Citation Nr: 20002986 Decision Date: 01/14/20 Archive Date: 01/14/20 DOCKET NO. 15-18 645 DATE: January 14, 2020 ORDER Restoration of the 20 percent rating for multilevel cervical spondylosis, cervical degenerative disc disease, and cervical muscle strain is granted from the date of the reduction. A rating higher than 20 percent for multilevel cervical spondylosis, cervical degenerative disc disease, and cervical muscle strain is denied. A compensable rating for restrictive lung disease is denied. A compensable rating for tension headaches is denied. Service connection for surgical scars on the left heel and right second toe is granted. Service connection for a bilateral foot disability other than surgical scars is denied. Service connection for right hand hyperkeratosis and parakeratosis is denied. Service connection for a left wrist ganglion cyst is denied. Service connection for a right fifth finger disability is denied. Service connection for emphysema is denied. Service connection for asthma is denied. Service connection for chronic bronchitis is denied. Service connection for chronic obstructive pulmonary disease (COPD) is denied. REMANDED The issue of entitlement to a separate compensable rating or ratings for upper extremity radiculopathy is remanded. The issue of entitlement to service connection for gastritis is remanded. The issue of entitlement to service connection for a duodenal ulcer is remanded. The issue of entitlement to service connection for a left deltoid strain is remanded. FINDINGS OF FACT 1. Improvement in the Veteran’s service-connected cervical spine disability under the ordinary conditions of life has not been shown. 2. Throughout the appeal period, the Veteran’s service-connected cervical spine disability has been manifested by, at worst, forward flexion to 35 degrees, with additional estimated limitation of 5 to 10 degrees during flare-ups, and no evidence of ankylosis or incapacitating episodes of intervertebral disc syndrome (IVDS) requiring prescribed bedrest and treatment by a physician. 3. Throughout the appeal period, the Veteran’s service-connected restrictive lung disease has been manifested by FEV-1 of 94 percent predicted, FEV-1/FVC of 102 percent, and DLCO/VA of 102 percent based on the tests the VA examiners indicated most accurately reflected the Veteran’s disability level. 4. Throughout the appeal period, the Veteran’s service-connected tension headaches have not been manifested by characteristic prostrating attacks averaging one in two months over the last several months. 5. The Veteran’s surgical scars on the left heel and right second toe were incurred during service. 6. The preponderance of the evidence is against a finding that the Veteran has a current foot disability other than surgical scars. 7. The preponderance of the evidence is against a finding that the Veteran’s claimed right-hand hyperkeratosis and parakeratosis were incurred in or caused by service. 8. The preponderance of the evidence is against a finding that the Veteran’s claimed left wrist ganglion cyst was incurred in or caused by service. 9. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a right fifth finger disability. 10. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of emphysema. 11. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of asthma. 12. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of chronic bronchitis. 13. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of COPD. CONCLUSIONS OF LAW 1. The criteria for restoration of the 20 percent rating for Veteran’s service-connected cervical spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5010- 5237. 2. The criteria for a rating higher than 20 percent for the Veteran’s service-connected cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DCs 5010-5237. 3. The criteria for a compensable rating for restrictive lung disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.96, 4.97, DCs 6899-6845. 4. The criteria for a compensable rating for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, DC 8100. 5. The criteria for establishing entitlement to service connection for surgical scars on the left heel and right second toe been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 6. The criteria for establishing entitlement to service connection for a bilateral foot disability other than surgical scars have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 7. The criteria for establishing entitlement to service connection for right hand hyperkeratosis and parakeratosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 8. The criteria for establishing entitlement to service connection for a left wrist ganglion cyst have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 9. The criteria for establishing entitlement to service connection for a right fifth finger disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 10. The criteria for establishing entitlement to service connection for emphysema have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 11. The criteria for establishing entitlement to service connection for asthma have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 12. The criteria for establishing entitlement to service connection for chronic bronchitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 13. The criteria for establishing entitlement to service connection for COPD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1975 to January 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran has perfected appeals of several other claims, including entitlement service connection for peripheral neuropathy, a bilateral knee disability, and a low back disability; entitlement to higher ratings for anemia and sinusitis with allergic rhinitis; and entitlement to a total disability rating based on individual unemployability (TDIU). However, those issues will be addressed in a separate Board decision. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2019). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability; resolving any reasonable doubt regarding the degree of disability in favor of the claimant; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10 (2018); see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2019); see also 38 C.F.R. §§ 4.45, 4.59 (2019). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. Cervical spondylosis with degenerative disc disease and muscle strain The Veteran’s service-connected cervical spine disability has been assigned an initial 20 percent rating, effective December 17, 2012. After the Veteran appealed the initial rating assigned to his service-connected cervical spine disability, an October 2017 rating decision reduced the rating to 10 percent, effective June 21, 2017. The reduced rating did not result in a reduction of compensation payments currently being made. Pursuant to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), a 10 percent rating is warranted forward flexion of the cervical spine is greater than 30 degrees, but not greater than 40 degrees; or where the combined range of motion of the cervical spine is greater than 170 degrees, but not greater than 335 degrees; or where there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or where there is vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, General Rating Formula. A 20 percent rating is warranted where forward flexion of the cervical spine is greater than 15 degrees, but not greater than 30 degrees; or where the combined range of motion of the cervical spine is not greater than 170 degrees; or where muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent rating is warranted where forward flexion of the cervical spine is 15 degrees or less; or where there is favorable ankylosis of the entire cervical spine. Id. A 40 percent rating is warranted where there is unfavorable ankylosis of the entire cervical spine. Id. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastro- intestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). The General Rating Formula provides further guidance in rating diseases or injuries of the spine. In pertinent part, Note (1) provides that any associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Id. at Note (1). Alternatively, IVDS can be rated based on incapacitating episodes under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula) or the General Rating Formula. whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Id. at Note (6). Under the IVDS Formula, a 10 percent rating is warranted for incapacitating episodes having a total duration of at least one week, but less than two weeks during the past 12 months. 38 C.F.R. § 4.71a, IVDS Formula. A 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months. Id. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months. Id. A maximum 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. Id. An “incapacitating episode” is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, IVDS Formula, Note (1). Additionally, in any rating-reduction case, VA must determine (1) whether the evidence reflects an actual change in the disability based upon review of the entire recorded history of the condition; (2) whether the examination reports reflecting such change are based upon thorough examinations; and (3) whether any improvement actually reflects an improvement in the veteran’s ability to function under the ordinary conditions of life and work. Murphy v. Shinseki, 26 Vet. App. 510, 516-17 (2014) citing Brown v. Brown, 5 Vet. App. 413, 421 (1993); see also Faust v. West, 13 Vet. App. 342, 349 (2000) (summarizing the requirements that VA must follow all reduction cases, “regardless of the rating level or the length of time that the rating has been in effect”). The Veteran underwent a VA examination in January 2014, during which he reported worsening neck pain, and a physical examination revealed moderate tenderness and guarding or muscle spasm not resulting in abnormal gait or spinal contour. It was noted that magnetic resonance imaging (MRI) performed in October 2011 showed multilevel cervical spondylosis, which was most severe at C3-4, “where a moderate to severe disk outside complex causes mass effect and displacement on the upper cervical cord.” There was no diagnosis of IVDS. Range of motion testing of the cervical spine revealed flexion to 40 degrees, with pain beginning at 30 degrees; extension to 35 degrees, with pain beginning at 30 degrees; left and right lateral flexion to 40 degrees, with pain beginning at 35 degrees on the right and 30 degrees on the left; right lateral rotation to 70 degrees, with pain beginning at 65 degrees; and left lateral rotation to 65 degrees, with pain beginning at 65 degrees. Upon repetition, flexion and extension were limited to 35 degrees, left and right lateral flexion were limited to 40 degrees, and left and right lateral rotation were limited to 65 degrees. There was no evidence of ankylosis. The examiner noted functional loss in the form of pain, weakness, fatigability, and/or incoordination and estimated additional limitation of motion during flare-ups and with repeated use over time to be approximately 5 to 10 degrees. The Veteran underwent another VA examination in January 2015, during which he reported constant neck pain, which worsened with sleeping and prolonged sitting and computer use. A physical examination revealed no evidence