F.R. § 4.85, the Veteran's right ear corresponded with Level II hearing loss, the left ear corresponded with Level II hearing loss. These levels correspond with a noncompensable evaluation. In sum, hearing was, at worst, level II in the right ear and level II in the left ear. A comparison between these hearing levels and 38 C.F.R. § 4.85, Table VII, yields a noncompensable evaluation, consistent with the currently assigned rating. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral the rating should include the application of the bilateral factor. 38 C.F.R. § 4.124a. A 20 percent evaluation is warranted for mild incomplete paralysis of the upper, middle, lower radicular groups, and all groups of the major and minor extremities. A 40 percent evaluation is warranted for moderate incomplete paralysis of the upper, middle, lower and all radicular groups of the major extremity, while a 30 percent evaluation is warranted for the minor extremity. A 50 percent evaluation is warranted for severe incomplete paralysis of the upper, middle lower, and all radicular groups of the major extremity, while a 40 percent evaluation is warranted for the minor extremity. A 70 percent evaluation is warranted for severe incomplete paralysis of the upper, middle lower, and all radicular groups of the major extremity, while a 60 percent evaluation is warranted for the minor extremity. 38 C.F.R.§ 4.124a, Diagnostic Codes 8510, 8511, 8512, 8513. Under 38 C.F.R. § 4.124a, DC 8514, mild incomplete paralysis of the musculospiral nerve (radial nerve) of either upper extremity, or moderate incomplete paralysis in the minor extremity warrants a 20 percent rating. A 30 percent rating is warranted for moderate incomplete paralysis of the radial nerve in the major extremity. Severe incomplete paralysis of the radial nerve in the minor extremity warrants a 40 percent rating, and the same in the major extremity warrants a 50 percent rating. Complete paralysis of the radial nerve in the minor extremity warrants a 60 percent rating, and such warrants a maximum 70 percent rating in the major extremity. Complete paralysis of the radial nerve contemplates symptoms such as drop of hand and fingers, perpetual flexion of the wrist and fingers, adduction of the thumb with the thumb falling within the line of the outer border of the index finger, an inability to extend the hand at the wrist, an inability to extend the proximal phalanges of the fingers, and inability to extend the thumb, and inability to move the wrist laterally, weakened supination of the hand, weakened extension and flexion of the elbow, and the loss of synergic motion of the extensors which seriously impairs the hand grip. (Total paralysis of the triceps occurs only as the greatest rarity). Under 38 C.F.R. § 4.124a, Diagnostic Code 8515, where there is complete paralysis of the median nerve with the major hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to palm; weakened wrist flexion; and pain with trophic disturbances; a 70 percent evaluation is warranted for the major extremity, while a 60 percent is warranted for the minor extremity. Incomplete, severe paralysis warrants assignment of a 50 percent evaluation for the major extremity and a 40 percent evaluation for the minor extremity. Incomplete, moderate paralysis warrants assignment of a 30 percent rating for a major extremity and a 20 percent evaluation for a minor extremity; and incomplete mild paralysis warrants assignment of a 10 percent evaluation for either upper extremity. Diagnostic Code 8615 pertains to neuritis and Diagnostic Code 8715 to neuralgia. Under 38 C.F.R. § 4.124a , Diagnostic Code 8516, complete paralysis, productive of the griffin claw deformity, due to flexor contraction of the ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences, loss of extension of ring and little fingers, cannot spread fingers (or reverse), cannot adduct thumb, flexion of wrist weakened, is evaluated as 60 percent disabling for the major extremity and 50 percent disabling for the minor extremity. Incomplete paralysis that is severe is evaluated as 40 percent disabling for the major extremity and 30 percent disabling for the minor extremity; moderate, as 30 percent disabling for the major extremity and 20 percent for the minor; and mild, as 10 percent disabling for either the major or minor extremity. The Note following 38 C.F.R. § 4.124a, DC 8719 indicates that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, to consider radicular group ratings. Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, which provides criteria for rating impairment of the sciatic nerve, a 10 percent evaluation is warranted for mild incomplete paralysis. A 20 percent rating requires moderate incomplete paralysis, and a 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. The next higher evaluation of 60 percent requires severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent evaluation requires complete paralysis of the sciatic nerve, in which the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. Paralysis of the musculotaneous nerve (superficial peroneal) nerve is rated under Diagnostic Code 8522, and paralysis of the anterior tibial nerve (deep peroneal) nerve is rated under Diagnostic Code 8523. When there is complete paralysis of either of these nerves, a 30 percent rating is assigned. When there is severe incomplete paralysis, then a 20 percent rating is assigned. When there is moderate incomplete paralysis, then a 10 percent rating is assigned. When there is mild incomplete paralysis, then a 0 percent rating is assigned. Paralysis of the superficial peroneal nerve is measured by whether eversion of the foot is weakened, and paralysis of the deep peroneal nerve is measured by whether dorsal flexion of the foot is lost. 38 C.F.R. § 4.124(a), Diagnostic Codes 8522-8523 (2017). 38 C.F.R. § 4.124a , DC 8524 addresses paralysis of the internal popliteal (tibial) nerve. Under DC 8524, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 30 percent rating is warranted for severe incomplete paralysis; and a 40 percent rating is warranted for complete paralysis resulting in loss of plantar flexion, frank adduction of the foot impossible, flexion and separation of toes abolished, no muscle in sole can move, and loss of plantar flexion in lesions of the nerve high in popliteal fossa. 38 C.F.R. § 4.124a, DC 8524. DC 8525 provides ratings based on paralysis of the posterior tibial nerve. The minimum 10 percent rating is warranted for incomplete mild paralysis. A 10 percent rating is warranted for moderate incomplete paralysis. A 20 percent rating is warranted for severe incomplete paralysis. The maximum 30 percent rating is warranted for complete paralysis of all muscles of the sole of the foot, frequently with painful paralysis of a causalgic nature; toes cannot be flexed; adduction is weakened; plantar flexion is impaired. 38 C.F.R. § 4.124a, DC 8525 (2016). 38 C.F.R. § 4.124a , Diagnostic Code 8526 provides the rating criteria for evaluation of paralysis of the anterior crural nerve (femoral). Under this provision, mild incomplete paralysis warrants a 10 percent disability evaluation; moderate incomplete paralysis warrants a 20 percent disability evaluation; and severe incomplete paralysis warrants a 30 percent disability evaluation. A 40 percent disability evaluation is warranted for complete paralysis of quadriceps extensor muscles. 38 C.F.R. § 4.124a, Diagnostic Code 8526. 38 C.F.R. § 4.124a, Diagnostic Code 8528 provides the rating criteria for evaluation of paralysis of the obturator nerve. Under this provision, mild or moderate paralysis warrants a 0 (zero) percent disability evaluation; and, severe to complete paralysis warrants a 10 percent disability evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8528. The Veterans Benefits Administration (VBA) has determined that there are 5 separate nerve branches in the lower extremities that may be separately rated. M21-1, III.iv.4.G.4.c. According to VBA, the sciatic nerve (DCs 8520, 8620 and 8720), the external popliteal nerve (common peroneal) (DCs 8521, 8621 and 8721), the musculotaneous nerve (DCs 8522, 8622 and 8722), the anterior tibial nerve (deep peroneal) (DCs 8523, 8623, 8723), the internal popliteal nerve (tibial) (DCs 8524, 8624, and 8724), and the posterior tibial nerve (DCs 8525, 8625, and 8725) affect the foot and leg sensory and motor function of the buttock, leg, knee, muscles below knee, lower leg, fibula, foot, muscles of the sole of the feet, plantar flexion, and toes. Id. M21-1, Part III, Subpart iv, 4.G.4.c. Assigning separate ratings from within these nerve branches is not warranted as it would constitute impermissible pyramiding. M21-1, III.iv.4.G.4.d. The anterior crural nerve (femoral) (DCs 8526, 8626, and 8726) and internal saphenous nerve (DCs 8527, 8627, and 8727) affect the thigh and leg sensory and motor function of the quadriceps muscle, front of thigh; medial calf; and medial malleolus. M21-1, Part III, Subpart iv, 4.G.4.c. These are part of a separate nerve group that may receive a separate evaluation from the sciatic nerve group. M21-1, III.iv.4.G.4.d. The obturator (DCs 8528, 8628, and 8728) affects the motor and sensory function of the hip and muscles of the hip; and medial thigh. The external cutaneous nerve of thigh (DCs 8529, 8629, and 8729) affects the sensory function of the lateral thigh. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability that are not duplicative or overlapping. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The Veteran maintains that the symptomatology associated with his upper and lower extremity neuropathy is worse than that which is contemplated by the currently assigned disability evaluations. In conjunction with his claim, the Veteran was afforded a VA examination in January 2013. At the time of the examination, the Veteran was diagnosed as having diabetic peripheral neuropathy of the upper and lower extremities. Physical examination revealed moderate paresthesias and/or dysthesia of the right and left upper extremities and moderate numbness of the upper extremities. Strength in the upper extremities was described as normal. Deep tendon reflexes were also normal. Light touch/monofilament testing revealed decreased sensation in the hands/fingers. Position sense was normal but vibration sensation was decreased in both upper extremities. Cold sensation was normal and there was no muscle atrophy. There were no trophic changes. The examiner indicated that the Veteran had mild incomplete paralysis of the radial (musculospiral nerve) for both upper extremities. Mild incomplete paralysis of the median nerve was noted for both upper extremities. Mild incomplete paralysis of the ulnar nerve was also noted for both upper extremities. The examiner indicated that the Veteran's diabetic neuropathy limited his ability to perform fine dexterity work. As to the lower extremities, the examiner indicated that the Veteran had mild paresthesias and/or dysthesia and numbness of both lower extremities. Neurological examination revealed normal strength. Deep tendon reflexes for the knee and ankle were normal. Light touch/monofilament testing was decreased for the feet and toes. Positon sensation, vibration sensation, and cold sensation were all normal. There was no muscle atrophy or trophic changes. The Veteran was noted to have mild incomplete paralysis of the right and left sciatic nerve. The femoral nerve (anterior crural nerve) was normal. In a November 2013 VA knee and lower leg questionnaire filled out by the Veteran's private physician, R. R., M.D., it was noted that the Veteran had severe constant pain, intermittent pain, paresthesias/dysthesia, and numbness of both upper extremities. Strength was 4/5 for elbow extension and elbow flexion; 3/5 for wrist extension and flexion; 2/5 for grip; and 1/5 for pinch for both upper extremities. Deep tendon reflexes were normal for both upper extremities. Light touch sensation was decreased for the hand/fingers. The Veteran had mild incomplete paralysis of the radial (musculospiral) nerve. Supination was impaired with weak grip/flexion, bilaterally. The median nerve was normal. There was moderate incomplete paralysis of the ulnar nerve. The Veteran could not spread his fingers. The musculoskeletal nerve was normal. The circumflex nerve revealed mild incomplete paralysis on the right with normal findings on the left. The long thoracic nerve revealed severe incomplete paralysis on the right and mild incomplete paralysis on the left. The examiner indicated that the Veteran had moderate incomplete paralysis of the upper radicular groups. Moderate incomplete paralysis was noted for the middle radicular group and severe incomplete paralysis was present for the lower radicular group. As to the lower extremities, the examiner indicated that the Veteran had moderate constant pain, moderate intermittent pain, moderate paresthesia/dysthesia, and moderate numbness. Strength was 2/5 for knee extension and ankle dorsiflexion and 3/5 for ankle plantar flexion. Reflex examination 3+ for the knee and 2+ for the ankle. Sensory examination was decreased for the upper anterior thigh, thigh/knee, and lower leg/ankle. It was absent for the foot/toes. The Veteran had loss of hair and smooth skin on the lower extremities. As to gait, the examiner indicated that the Veteran stepped on his heel and pivoted on his heels to turn. He would step on the lateral edges of his feet to feel the ground. He reported falling. As to the nerves, normal findings were reported for the sciatic and external popliteal (common peroneal) nerve. Moderate