Citation Nr: 20008484 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 17-59 840 DATE: January 31, 2020 ORDER Entitlement to an initial rating in excess of 10 percent for service-connected left bimalleolar ankle fracture and dislocation is denied; however, effective November 28, 2017, a 20 percent rating, but no higher, is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for Mondor's syndrome and superficial thrombophlebitis is denied. REMANDED Entitlement to an initial, compensable rating for service-connected right cubital tunnel release is remanded. Entitlement to an initial, compensable rating for service-connected lumbar spine strain is remanded. Entitlement to an initial, compensable rating for service-connected left shoulder acromioclavicular (AC) strain is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for right lower extremity sciatica is remanded. Entitlement to service connection for a left toe disability is remanded. FINDINGS OF FACT 1. Prior to November 28, 2017, the Veteran’s left ankle disability was manifested by dorsiflexion limited to no less than 12 degrees and plantar flexion limited to no less than 25 degrees, to include as a result of pain or decreased muscle strength, after repetitive motion, or during flare-ups. 2. From November 28, 2017, the Veteran’s left ankle disability was manifested by dorsiflexion limited to five degrees and normal plantar flexion, but pain, weakness, and other factors resulted in an additional loss of five degrees in dorsiflexion and plantar flexion and the Veteran experienced slightly decreased muscle strength. 3. The Veteran has a current diagnosis of tinnitus, which was first manifested during service and has not been attributed to a clear intercurrent cause. 4. The preponderance of the evidence does not reflect that the in-service diagnoses of Mondor’s disease and superficial thrombophlebitis resulted in a chronic disability during or since service, to include during the pendency of this appeal. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for service-connected left bimalleolar ankle fracture and dislocation have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.124a, DC 5271. 2. From November 28, 2017, the criteria for a 20 percent rating, but no higher, for service-connected left bimalleolar ankle fracture and dislocation have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.124a, DC 5271. 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1111, 1112, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a). 4. The criteria for service connection for Mondor’s syndrome and superficial thrombophlebitis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2005 to October 2014. Increased Rating 1. Entitlement to an initial rating in excess of 10 percent for service-connected left bimalleolar ankle fracture and dislocation In the April 2015 rating decision on appeal, the RO assigned an initial 10 percent rating for the service-connected left ankle disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271, which evaluates limitation of motion of the ankle. The Veteran has appealed the rating assigned to his left ankle disability. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Normal range of motion in the ankle includes dorsiflexion from zero to 20 degrees and plantar flexion from zero to 45 degrees. See 38 C.F.R. § 4.71a, Plate II. The Rating Schedule does not otherwise define “moderate” or “marked;” however, according to MERRIAM WEBSTER, “moderate” means “tending toward the mean or average amount or dimension.” See www.merriam-webster.com/dictionary/moderate. “Marked” means “having a distinctive or emphasized character.” See www.merriam-webster.com/dictionary/marked. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). After review of the evidence, the Board finds the preponderance of the evidence is against the grant of an initial rating in excess of 10 percent; however, effective November 28, 2017, the preponderance of the evidence supports the grant of a 20 percent rating, but no higher. The relevant and probative evidence of record includes VA examinations conducted in January 2015 and November 2017. The Board acknowledges that the Veteran also submitted a Disability Benefits Questionnaire from a private physician, Dr. von Bun, in November 2017; however, the DBQ is incomplete and provides inconsistent information. For example, the DBQ reflects that the Veteran was unable to perform dorsiflexion in the left ankle but also that the maximum range in dorsiflexion was 15 degrees. Similarly, Dr. von Bun responded “yes” regarding the range of motion measurements for left ankle plantar flexion without providing any indication as to the degree of range of motion. Dr. von Bun also indicated that there was a reduction in muscle strength in the left ankle but did not identify the severity of the decreased muscle strength. See November 2017 DBQ. Because of the incomplete and inconsistent responses provided by Dr. von Bun, the Board finds that the probative value of the November 2017 DBQ report is significantly lessened and, as such, will not be considered in evaluating the appropriate rating in this case. The relevant evidence of record shows the Veteran’s left ankle disability has been consistently manifested by pain, stiffness, and limited range of motion. The Veteran has also consistently reported having flare-ups of increased, aching pain in his left ankle with physical activity, such as walking and standing for extended periods of time, and during cold weather. See January 2015 VA Ankle examination; December 2017 VA Ankle examination. During the January 2015 VA examination, the Veteran’s dorsiflexion was limited to 12 degrees, while his plantar flexion was limited to 25 degrees. There was no objective evidence of painful motion; nor was there any additional limitation of function or motion after three repetitions. The January 2015 VA examiner noted that pain and lack of endurance significantly limited the Veteran’s functional ability during flare-ups, but he stated he was unable to describe the additional limitation in terms of range of motion, as it would be variable based upon the severity of the flare-up. Otherwise, the Veteran demonstrated normal muscle strength in the left ankle and there was no evidence of muscle atrophy, ankylosis, or instability in the left ankle joint. During the November 2017 VA examination, the Veteran’s dorsiflexion was limited to five degrees, while his plantar flexion was normal. There was no additional loss of function or motion after repetitive motion. There was, however, evidence of painful motion in dorsiflexion and plantar flexion, as well as pain noted with passive range of motion, weight-bearing, and non-weight-bearing. The examiner noted that pain, fatigability, weakness, and lack of endurance significantly limited the Veteran’s functional ability during flare-ups and with repetitive use over time and estimated an additional loss of five degrees of motion in both instances. That is, the examiner estimated that the Veteran’s dorsiflexion and plantar flexion would be limited to zero and 40 degrees, respectively, during flare-ups and with repetitive use. Objective examination also revealed slightly decreased (4/5) muscle strength in dorsiflexion and plantar flexion; however, there was no evidence of muscle atrophy or instability in the left ankle joint. Based on the foregoing, the Board finds that the evidence dated prior to November 2017 is consistent with the initial 10 percent rating currently assigned for the service-connected left ankle disability. Indeed, the evidence dated prior to November 2017 shows that the Veteran’s range of motion was slightly decreased to 12 out of 20 degrees in dorsiflexion and also decreased to 25 out of 45 degrees in plantar flexion, which is more than half of that plane of excursion. See January 2015 VA examination. The Board finds that this evidence is reflective of no more than a moderate limitation of motion in the left ankle and, in making this determination, again notes there was no evidence of additional functional loss due to pain or repetitive motion at that time. However, the evidence dated from November 28, 2017 reflects that the Veteran’s left ankle limitation of motion increased in severity. Indeed, while the Veteran demonstrated normal plantar flexion to 45 degrees, his plantar flexion was limited to five out of 20 degrees which, on its face suggests more than a moderate limitation of motion in plantar flexion. However, the examiner also noted that additional factors, such as pain, weakness, and fatigability, would additionally limit his movement in both planes of excursion by an additional five degrees, which would result in plantar flexion being limited to zero degrees or, in other words, no movement in plantar flexion. The evidence dated from November 28, 2017 also shows that the Veteran’s muscle strength was slightly limited in dorsiflexion and plantar flexion, which would also likely impact the movement and functional ability in his left ankle. Therefore, after resolving all reasonable doubt in favor of the Veteran, the Board finds the evidence shows symptoms and functional impairment that more nearly approximate marked limitation of motion in the left ankle, which warrants a 20 percent rating under DC 5271, effective November 28, 2017. The higher 20 percent rating is not warranted prior to November 28, 2017 because symptoms consistent with marked limitation of motion are not shown prior to that date, as discussed above. The Board also notes that a 20 percent rating is the highest schedular rating available for limited motion of the ankle under DC 5271 and the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code, including ankylosis of the left ankle. See 38 C.F.R. § 4.71a, DC 5270. Therefore, a rating higher than 20 percent is not warranted at any point from November 28, 2017. In evaluating this claim, the Board has considered the lay and medical evidence of record and, as noted, has resolved all reasonable doubt in favor of the Veteran. Therefore, based on the foregoing, the Board finds that the preponderance of the evidence is against the grant of an initial rating in excess of 10 percent for the service-connected left ankle disability; however, effective November 28, 2017, the preponderance of the evidence supports the grant of a 20 percent rating, but no higher. Service Connection Generally, to establish service connection, a claimant must show: (1) a present 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). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within a specified time period after the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). 2. Entitlement to service connection for tinnitus Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within a specified time period after the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The term “chronic disease” is defined in 38 C.F.R. § 3.309(a); however, the Court of Appeals for Veterans Claims has clarified that the list of chronic diseases in 38 C.F.R. § 3.309(a) also “includes tinnitus, at a minimum where there is evidence of acoustic trauma, as an ‘organic disease[] of the nervous system.’“ Fountain v. McDonald, 27 Vet. App. 258, 260 (2015). During the January 2015 VA examination, the Veteran reported that he experiences recurring tinnitus, which he is competent to report. See Charles v. Principi, 16 Vet. App. 370, 374-375 (2002). Accordingly, the first element of service connection is established. During the January 2015 examination, the Veteran also reported that he first noticed periodic ringing in his ears approximately three to four years ago, which would place the onset of his tinnitus in approximately 2011 when the Veteran was on active duty. While the Veteran stated that he was unaware of the cause or a specific incident that led to the onset of tinnitus during service, he has attributed his tinnitus to exposure to acoustic trauma during service. See September 2019 Brief. In this context, the Board notes that the Veteran’s service personnel records reflect that his military occupational specialty (MOS) was an avionics repair technician and officer, which has a high probability of hazardous noise exposure. Therefore, the Veteran’s in-service noise exposure is conceded and the reported onset of tinnitus during service is considered competent and credible evidence of such. Turning to the question of nexus, the Board notes that the January 2015 VA examiner opined that it is less likely than not that the Veteran’s tinnitus is a result of his military noise exposure. In making this determination, the examiner noted the Veteran did not have a significant shift in his hearing during service and that the Veteran did not report any known cause or specific incident that led to the onset of tinnitus during service, including acoustic trauma. Notably, the VA examiner did not attribute the Veteran’s tinnitus to a non-service-connected disability, to include hearing loss, or any intercurrent or post-service event or injury. Indeed, irrespective of whether the Veteran’s tinnitus was caused by his military noise exposure or hearing loss, the Board notes that the manifestation of tinnitus for the first time in service and its continued or subsequent manifestation following service, without a clear intercurrent cause, permits service connection on a presumptive basis as a chronic disease. 38 C.F.R. §§ 3.303(b), 3.304(b), 3.307(a), 3.309(a). Therefore, service connection for tinnitus is granted. 3. Entitlement to service connection for Mondor's syndrome and superficial thrombophlebitis The Veteran’s service treatment records (STRs) reflect that, in July 2010, the Veteran sought treatment for a penile mass that had been present for two weeks. Objective evaluation revealed a mass on the right side of his penis near the glands and the assessment was Mondor’s disease and mild superficial thrombophlebitis of the penis. The Veteran was advised to use a cool compress and non-steroidal anti-inflammatory drugs (NSAIDs) but to discontinue the use of a supplement that was believed to contribute to the thrombophlebitis and to avoid sexual activity for two weeks. He was also advised that the condition would likely resolve in four to six weeks but to return to the clinic if the vein increased in size, his pain worsened, or he experienced any new symptoms. See July 2010 STR. The Veteran did not seek any further or subsequent treatment for Mondor’s syndrome, superficial thrombophlebitis, or any similar symptoms throughout the remainder of service. In fact, the Veteran did not lodge any relevant complaints during the medical examination conducted in April 2014; nor did physical examination reveal any relevant or similar findings to those noted in July 2010. While the Veteran filed a claim for Mondor’s disease in October 2014, he has not submitted any medical evidence showing treatment for Mondor’s disease or superficial thrombophlebitis since discharge from service and, notably, he has not provided any lay statements or evidence establishing that he continued to experience symptoms of those disabilities during the remainder of service or that those disabilities or symptoms have persisted since discharge from service. Based on the foregoing, the Board finds that the Mondor’s disease and superficial thrombophlebitis diagnosed during service was likely acute and transitory in nature, as clinicians noted that the disability would likely resolve in four to six weeks and the Veteran did not subsequently complain of or seek any treatment, including after separation from service. The lack of evidence showing complaint or treatment for Mondor’s disease or superficial thrombophlebitis during the remainder of service or at any time since service suggests that those disabilities resolved no later than 2010, more than four years before the Veteran filed a claim for VA benefits. The Board acknowledges that VA did not obtain a medical examination or opinion in this case. However, without competent lay or medical evidence indicating that the Veteran currently has the claimed disability or persistent or recurrent symptoms of the claimed disability, a VA examination is not needed. See McLendon v. Nicholson, 20 Vet. App. 79, 81-2 (2006). In this regard, the Board notes that service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Indeed, in the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, service connection for Mondor’s disease and superficial thrombophlebitis is not warranted as the evidence of record does not reflect that those conditions resulted in a chronic disability during service or at any time during the pendency of the claim or just prior to the filing of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). REASONS FOR REMAND 1. Entitlement to an initial, compensable rating for service-connected right cubital tunnel release In the April 2015 rating decision on appeal, the RO granted service connection for right cubital tunnel release, which was noted to be claimed as a right elbow nerve condition. The RO also granted service connection for right carpal tunnel syndrome, status post ulnar nerve transposition and right carpal tunnel release and assigned separate, initial, noncompensable ratings for both disabilities, effective October 2, 2014. The rating for right cubital tunnel release was assigned pursuant to 38 C.F.R. § 4.124a, DC 8516, which evaluates the ulnar nerve, whereas the rating for right carpal tunnel syndrome was assigned pursuant to DC 8515, which involves the median nerve. See April 2015 Rating Decision & Codesheet. In May 2015, the Veteran filed a notice of disagreement (NOD) for several disabilities, including the evaluation of disability assigned for the “right elbow nerve condition,” which the RO accepted as disagreement with only the rating assigned for right cubital tunnel release. See May 2015 NOD; September 2017 SOC. Therefore, only the issue of entitlement to an increased rating for service-connected right cubital tunnel syndrome was certified to the Board for adjudication. The Veteran was afforded a VA Peripheral Nerves examination in November 2017, during which the examiner noted the diagnoses of bilateral carpal tunnel and cubital tunnel syndrome and identified the various symptoms and findings affecting the left and right upper extremities. The VA examiner specifically noted that, in the right upper extremity, the Veteran experienced severe, incomplete paralysis of the median nerve, as well as mild, incomplete paralysis of the ulnar nerve. While the examiner stated that the Veteran’s ulnar nerve impairment was consistent with mild, incomplete paralysis, objective findings, such as muscle strength in wrist flexion and pinch function (thumb to index finger) were reported as normal. However, the examiner noted additional symptoms in the right upper extremity but did not explicitly distinguish the symptoms attributable to the median nerve and ulnar nerve impairments. In January 2018, the RO increased the Veteran’s rating for service-connected right carpal tunnel syndrome to 50 percent, effective November 3, 2017, based upon the VA examiner’s finding of severe, incomplete paralysis of the median nerve. The Board has considered granting a 10 percent rating based upon the November 2017 VA examiner’s finding of mild, incomplete paralysis of the ulnar nerve. However, the Board notes that the evaluation of the same symptoms under various diagnoses, known as pyramiding, is to be avoided. See 38 C.F.R. § 4.14. In this case, the Board finds that the medical evidence does not establish what symptoms are attributed to the service-connected right cubital tunnel release (ulnar nerve impairment), as opposed to the service-connected right carpal tunnel syndrome (median nerve impairment) and, as a result, the Board is unable to determine if the Veteran should be compensated for any symptoms attributable to the right cubital tunnel release disability without engaging in prohibited pyramiding. Therefore, this issue must be remanded for a VA examiner to distinguish separate and distinct symptoms attributable to service-connected right cubital tunnel release (ulnar nerve impairment), if any, from the service-connected right carpal tunnel syndrome (median nerve impairment). 2. Entitlement to an initial, compensable rating for service-connected lumbar spine strain is remanded. 3. Entitlement to an initial, compensable rating for service-connected left shoulder acromioclavicular (AC) strain is remanded. The Veteran was last afforded a VA spine and shoulder examination in January 2015; however, those examinations were not adequate because the range of motion test results provided failed to comply with 38 C.F.R. § 4.59 and the Court’s holding in Correia v. McDonald, 28 Vet. App. 158 (2016). The examination also failed to comply with the holdings in DeLuca v. Brown, 8 Vet. App. 202 (1995) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Specifically, the range of motion testing did not include passive range of motion and the examiners did not provide an adequate opinion or estimate of additional range of motion loss due to pain, weakness, fatigue and/or incoordination during repetitive use or flare-ups. In addition to the foregoing, the evidence of record suggests that the Veteran’s lumbar spine and left shoulder disabilities may have worsened since the January 2015 examinations. In November 2017, the Veteran submitted DBQ’s conducted by a private physician, Dr. von Bun, who noted the Veteran was unable to perform forward flexion, extension, and lateral flexion in either direction with his lumbar spine. He also noted that the Veteran’s abnormal range of motion in his left shoulder contributed to functional loss but also stated that range of motion testing in flexion, external rotation, and internal rotation of the shoulder was “not indicated.” In this regard, the Board notes that the November 2017 DBQs are incomplete and provide inconsistent information regarding the severity of the Veteran’s lumbar spine and left shoulder disabilities; however, the Board is unable to ascertain if the information provided is wholly incorrect. Given the foregoing, the Board finds a remand is needed to afford the Veteran an updated VA examination that evaluates the current nature and severity of his lumbar spine and left shoulder disabilities, to include the additional functional impairment caused during repetitive use and flare-ups. 4. Entitlement to service connection for asthma is remanded. The RO denied this claim on the basis that there was no evidence showing that the Veteran’s asthma, which existed prior to service, was permanently worsened as a result of his military service. In support of this decision, the RO noted that a VA examiner noted the Veteran had childhood asthma; however, the Board is unable to locate any such notation in the VA examinations of record. See May 2010 VA examination report; January 2015 VA examination report. The Board also notes that the June 2005 entrance examination does not reflect that asthma or any other respiratory disability was noted at entry into service. Instead, the STRs show the Veteran complained of initial respiratory symptoms in 2008 and was diagnosed with asthma at that time, without any indication or evidence that his symptoms existed prior to that time. The STRs also show the Veteran was diagnosed with intermittent asthma in May 2014, at which time clinicians noted he was previously diagnosed with asthma in 2008 but no earlier. When no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran’s disability was both preexisting and not aggravated by service. See, e.g., Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The clinician who conducted the January 2015 VA examination noted the in-service diagnoses of asthma but noted that physical examination and PFTs were normal at the time of the examination and that the Veteran did not have any asthma attacks with episodes of respiratory failure in the previous 12 months. As a result, the examiner did not provide a nexus opinion. Despite the VA examiner’s notation regarding the Veteran’s symptoms during the January 2015 examination, the Board notes that there remains a question as to whether the Veteran’s asthma has resolved or if his asthma was dormant at the time of the examination, given that his asthma has been characterized as intermittent. The Board also notes that the diagnosis of intermittent asthma in May 2014 is likely evidence of a “current disability” for the purposes of this claim, as it was rendered no more than five months before the Veteran filed his service connection claim. Therefore, the Board finds a remand is needed to obtain an opinion that clarifies if the Veteran has a current diagnosis of asthma and, if so, whether the current disability is related to his military service. 5. Entitlement to service connection for a right shoulder disability is remanded. The Veteran’s STRs show complaints and treatment for right shoulder pain. However, the RO denied this claim on the basis that there is no evidence of a permanent, residual, or chronic disability in the service or post-service evidence. Since that time, the Veteran has provided medical evidence showing he has been diagnosed with right rotator cuff tendinitis and extensor tendinosis. See November 2017 Disability Benefits Questionnaire (DBQ). There is, however, no medical opinion of record that addresses whether the current right shoulder disabilities are related to the in-service complaints of right shoulder pain. Therefore, a remand is needed to obtain a medical opinion. 6. Entitlement to service connection for right lower extremity sciatica is remanded. During the January 2015 VA Back examination, the Veteran reported having low back pain that “sometimes” radiated into the right lower extremity. Despite the Veteran’s subjective complaints of right lower extremity, the examiner noted the Veteran did not have any radicular pain or other signs or symptoms of radiculopathy. See January 2015 VA Back examination. In this context, the Board finds probative that the Veteran’s current complaints of occasional right lower extremity radiating pain are similar to the symptoms of radiating pain he endorsed having during service, which were the basis of a diagnosis of sciatic radiculopathy. See e.g., January 2006 STRs. The Veteran has also submitted a DBQ completed by a private physician which suggests, but does not sufficient establish, that he has intermittent right sciatica. See November 2017 Back DBQ. The Board also notes that, while the Veteran was afforded a VA Peripheral Nerves examination in January 2015 and November 2017, those examinations were performed solely to evaluate his upper extremity carpal tunnel disability and, thus, did not rule out if the Veteran has right lower extremity sciatica or radiculopathy. Given the foregoing, the Board finds a medical examination and opinion are needed to clarify whether the Veteran has a neurologic condition affecting his right lower extremity, to include radiculopathy or neuropathy, including periodic episodes of such. 7. Entitlement to service connection for a left toe disability is remanded. During the January 2015 VA Foot examination, the examiner noted the Veteran had problems with his left foot during service, which was manifested by discomfort between the third and fourth toes on the plantar aspect of his left foot and was diagnosed as Morton’s neuroma. The examiner noted the Veteran had an operation in 2010 and that he has done well since that time, except for continued discomfort between the toes, which the examiner stated is most likely because of regeneration of the nerve. The Board notes that service connection has been established for Morton’s neuroma; however, there remains a question as to whether the remaining discomfort between the Veteran’s toes is attributable to a separate and distinct disability from his service-connected Morton’s neuroma, to include a nerve degeneration disability. Therefore, a remand is needed to obtain a medical opinion that addresses the question. The matters are REMANDED for the following action: 1. Return the claims file to the clinician who performed the November 2017 VA Peripheral Nerves examination and request that he provide an opinion that distinguishes the symptoms attributable to the Veteran’s service-connected right cubital tunnel release (ulnar nerve impairment) and right carpal tunnel syndrome (median nerve impairment). If the November 2017 VA examiner is no longer available, another appropriate medical professional should be asked to provide the opinion. The need for an additional examination is left to the discretion of the examiner. If the examiner is unable to distinguish the symptoms and impairment attributable to the ulnar and median nerves, he or she must explain why this is so. 2. Schedule the Veteran VA examinations to assess the severity of his lumbar spine and left shoulder disability, which includes testing the range of motion and pain levels in active and passive range of motion and after repetitive use. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flare-ups or repetitive use, and if so, estimate range of motion during flare-ups or repetitive use. If the examination does not take place during a flare-up or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flare-ups or repetitive use and provide the extent of motion loss described in terms of degrees based upon the lay and medical evidence of record. 3. Request that a medical professional review the claims file and obtain a medical opinion that addresses the following: (a) Is there clear and clear and unmistakable (undebatable) evidence that asthma existed prior to service? If so, identify the evidence. (b) If there is clear and unmistakable evidence that asthma pre-existed service, the examiner must also state if there is clear and unmistakable (undebatable) evidence that asthma was not aggravated during service? In other words, is there undebatable evidence that there was no increase in the disability during service or that any increase in disability was due to the natural progress of the pre-existing condition? (c) If the answer to (a) and (b) is no, the examiner should opine whether it is as likely as not (i.e., probability of 50 percent or higher) that the Veteran’s asthma was incurred during or as a result of the Veteran’s military service. (d) If deemed necessary, the examiner may discuss whether the asthma diagnosed during service has resolved or is manifested by periods in which it is active and/or dormant in nature. In doing so, the examiner should identify all evidence that supports his/her conclusion. (e) A complete, well-reasoned rationale should be provided for each opinion offered. 4. Request that an appropriate medical professional review the claims file and provide a medical opinion regarding the Veteran’s right shoulder disability. The need for an examination is left to the discretion of the examining physician. The claims file must be reviewed and the examination report must reflect that such review was accomplished. The examiner is requested to provide an opinion as to each of the following: (a) Identify all right shoulder disabilities manifested and diagnosed during the appeal period, i.e., since October 2014. (b) For each disability identified above, opine whether it is as likely as not (i.e., a 50 percent or greater probability) that the current diagnosis was incurred in or as a result of his military service? In answering the foregoing, the examiner must consider and address the service treatment records, as well as the Veteran’s lay statements. A response must be provided for each of the foregoing questions and well-reasoned rationale must be provided in support of each opinion offered. 5. Schedule the Veteran a VA Peripheral Nerves examination to determine if the Veteran has a neurologic condition affecting his right lower extremity. The claims file must be reviewed and the examination report must reflect that such review was accomplished. All indicated tests and studies should be conducted and, if a neurologic disability is identified, the examiner should identify the specific nerve(s) affected and describe the sensory and functional impairment caused by the disability. The examiner must consider and address the medical and objective evidence in this case, as well as the Veteran’s lay assertions regarding the nature and severity of his right lower extremity symptoms. A complete, well-reasoned rationale should be provided for any opinion offered. 6. Request that an appropriate medical professional review the claims file and provide a medical opinion regarding the Veteran’s left toe symptoms. The claims file must be reviewed and the examination report must reflect that such review was accomplished. The examiner is requested to provide an opinion as to whether it is likely as not (i.e., a 50 percent or greater probability) that the remaining discomfort between the Veteran’s toes identified in the January 2015 VA Foot examination is attributable to a separate and distinct disability from his service-connected Morton’s neuroma, to include a nerve degeneration disability. The need for an additional examination is left to the discretion of the examining physician. In answering the foregoing, the examiner must consider and address the service treatment records, as well as the Veteran’s lay statements as to the nature of his left toe symptoms.   A complete, well-reasoned rationale should be provided for any opinion offered. T.D. JONES Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Turnipseed, 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.