of localized tenderness, pain on palpation, muscle spasm, guarding, or pain with weight bearing. There was no diagnosis of IVDS. Range of motion testing of the cervical spine revealed flexion to 45 degrees, extension to 45 degrees, left and right lateral flexion to 45 degrees, and left and right lateral rotation to 80 degrees, with pain noted on extension and lateral flexion. There was no evidence of ankylosis. The examiner indicated that the Veteran’s examination was conducted after repetitive use over time, but he was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups, as the Veteran was not evaluated during a flare-up, and an opinion on the matter would be mere speculation. The Veteran underwent a third VA examination in June 2017, during which he reported constant waxing and waning pain at the base of the posterior neck, which he described as sharp and throbbing. He characterized his pain as ranging from a 5 to 10, out of 10, in severity. A physical examination revealed pain to palpation of the posterior spinous process, but no muscle spasm or guarding. There was no diagnosis of IVDS. Range of motion testing of the cervical spine revealed flexion to 45 degrees, extension to 45 degrees, left and right lateral flexion to 45 degrees, and left and right lateral rotation to 80 degrees, with no additional limitation upon repetition. Pain was noted in all directions. There was no evidence of ankylosis. A review of the Veteran’s treatment records does not reveal symptoms more severe than those documented during the VA examinations. Upon review of the record, the Board finds that restoration of the 20 percent rating is warranted. The record shows that the Veteran has continued to report constant, sharp, throbbing pain at the base of the neck, and VA examiners observed objective evidence of pain with motion in all directions. Resolving all doubt in favor of the Veteran, the Board finds that evidence of record does not reflect improvement in the Veteran’s ability to function under the ordinary conditions of life and work. Therefore, the 20 percent rating is restored. Upon review of the record, the Board finds that a rating higher than 20 percent is not warranted at any point during the period under review. Even considering the Veteran’s subjective complaints of pain and other symptoms described in DeLuca, forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine has not been shown such that a higher rating would be warranted. See Thompson, 815 F.3d at 786. Forward flexion was, at worst, to 35 degrees after three repetitions during the January 2014 VA examination. Even considering the examiner’s estimate of an additional 5 to 10 degrees of limitation during flare-ups, forward flexion would be, at worst, to 25 degrees. Accordingly, a rating in excess of 20 percent is not warranted at any point during the period under review. Additionally, the evidence of record does not demonstrate IVDS resulting in incapacitating episodes. Therefore, a higher rating is not warranted under the IVDS formula. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board has also considered whether a separate rating is warranted for an associated neurological. However, the issue of entitlement to a separate compensable rating or ratings for upper extremity radiculopathy is remanded, and the record shows no other neurological deficits associated with the Veteran’s service-connected cervical spine disability. 2. Restrictive lung disease Te Veteran’s service-connected restrictive lung disease has been assigned a noncompensable rating under the criteria set forth in the General Rating Formula for Restrictive Lung Disease. Pursuant to the General Rating Formula for Restrictive Lung Disease, a 10 percent rating is warranted where the forced expiratory volume in one second (FEV-1) is 71 to 80 percent predicted; or where the ratio of FEV-1 to forced vital capacity (FVC) (FEV-1/FVC) is 71 to 80 percent; or where diffusion capacity of the lung for carbon monoxide by the single breath method (DLCO (SB)) is 66 to 80 percent predicted. 38 C.F.R. § 4.97, Diagnostic Code 6845. A 30 percent rating is warranted for FEV-1 of 56 to 70 percent predicted; or FEV-1/FVC of 56 to 70 percent; or DLCO (SB) of 56 to 65 percent predicted. Id. A 60 percent rating is warranted for FEV-1 of 40 to 55 percent predicted; or FEV-1/FVC of 40 to 55 percent; or DLCO (SB) of 40 to 55 percent predicted; or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). Id. A 100 percent rating is warranted for FEV-1 of less than 40 percent predicted; or FEV-1/FVC of less than 40 percent; or DLCO (SB) of less than 40-percent predicted; or maximum exercise capacity of less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation); or cor pulmonale (right heart failure); or right ventricular hypertrophy; or pulmonary hypertension (shown by Echo or cardiac catheterization); or episode(s) of acute respiratory failure; or required outpatient oxygen therapy. Id. When evaluating based on pulmonary function testing (PFT), post-bronchodilator results should be applied to the rating criteria unless post-bronchodilator results were poorer than the pre-bronchodilator results, in which case the pre-bronchodilator results should be used. 38 C.F.R. § 4.96(d)(5) (2019). If the DLCO (SB) test is not of record, the lung disability should be evaluated based on alternative criteria, as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96(d)(2) (2019). When there is a disparity between the different PFTs so that the level of evaluation would differ depending on which test would be used, VA should use the test result that the examiner states most accurately reflects the level of disability. 