incomplete paralysis was noted for the musculocutaneous (superficial peroneal) nerve. Moderate incomplete paralysis was also noted for the anterior tibial (deep peroneal) nerve and the internal popliteal (tibial) nerve. Severe incomplete paralysis was reported for the posterior tibial on the right and moderate incomplete paralysis on the left. Moderate incomplete paralysis was present for the anterior crural (femoral) nerve on the right and left. Moderate incomplete paralysis was also present for the internal saphenous and obturator nerves on the right and left. Normal findings were reported for the external cutaneous and ilioinguinal nerves. In conjunction with the February 2016 Board remand, the Veteran was afforded a VA examination in July 2016. At the time of the examination, the Veteran was found to have no constant pain, intermittent pain, or paresthesia/dysthesia in either upper extremity. Mild numbness was noted to be present. 5/5 strength was noted for elbow flexion and extension, wrist flexion and extension, grip, and pinch. Reflexes were normal for the upper extremities. Sensory was decreased for the right shoulder area but was normal for the left and the forearms and hand/fingers. There were no trophic changes. Nerve testing revealed normal findings for the radial nerve (musculospiral nerve). As to the median nerve, there was mild incomplete paralysis on the right and moderate incomplete paralysis on the left. The musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves were all normal. As to the lower extremities, the Veteran was noted to have no constant pain, mild intermittent pain, moderate paresthesias/dysthesia, and mild numbness. Strength was 5/5 for knee extension, ankle plantar flexion and ankle dorsiflexion. There was no muscle atrophy. Reflex examination was normal for the knee and ankle. Sensory examination was normal for the upper anterior thigh and thigh/knee and was decreased for the lower leg/ankle, and absent for the foot/toes. There were no trophic changes. The Veteran had a normal gait. As to the lower extremity nerves, normal findings were reported for the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal) , anterior tibial (deep peroneal), internal popliteal, anterior crural (femoral), internal saphenous, obturator, and external cutaneous, and ilioinguinal nerves. The posterior tibial nerve revealed moderate incomplete paralysis. The examiner indicated that the Veteran was not significantly impaired with respect to his feet. His intact position sense, normal gait, cast some doubt on his concerns about not knowing where his feet were in space (which may be psychosomatic.) Right Upper Extremity At the outset, the Board notes that the Veteran is right hand dominant. As to the right upper extremity, the Board finds that the Veteran had mild incomplete paralysis of the right radial nerve at the time of the January 2013 VA examination, warranting a 20 percent disability evaluation under DC 8514. While mild incomplete paralysis of the ulnar nerve was also present and mild incomplete paralysis was also noted for the median nerve, which would warrant separate ratings of 10 percent if these were the sole nerves involved, such a combination would constitute pyramiding, which is not allowed. See DC 8719 which indicates that combined nerve injuries should be rated by reference to the major involvement, which in this case is the radial nerve. Moreover, as there was no more than mild involvement of any of the reported nerves, no more than a 20 percent rating would be warranted for all radicular groups under 8511, 8512, or 8513. There were no other nerves noted to be involved at that time. As such, no more than a 20 percent disability evaluation is warranted prior to November 18, 2013. At the time of the November 18, 2013 examination report prepared by the Veteran's private physician R. R., M.D., the Veteran was noted to have mild incomplete paralysis of the radial nerve. The median nerve was found to be normal. The circumflex nerve was noted to have mild neurological impairment. The ulnar nerve was noted to have moderate incomplete paralysis. The long thoracic nerve was found to have severe incomplete paralysis. Moderate incomplete paralysis was found in the upper and middle radicular groups, with severe incomplete paralysis being reported for the lower radicular groups. Resolving reasonable doubt in favor of the Veteran, the Board will find, based upon the above, that the Veteran had symptomatology akin to that of severe incomplete paralysis