Citation Nr: 19130992 Decision Date: 04/19/19 Archive Date: 04/19/19 DOCKET NO. 16-35 231A DATE: April 19, 2019 ORDER Entitlement to service connection for right shoulder disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for lumbar spine disability is denied. Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for dry throat is denied. Entitlement to an initial disability rating in excess of 10 percent prior to December 14, 2016 and in excess of 20 percent thereafter for service-connected cold weather residuals of the left foot is denied. Entitlement to an initial disability rating in excess of 10 percent prior to December 14, 2016 and in excess of 20 percent thereafter for service-connected cold weather residuals of the right foot is denied. Prior to December 14, 2016, entitlement to an initial disability rating of 20 percent, but no higher, for service-connected cold weather residuals in the left hand is granted. Since December 14, 2016, entitlement to an initial disability rating in excess of 30 percent for service-connected cold weather residuals in the left hand is denied. Prior to December 14, 2016, entitlement to an initial disability rating of 20 percent, but no higher, for service-connected cold weather residuals in the right hand is granted. Since December 14, 2016, entitlement to an initial disability rating in excess of 30 percent for service-connected cold weather residuals in the right hand is denied. Entitlement to an initial compensable disability rating prior to December 14, 2016 and in excess of 10 percent thereafter for service-connected hemorrhoids is denied. FINDINGS OF FACT 1. The most probative evidence of record establishes that the Veteran’s right shoulder disability is not etiologically related to his active duty service. 2. The most probative evidence of record establishes that the Veteran’s cervical spine disability is not etiologically related to his active duty service. 3. The most probative evidence of record establishes that the Veteran’s lumbar spine disability is not etiologically related to his active duty service. 4. The most probative evidence demonstrates that the Veteran’s bilateral pes planus was noted upon entry into active duty service and did not increase in severity during active duty service. 5. The most probative evidence of record establishes that the Veteran’s dry throat is not etiologically related to his active duty service. 6. Prior to December 14, 2016, the Veteran’s cold injury residuals of the left foot manifested as pain, numbness, and cold sensitivity. Since December 14, 2016, the Veteran’s cold injury residuals of the left foot have manifested as cold sensitivity, numbness, and locally impaired sensation. 7. Prior to December 14, 2016, the Veteran’s cold injury residuals of the right foot manifested as pain, numbness, and cold sensitivity. Since December 14, 2016, the Veteran’s cold injury residuals of the right foot have manifested as cold sensitivity, numbness, and locally impaired sensation. 8. Prior to December 14, 2016, the Veteran’s cold injury residuals of the left hand were manifested by pain, numbness, and cold sensitivity with x-ray abnormalities. Since December 14, 2016, the Veteran’s cold injury residuals of the left hand have manifested as cold sensitivity, color changes, and locally impaired sensation with x-ray abnormalities. 9. Prior to December 14, 2016, the Veteran’s cold injury residuals of the right hand were manifested by pain, numbness, and cold sensitivity with x-ray abnormalities. Since December 14, 2016, the Veteran’s cold injury residuals of the left hand have manifested as cold sensitivity, color changes, and locally impaired sensation with x-ray abnormalities. 10. Prior to December 14, 2016, the Veteran exhibited mild or moderate internal hemorrhoids. Since December 14, 2016, the Veteran has experienced large or thrombotic external hemorrhoids. The Veteran’s hemorrhoids have never resulted in persistent bleeding and secondary anemia or fissures. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 2. The criteria for entitlement to service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 3. The criteria for entitlement to service connection for lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 4. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. 5. The criteria for entitlement to service connection for dry throat have not been met. 38 U.S.C. §§ 1110, 1113, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 6. The criteria for entitlement to an initial disability rating in excess of 10 percent prior to December 14, 2016 and in excess of 20 percent thereafter for service-connected cold weather residuals of the left foot have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 7. The criteria for entitlement to an initial disability rating in excess of 10 percent prior to December 14, 2016 and in excess of 20 percent thereafter for service-connected cold weather residuals of the right foot have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 8. Prior to December 14, 2016, the criteria for entitlement to an initial disability rating of 20 percent, but no higher, for service-connected cold weather residuals in the left hand have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 9. Since December 14, 2016, the criteria for entitlement to an initial disability in excess of 30 percent for service-connected cold weather residuals in the left hand have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 10. Prior to December 14, 2016, the criteria for entitlement to an initial disability rating of 20 percent, but no higher, for service-connected cold weather residuals in the right hand have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 11. Since December 14, 2016, the criteria for entitlement to an initial disability in excess of 30 percent for service-connected cold weather residuals in the right hand have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code 7122. 12. The criteria for entitlement to an initial compensable disability rating prior to December 14, 2016 and in excess of 10 percent thereafter for service-connected hemorrhoids have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.114, Diagnostic Code 7336. REFERRED CLAIM In a May 2016 rating decision, the Veteran was granted service connection for posttraumatic stress disorder (PTSD) with secondary major depressive disorder and was assigned a 50 percent disability rating effective July 17, 2012. The Veteran did not file a notice of disagreement. In August 2016, the Veteran filed a formal claim seeking service connection for a sleep disturbance. In a December 2016 rating decision, the Regional Office (RO) determined that the Veteran’s sleep disturbance was a symptom of his service-connected PTSD with major depressive disorder and readjudicated the rating assigned for this service-connected psychiatric disability. The Veteran did not file a notice of disagreement. In June 2017, the Veteran submitted a formal claim seeking an increased rating for his service-connected PTSD with major depressive disorder which was adjudicated in an August 2017 rating decision. The Veteran did not file a notice of disagreement. In May 2018, the Veteran filed a formal claim seeking an increased rating for service-connected PTSD with major depressive disorder and entitlement to a total disability rating based on individual unemployability (TDIU). In June 2018, the RO incorrectly notified the Veteran that his increased rating claim for PTSD was in appellate status, stemming from an April 21, 2014 claim (no such claim exists). In a September 2018 rating decision, the Veteran was denied entitlement to a TDIU and in the accompanying notification letter the RO stated that “[t]he issue of increased evaluation for PTSD is on appeal; therefore, that issue is not being addressed in this rating decision.” The Board has fully reviewed the Veteran’s electronic claims file and the issue of an increased disability rating for service-connected PTSD with major depressive disorder is not on appeal, and the Board has no jurisdiction to consider such a claim. 