38 C.F.R. § 4.96(d)(6) (2019). Upon review of the record, the Board finds that a compensable rating for restrictive lung disease is not warranted at any time during the period under review. The Veteran underwent a VA respiratory examination in January 2014, during which he reported symptoms of shortness of breath. PFTs revealed FEV-1 of 88 percent predicted and FEV-1/FVC of 102 percent, which the examiner indicated were indicative of no limitation in pulmonary function. The examiner indicated that the DLCO test was not indicated for the Veteran’s condition and that the FEV-1/FVC most accurately reflected the Veteran’s current pulmonary function. As the Veteran’s FEV-1/FVC was greater than 80 percent, the PFTs performed during the January 2014 VA examination warrant a noncompensable rating. The Veteran underwent another VA respiratory examination in January 2015, during which he reported symptoms of wheezing and shortness of breath. He also reported having a prescription for inhalers, but he stated that he did not use them. The examiner indicated that the Veteran did not appear to have restrictive lung disease, as restrictive lung disease causes a reduced total lung capacity (TLC), and the Veteran’s TLC was well within normal limits. PFTs revealed FEV-1 of 99 percent predicted, FEV-1/FVC of 95 percent predicted, and DLCO of 71 percent predicted. The examiner indicated that the DLCO most accurately reflected the Veteran’s level of disability; however, DLCO should not be used in the Veteran’s case due to his anemia. The examiner indicated that the hematocrit adjusted DLCO (DLCO/VA) should instead be used in the Veteran’s case. As the examiner indicated that the DLCO is not appropriate in the Veteran’s case, the Board finds that a compensable rating is not warranted based on the DLCO of 71 percent. Moreover, as the examiner indicated that the Veteran’s DLCO/VA of 102 was well within normal limits, the Board finds that a compensable rating is not warranted based on the results of the January 2015 PFTs. The Veteran underwent another VA examination in June 2017, during which he reported having to get up and move around to “loosen things up” in his lungs if he sat too long. The examiner indicated that such was not a typical symptom of restrictive lung disease, and the Veteran exhibited no symptoms of cough, shortness of breath, or wheezing. PFTs revealed FEV-1 of 94 percent predicted, FEV-1/FVC of 78 percent, DLCO of 65 percent predicted, and DLCO/VA of 84 percent predicted, which the examiner indicated were normal. The examiner noted that while the Veteran’s DLCO was mildly decreased, his DLCO/VA was normal, and DLCO is not typically used as a sole indicator of lung function; therefore, the mildly decreased DLCO was of no clinical significance. The examiner further indicated that FEV-1 most accurately reflected the Veteran’s disability level based on the condition being evaluated. As the Veteran’s FEV-1 was greater than 80 percent predicted, the Board finds that a compensable rating is not warranted based on the results of the June 2017 PFTs. Additionally, a review of the Veteran’s treatment records does not reveal symptoms more severe than those noted during the VA examinations. Accordingly, a compensable rating for restrictive lung disease is denied. 3. Tension headaches The Veteran’s tension headaches have been assigned a noncompensable rating under Diagnostic Code 8100, relating to migraine headaches. Under Diagnostic Code 8100, a noncompensable rating is warranted for less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A 10 percent rating is warranted for characteristic prostrating attacks averaging one in two months over the last several months. Id. A 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. Id. A maximum 50 percent rating is warranted for very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. Id. Dorland’s Medical Dictionary defines “prostration” as “extreme exhaustion or powerlessness.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1531 (32nd ed. 2012). Upon review of the record, the Board finds that compensable rating for tension headaches is not warranted at any point during the period under review. The Veteran underwent a VA examination in January 2014, during which he reported daily tension headaches with symptoms of lightheadedness and sometimes nausea and severe fatigue, for which he took Tylenol. He denied any characteristic prostrating attacks of migraine or non-migraine headache pain. The Veteran underwent another VA examination in June 2017, during which he stated that his head was always hurting. He described the pain as ranging from dull to sharp and ranging from a 4 to 8, out of 10, in severity. He denied any characteristic prostrating attacks of migraine or non-migraine headache pain. The Veteran’s treatment records show that he reported symptoms of headache and sinus pressure in May 2014, and the assessment was allergic rhinitis. Otherwise, treatment records show no mention of headaches during the appeal period, and he denied having headaches in February 2014 and March 2014. As the record does not show characteristic prostrating attacks averaging one in two months over the last several months, the Board finds that a compensable rating for tension headaches is not warranted at any time during the period under review. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). 