of all radicular groups as of November 18, 2013, warranting a 70 percent disability evaluation from November 18, 2013 to July 6, 2016. At the time of the Veteran's July 7, 2016 VA examination, normal findings for the radial nerve (musculospiral nerve), the musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves were reported. As to the median nerve, there was mild incomplete paralysis. Based upon these findings a 10 percent evaluation, and no more, is warranted for the median nerve under DC 8515, from July 7, 2016. Left Upper Extremity As to the left upper extremity, the Board finds that the Veteran had mild incomplete paralysis of the right radial nerve at the time of the January 2013 VA examination, warranting a 20 percent disability evaluation under DC 8514. While mild incomplete paralysis of the ulnar nerve was also present and mild incomplete paralysis was also noted for the median nerve, which would warrant separate ratings of 10 percent if these were the sole nerves involved, such a combination would constitute pyramiding, which is not allowed. See DC 8719 which indicates that combined nerve injuries should be rated by reference to the major involvement, which in this case is the radial nerve. Moreover, as there was no more than mild involvement of any of the reported nerves, no more than a 20 percent rating would be warranted for all radicular groups under 8511, 8512, or 8513. There were no other nerves noted to be involved at that time. As such, no more than a 20 percent disability evaluation is warranted prior to November 18, 2013. At the time of the November 18, 2013 examination report prepared by the Veteran's private physician R. R., M.D., the Veteran was noted to have mild incomplete paralysis of the radial nerve. The median nerve was found to be normal. The circumflex nerve was noted to have mild neurological impairment. The ulnar nerve was noted to have moderate incomplete paralysis. The long thoracic nerve was found to have severe incomplete paralysis. Moderate incomplete paralysis was found in the upper and middle radicular groups, with severe incomplete paralysis being reported for the lower radicular groups. Resolving reasonable doubt in favor of the Veteran, the Board will find, based upon the above, that the Veteran had symptomatology akin to that of severe incomplete paralysis of all radicular groups as of November 18, 2013, warranting a 60 percent disability evaluation from November 18, 2013 to July 6, 2016. At the time of the Veteran's July 7, 2016 VA examination, normal findings for the radial nerve (musculospiral nerve), the musculocutaneous, circumflex, long thoracic, upper radicular, middle radicular, and lower radicular nerves were reported. As to the median nerve, there was moderate incomplete paralysis. Based upon these findings a 20 percent evaluation, and no more, is warranted for the median nerve under DC 8515, from July 7, 2016. Left Lower Extremity As noted above, the Veteran was afforded a VA examination in conjunction with his claim in January 2013. At that time, the Veteran was noted to have mild incomplete paralysis of the left sciatic nerve warranting a 10 percent disability evaluation under DC 8520. The femoral nerve (anterior crural nerve) was normal. There were no other nerves reported to be involved. As such, prior to November 18, 2013, no more than a 10 percent disability evaluation was warranted. At the time of the Veteran's November 18, 2013 private examination, normal findings were reported for the sciatic and external popliteal (common peroneal) nerve, warranting noncompensable disability evaluations under DC 8520 and 8521 respectively. Moderate incomplete paralysis was noted for the musculocutaneous (superficial peroneal) nerve, the anterior tibial (deep peroneal) nerve, and the internal popliteal (tibial) nerve. However, as noted above, these nerves must be considered as one in order to avoid pyramiding. Thus, no more a 20 percent evaluation is warranted for these affected nerves. Moderate incomplete paralysis was reported for the posterior tibial and anterior crural (femoral) nerves warranting a 20 percent disability evaluation under DC 8525 or 8526; however, separate evaluations are not warranted as this would also constitute pyramiding. Moderate incomplete paralysis was also present for the internal saphenous and obturator nerves, warranting noncompensable disability evaluations. Normal findings were reported for the external cutaneous and ilioinguinal nerves. The above ratings were warranted from November 18, 2013 