38 U.S.C. §§ 7104, 7105. Accordingly, the May 2018 formal claim seeking an increased rating for service-connected PTSD with major depressive disorder is REFERRED to agency of original jurisdiction for initial adjudication and issuance of a rating decision. 38 C.F.R. §19.9(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty October 1979 to October 1994. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by a RO of the United States Department of Veterans Affairs (VA). In lieu of a VA form 9, Substantive Appeal, the Veteran filed a timely July 2016 submission which contained the necessary information to perfect an appeal to the Board of all claims adjudicated in the May 2016 Statement of Case. 38 C.F.R. § 20.202. During the pendency of this appeal, neither the Veteran nor his representative has requested a Board hearing. The undersigned Veterans Law Judge has been assigned to consider this appeal pursuant to 38 C.F.R. § 19.3(a). Neither the Veteran nor his representative has raised any issues with VA’s duty to notify or VA’s duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); See also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Service Connection Generally, to establish direct service connection, a veteran must show: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be satisfied before direct service connection may be achieved. Right Shoulder Disability The presence of a current right shoulder disability within the appellate period is not in dispute. At the November 2012 VA examination, the Veteran reported periodic right shoulder pain. At the December 2016 VA examination the Veteran was diagnosed with a strain and acromioclavicular joint osteoarthritis in the right shoulder. Thus, the Veteran has satisfied the current disability prong of a direct service connection claim. Turning to the in-service incurrence of disease or injury element, the Veteran’s service treatment records contain a notation from December 1984 where the Veteran experienced pain in the upper right shoulder blade. The Veteran was diagnosed with a strain and restricted from performing push-ups, pull-ups, or lifting over 20 pounds. The service treatment records contain no other reference to right shoulder complaints or treatment. While no service exit examination is of record, the September 1993 periodic service examination, which was performed one year prior to service discharge, showed clinically normal upper extremities, with no reference to a right shoulder disability. Nevertheless, the December 1984 notation of a right shoulder injury is sufficient to satisfy the in-service incurrence prong of a direct service connection claim. Having satisfied the current disability and in-service incurrence element of a direct service connection claim, the Board turns to the dispositive issue of medical nexus. The Veteran was afforded a VA examination in November 2012 to assess the nature of his claimed right shoulder disability. The VA examiner issued a conditional, yet favorable medical nexus opinion. The VA examiner noted the December 1984 right shoulder complaint in the Veteran’s service treatment records and stated that since he could not find any further specific shoulder complaints, and given the fact that the Veteran was right-handed, his right shoulder disability was as likely as not a result of service-related repeated biomechanical stresses. However, this medical opinion is not entitled to probative value in this determination as it was based on an inaccurate factual premise and was not fully informed, as discussed below. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In September 2013, RO personnel determined that the November 2012 VA examiner’s opinion was insufficient for adjudicative purposes due to irregularities and requested an addendum medical opinion, which was received in September 2013. The September 2013 VA examiner explained that the November 2012 examiner did not have or did not review the Veteran’s post-service treatment records and did not consider or discuss this evidence in the issued medical nexus opinion. The September 2013 VA examiner explained that the November 2012 VA examiner’s conclusion that combat engineer biomechanical stress led to degenerative pathology of the right shoulder was not supported by his personal and medical experience. The September 2013 VA examiner stated: I served 30 years as an active duty Surgeon. I deployed in the field (training & combat) with combat engineer (CE) units. I have seen them perform their field duties first hand. I have received formal course training and certifications through the Army’s Medical Evaluation Board (MEB) program and the Joint Services Physical Evaluation Board program. I have served as the Chief of the Medical Staff at a major Army garrison hospital and [have] been the approval/signature authority for all MEBs coming out of that Medical Treatment Facility. I have reviewed and signed off on many hundreds of orthopedic MEBs involving soldiers in every Military Occupational Specialty, including CE. In short, I am an expert in U.S. Army induced orthopedic disabilities. In my expert opinion, 15 years of CE service does not routinely, much less automatically, lead to [right shoulder] impingement (as diagnosed and nexus connected by the 11/28/2012 [VA] examiner). … My review of the [service treatment records] confirmed the 11/28/2012 [VA] examiner’s documentation of a 12/1984 [service treatment record] for spasm/strain of the right scapular/back rhomboid/latissimus muscles. Let me be very clear here... a 1984 isolated minor “outside the shoulder joint” muscle strain cannot possibly lead decades later to an “inside the shoulder joint” impingement condition. The first notation of any chronic [right shoulder] pain complaints were 10MG documented on 4/3/2008 and once again were related to a Postal Service heavy lifting etiology. In my opinion, the weight of the medical evidence is that Veteran’s current 11/2012 [right shoulder] impingement condition is due to, or the result of, post-active duty Postal Service lifting injuries. Indeed, the record reflects that the Veteran has been employed with the U.S. Postal Service since 1994, where he started as a part-time employee and transitioned into full-time employment in 1996. The Veteran’s May 2018 VA form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, indicated that the Veteran was still employed at the U.S. Postal Service on a full-time basis as of May 2018. Likewise, post-service treatment records from April 2008 demonstrate that the Veteran’s complaint of right shoulder pain was likely related to physical injury sustained as a result of working out or performing heavy lifting during his duties as a postal clerk. This was the first reference to right shoulder pain since the documented complaints in the December 1984 service treatment record, a temporal gap of approximately 24 years. Weighing the competing medical nexus opinions, the Board finds the September 2013 VA examiner’s opinion to be far more probative. Unlike the November 2012 VA examiner, the September 2013 VA examiner engaged in a comprehensive review of all available records and discussed such evidence in the narrative report, resulting in an extremely thorough and fully-informed medical opinion that was supported by a cogent explanatory rationale based on the VA examiner’s expertise in military orthopedic disabilities, the Veteran’s unique medical history, and an accurate factual premise. In adjudicating this appeal, the Board has considered the Veteran’s lay statements. In doing so, the Board notes that the Veteran has not provided very many statements regarding his theory of entitlement with respect to this service connection claim. Nonetheless, the Board observes that in April 2008 post-service physical therapy records, the Veteran reported that he was experiencing right-sided upper extremity pain and shoulder discomfort, the onset of which he placed in 1994 as a result of carrying a rucksack during his military service. He indicated that he had experienced intermittent right shoulder symptoms since service. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, the Veteran is competent to report his symptoms as shoulder pain can be experienced through lay senses. Id. at 70. However, in light of the record before the Board, the Veteran’s reports of continuous right shoulder symptoms since service discharge are not credible. There are no documented right shoulder complaints in the post-service medical records until April 2008, approximately 24 years after the documented December 1984 right shoulder complaints in the Veteran’s service treatment records, and approximately 14 years after exit from military service. This lengthy period without complaint or treatment is one piece of evidence that there has not been ongoing symptomatology and detracts from the credibility of the Veteran’s lay assertion. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, the record demonstrates that the Veteran was seen on numerous occasions for orthopedic complaints during this interval period, yet he never reported right shoulder symptomatology. In evaluating credibility of lay assertions, the Board has the authority to consider factors such as internal inconsistency, facial plausibility, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 512 (1995). This discrepancy in the medical evidence weighs heavily against his lay assertions regarding continuity of symptoms. Based on the foregoing analysis, the Veteran’s claim seeking direct service connection for a right shoulder disability must be denied due to the lack of competent medical nexus evidence linking this disability to his active duty service. The Board has also considered relevant presumptive service connection provisions. The Veteran served in the Southwest Asia theater of operations, however presumptive service connection under 38 C.F.R. § 3.317 is unavailable as the Veteran’s disability has been attributed to a known clinical diagnosis. Presumptive service connection as a chronic disease under 38 C.F.R. § 3.309 is also for consideration, as the Veteran’s right shoulder impingement has an arthritic component. See December 2016 VA examination. Nevertheless, the most probative evidence fails to substantiate that the Veteran experienced a chronic right shoulder disability in service that has persisted to the present. Arthritis in the right shoulder joint was not x-ray confirmed until more than 2 decades after his active duty service had ended. See December 2016 VA examination. The evidence does not show that the Veteran’s right shoulder arthritis was chronic in service (or within an applicable presumptive period), it did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. His lay assertions regarding continuous right shoulder symptoms with onset in service have been deemed not credible. Based on these considerations, the Veteran has not proven entitlement to presumptive service connection under the relevant regulations and his claim is also denied on this basis. Cervical Spine Disability The Veteran seeks entitlement to service connection for a cervical spine disability. The Veteran has not provided any specific argument in support of this claim. There is no dispute as to whether the Veteran has experienced a cervical spine disability within the appellate period. Magnetic resonance imaging (MRI) conducted in May 2011 documented the presence of a minimal disc bulge at the C6-C7 vertebrae. The November 2012 VA examiner diagnosed the Veteran with mild cervical degenerative spondylosis. Thus, the Veteran has satisfied the current disability prong of a direct service connection claim. Review of the Veteran’s service treatment records document complaints of cervical/neck pain. The Veteran experienced whiplash as a result of a May 1987 motor vehicle accident and reported pain in his neck. Physical examination preformed after the accident demonstrated that the cervical spine was within normal limits. Service treatment records dated in November 1987 documented residual cervical muscle spasm with occipital neuralgia as a result of this motor vehicle accident. While no service exit examination is of record, the September 1993 periodic service examination, which was performed one year prior to service discharge, showed a clinically normal neck and musculoskeletal/spine, with no reference to a cervical spine disability. Nevertheless, the 1987 notations of cervical spine pain and spasms are sufficient to satisfy the in-service incurrence prong of a direct service connection claim. Having satisfied the current disability and in-service incurrence element of a direct service connection claim, the Board turns to the dispositive issue of medical nexus. The Veteran was afforded a VA examination in November 2012 to assess the nature of his claimed cervical spine disability. The VA examiner issued a conditional, yet favorable medical nexus opinion. The Veteran reported onset of symptoms in 1994, contemporaneous in time with his exit from military service, and without injury. He told the VA examiner that he treated his neck pain with simple stretches and Ibuprofen, as needed. The VA examiner was unable to locate the results of his post-service cervical MRI findings, which serves as proof that the examiner did not fully review the electronic claims file, as these diagnostic imaging results are of record. The November 2012 VA examiner opined that since the Veteran “recalls no other neck injuries before, during, or following service, and in as much as the Veteran did present with cervical whiplash symptoms following the motor vehicle accident, this examiner would maintain that the current cervical spine condition is at least as likely as not the result of the service-connected motor vehicle accident as well as the biomechanical strains of being a combat engineer over 15 years of service.” The VA examiner’s opinion was based on an inaccurate factual premise, as the Veteran’s post-service medical records establish chronic neck issues following years of employment as a postal clerk. Accordingly, this medical nexus opinion is entitled to no evidentiary weight. In September 2013, the RO obtained a VA addendum medical opinion from the same VA examiner who issued the opinion on the right shoulder, discussed supra. This examiner was well-versed in assessing orthopedic injuries/disabilities in a military context based on his unique experience as an active duty surgeon and his deployments with combat engineer units. The September 2013 VA examiner declined to link the Veteran’s current cervical spine disability to his active duty service and explained: My review of the [service treatment records] confirmed the 11/28/2012 [VA] examiner’s