4. Entitlement to service connection for a bilateral foot disability. The Veteran seeks service connection for bilateral calcaneal spurs, which he asserts were incurred during service. In a January 2012 written statement, he indicated that he was diagnosed with and treated for bilateral calcaneal spurs in January 1991. He also submitted a May 2015 written statement from his son, who recalled the Veteran having problems with his feet while on active duty. Upon review of the record, the Board finds that service connection for surgical scars on the left heel and right second toe is warranted; however, the evidence of record does not show that the Veteran has a current foot disability other than surgical scars. Service treatment records show that the Veteran complained of foot pain on several occasions during service, and x-rays performed in March 1990 revealed a large inferior calcaneal spur on the left. The Veteran was also diagnosed with intractable plantar keratosis on the second and fifth metatarsophalangeal joints of the right foot in March 1990. In January 1991, he underwent a right second and fifth metatarsal head resection and surgery to remove his left calcaneal spur. Thereafter, he was placed on physical profile for a post-surgical heel spur through March 1991. A November 1995 report of medical history shows that the Veteran reported having or ever having had foot trouble. The physician’s summary and elaboration of pertinent data notes that the Veteran had a heel spur and underwent foot surgery during service. A November 1995 report of medical examination indicates that the Veteran’s feet were normal upon his retirement. However, a one-inch scar was noted on the medical left heel, and a one-and-a-half-inch scar was noted on the right second toe. Post-service treatment records do not show a diagnosis of calcaneal spurs or any other foot disability. The Veteran underwent a VA foot examination in January 2015, during which he reported having a left calcaneal spur removed and a right foot deformity corrected during service. He also reported current symptoms of foot pain and pointed a scar on the top of his right second distal metatarsal joint. X-rays of booth feet revealed no calcaneal spurs, arthritis, or any other significant findings, and there was no evidence of functional loss related to the Veteran’s reported foot pain. The examiner indicated that the Veteran was diagnosed with calcaneal spurs during service, but he did not have a current diagnosis of a foot disability. Although the Veteran is competent to report symptoms of foot pain, the diagnosis of a disability manifested by such symptoms requires medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis of a current foot disability not competent medical evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis or etiology). Additionally, the Board acknowledges that pain resulting in functional impairment can constitute a disability even without an identified underlying diagnosis. See Saunders v. Wilkie, 866 F.3d 1356, 1367-68 (Fed. Cir. 2018). However, in this case, there is no objective evidence of foot pain resulting in functional impairment. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that “[i]n the absence of proof of a present disability, there can be no valid claim”). As there is no competent evidence of record showing that the Veteran has a current foot disability other than surgical scars from his in-service foot surgeries, there is no basis upon which service connection can be awarded for a foot disability other than surgical scars. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Accordingly, service connection for surgical scars on the feet is granted; however, service connection for a foot disability other than surgical scars is denied. 5. Entitlement to service connection for right hand hyperkeratosis and parakeratosis. The Veteran seeks service connection for right hand hyperkeratosis and parakeratosis. In a January 2012 written statement, he indicated that he was diagnosed with and treated for right hand hyperkeratosis, parakeratosis, and acanthosis in September 1997. Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s claimed right-hand hyperkeratosis, parakeratosis, and/or acanthosis were incurred in or caused by service. Service treatment records show no complaints of treatment for hyperkeratosis, parakeratosis, acanthosis, or any other skin condition on the right-hand during service. A November 1995 report of medical examination shows that the Veteran’s upper extremities were normal upon his retirement, and the only skin conditions noted were three scars. He also denied any history of skin diseases on an accompanying report of medical history. Post-service treatment records show that in September 1997, the Veteran had a skin growth biopsied from the right occiput region of the head, which had been present for about one year. The preoperative diagnosis was as keratin horn. Although the operative findings appear to note a hand skin growth, the pathological report noted marked hyperkeratosis, parakeratosis, and acanthosis on the skin of the right occiput. To the extent that the Veteran believes that he has current skin disability on the right hand that is related to service, as a lay person, he has not shown that he has specialized training enough to render such an opinion. See Jandreau, 492 F.3d at 1377. In this regard, the diagnosis and etiology of a skin condition, which did not appear until approximately nine months after service, are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the etiology of a current skin disability on the right hand is not competent medical evidence. The Board acknowledges that the Veteran has not received a VA examination pursuant to his service connection claim for right hand hyperkeratosis and parakeratosis. However, as there is no evidence of an in-service event, injury, or disease and no competent evidence suggesting that a current skin disability on the right hand is related to service, a VA medical examination or opinion is not required. See 38 C.F.R. § 3.159(c) (2019); see also McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a conclusory lay statement that a current condition is related to service is insufficient to warrant a medical examination because it would “eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations in virtually every veteran’s disability case”). 