Citation Nr: 21000744 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 15-16 392 DATE: January 6, 2021 ORDER Entitlement to service connection for a left foot disability is granted. Entitlement to an increased disability rating for left knee strain in excess of 10 percent is denied. Entitlement to an increased disability rating for right knee strain in excess of 10 percent is denied. Entitlement to an increased disability rating for degenerative joint disease of the back in excess of 20 percent prior to January 22, 2020 and in excess of 40 percent thereafter is denied. Entitlement to an initial evaluation greater than 20 percent for detrusor instability associated with urinary frequency is denied. REMANDED Entitlement to service connection for a right foot disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence shows symptoms of the Veteran’s left foot disability manifested within one year of separation from service and continuity of symptoms of the disability have been shown since service. 2. Flexion of the Veteran’s left knee, even with pain and after repetitive testing, is greater than 30 degrees and extension is not limited to 15 degrees. 3. Flexion of the Veteran’s right knee, even with pain and after repetitive testing, is greater than 30 degrees and extension is not limited to 15 degrees. 4. For the prior to January 22, 2020, forward flexion of the lumbar spine, even with pain and after repetitive testing, is greater than 30 degrees, the combined range of motion of the lumbar spine is greater than 120 degrees, and there is no ankylosis of the lumbar spine. There is also no evidence of incapacitating episodes related to intervertebral disc syndrome. 5. For the period following January 22, 2020, even with pain and after repetitive testing, there is no evidence of ankylosis of the lumbar spine. There is also no evidence of incapacitating episodes related to intervertebral disc syndrome. 6. The Veteran’s detrusor instability has been shown to require the wearing of absorbent material which must be changed less than 2 times per day; daytime voiding every 1-2 hours, with voiding 3 times per night; and no evidence of obstructed voiding. CONCLUSIONS OF LAW 1. The criteria for service connection for a left foot disability have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an increased disability rating for a left knee strain in excess of 10 percent have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 and 5261. 3. The criteria for an increased disability rating for a right knee strain in excess of 10 percent have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 and 5261. 4. The criteria for an increased disability rating for degenerative joint disease of the back in excess of 20 percent prior to January 22, 2020 and in excess of 40 percent thereafter have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5235-5242. 5. The criteria for an increased disability rating for detrusor instability associated with urinary frequency in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.27, 4.115a, 4.115b, Diagnostic Code 7512. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1984 to November 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in November 2018. A transcript of the hearing has been associated with the record. Service Connection 1. Entitlement to service connection for a left foot disability The Veteran contends that his left foot disability, to include pes planus and arthritis, is related to active service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the claimed in-service disease or injury and the present disability. See, e.g., Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. § 1101, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, arthritis is a chronic disease. 38 U.S.C. § 1101. Therefore, section 3.303(b) is potentially applicable. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). The Veteran contends that symptoms of his left foot disability began during service. The Veteran’s service treatment records (STRs) show an August 1987 complaint of irritation of the second toe on the left foot. An October 2004 record indicates that the Veteran twisted his left ankle, causing pain in the foot and ankle with walking. The post-service evidence of record related to the Veteran’s left foot disability includes an April 2005 record documenting treatment for pes planus within 1 year after active service; a September 2009 record noting mild degenerative changes of the metatarsophalangeal joint; a November 2009 diagnosis of left foot hallux limitus; and the Veteran’s April 2005 statement that he was told by his physician that his flat feet were related to his knees, feet, and back disabilities. The Veteran was afforded a VA examination in January 2020. The examiner noted that the evidence confirmed that the Veteran had left foot issues including pes planus, hallux limitus requiring surgery, and that he was diagnosed with arthritis between 2005-2009. The examiner added that this evidence shows that the Veteran’s symptoms began within the first year of his separation from active service. The examiner concluded that it is at least as likely as not that the Veteran’s left foot disability was incurred in or is related to active service. The medical evidence of record also includes a September 2020 opinion that was requested to clarify the findings of the January 2020 examiner. The September 2020 examiner concluded that the Veteran’s left foot disability was not related to active service; noting that treatment of the Veteran’s feet in 2017 was several years after his release from service, and no medical encounters were found that would link the Veteran’s foot condition to his time in service. The Board finds that the September 2020 medical opinion was based on an inaccurate factual premise. Notably, the medical evidence shows that the Veteran received treatment for his left foot, to include surgery, on several occasions prior to 2017. Accordingly, this September 2020 opinion is of no probative value. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board further notes that the January 2020 examiner also rendered an opinion which appeared to indicate that the Veteran’s left foot disability was caused or aggravated a service connected disability. Adversely, the September 2020 clarification opinion indicated that the Veteran’s left foot was not aggravated by any service-connected condition. However, neither opinion is relevant as the grant herein is based on continuity of symptoms of the Veteran’s left foot disability, as arthritis, since separation from active service. The Board finds that the January 2020 examiner’s opinion is the most probative evidence of record, as it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, there is no competent and probative medical opinion of record to refute the findings of the January 2020 opinion. The Board finds that the preponderance of the evidence supports a finding that symptoms of the Veteran’s left foot disability began within one year of separation from active service and have continued since, and that the Veteran has a current diagnosis of arthritis of the left foot. Accordingly, service connection for a left foot disability is warranted. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disability. 38 U.S.C. § 1155. Evaluation of a service-connected disability requires a review of the Veteran's entire medical history regarding that disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59. 2. Entitlement to an increased disability rating for left knee strain in excess of 10 percent 3. Entitlement to an increased disability rating for right knee strain in excess of 10 percent For the period on appeal, the Veteran has been in receipt of a 10 percent rating for each knee under Diagnostic Code 5261 based on limitation of flexion. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The medical evidence of record for the period on appeal consists of December 2009 and January 2020 VA examinations. At the time of the December 2009 examination, the examiner noted that the Veteran was not undergoing treatment for the knees and that x-rays taken in 2005 showed findings that were normal for the Veteran’s age. While the examiner noted pain, there was no evidence of deformity, giving way, instability, pain, stiffness, weakness, incoordination, or decreased speed of joint motion. There was no evidence of dislocation or instability, locking, effusion, inflammation, or flare-ups. Range of motion (ROM) testing showed full extension of the knee and flexion to 125 degrees. During the Veteran’s February 2019 hearing, he described worsening knee pain and denied any instability. He also described decreased motion and pain with exercise. The Veteran was afforded a VA examination in January 2020. The examiner noted a diagnosis of a bilateral knee strain. The Veteran reported daily pain that was a 3-4/10 in severity, with exacerbation in the winter and with physical activity. The Veteran described moderate flare-ups of the knee, 3-4 times a year, that last a couple of days and are alleviated by rest. On ROM testing, flexion of the right knee was measured to 60 degrees with no evidence of pain on movement. The Veteran had full extension of the right knee. Flexion of the left knee was measured to 50 degrees with no evidence of pain on movement. The Veteran also had full extension of the left knee. ROM of the knees was not found to contribute to functional loss. On repetitive-use testing, there was a 10-degree loss of flexion of both knees. Pain was noted to cause functional loss on repetitive use. On repeated use over time, pain was found to significantly limit functional ability in both knees. As to ROM findings of the left knee, flexion was measured to 35 degrees with full extension. Flexion of the right knee was measured to 40 degrees with full extension. On flare-up, pain was also found to significantly limit functional ability in both knees. As to ROM findings of the left knee, flexion was measured to 50 degrees with full extension. Flexion of the right knee was measured to 60 degrees with full extension. Muscle strength testing of the knees showed active movement against some resistance and there was evidence of muscle atrophy. There was no evidence of patellar subluxation or dislocation, instability, recurrent effusion, shin splints, or meniscal conditions. All joint stability testing was normal. The Veteran was noted to use a cane on a constant basis. Passive ROM and non-weight-bearing testing could not be performed due to pain. Based on the evidence of record, the Board finds that an evaluation in excess of 10 percent is not warranted for Veteran’s bilateral knee disabilities. Objective findings from the Veteran's VA examinations are consistent with a 10 percent evaluation, but no greater. Flexion, even with pain and after repetitive testing, is greater than 30 degrees and extension is not limited to 15 degrees in either knee. Deluca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, instability or subluxation, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5257, 5259, 5262, and 5263 do not apply. In reaching this conclusion, the Board has not overlooked the Veteran’s statements with regard to the severity of his disability during this period. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran’s reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board has considered the Veteran’s reports along with findings from the Veteran’s VA examinations. The Board notes, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have, the objective medical findings and opinions provided by the Veteran’s VA examination reports in particular, have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). For the reasons stated above, the Board finds that ratings in excess of 10 percent are not warranted for the Veteran’s right or left knee disability. 