until July 7, 2016. At the time of the Veteran's July 7, 2016 VA examination, normal findings were reported for the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal, anterior crural, internal saphenous, obturator, external cutaneous, and ilioinguinal nerves, warranting noncompensable disability evaluations for these nerves, while severe incomplete paralysis was present for the posterior tibial nerve, warranting a 20 percent evaluation. Right Lower Extremity As noted above, the Veteran was afforded a VA examination in conjunction with his claim in January 2013. At that time, the Veteran was noted to have mild incomplete paralysis of the right sciatic nerve warranting a 10 percent disability evaluation under DC 8520. The femoral nerve (anterior crural nerve) was normal. There were no other nerves reported to be involved. As such, prior to November 18, 2013, no more than a 10 percent disability evaluation was warranted. At the time of the Veteran's November 18, 2013 private examination, normal findings were reported for the sciatic and external popliteal (common peroneal) nerve, warranting noncompensable disability evaluations under DC 8520 and 8521 respectively. Moderate incomplete paralysis was noted for the musculocutaneous (superficial peroneal) nerve; the anterior tibial deep peroneal) nerve; and the internal popliteal (tibial) nerve. However, as noted above, these nerves must be considered as one in order to avoid pyramiding. Thus, no more than a 20 percent evaluation is warranted for these affected nerves. Severe incomplete paralysis was reported for the posterior tibial nerve and moderate incomplete paralysis was present for the anterior crural (femoral) nerve warranting a 20 percent disability evaluation under DC 8525 or a 20 percent disability evaluation under DC 8526; however, as noted above, separate evaluations are not warranted as this would constitute pyramiding. Moderate incomplete paralysis was also present for the internal saphenous and obturator nerves, warranting noncompensable disability evaluations. Normal findings were reported for the external cutaneous and ilioinguinal nerves. The above ratings are warranted from November 18, 2013, until July 6, 2016. At the time of the Veteran's July 7, 2016 VA examination, normal findings were reported for the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal, anterior crural (femoral), internal saphenous, obturator, external cutaneous, and ilioinguinal nerves, warranting noncompensable disability evaluations for these nerves while moderate incomplete paralysis was present for the posterior tibial nerve, warranting a 20 percent evaluation. ORDER Service connection for a gall bladder disorder is denied. A compensable disability evaluation for bilateral hearing loss is denied. A 20 percent disability evaluation, and no more, for mild incomplete paralysis of the radial, ulnar, and median nerves of the right upper extremity from October 12, 2011, to November 17, 2013, is granted. A 70 percent disability evaluation for all radicular groups of the right upper extremity from November 18, 2013 to July 6, 2016, is granted. A 10 percent disability evaluation for mild incomplete paralysis of the median nerve of the right upper extremity from July 7, 2016, is granted. A 20 percent disability evaluation, and no more, for mild incomplete paralysis of the radial, ulnar, and median nerves of the left upper extremity from October 12, 2011, to November 17, 2013, is granted. A 60 percent disability evaluation for all radicular groups of the left upper extremity from November 18, 2013 to July 6, 2016, is granted. A 20 percent disability evaluation, and no more, for moderate incomplete paralysis of the left median nerve of the left upper extremity from July 7, 2016, is granted. A 10 percent disability evaluation, and no more, for mild incomplete paralysis of the sciatic nerve of the left lower extremity from October 12, 2011, to November 17, 2013, is granted. A 20 percent evaluation, and no more, for moderate incomplete paralysis of the musculocutaneous (superficial peroneal) nerve, the internal popliteal (tibial) nerve, and the anterior tibial (deep peroneal) nerve of the left lower extremity, from November 18, 2013 to July 6, 2016, is granted. A 20 percent evaluation, and no more, for moderate incomplete paralysis of the anterior crural (femoral) nerve and moderate incomplete paralysis of posterior tibial nerve of the left lower extremity from November 18, 2013 to July 6, 2016, is granted. For the left lower extremity, a compensable