6. Entitlement to service connection for a left wrist ganglion cyst. The Veteran seeks service connection for a left wrist ganglion cyst. In a January 2012 written statement, he indicated that he was diagnosed with and treated for a left wrist ganglion cyst in February 1999. Upon review of the record, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s left wrist ganglion cyst was incurred in or caused by service. Service treatment records show no complaints of treatment for a left wrist ganglion cyst during service. As previously noted, A November 1995 report of medical examination shows that the Veteran’s upper extremities were normal upon his retirement, and the only skin conditions noted were three scars. On an accompanying report of medical history, he denied any history of skin diseases, growths, or cysts. Post-service treatment records show that in December 1998, the Veteran sought treatment for a possible lipoma or cyst over the left forearm, which had been present for the past few weeks. In February 1999, he underwent a left wrist ganglion cyst excision. During a January 2014 VA examination, the Veteran reported symptoms of left wrist swelling and knots since 1999. He stated that he subsequently underwent surgery and continues to experience tingling, numbness, and pain in the left wrist. To the extent that the Veteran believes that his left wrist ganglion cyst was related to service, as a lay person, he has not shown that he has specialized training enough to render such an opinion. See Jandreau, 492 F.3d at 1377. In this regard, the diagnosis and etiology of a ganglion cyst, which did not appear until nearly two years after service, are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the etiology of his left wrist ganglion cyst is not competent medical evidence. The Board acknowledges that VA has not obtained a medical opinion with respect to the Veteran’s service connection claim for a left wrist ganglion cyst. However, as there is no evidence of an in-service event, injury, or disease and no competent evidence suggesting that the Veteran’s left wrist ganglion cyst is related to service, a VA medical opinion is not required. See 38 C.F.R. § 3.159(c) (2019); see also McLendon, 20 Vet. App. at 84; Waters, 601 F.3d at1278. 7. Entitlement to service connection for a right fifth finger disability. The Veteran seeks service connection for a disability of the right fifth finger, which he asserts was incurred during service. Upon review, the Board finds that the evidence of record does not show that the Veteran has a current disability of the right fifth finger. Service treatment records show that the Veteran hit a wall while playing basketball in July 1978. A physical examination revealed swelling at the proximal interphalangeal joint of the right fifth finger and a small abrasion above the joint. The diagnosis was a soft tissue injury. The Veteran was advised to use a splint and ice, followed by heat, and to return as needed. Thereafter, the record shows no complaints of or treatment for symptoms related to the right fifth finger during service, and a November 1995 report of medical examination shows that the Veteran’s upper extremities were normal upon his retirement. On an accompanying report of medical history, he denied any swollen or painful joints or bone, joint, or other deformity. Post-service treatment records show no treatment for or diagnosis of a right fifth finger disability, and the Veteran has not reported any current symptoms that he attributes to the July 1978 in-service finger injury. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. See Brammer, 3 Vet. App. at 225. As there is no competent evidence of record showing that the Veteran has a current disability of the right fifth finger, there is no basis upon which service connection can be awarded. See Degmetich, 104 F.3d at 1333. Accordingly, service connection for a right fifth finger disability is denied. 8. Entitlement to service connection for a lung disability other than restrictive lung disease, to include emphysema, asthma, chronic bronchitis, and COPD. Service connection has already been granted for restrictive lung disease. However, the Veteran also seeks service connection for emphysema, asthma, chronic bronchitis, and COPD, which he asserts were incurred during service. Upon review, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of emphysema, asthma, chronic bronchitis, or COPD. Service treatment records show that the Veteran reported exposure to asbestos in December 1980 and underwent pulmonary function testing. Spirometry performed in March 1981 revealed decreased FVC and maximum voluntary ventilation (MVV). The assessment was mild restrictive lung disease, and full lung volumes and diffusion studies were recommended. A chest x-ray performed in March 1981 was normal. A February 1990 spirometry report notes that the Veteran’s pulmonary function was within normal limits. In October 1990, the Veteran sought treatment for a cold, chest congestion, sore throat, and some coughing. The impression appears to have been bronchitis versus mild asthma. Later that month, it was noted that the Veteran’s cough was improving, but the treatment provider noted symptoms of wheezing. The impression again appears to have been bronchitis versus asthma. Post-service treatment records show that in December 1996, the Veteran reported symptoms of wheezing, and he was diagnosed with asthma and upper respiratory infection (URI). A May 1997 treatment record notes symptoms of mild wheezing. In June 1997, the Veteran complained of coughing and wheezing, and the assessment was bronchitis. In January 1997, he reported symptoms of coughing, headache, chills, runny nose, and slight wheezing, and he was diagnosed with URI. In January 1999, he reported symptoms of a productive cough and was diagnosed with bronchitis/URI. A June 2001 treatment record shows that the Veteran reported a cough for the past week. It was noted that he smoked a half a pack of cigarettes a day for the past 17 years and had no history of asthma. The assessment was bronchitis. In July 2001, the Veteran reported a recurrent cough for the past two months, and a chest x-ray revealed hypolucent and hyperinflated lung fields with flattened diaphragms, which was consistent with COPD. The impression was COPD and emphysema. In November 2002, the Veteran reported symptoms of a productive cough, congestion, and difficulty breathing. He reported possibly having emphysema; however, it was noted that the diagnosis had not been confirmed. A February 2004 treatment record shows that the Veteran complained of a cough, chest congestion, body aches, and headaches for the past five days. The assessment was bronchitis/atypical pneumonia and tobacco use. In February 2005, the Veteran reported having a cough, but no shortness of breath. Subsequent treatment records show that the Veteran reported minimal cough and denied any dyspnea in May 2009 and June 2009. He denied any symptoms of dyspnea, cough, or wheezing in July 2010, November 2010, and August 2011. In December 2011, he denied any cough, shortness of breath, or dyspnea on exertion. Treatment records do not show any treatment for or diagnosis of a lung disorder during the course of the Veteran’s claim, which was filed in January 2012. Indeed, he denied symptoms of dyspnea and cough in February 2014, March 2014, September 2014, and March 2015. The Veteran underwent a VA respiratory examination in January 2014, during which he reported being diagnosed with emphysema, mild restrictive lung disease, asthma, and COPD 10 years earlier. He reported current symptoms of shortness of breath. A chest x-ray was negative, and PFTs revealed no limitation in pulmonary function. The examiner indicated that the Veteran was diagnosed with COPD in 2001, but he did not have a diagnosis of asthma, emphysema, or chronic bronchitis. The Veteran underwent another VA respiratory examination in January 2015, during which he reported symptoms of wheezing and shortness of breath. He also reported having a prescription for an Albuterol inhaler, but stated that he did not use it. The examiner indicated that the Veteran did not appear to have restrictive lung disease, as restrictive lung disease will show a reduced TLC, and the Veteran’s TLC was well within normal limits. It was noted that his FEF25-75% was lower than predicted, which suggests small airway disease or a mild obstructive pattern; however, it has not been definitively determined that early onset asthma will show a reduced FEF25-75% in the setting of a normal FVC, FEV1, and FEV1/FVC. The examiner indicated that based on a review of the Veteran’s service treatment records, he did not have a pulmonary condition that was incurred in or caused by service, as there was only one in-service consult discussing restrictive lung disease, which was clearly not present during the VA examination. The examiner further noted that the Veteran did not have chronic bronchitis, emphysema, or COPD at the time of the examination. The Veteran underwent another VA examination in June 2017, during which he reported having to get up and move around to “loosen things up” in his lungs if he sits too long. He exhibited no symptoms of cough, shortness of breath, or wheezing, and he denied using any medications to treat a lung condition. PFT testing was normal. The examiner indicated that the Veteran’s DLCO was mildly decreased; however, the DLCO/VA was normal, and since DLCO is not typically used as a sole indicator of lung function, the Veteran’s mildly decreased DLCO was of no clinical significance. The examiner indicated that the Veteran did not have a current diagnosis of a lung condition. Although the Veteran’s post-service treatment records note diagnoses of asthma, COPD, emphysema, and bronchitis, the Board finds that these diagnoses are not sufficiently proximate to the Veteran’s claim to support a finding that he has a current lung disability. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). Notably, these diagnoses were rendered over seven years before the Veteran filed his service connection claim in December 2012. Furthermore, subsequent treatment records show that the Veteran denied symptoms of cough, shortness of breath, and dyspnea on exertion, and his prescription for Albuterol was never refilled after it expired in 2014. Moreover, the Veteran underwent three VA examinations during the course of his claim, which included PFT testing, and none of the VA examiners who evaluated the Veteran indicted that he currently had objective evidence of emphysema, asthma, chronic bronchitis, or COPD. Although the January 2015 VA examiner noted that the Veteran’s FEF 25-75% level could suggest small airway disease or a mild obstructive pattern, no diagnosis of a lung disability was provided, and subsequent PFT testing was within normal limits. Accordingly, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of emphysema, asthma, chronic bronchitis, or COPD. Although the Veteran is competent to report symptoms of a cough and/or breathing problems, the diagnosis of a disability manifested by such symptoms requires medical expertise to determine. Thus, the opinion of the Veteran regarding the diagnosis of a current lung disability is not competent medical evidence. See Jandreau, 492 F.3d at 1376-77. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. See Brammer, 3 Vet. App. at 225. As there is no competent evidence of record showing that the Veteran has a current lung disability other than his already service-connected restrictive lung disease, there is no basis upon which service connection can be awarded. See Degmetich, 104 F.3d at 1333. Accordingly, service connection for emphysema, asthma, chronic bronchitis, and COPD is denied. REASONS FOR REMAND 1. Entitlement to a separate compensable rating or ratings for upper extremity radiculopathy is remanded. The record shows that the Veteran has reported symptoms of numbness and tingling in the upper extremities, and the January 2015 VA examiner indicated that the Veteran had symptoms of radiculopathy in the form of mild intermittent pain and paresthesias and/or dysthesias in both upper extremities. However, when asked to characterize the severity of the Veteran’s radiculopathy, the examiner checked the box indicating “not affected.” Therefore, the Board finds that a remand is necessary in order to determine the nature and severity of the Veteran’s reported upper extremity numbness and tingling. 2. & 3. Entitlement to service connection for gastritis and duodenal ulcer is remanded. Service treatment records show multiple complaints of chronic stomach/abdominal pain, epigastric pain, nausea, and vomiting during service. In May 1990, the assessment was a duodenal ulcer. In January 1991, it was noted that the Veteran had ulcer/gastritis symptoms for the past month. In February 1991, the assessment was rule out dyspepsia, medicine-induced gastritis, and ulcer. In March 1995, the assessment was gastritis. In June 1997, the assessment was possibly ulcers. In October 1997, he was treated for an H. pylori infection. Post-service treatment records show that an upper endoscopy performed in June 2009 revealed evidence of gastritis with erosions, and the Veteran was diagnosed with a hiatal hernia, esophagitis, gastro erosions, and duodenitis. In April 2015, a VA examiner reviewed the evidence of record and opined that it was less likely than not that a duodenal ulcer or gastritis was incurred in or caused by service because the Veteran was not treated for or diagnosed with a duodenal ulcer or gastritis during service. Because the examiner’s rationale is not supported by the evidence of record, the Board finds that a remand is necessary in order to provide the Veteran with a VA examination to determine the nature and etiology of any current gastrointestinal disorder or disorders. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that “[a]n opinion based on an inaccurate factual premise has no probative value”). 4. Entitlement to service connection for a left deltoid strain is remanded. Service treatment records show that the Veteran was diagnosed with a left deltoid muscle spasm in April 1987, and post-service treatment records show that the Veteran reported symptoms of shoulder pain in December 2007. Accordingly, the Board finds that the Veteran should be provided with a VA examination to determine the nature and etiology of a current left shoulder disability. See McLendon, 20 Vet. App. at 84. The matters are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination pursuant to a claim for a separate compensable rating or ratings for upper extremity radiculopathy. All indicated testing must be conducted, and all pertinent symptomatology must be reported. Upon examination and review of the claims file, the examiner should answer the following: a.) Is it at least as likely as not (50 percent probability or greater) that Veteran’s reported symptoms of upper extremity pain, paresthesias, and/or dysthesias are attributable to radiculopathy associated with his service-connected cervical spine disability? Please explain why or why not. b.) If a diagnosis of upper extremity radiculopathy is provided, the examiner should characterize the radiculopathy as mild, moderate, or severe incomplete nerve paralysis, or complete nerve paralysis. 2. Schedule the Veteran for a VA examination pursuant to his claims for service connection for gastritis and duodenal ulcer. Upon examination and review of the claims file, the examiner should answer the following: a.) Identify any diagnoses present associated with the Veteran’s claimed gastrointestinal symptoms. b.) For each gastrointestinal disability diagnosed, is it at least as likely as not (50 percent probability or greater) a continuation of or otherwise related to the Veteran’s in-service complaints of chronic stomach/abdominal pain, epigastric pain, nausea, and/or vomiting? Please explain why or why not. 3. Schedule the Veteran for a VA examination pursuant to his claim for service connection for a left deltoid muscle strain. Upon examination and review of the claims file, the examiner should answer the following: a.) Identify any diagnoses present associated with the Veteran’s left shoulder/deltoid. (Continued on the next page)   b.) For any disability diagnosed, is it is at least as likely as not (50 percent probability or greater) a continuation of or otherwise related to the Veteran’s in-service deltoid muscle spasm? Please explain why or why not. A.M. CLARK Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Banister, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.