4. Entitlement to an increased disability rating for degenerative joint disease of the back in excess of 20 percent prior to January 22, 2020 and in excess of 40 percent thereafter The Veteran was awarded service connection for degenerative joint disease of the back, rated as 20 percent disabling. During the appellate period, he was awarded an increased 40 percent rating for his lower back disability, effective January 22, 2020. The Veteran contends that a rating in excess of 20 percent was warranted prior to January 22, 2020, and in excess of 40 percent thereafter. Spinal conditions are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Codes, 5243. The General Rating Formula provides for a 20 percent disability rating where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis. a 40 percent rating for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243). According to the Formula for Rating IVDS, a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. An "incapacitating episode" is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). If IVDS is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment will be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Id. at Note (2). Period prior to January 22, 2020 The Veteran was afforded a VA examination in December 2009. On range of motion (ROM) testing, forward flexion was measured to 70 degrees; extension to 10 degrees; and right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation were all measured to 30 degrees. There was objective evidence of pain on active ROM. The examiner noted objective evidence of pain following repetitive motion, with no additional loss of ROM. There were no incapacitating episodes of spine disease, ankylosis, guarding, abnormal gait, fatigue, weakness, spasm, pain, or flare-up. The Veteran’s lumbar spine condition was noted to affect his occupational activities. The Veteran’s VA treatment records for this period show complaints of pain and treatment for his lower back disability. However, the treatment records show no evidence of incapacitating episodes of IVDS. Based on the evidence of record, the Board finds that an evaluation in excess of 20 percent for the Veteran’s lumbar spine disability is not warranted. Objective findings from the Veteran's VA examinations are consistent with a 20 percent evaluation, but no greater. Forward flexion, even with pain and after repetitive testing, is greater than 30 degrees, the combined range of motion of the lumbar spine is greater than 120 degrees, and there is no ankylosis of the lumbar spine. Deluca, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. Period following January 22, 2020 At the time of the January 2020 examination, the Veteran reported worsening symptoms, with pain that was 6/10 in severity on average, and was exacerbated by bending. He denied flare-ups, functional loss or impairment. On ROM testing, forward flexion was measured to 40 degrees with pain; extension to 15 degrees with pain; right lateral flexion to 20 degrees; and left lateral flexion, right lateral rotation, and left lateral rotation were all measured to 15 degrees. Pain was also noted on left lateral flexion. Pain was noted to contribute to functional loss, while the Veteran’s ROM itself was not. There was no evidence of pain with weight-bearing or localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was unable to perform repetitive use testing due to pain. Pain was also found to significantly limit functional ability with repeated use over a period of time. ROM after repeated use over time showed forward flexion to 30 degrees; extension to 15 degrees; right lateral flexion to 15 degrees; left lateral flexion to 10 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 15 degrees. There was no evidence of guarding, muscle spasm, muscle atrophy, ankylosis, or IVDS. The Veteran was noted to use a cane on a constant basis for support and balance. The functional impact of the Veteran’s lumbar spine condition was noted as an inability to bend down to connect network cables, sit, or stand for long periods of time. There was no evidence of pain on passive ROM or non-weight bearing testing. The Veteran’s VA treatment records for this period show complaints of pain and treatment for his lower back disability. The treatment records show no evidence of incapacitating episodes of IVDS. Based on the evidence of record, the Board finds that an evaluation in excess of 40 percent for the Veteran’s lumbar spine disability is not warranted. Findings from the Veteran's VA examinations are consistent with a 40 percent evaluation, but no greater. Even with pain and after repetitive testing, there is no evidence of ankylosis of the lumbar spine. Deluca, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. In reaching the above conclusions, the Board has not overlooked the Veteran's statements with regard to the severity of his disability during these periods. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran's reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board has considered the Veteran's reports along with findings from the Veteran's VA examinations. The Board notes, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have, the objective medical findings and opinions provided by the Veteran's VA examination reports in particular, have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). For the reasons stated above, the Board finds that a rating in excess of 20 percent prior to January 22, 2020, and in excess of 40 percent thereafter, is not warranted. 5. Entitlement to an initial evaluation greater than 20 percent for detrusor instability associated with urinary frequency The Veteran's detrusor instability associated with urinary frequency is evaluated under 7599-7512, determining that the DC most analogous was DC 7512, and is to be rated as voiding dysfunction. The criteria for voiding dysfunction are found in §4.115a. Under 38 C.F.R. § 4.115a, a voiding dysfunction can be rated according to urine leakage, frequency, or obstructed voiding. The Veteran’s disability was previously rated as 20 percent disabling according to urinary frequency. Currently, the Veteran’s condition remains rated as 20 percent disabling, based on urine leakage. For urine leakage, a 20 percent rating for a voiding dysfunction is warranted when wearing absorbent materials which must be changed less than two times per day is required. A 40 percent rating is warranted for requiring the wearing of absorbent materials which must be changed two to four times per day. A 60 percent rating is warranted for requiring the use of an appliance or wearing of absorbent materials which must be changed more than four times per day. Urinary frequency has ratings ranging from 10 to 40 percent. A 40 percent rating contemplates daytime voiding intervals of less than one hour, or; awakening to void five or more times per night. A 20 percent rating contemplates daytime voiding intervals between one and two hours, or; awakening to void three to four times per night. A 10 percent rating contemplates daytime voiding intervals between two and three hours, or; awakening to void two times per night. Obstructed voiding has ratings ranging from noncompensable to 30 percent. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. A 10 percent rating contemplates marked obstructive symptomatology, such as hesitancy, slow or weak stream, decreased force of stream, with any one or combination of the following: (1) post void residuals greater than 150 cc.; (2) uroflowmetry; markedly diminished peak flow rate, less than 10 cc/sec; (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. The medical evidence of record for the period on appeal consists of April 2010 and January 2020 VA examinations. At the time of the April 2010 examination, the examiner noted that the Veteran’s detrusor instability associated with urinary frequency was manifested by urinary urgency, dribbling, daytime voiding every 1-2 hours, and voiding 3 times per night. There was no evidence of urinary leakage and physical examination of the Veteran’s genitals was normal. During the January 2020 examination, the Veteran was noted to have a voiding dysfunction due to a neurogenic bladder. The Veteran’s voiding dysfunction was noted to cause urine leakage which requires absorbent material which must be changed less than 2 times per day. The voiding dysfunction did not require the use of an appliance or cause increased urinary frequency. There was no evidence of obstructed voiding. The examiner indicated that the voiding dysfunction did not cause urinary frequency. The Board also notes that the Veteran underwent urodynamic testing in February 2019. However, the records from such testing, which were associated with the claims file in April 2019, do not address urinary frequency during daytime or night, or the frequency of which absorbent materials must be changed. Having carefully considered the medical evidence of record, the Board finds that a disability rating greater than the 20 percent assigned is not warranted. The Veteran’s disability is not manifested by requiring the wearing of absorbent materials which must be changed two to four times per day, to warrant an increased 40 percent rating for urine leakage. At most, the Veteran’s urinary leakage has been shown to require the wearing of absorbent material which must be changed less than 2 times per day. An increased 40 percent rating is also not warranted for urinary frequency, as there is no evidence of daytime voiding intervals of less than one hour, or; awakening to void five or more times per night. At most, the April 2010 examination indicated daytime voiding every 1-2 hours, and voiding 3 times per night. Additionally, there has been no evidence of obstructed voiding during the period on appeal. In reaching this conclusion, the Board has not overlooked the Veteran’s statements with regard to the severity of his disability during this period. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran’s reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). To that extent, the Board notes the Veteran’s testimony during his February 2019 hearing, regarding voiding intervals of less than one hour. The Board has considered the Veteran’s reports along with findings from the Veteran’s VA examinations, particularly that of the January 2020 in-person examination, which showed that the Veteran’s voiding dysfunction did not cause increased urinary frequency. The Board notes, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have, the objective medical findings and opinions provided by the Veteran’s VA examination reports in particular, have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). For the reasons stated above, the Board finds that a rating in excess of 20 percent ais not warranted for the Veteran’s detrusor instability associated with urinary frequency. REASONS FOR REMAND Entitlement to service connection for a right foot disability is remanded. The Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran’s right foot disability was not caused by a service-connected condition; noting only that (s)he was “unable to find evidence to support within file”. No opinion was rendered to address whether the condition was aggravated by a service-connected disability. Accordingly, an addendum opinion was sought to clarify whether the Veteran’s right foot disability was aggravated by a service-connected disability. The Veteran was then afforded an addendum opinion in September 2020. The examiner opined that it was less likely than not that the Veteran’s right foot disability was aggravated beyond its normal progression by a service-connected disability. The examiner indicated that there were no medical encounters of record that would suggest his symptoms worsened over the years, as the only encounter seen was in 2017. However, the Board notes that the Veteran was treated in April 2005 for pain in the right foot, with an assessment of pronation syndrome and plantar fasciitis. Accordingly, the Board finds that the September 2020 medical opinion was based on an inaccurate factual premise, and is therefore incomplete for adjudicative purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Based on the foregoing, remand is warranted to obtain an addendum opinion which addresses the etiology of the Veteran’s right foot disability. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of any bilateral pes planus. The examiner must provide the following opinions: a.) Whether it at least as likely as not that the Veteran’s right foot disability (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. b.) Whether it is at least as likely as not that the Veteran’s right foot disability is (1) proximately due to, or (2) aggravated beyond its natural progression by service-connected bilateral knee strains, left ankle, left foot, or back degenerative joint disease. The examiner’s attention is invited to the following: April 2005 record documenting treatment for pes planus within 1 year after active service, noting pain and an assessment of pronation syndrome and plantar fasciitis; and the Veteran’s April 2005 statement that he was told by his physician that his flat feet were related to his knees, feet, and back disabilities. \ K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Marsh II, Associate 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.