documentation of a 5/1987 motor vehicle whiplash injury to the neck. However, except for a single 11/1987 episode of neck spasm, I saw no evidence in the [service treatment records] that the 5/1987 whiplash injury led to any chronic neck pain (cNP) condition. Without the development of an active duty cNP condition, in my opinion, the whiplash injury was too minor to lead to the subsequent development of C-S DDD/DJD (cervical spine degenerative disc disease/degenerative joint disease. The 7/7/2009 10MG note and the 7/27/2009 Family Medical Leave Act (FLMA) note[] both documented the onset of the cNP condition in 2005 due to a Postal Service injury. In my opinion, the weight of the medical evidence is that Veteran’s current 11/2012 C-S DDD/DJD are due to, or the result of, post-active duty Postal Service neck injuries. Unlike the November 2012 VA examiner’s opinion, the September 2013 VA examiner’s opinion engaged in a full analysis of the record and issued a more comprehensive medical nexus statement that considered the Veteran’s entire medical history. The opinion was fully-informed, was supported by a thorough explanatory rationale, and is entitled to significant evidentiary weight in this determination. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The electronic claims file establishes a temporal gap of nearly 20 years between the Veteran’s November 1987 complaints of neck spasms and the next reported cervical complaints in the mid-2000s. At a February 2011 visit, the Veteran reported that he had “a ten[-]year history of neck pain,” placing the onset of his reported symptoms well after discharge from active duty service. At a July 2009 visit, the Veteran explained that his chronic neck pain started “about 2005” more than 10 years after his discharge from active duty service. Thus, on numerous occasions the Veteran has placed the onset of his current cervical symptoms well after his discharge from active duty service. As addressed by the September 2013 VA examiner, the record is also replete with references indicating the Veteran’s complaints of cervical pain are the result of injuries and/or chronic lifting of heavy boxes secondary to his employment as a postal clerk. See e.g. March 2012 medical record (dx: Low back pain with concurrent neck pain…he experienced his initial injury approximately 7 years ago. He was going to lift a package and had a hyperextension injury of the elbow which triggered nerve pain); May 2013 medical record (complaint of “acute L side neck pain…While lifting a box at work, he strained his L shoulder neck region); March 2014 medical record (pain in left neck, “he was lifting boxes when it first happened”). This evidence further weighs against a conclusion that the Veteran’s cervical disability is etiologically related to active duty service. In July 2011, the Veteran attended a neurological consultation to assess his cervical condition. The Veteran’s neurologic examination was normal and the only finding of significance was muscle tightness in the neck. The neurologist opined that the Veteran’s symptoms were due to a lack of relaxation and were caused by stress. This physician did not link the Veteran’s cervical disability to his active duty service. The most probative evidence of record is the September 2013 VA examiner’s opinion which did not establish a medical nexus between the Veteran’s current cervical disability and his active duty service. Having failed to establish all of the requisite elements of a direct service connection claim, his appeal is denied. The Board has also considered application of the presumptive service connection regulations for chronic diseases and certain disabilities occurring in Persian Gulf War veterans. 38 C.F.R. §§ 3.307, 3.309, 3.317. While the Veteran has a cervical arthritic condition, which is a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), it was not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Post-service medical records establish that the Veteran did not begin experiencing cervical symptoms until the mid-2000s, nearly a decade after his exit from service and two decades since his only reported cervical complaints in service. For these reasons, presumptive service connection for a chronic disease is denied. The record reflects that the Veteran served in the Southwest Asia theater of operations, however presumptive service connection under 38 C.F.R. § 3.317 is not warranted for his cervical disability because it is attributed to a known clinical diagnosis and is not the result of an undiagnosed illness or medically unexplained chronic multi symptom illness. There is no basis upon which the Veteran may achieve service connection for a cervical spine disability, and to this end, his appeal is denied. Lumbar Spine Disability The Veteran seeks entitlement to service connection for a lumbar spine disability. The Veteran has not provided any specific argument in support of this claim. The evidence affirmatively establishes that he has carried a current lumbar spine disability within the appellate period. MRI results from April 2011 establish that the Veteran has experienced lumbar spinal arthropathy and degenerative disc findings most predominantly at the L5-S1 vertebrae. Thus, the Veteran has met the current disability prong of a direct service connection claim. As to in-service incurrence of disease or injury, the Veteran’s service treatment records document a few acute and isolated complaints of low back pain. A radiograph taken in November 1983 for complaints of hematuria showed mild levoscoliosis of the mid-lumbar spine with occult spina bifida at S1. In April 1987, the Veteran reported an 8-month history of low back pain. He did not provide any indication as to what caused this pain. Following the May 1987 motor vehicle accident, the Veteran complained of pain in the low back. Physical examination of the lumbar spine was within normal limits. In September 1990, the Veteran was seen for a 2-day complaint of low back pain. He was provisionally diagnosed with runner’s hematuria. In January 1992 the Veteran reported pain in the spinal cord. After conservative treatment there were no residual complaints. Despite these intermittent complaints, the Veteran’s periodic service examination performed in September 1993, one year prior to discharge from active duty, showed a normal musculoskeletal examination and did not note a chronic lumbar disability or complaints. Nevertheless, the Veteran’s service treatment records document lumbar complaints sufficient to satisfy the in-service element of a direct service connection claim. Much like the right shoulder and cervical disability claims, the November 2012 VA examiner’s favorable opinion linking the Veteran’s lumbar disability to the biomechanical stresses associated with combat engineer service is not probative as it failed to take into consideration or evaluate the Veteran’s post-service medical records. As this opinion was not based a complete understanding of the Veteran’s medical history, it is not probative in this determination. Reonal, 5 Vet. App. at 461. In September 2013, the RO obtained a VA addendum medical opinion from the same VA examiner who issued the opinion on the right shoulder and cervical spine disability, discussed supra. This examiner has extensive experience assessing the etiology of service-related orthopedic disabilities. The September 2013 VA examiner was fully apprised of the Veteran’s entire medical history and issued a negative medical nexus opinion. The VA examiner explained: The mild scoliosis and spina bifida conditions are congenital and are of no clinical significance whatsoever. The [service treatment records] first documented these conditions on a non-spinal (hematuria indication) KUB radiograph dated11/18/1983. These radiographic findings persist unchanged through the 11/28/2012 [VA] exam radiographs. There are no service or post-service treating medical records that these two conditions have engendered any complaints, evaluations, treatments, or pathology. The 11/28/2012 [VA] exam diagnosis should have been lumbar spine degenerative disc and degenerative joint disease (L-S DDD/DJD) based on the radiograph report. In my opinion, the 11/28/2012 [VA] examiner’s nexus connection of the L-S DDD/DJD to active duty CE biomechanical stress is without merit. The [VA] examiner noted a 4/27/1987 urethritis service treatment record that recorded “LBP x 8 months.” I presume “LBP” meant low back pain and the urethritis provider was attributing the LBP to the urethritis because no other LBP details were noted. The [service treatment records] did contain one 2/28/1992 ER note of a one[-]hour complaint of low back pain (LBP) that was induced by raising up from a bending position. However, on my review of the [service treatment records] there was no active duty trauma or major injury to the lumbar spine that induced any active duty chronic low back pain (cLBP) condition. As such, there is no evidence that the Veteran had any pathologic L-S cLBP condition on active duty that could progress to L-S DJD/DDD. The 2/8/2006 Dr. Fellhauer (Dr. F) complete History & Physical Exam noted no change in the Veteran’s health since 2003 with the only concerns/problems being headaches and urinary frequency. The 3/9/2010 10th Medical Group (10MG) note recorded “no previous recorded history of back pain” and stated the onset of the cLBP with sciatica was only two days ago. The 4/3/2008 10MG Family Practice not[e] and the 3/18/2011 Physical Therapy note (VISTA) both documented the Veteran does a lot of heavy lifting at his post-service Postal Service job. A 7/21/2005 note of Dr. F documented a low back strain lifting injury the previous day at work. In my opinion, the weight of the medical evidence is that Veteran’s current 11/2012L-S DDD/DJD are due to, or the result of, post-active duty Postal Service low back lifting injuries. The September 2013 VA examiner engaged in a thorough review and analysis of the Veteran’s service treatment records and post-service medical records. This medical opinion was extremely meticulous and was supported by a detailed rationale explaining that the Veteran’s reported complaints of low back pain during service were acute and that the degeneration in the lumbar spine that the Veteran currently experiences was more likely the result of post-service low-back lifting injuries. As this medical opinion was factually accurate, fully articulated, and contained a sound reasoning for the conclusion, it is highly probative in this determination. As the September 2013 VA examiner’s negative medical opinion is the most probative nexus evidence of record, the third element of a direct service connection claim has not been met and direct service connection cannot be achieved on this basis. The Board has also considered application of the presumptive service connection regulations for chronic diseases and certain disabilities occurring in Persian Gulf War veterans. 38 C.F.R. §§ 3.307, 3.309, 3.317. While the Veteran has a lumbar arthritic condition, which is a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), it was not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Following discharge from active duty, the Veteran did not again reference complaints of back pain until the mid-2000s, nearly a decade after his military service had ended. For these reasons, presumptive service connection for a chronic disease is denied. The record reflects that the Veteran served in the Southwest Asia theater of operations, however presumptive service connection under 38 C.F.R. § 3.317 is not warranted for his lumbar disability because it is attributed to a known clinical diagnosis and is not the result of an undiagnosed illness or medically unexplained chronic multi symptom illness. There is no basis upon which the Veteran may achieve service connection for a lumbar spine disability, and to this end, his appeal is denied. Bilateral Pes Planus The Veteran seeks entitlement to service connection for bilateral pes planus. The Veteran has not provided any specific argument in support of this claim. Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). Such conditions are considered to be pre-existing. When a pre-existing disorder is noted on entry, a veteran has the burden of showing that it is at least as likely as not that the disorder increased in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). If a veteran meets that burden and shows that an increase in severity occurred, the burden then shifts to VA to show whether such increase is clearly and unmistakably due to the natural progression of the pre-existing disability rather than due to service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012); C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Here, the Veteran’s September 1979 service entrance examination clearly noted asymptomatic pes planus as a defect. Review of the Veteran’s service treatment records fails to yield any indication that the Veteran’s bilateral pes planus increased in severity during his active duty service. While the Veteran’s service treatment records document foot complaints, they were never diagnosed as or attributed to bilateral pes planus. For instance, in July 1981, the Veteran reported complaints of swollen feet, but it was determined to be a flare up of an infection he received from a poisonous bush while serving in Panama. In July 1983, the Veteran reported a blister on his left foot, yet there was no indication that this injury was in any way related to his noted bilateral pes planus. In March 1984, he complained of painful feet and it was determined that the Veteran’s symptoms were the result of friction irritation due to prolonged walking. A periodic service examination conducted in August 1986 made no reference to worsening bilateral pes planus. In August 1989, the Veteran was seen for bunions on his feet and severe pain with walking. It was suggested that this injury was the result of the Veteran’s footwear. Corns were removed from both feet and the Veteran was returned to normal duty. There was no indication that this injury was the result of the Veteran’s bilateral pes planus. A periodic service examination conducted in January 1991 made no reference to worsening bilateral pes planus. At a periodic service examination in September 1993, about one year prior to exit discharge, the Veteran’s bilateral pes planus was noted as asymptomatic. No service exit examination has been provided for consideration. While the evidence did not show worsening of bilateral pes planus during service, VA nevertheless obtained a VA examination in November 2012 to assess the nature and severity of the Veteran’s bilateral pes planus disability. In the medical history section of the examination report, the VA examiner noted that the Veteran’s pes planus was noted on service entry and that a periodic examination dated in September 1993 showed that his flatfeet remained asymptomatic. The examiner charted the Veteran’s lay reports that he did not begin experiencing symptoms in his bilateral foot arches until “recent years, exact date not recalled.” Following a complete evaluation, the VA examiner issued the following medical opinion: It is clear by the Veteran[‘s] history as well as his enlistment examination that his flatfeet are likely congenital and were clearly present prior to enlistment and not the result of service. Given the absence of chronic or recurrent feet problems while [on] active duty and with only one evaluation this examiner could find, 3 March 1984 of swollen small toes following a 3 day road march, and given the specific documentation of the 22 September 1993 periodic examination that the flatfeet remained asymptomatic, this examiner would comment that although the Veteran is recent years has had foot pain and benefits from arch supports, that this is the natural progression of pes planus with aging, and it is felt that this condition was not aggravated by service as well. The Board finds this medical opinion to be probative on the issue of whether the Veteran’s pre-existing bilateral pes planus—which was noted on service entry—was aggravated by his active duty service. The examiner engaged in a thoughtful analysis of the record and concluded that the Veteran’s bilateral pes planus did not become symptomatic until recent years and this was due to the natural progression of the condition. As to the severity of the condition during the Veteran’s period of active duty, the VA examiner found there was no increase in disability or aggravation. The Veteran has the burden to show aggravation with evidence of worsening or increase in disability during active duty service. 38 C.F.R. § 3.306(b). Here, there is no competent evidence to show that in-service increase or aggravation of bilateral pes planus occurred, and the Veteran has not satisfied his burden in this regard. With no competent evidence to show an increase in severity of the bilateral pes planus during service, the presumption of aggravation does not arise. As such, a discussion of clear and unmistakable evidence to rebut the presumption of aggravation is not required. Wagner, 370 F.3d at 1096. Because the Veteran’s pre-existing bilateral pes planus was not aggravated by his active duty service his service connection claim must be denied. Dry Throat The Veteran seeks entitlement to service connection for dry throat. The Veteran has not provided any specific argument in support of this claim. Review of the Veteran’s post-service medical records establishes that the Veteran has experienced a sore throat during the appellate period, however there is very little, if any, clinical evidence noting “dry throat.” Despite this, the Veteran described his experience with a dry throat to the November 2012 VA examiner (discussed further infra). The Veteran is competent to report symptoms which are observable to his lay senses. See Layno, 6 Vet. App. at 470. As there is no reason to cast doubt on these lay assertions, they are sufficient to establish the current disability prong of a direct service connection claim. The Veteran’s service treatment records reference complaints of and treatment for sore throat during his active duty service. These complaints were most often attributed to viral or bacterial illness. See e.g. September 1991 complaint of sore throat diagnosed as viral syndrome, September 1984 complaint of sore throat diagnosed as chicken pox, January 1988 complaint of sore throat treated with antibiotics, November 1991 complaint of sore throat diagnosed as pharyngitis, March 1992 complaint of sore throat without assessment provided, but no indication of chronic illness. While no exit examination is of record, the September 1993 periodic service examination, which was performed one year prior to service discharge, made no reference to a dry throat and examination of the mouth/throat was found to be clinically normal. Although the evidence establishes that the Veteran experienced episodic sore throat secondary to acute viral and bacterial illnesses, there is no indication of persistent dry throat in his service treatment records. In November 2012, the Veteran was afforded a VA examination to assess the nature of his claimed dry throat disability. At the VA examination, the Veteran reported that he would frequently wake up in the middle of the night while mouth breathing with dryness in his throat. The VA examiner reported the Veteran’s medical history, as follows: [H]e has had no history of lack of saliva or lack of tears, no voice changes, no dysphasia. No thyroid problem, diabetes, sicca syndrome, no history of throat irradiation or surgeries, nor history of any other laryngeal, lingular, or throat condition involving infections or neoplasms. In review of the service treatment record, there are many episodic visits for acute sore throats most often viral upper respiratory infections, although at least on one occasion a strep pharyngitis (all in the context of a time in life when his wife and children also frequently had upper respiratory infections or strep throat). These visits include, for example, 5 November 1979 associated with laryngitis, 11 January 1988, 7 November 1991. In which case, all of these events were treated symptomatically, infrequently with antibiotics, and were resolved without any chronic residual. Currently, other than the habit of keeping his hydration levels up and dry mouth when sleeping with his mouth open, the Veteran has had no other diagnostic tests or treatment for any throat conditions to include no antibiotics, no artificial saliva or lubricants or dental work. It has not been a condition that is impacted his activities of daily living or required accommodations for work. When asked whether the Veteran’s reported dry throat was etiologically linked to the Veteran’s active duty service, the VA examiner declined to establish such a medical nexus. The VA examiner explained: As the focused ears, nose, and throat examination today reveals no abnormalities, with normal saliva pool sublingually, normal tongue, normal oral mucosa with no ulcers or vesicles, no post nasal draining, normal sinus exam, no cervical adenopathy, normal voice, and normal thyroid on exam, this current condition is not felt to be a residual of acute self-limited viral or streptococcal pharyngitis, which occurred in service years ago but is simply the result of mouth breathing, hydration, and low environmental Colorado humidity. Although the November 2012 VA examiner did not have review/discuss the Veteran’s full post-service medical records, he based his medical nexus opinion largely on his clinical examination and the Veteran’s lay reports. This opinion was based on the necessary information and is probative in this determination. In July 2013, the Veteran was seen by his primary care physician with a complaint of severe sore throat. He was concerned that he had throat cancer due to his years of smoking tobacco and a familial history of throat cancer. Examination showed minimal erythema on the posterior pharyngeal wall with no exudate. While he reported tenderness to palpation in the tonsillar area, there was no obvious lymphadenopathy. The primary care physician opined that the Veteran’s symptoms were most likely related to environmental allergies, and possible postnasal drip. This medical opinion further bolsters the conclusion of the November 2012 VA examiner. As the record contains no other competent medical nexus opinion linking the Veteran’s current disability to his active duty service, the Veteran’s service connection claim must be denied on a direct basis. Shedden, 381 F.3d at 1167. The Veteran’s service personnel records establish that he served in the Southwest Asia theater of operations from January 1991 to July 1991 and is eligible for presumptive service connection consideration under the regulatory provisions of 38 C.F.R. § 3.317. Regrettably, presumptive service connection under 38 C.F.R. § 3.317 cannot be achieved as the Veteran’s dry mouth is a condition with a known etiology (mouth breathing, hydration, and low environmental humidity) and is not due to an undiagnosed illness or medically unexplained chronic multi symptom illness. No other regulatory presumptive provisions apply to the Veteran’s circumstances. Accordingly, the Veteran’s service connection claim must also be denied on a presumptive basis. Increased Ratings The Veteran seeks higher initial increased ratings for his service-connected disabilities of cold injury residuals of the bilateral feet, cold injury residuals of the bilateral hands, and hemorrhoids. The Board has considered whether an inferred claim of entitlement to TDIU has been raised in conjunction with the increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The available evidence suggests that the Veteran is still employed with the U.S. Postal Service on a full-time basis and there is no indication that this employment is marginal or in a protected environment. Accordingly, the issue of entitlement to TDIU during the appellate period is not reasonably raised by this record. The Veteran is reminded that he was denied entitlement to a TDIU in a September 2018 rating decision. If he wishes to challenge that determination, he must do so through the timely filing of a VA form 21-0958, Notice of Disagreement, within one-year of the notification of that rating decision. Cold Injury Residuals of the Bilateral Feet The Veteran was awarded service connection for cold injury residuals of the bilateral feet in a September 2013 rating decision. The Veteran is currently in receipt of a 10 percent disability prior to December 14, 2016 and a 20 percent rating thereafter for service-connected cold injury residuals in the left foot and a 10 percent disability prior to December 14, 2016 and a 20 percent rating thereafter for service-connected cold injury residuals in the right foot. These disabilities are rated under Diagnostic Code 7122, 38 C.F.R. § 4.104. The Veteran seeks higher initial disability ratings. Following a complete review of the appellate record, the Board finds no basis to award higher initial ratings for the Veteran’s service-connected cold injury residuals of the bilateral feet. The Veteran was afforded a VA cold injury residuals examination in November 2012. The Veteran reported that if he is exposed to prolonged cold, such as using a snowblower or shoveling snow, he is likely to have some cold sensitivity in his toes, but no other arthralgias, numbness, loss of strength, weakness, hyperhidrosis, or Reynaud’s were described. The VA examiner found that the Veteran only exhibited cold sensitivity in his left and right feet as a result of his in-service cold injury. There were no x-ray abnormalities noted in the bilateral feet and the Veteran did not require the use of assistive devices for locomotion. In October 2013, Apri 2014, August 2014, and September 2014, the Veteran was seen by his primary care provider with complaints of numbness and pain in his toes bilaterally. Based on the findings of the November 2012 VA examination, the Veteran was properly awarded separate 10 percent disability ratings for each foot under Diagnostic Code 7122. A 10 percent rating is warranted when there is evidence of arthralgia or other pain, numbness, or cold sensitivity. A higher 20 percent rating cannot be achieved without these symptoms, plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). Review of the medical evidence prior to December 14, 2016 establishes that the only symptoms or findings relevant to his cold injury residuals in the bilateral feet were numbness, pain, and cold sensitivity which are directly contemplated by a 10 percent disability rating. There is no medical or lay evidence to substantiate disability rating higher than the currently assessed 10 percent awarded for each foot under Diagnostic Code 7122 prior to December 14, 2016. The Veteran was afforded a second VA cold injury residuals examination on December 14, 2016. In the medical history portion of the narrative report, the VA examiner noted that the Veteran experienced cold sensitivity, paresthesias, and pain with cold exposure. Upon examination, the VA examiner found that the Veteran exhibited cold sensitivity, numbness, and locally impaired sensation in the left and right feet. There were no x-ray abnormalities noted in the bilateral feet, the Veteran did not require the use of assistive devices for locomotion, and there was no functional impairment so severe that it would be equally well-served by an amputation with prosthesis. As the Veteran exhibited cold sensitivity, numbness, and locally impaired sensation, the RO properly awarded a higher 20 percent rating under Diagnostic Code 7122 for each foot as of the date of the December 14, 2016 VA examination. At no time prior to the VA examination, does the evidence support a 20 percent rating or higher in each foot for service-connected cold injury residuals. In addition, there is no evidence to support a higher 30 percent disability rating since December 14, 2016. The highest, 30 percent, rating is warranted where there is evidence of arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). Since December 14, 2016, the Veteran’s cold injury residuals in each foot have been manifested by cold sensitivity, numbness, and locally impaired sensation only sufficient to warrant a 20 percent evaluation under Diagnostic Code 7122. There is no evidence from the December 14, 2016 VA examination or the Veteran’s medical records thereafter to demonstrate any other symptoms or findings from the rating criteria to warrant a higher 30 percent evaluation under Diagnostic Code 7122 for each foot. In light of the above analysis, the Board concludes that the Veteran’s current 10 percent disability rating prior to December 14, 2016 and 20 percent rating thereafter for each foot, rated separately, for service-connected cold injury residuals is proper and there is no evidence or basis to support higher initial disability rating during the appellate period. Accordingly, the Veteran’s appeal is denied. Cold Injury Residuals of the Bilateral Hands The Veteran is currently in receipt of a 10 percent disability rating prior to December 14, 2016 and a 30 percent rating thereafter for each hand due to service-connected cold injury residuals under 38 C.F.R. § 4.104, Diagnostic Code 7122. The Veteran seeks higher initial disability ratings. The Board has reviewed the evidence and finds that the Veteran is entitled to a higher 20 recent rating for the period prior to December 14, 2016 for each hand due to service-connected cold injury residuals. The Veteran was afforded a VA examination in November 2012 where he reported his only symptoms were cold sensitivity in the fingertips when exposed to cold for long periods of time and periodic superficial peeling of the skin. Upon examination, the VA examiner noted that the only symptom exhibited was cold sensitivity in both hands. Based on this examination, the RO assigned initial disability ratings of 10 percent for each hand due to the presence of a single symptom under the rating criteria set forth in 38 C.F.R. § 4.104, Diagnostic Code 7122. This rating was also supported by the clinical evidence of record, such as October 2013, April 2014, August 2014, and September 2014 notations where the Veteran described numbness and pain in the fingers—symptoms which are fully contemplated by the 10 percent disability rating. The Board’s review of the Veteran’s medical records shows that x-ray imaging conducted on June 16, 2014 confirmed the presence of osteoarthritis in the right hand involving the second and third distal interphalangeal joints and the first carpometacarpal joint and a small calcification adjacent to the fourth metacarpophalangeal joint in the left hand. The record further reflects complaints of bilateral arthritic-like hand pain dating as far back as December 2011, prior to the period on appeal. The evidence establishes that the Veteran was experiencing bilateral hand cold sensitivity with x-ray abnormalities as of June 14, 2014 sufficient to warrant a higher 20 percent rating. Given the Veteran’s credible reports of bilateral hand pain prior to this date and prior to the appeal period, the Board finds this 20 percent evaluation should go back to the start of the appellate period. Consequently, the Board grants a higher 20 percent disability rating for each hand prior to December 14, 2016 for service-connected cold injury residuals. To this extent only, the Veteran’s appeal is granted. The Veteran is not entitled to a higher 30 percent disability rating for each hand prior to December 14, 2016 because his only symptoms and findings were pain, numbness, and cold sensitivity with x-ray abnormalities. A 30 percent rating under Diagnostic Code 7122 is only warranted if the evidence demonstrates arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). The Veteran did experience any tissue loss, nail abnormalities, color changes, locally impaired sensation, or hyperhidrosis prior to December 14, 2016 sufficient to warrant a 30 percent rating during this period. The Board notes that the Veteran reported superficial peeling fingertips to the VA examiner, but this finding was not objectively noted on examination, and is not objectively supported elsewhere in the Veteran’s clinical records. The Veteran’s reports, while competent and credible, are outweighed by the medical findings of record which fail to objectively document tissue loss in either hand prior to December 14, 2016. The Veteran was afforded a second VA cold injury residuals examination on December 14, 2016. Upon physical examination, the VA examiner noted cold sensitivity, locally impaired sensation, and color changes in both hands. The Veteran did not use any assistive devices and the cold injury residuals in each hand were not severe enough that they would be equally well-served by and amputation with prosthesis. Oddly, the VA examiner remarked there was no evidence of osteoarthritis, osteoporosis, or subarticular punched out lesions in either hand, although a VA hand examination performed the same day by the same examiner confirmed the presence of x-ray confirmed degenerative arthritis in the right hand. Regardless, based on these VA examination findings the RO granted a 30 percent disability rating under 38 C.F.R. § 4.104, Diagnostic Code 7122 for each hand effective the date of the examination, December 14, 2016. Upon review of all the evidence of record, the Board finds that ratings in excess of 30 percent since December 14, 2016 are not warranted for the Veteran’s cold injury residuals in the bilateral hands, as the Veteran has been assigned the maximum rating allowed under Diagnostic Code 7122 during this time period. The evidence does not suggest, and the Veteran does not contend that he has any cold injury residuals in the hands during this time period that are not contemplated by his current disability ratings. There are no other applicable rating criteria that would provide a higher rating or an additional rating for either hand. The Veteran’s appeal seeking an initial disability rating in excess of 30 percent for each hand due to service-connected cold injury residuals since December 14, 2016 is denied. Hemorrhoids The Veteran was granted service connection for hemorrhoids in a September 2013 rating decision and was assigned a noncompensable rating effective July 17, 2012 under Diagnostic Code 7336, 38 C.F.R. § 4.114. This rating was in effect until December 14, 2016, at which time he was granted a 10 percent evaluation under Diagnostic Code 7336, which remains in effect. The Veteran seeks initial higher disabilities ratings. Under Diagnostic Code 7336, a noncompensable rating is warranted for external or internal hemorrhoids that are mild or moderate. 38 C.F.R. § 4.114. A 10 percent disability rating is warranted when hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The maximum 20 percent disability rating is warranted when there are hemorrhoids with persistent bleeding and secondary anemia or fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. The criteria for a 20 percent disability rating are conjunctive, not disjunctive. Thus, both criteria (persistent bleeding and secondary anemia or anal fissures) must be met. See Melson v. Derwinski, 1 Vet. App. 334, 337 (1991) (use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met). The Veteran was afforded a VA hemorrhoid examination in November 2012. The VA examiner diagnosed the Veteran with mild or moderate hemorrhoids resulting in intermittent rectal itch and occasional hemorrhoid protrusion that the self-reduce, with intermittent bleeding and discomfort. Upon examination, the VA examiner found no external hemorrhoids, but observed a moderate internal hemorrhoid with mild protrusion with inspection during voluntary Valsalva without frank prolapse. The Veteran was afforded a second VA hemorrhoid examination on December 14, 2016. The Veteran was diagnosed with internal or external hemorrhoids. The Veteran described his hemorrhoids as permanent and requiring preparation H, tuck pads, and sitz baths, as needed. Upon examination, the VA examiner identified large external hemorrhoids described as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The Veteran’s post-service medical records from the applicable period listed hemorrhoids as an active problem but contained very little information useful in evaluating the severity of the Veteran’s disability under the rating criteria in Diagnostic Code 7336. A colonoscopy performed in January 2011, slightly before the rating period, noted the presence of internal hemorrhoids. A rectal examination performed in March 2011 documented internal hemorrhoids which were reduced spontaneously and were not tender, swollen, or firm. In April and June 2015, the Veteran reported rectal pain and bleeding as a result of his hemorrhoids. Prior to December 14, 2016, the most probative evidence of record are the results of the November 2012 VA examination which described mild to moderate internal hemorrhoids. There is no medical or competent lay evidence establishing that the Veteran experienced large or thrombotic hemorrhoids during this period to warrant a compensable 10 percent disability rating. At the December 14, 2016 VA examination, there was evidence of large or thrombotic hemorrhoids sufficient to support a higher 10 percent disability rating, and the RO properly granted an increased rating to 10 percent on the date of this examination. At no point in the appellate period has the Veteran ever experienced internal or external hemorrhoids with persistent bleeding and secondary anemia or fissures to warrant a 20 percent disability rating under Diagnostic Code 7336. Based on the foregoing analysis, the Veteran’s request for higher initial disability ratings for his service-connected hemorrhoids is not supported by the evidence and his appeal is denied. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Galante, Associate Counsel