disability evaluation for neurological impairment of the internal saphenous and obturator nerves is denied. For the left lower extremity, a 10 percent disability evaluation, and no more, for posterior tibial nerve impairment from July 7, 2016, is granted. For the right lower extremity, a 10 percent disability evaluation, and no more, for mild incomplete paralysis of the sciatic nerve from October 12, 2011, to November 17, 2013, is granted. A 20 percent evaluation, and no more, for moderate incomplete paralysis of the musculocutaneous (superficial peroneal), internal popliteal (tibial); and anterior tibial (deep peroneal) nerves of the right lower extremity, from November 18, 2013 to July 6, 2016, is granted. A 20 percent evaluation, and no more, for moderate incomplete paralysis of the anterior crural (femoral) nerve and severe incomplete paralysis of posterior tibial nerve of the right lower extremity from November 18, 2013 to July 6, 2016, is granted. A compensable disability evaluation for neurological impairment of the internal saphenous and obturator nerves of the right lower extremity is denied. For the right lower extremity, a 10 percent disability evaluation, and no more, for neurological impairment of the posterior tibial nerve from July 7, 2016, is granted. REMAND As it relates to the claim of service connection for a bilateral knee disorder, the Board notes that subsequent to the Board's prior remand, the Veteran was afforded a VA examination which resulted in service connection being granted for specified trauma and stress related disorder (TSRD) , subclinical PTSD, and a 50 percent disability evaluation being assigned. Although an opinion was rendered as to whether the Veteran's current knee disorders were related to his service-connected disabilities in June 2107, service connection was not in effect for TRSD at that time. In his November 2017 written argument, the Veteran's representative noted that while the examiner referenced the Veteran's body habitus ("BMI 33.94, NIH Class I obesity") in explaining why the symmetric knee conditions were unlikely related to service, he failed to carry that particular point on to the discussion on whether a secondary relationship existed. The representative noted that the Veteran was service-connected for a mental health disability that included the manifestation of chronic sleep impairment, as shown in the various treatment records, the June 2017 psychiatric examination, and conceded in the rating decision, that established service connection and assigned an initial 50 percent rating for the condition. He observed that currently accepted medical principles indicated a causal, or aggravation, link between chronic sleep impairment and obesity. The representative stated that the fact that the record demonstrated the Veteran had a chronic sleep impairment associated with his service-connected condition; that the Veteran was obese; that medical treatise information linked chronic sleep impairment to obesity; and that the VA orthopedic examiner linked the obesity to the knee problems but failed to recognize the additional links between the obesity and the service-connected issues rendered the examination inadequate. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Given the representative's arguments and the fact that service connection was not in effect for TSRD when the examiner rendered the June 2017 opinion, additional development is warranted on the issue of service connection for a bilateral knee disorder. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. If available, return the claim folder to the examiner who rendered the June 2017 VA knee opinion. Following a review of the record the examiner is to render the following opinions: Is it at least as likely as not that the Veteran's current knee disorder is caused and/or aggravated by his TRSD? When rendering the opinion, the examiner must address the above noted November 2017 argument by the Veteran's representative that the record demonstrated the Veteran had chronic sleep impairment associated with his service-connected TSRD; that the Veteran was obese; that medical treatise information linked chronic sleep impairment to obesity; and that the VA orthopedic examiner linked the obesity to the knee problems. Detailed rationale is requested for any opinion that is rendered. 2. After the above has been completed, the RO must review the record and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the remaining issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs