Citation Nr: 20031758 Decision Date: 05/06/20 Archive Date: 05/06/20 DOCKET NO. 13-21 897 DATE: May 6, 2020 ORDER New and material evidence having been received, the application to reopen the claim for service connection for a left ankle disorder is granted. Service connection for bilateral carpal tunnel syndrome (CTS) is denied. Service connection for a gastrointestinal disorder is denied. Service connection for a headache disorder is denied. Service connection for a right foot disorder is denied. An initial rating in excess of 10 percent for right ankle sprain is denied. REMANDED Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected right ankle sprain, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right ankle sprain, is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right ankle sprain, is remanded. FINDINGS OF FACT 1. In a final rating decision issued in October 2007, the Agency of Original Jurisdiction (AOJ) denied service connection for a left ankle disorder. 2. Evidence added to the record since the final October 2007 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim for service connection for a left ankle disorder. 3. Bilateral CTS is not shown to be etiologically or causally related to any disease, incident, or injury in service. 4. A gastrointestinal disorder, attributed to a known clinical diagnosis of gastroesophageal reflux disease (GERD), is not shown to be etiologically or causally related to any disease, incident, or injury in service. 5. A headache disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service. 6. At no time during the pendency of his claim does the Veteran have a current disability of a right foot disorder, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. 7. For the entire appeal period, the Veteran’s service-connected right ankle sprain results in, at most, moderate limitation of motion, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis of the ankle or subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. CONCLUSIONS OF LAW 1. The October 2007 rating decision that denied service connection for a left ankle disorder is final. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2007). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a left ankle disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for bilateral CTS have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a right foot disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for an initial rating in excess of 10 percent for a right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States (U.S.) Marine Corps from June 1974 to June 1978, and a period of federalized active duty in the Arkansas Air National Guard from October 2002 to August 2003. The Veteran performed additional inactive service in the Arkansas Army and Air National Guard during the period from January 1986 to December 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2015, the Veteran and P.C. testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In a May 2016 decision, the Board found no clear and unmistakable error (CUE) in the August 2006, September 2007, and October 2007 rating decisions that denied service connection for low back pain; denied an initial compensable rating prior to November 3, 2010, and in excess of 10 percent thereafter for pseudofolliculitis barbae; denied an application to reopen a claim for service connection for a left ankle disorder; reopened and remanded the claim for service connection for a low back disorder; reopened and denied the claim for service connection for bilateral CTS; denied the claims for service connection for a gastrointestinal disorder, an acquired psychiatric disorder, a headache disorder, and a right foot disorder; and remanded the claims for service connection for a left knee disorder and an initial rating in excess of 10 percent for a right ankle sprain. Thereafter, the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2017 Joint Motion for Partial Remand (JMR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the May 2016 decision as to the above issues that were not remanded by the Board, determining that the decision was premature as all relevant federal records had not been obtained prior to its promulgation. At the parties’ request, the Court did not disturb the Board’s finding of no CUE in the August 2006, September 2007, and October 2007 rating decisions; a determination that new and material evidence had not been received in order to reopen the claims for service connection for low back pain and CTS; and the denial of an initial compensable rating prior to November 3, 2010 and in excess of 10 percent thereafter for pseudofolliculitis barbae. The Court granted the JMR in a February 2017 Order. The claims remanded by the Court in February 2017, as well as the claims remanded by the Board in May 2016, were subsequently returned to the Board for further consideration. In July 2017, the Board remanded all claims to obtain the federal records identified as outstanding and potentially relevant in the parties’ JMR, namely VA treatment records, Social Security Administration (SSA) records, and service department records. As all relevant identified records have been obtained, and that the Veteran was informed of the unavailability of certain service records, this appeal is now ready for further appellate review. 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for a left ankle disorder. As referenced above, the parties moved the Court to vacate the Board’s May 2016 denial of the Veteran’s application to reopen the claim for service connection for a left ankle disorder after determining that the medical evidence relied upon by the Board when rendering this decision was incomplete. Specifically, the parties identified relevant outstanding VA treatment records, SSA records, and service department records, and efforts to obtain these identified records were undertaken by the Board in July 2017. In this regard, VA received the Veteran’s original claim for service connection for a left ankle disorder in March 2007. In an October 2007 rating decision, the AOJ considered his service treatment records from his first period of active duty and private post-service treatment records, and found that, as such records were negative for any complaints, treatment, or diagnosis referable to a left ankle disorder, there was no evidence to demonstrate that a chronic left ankle disorder was incurred in or caused by the Veteran’s military service. Therefore, service connection for such disorder was denied. Later that month, the Veteran was advised of the decision and of his appellate rights, but he did not enter a notice of disagreement with such decision. Additionally, no new and material evidence was physically or constructively associated with the record within one year of the issuance of such decision. While additional service treatment and personnel records were subsequently received, such are irrelevant to the previously decided issue as they are either duplicative of the evidence already of record or are negative for any reference to a left ankle disorder. Therefore, the October 2007 rating decision is final. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2007). Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). As noted previously, the AOJ denied the Veteran’s claim for service connection for a left ankle disorder in October 2007 based on the lack of evidence reflecting that a chronic left ankle disorder was incurred in or caused by the Veteran’s military service, and the January 2011 rating decision and vacated May 2016 Board decision declined to reopen such claim as the evidence of record likewise failed to demonstrate a current left ankle disorder. Indeed, while July 2010 VA left ankle x-rays were interpreted to be normal, subsequent VA left ankle x-rays performed in August 2015 were interpreted to reveal osteophytic spurring. Further, this new evidence, when coupled with the Veteran’s assertions that his current left ankle disorder is secondary to his service-connected right ankle disability, triggers VA’s duty to obtain a medical opinion addressing such theory of entitlement. See Shade, 24 Vet. App. 110. Therefore, the Board finds that the evidence added to the record since the final October 2007 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran’s claim for service connection for a left ankle disorder. Therefore, new and material evidence has been received, and the Veterans claim for service connection for a left ankle disorder is reopened. 2. Entitlement to service connection for bilateral CTS. 3. Entitlement to service connection for a gastrointestinal disorder. 4. Entitlement to service connection for a headache disorder. 5. Entitlement to service connection for a right foot disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. To have basic eligibility for veterans benefits based on a period of duty as a member of a state Army National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States, see 10 U.S.C. § 12401, or must have performed “full-time duty” under the provisions of 32 U.S.C. §§ [315], 502, 503, 504, or 505. See 38 U.S.C. §§ 101(21), (22)(C); see also 32 U.S.C. §§ [315] (providing for detailing of regular members of the U.S. Army and Air Force to duty with the Army or Air National Guard of each State); 502(a)(2) (stating that “each company, battery, squadron, and detachment of the National Guard... shall... participate in training at encampments, maneuvers, outdoor target practice, or other exercises, at least 15 days each year”); 503 (providing for participation in field exercises); 504 (dealing with National Guard Schools and small arms competitions); 505 (dealing with U.S. Army and Air Force schools and field exercises). Allen v. Nicholson, 21 Vet. App. 54, 58 (2007). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to include organic diseases of the nervous system, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term “disability” as used in 38 U.S.C. § § 1110 “refers to the functional impairment of earning capacity, not the underlying cause of said disability,” and held that “pain alone can serve as a functional impairment and therefore qualify as a disability”). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the United States Court of Appeals for Veterans Claims (Court) held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant 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. However, notwithstanding the foregoing laws and regulations, service connection may also be granted for a disability due to a qualifying chronic disability of a Veteran who served in the Southwest Asia Theater of operations during the Persian Gulf War provided that such disability became manifest during either active service in the Southwest Asia Theater of Operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4, not later than December 31, 2016, and by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In this case, the record reflects that the Veteran had service in Southwest Asia from February 2003 to July 2003 during the Persian Gulf War and, therefore, these laws and regulations are applicable to his claims. A chronic qualifying disability means a chronic disability resulting from an (A) undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). For the purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As an initial matter, the Board denied the instant claims in the vacated May 2016 decision. When moving the Court to vacate such decision, the parties agreed that the evidence relied upon by the Board when rendering the decision was incomplete, as efforts were required to obtain relevant outstanding VA treatment records, SSA records, and service department records. As the parties noted no other deficiencies in the record, and for the sake of judicial economy, the Board will focus the instant decision on the above identified areas of deficiency. See generally Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014), vacated on other grounds sub nom Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015). Turning first to the Veteran’s claim for service connection bilateral CTS, as reflected in the vacated May 2016 decision, the Board denied this claim based on the lack of a nexus between the Veteran’s currently-diagnosed bilateral CTS and his military service. In this regard, the Board found that the probative evidence, to include a November 2010 VA opinion, reflected that such disorder had its onset after service and was unrelated to service. Since this decision, the VA treatment records, SSA records, and service personnel records that were recently associated with the record pursuant to the Court mandated development continue to fail to reflect any treatment for CTS during a period of active service or otherwise suggest a relationship to service. With regard to the Veteran’s claim for service connection for a gastrointestinal disorder, per the vacated May 2016 decision, the Board denied the claim because the probative evidence, to include a June 2010 VA examination, reflected that the Veteran’s gastrointestinal symptoms were attributed to a known clinical diagnosis of GERD, thereby failing to show that he had an undiagnosed gastrointestinal illness attributable to his service in Southwest Asia, and such disorder was unrelated to his military service. In such regard, the Veteran’s service treatment records then of record failed to show any related treatment during service or for many years thereafter, the records obtained pursuant to the Court-required development likewise fail to reflect any such in-service treatment or other suggestion of a correlation to service. Pertinent to the Veteran’s claim for service connection for a headache disorder, as reflected in the vacated May 2016 decision, the Board denied this claim based on the fact that the probative evidence of record failed to demonstrate a nexus between the Veteran’s currently-diagnosed tension headaches and his military service. In such regard, the Veteran’s active service treatment records then of record failed to reflect any treatment for headaches, and the Veteran denied a history of headaches when exiting both periods of active service. The newly associated evidence still fails to reflect any such in-service treatment and indicates that the Veteran developed his headache disorder many years after service, with a suggested etiology of post-service cerebritis or encephalitis. With regard to Veteran’s claim for service connection for a right foot disorder, as reflected in the vacated May 2016 decision, the Board denied this claim based on the lack of a current disability. Indeed, the evidence then of record reflected the Veteran’s own assertions that he does not have a current right foot impairment, and the records obtained since that vacatur do not reflect any current indications of a right foot disorder. Based on the foregoing, the Board reasserts its prior conclusions that the preponderance of the evidence is against the Veteran’s claims for service connection for bilateral CTS, and gastrointestinal, headache, and right foot disorders. Therefore, there is no doubt to be resolved on the Veteran’s behalf. Accordingly, the Board concludes that service connection for bilateral CTS, and gastrointestinal, headache, and right foot disorders is not warranted. 6. Entitlement to an initial rating in excess of 10 percent for right ankle sprain. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 ; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59 ; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Throughout the appeal period stemming from the April 6, 2010, date of service connection, the Veteran’s right ankle sprain has been rated as 10 percent disabling, and the most recent supplemental statement of the case indicates that this rating has been continued pursuant to 38 C.F.R. § 4.59, based on the most recent medical evidence reflecting painful, but noncompensable, limitation of right ankle motion. The normal range of motion in the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. Notably, the terms “moderate” and “marked,” as used in the rating criteria to define levels of impairment, are not defined under VA regulations. Those terms also do not appear to have a generally accepted medical definition. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “moderate” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The ankle rating criteria are outlined in 38 C.F.R. § 4.71, DC 5270 through DC 5274. Per DC 5270, ratings are assigned based on evidence of ankle ankylosis; per DC 5271, a 10 percent rating is assigned based on moderate limitation of ankle motion, and a 20 percent rating is warranted for marked limitation of ankle motion; per DC 5272, ratings are assigned based on ankylosis of the subastragalar or tarsal joint); per DC 5273, ratings are assigned based on evidence of malunion of the os calcis or astragalus; and per DC 5274, ratings are assigned based on evidence of astragalectomy. The Veteran’s three right ankle VA examination performed during the rating period (in July 2010, October 2014, and June 2016) all fail to reveal any more than moderate limitation of right ankle motion. Specifically, during all three examinations (which reflect the only recorded right ankle ranges of motion of record), the Veteran consistently demonstrated no limitation of dorsiflexion, with full 20 degrees of dorsiflexion recorded during every examination, and no more than moderate limitation of plantar flexion, with 40 degrees of plantar flexion during his 2010 examination, 20 degrees of plantar flexion during his 2014 examination, and a full 45 degrees of plantar flexion during his 2016 VA examination. Additionally, while some VA examiners noted that the Veteran would experience increased pain on repetitive ankle motion, he demonstrated no additional limitation of motion after several repetitions of his range of ankle motion testing, causing the examiners to opine that the Veteran would not experience an additional right ankle impairment based on functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Moreover, the examiners found no evidence of ankylosis of the right ankle or subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. The Veteran also did not demonstrate an antalgic gait during these examinations, and the Veteran’s gait was noted to be normal in subsequent VA treatment records. Further, the Veteran has not sought VA treatment for his right ankle disability during this appeal period, nor asserted that his right ankle disability has increased in severity since it was last assessed for VA purposes in 2016. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected right ankle disability; however, the evidence indicates the severity of such disability has remained stable throughout the period on appeal. Therefore, assigning staged ratings for such disability is not warranted. Further, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claim addressed herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Given the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran’s right ankle disability is more severe than is contemplated by his assigned 10 percent rating. Accordingly, there is no reasonable doubt to resolve on the Veteran’s behalf, and an initial rating higher than 10 percent for his service-connected right ankle disability is not warranted. REASONS FOR REMAND 7. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected right ankle sprain. As referenced above when reopening this claim, the evidence of record reflects radiographic evidence of a current left ankle disorder, and the Veteran asserts that such disorder is related to a documented in-service injury, or is caused or aggravated by his service-connected right ankle sprain. While the Veteran’ service treatment records are negative for any complaints, treatment, or diagnosis referable to a left ankle disorder (rather it appears that the referenced treatment was for his now service-connected right ankle), it is plausible that the altered biomechanics of one ankle would adversely impact the other. Thus, a VA opinion addressing the likelihood that it is secondary to his service-connected right ankle disability should be obtained. See McLendon, 20 Vet. App. 79 (2006) (holding that an examination is necessary if, inter alia, evidence indicates that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or service-connected disability). 8. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran’s recent VA treatment records reference a depressive disorder and depression among the Veteran’s current problems, and his recently-obtained SSA records include the report of a September 2013 psychiatric evaluation that reflects a diagnosis of PTSD based on the Veteran’s reports of exposure to stressful circumstances during his six months of service in the Persian Gulf. Specifically, the Veteran reported that he engaged in guard duty while stationed in the Persian Gulf and was tasked with checking vehicles for bombs, and a bomb exploded on base when he was not on duty, which triggered PTSD. Based on this evidence, the Board finds the Veteran should be afforded a VA examination to determine if he has an acquired psychiatric disorder related to his military service. See McLendon, 20 Vet. App. 79. 9. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right ankle sprain. In statements of record, the Veteran asserts that he developed his currently diagnosed low back disorder as a result of the cumulative impact of his in-service physical duties, which he describes as “playing war games” while wearing heavy backpacks and other gear. As the November 2010 and June 2016 VA opinions of record addressing the etiology of the Veteran’s back disorder does not address such theory of entitlement, but rather focuses on whether his current back disorder is related to his acute in-service back injuries or secondary to his right ankle sprain, a new medical opinion addressing the Veteran’s theory of service connection must be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 10. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right ankle sprain. A review of the record reveals that the November 2010 VA opinion that determines that the Veteran’s current left knee disorder is unrelated to service is based on an inaccurate factual premise. In that regard, the VA examiner cited the lack of medical evidence of a left knee impairment since the Veteran’s in-service knee sprain in 1977 until the time of the examination. However, during a November 1992 periodic National Guard medical history report, the Veteran reported experiencing an ongoing left knee impairment. Accordingly, a new medical opinion based on an accurate factual premise must be obtained. See id. The matters are REMANDED for the following action: 1. Forward the record to an appropriate VA clinician for a medical opinion addressing the etiology of the Veteran’s left ankle disorder. The record and a copy of this Remand must be made available to the clinician. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Thereafter, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current left ankle disorder (diagnosed as osteophytic spurring by an August 2015 X-ray) is caused or aggravated by his right ankle sprain. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 2. Afford the Veteran for an appropriate VA examination to determine the nature and etiology of any current acquired psychiatric disorder. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Thereafter, the examiner should address the following inquiries: (A) Identify all of the Veteran’s acquired psychiatric disorders that meet, or have met, the DSM-5 diagnostic criteria at any time since April 2010, or in close proximity thereto, to include depressive disorder noted in his VA treatment records and PTSD diagnosed during a September 2013 SSA psychiatric evaluation. (B) If a diagnosis of PTSD is rendered, the examiner should offer an opinion as to whether such is at least as likely as not (i.e., a 50 percent or greater probability) related to the Veteran’s fear of hostile military or terrorist activity coincident with his service in the Persian Gulf in 2003. (C) For each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disorder had its onset in, or is otherwise related to, the Veteran’s military service. A rationale for any opinion offered should be provided. 3. Forward the record to an appropriate VA clinician for a medical opinion addressing the etiology of the Veteran’s low back disorder. The record and a copy of this Remand must be made available to the clinician. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Thereafter, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current low back disorder (diagnosed as lumbar degenerative joint disease/ degenerative disc disease) had its onset in, or is otherwise related to, his military service, to include the cumulative impact of his in-service physical duties, to include playing war games while wearing rucksacks and other heavy gear. A rationale for any opinion offered should be provided. 4. Forward the record to an appropriate VA clinician for a medical opinion addressing the etiology of the Veteran’s left knee disorder. The record and a copy of this Remand must be made available to the clinician. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Thereafter, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s current left knee disorder (diagnosed as chondromalacia patella syndrome and degenerative joint disease) had its onset in, or is otherwise related to, his military service, to include the cumulative impact of his in-service physical duties, to include playing war games while wearing rucksacks and other heavy gear. When rendering this decision, the examiner is asked to consider and comment on the clinical significance of the following evidence: the Veteran’s December 1977 left knee sprain treatment; November 1992 report of left knee pain when completing a periodic medical history report; July 2010 VA examination diagnosis of left knee degenerative joint disease and chondromalacia patellar syndrome; August 2015 VA x-rays indicating mild to moderate osteoarthritis. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Northcutt, 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.