Citation Nr: 21001387 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 17-12 614 DATE: January 7, 2021 ORDER Entitlement to a compensable disability rating for circumcision scarring is denied. Entitlement to a disability rating in excess of 40 percent for right shoulder rotator cuff tear, subacromial/subdeltoid bursitis acromioclavicular joint osteoarthritis claimed as right shoulder disability secondary to service-connected left ankle (aggravated by constant falls due to left ankle) associated with left ankle sprain with instability (previously evaluated as arthritis, left ankle) is denied. Entitlement to service connection for dental/gum problem is denied. Entitlement to service connection for bilateral ear fungus is denied. Entitlement to service connection for bilateral dry eyes is denied. Entitlement to service connection for diverticulitis is denied. Entitlement to service connection for left leg calf atrophy secondary to the service-connected left ankle disability is denied. REMANDED Entitlement to service connection for skin discoloration of the bilateral legs, to include as secondary to his service-connected discogenic disease, lumbar spine also claimed as back condition associated with residuals of left ankle sprain with instability is remanded. Entitlement to service connection for right knee disability, to include as secondary to the service-connected left ankle disability is remanded. FINDINGS OF FACT 1. The Veteran’s circumcision scar measures 9 cm long and 0.2 cm wide for a for a total measurement of 1.8 sq. cm. 2. The Veteran’s circumcision scar is not of the head, face, or neck; is not deep and non-linear; and is not associated with underlying soft tissue damage; nor is it a painful or unstable scar. 3. The Veteran’s right shoulder rotator cuff tear, subacromial/subdeltoid bursitis acromioclavicular joint osteoarthritis claimed as right shoulder disability secondary to service-connected left ankle (aggravated by constant falls due to left ankle) associated with left ankle sprain with instability (previously evaluated as arthritis, left ankle); is rated as 40 percent disabling, which is the maximum schedular rating permitted for limitation of motion of the arm of the major extremity. 4. The preponderance of the evidence of record is against finding that the Veteran has had a dental or gum disability at any time during or approximate to the pendency of the claim. 5. The preponderance of the evidence is against finding that bilateral ear fungus began during active service or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that bilateral dry eyes began during active service or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that diverticulitis began during active service or is otherwise related to an in-service injury or disease. 8. The preponderance of the evidence of record is against finding that the Veteran has had left leg calf atrophy at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for circumcision scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7802. 2. The criteria for a rating in excess of 40 percent for right shoulder rotator cuff tear, subacromial/subdeltoid bursitis acromioclavicular joint osteoarthritis claimed as right shoulder disability secondary to service-connected left ankle (aggravated by constant falls due to left ankle) associated with left ankle sprain with instability (previously evaluated as arthritis, left ankle); have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003, Diagnostic Code 5010, Diagnostic Code 5201. 3. The criteria for service connection for dental/gum disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for bilateral ear fungus are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for bilateral dry eyes are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for diverticulitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for left leg calf atrophy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1975 until his honorable discharge in February 1979. The record reflects that the Veteran had subsequent service in the United States Army Ready Reserve until January 12, 1981. The Veteran subsequently enlisted in the Washington Army National Guard in September 1988 and then transferred to the Puerto Rico Army National Guard effective March 15, 1989. The Veteran was honorably discharged from the Puerto Rico Army National Guard in February 1990. Furthermore, there appears to be an undated transfer from the Puerto Rico Army National Guard to the Florida Army National Guard. See Military Personnel Record received on November 14, 2012, p. 36. The record also indicates that the Veteran was discharged from the Army Reserve in January 1996. However, the record does not reflect if the Veteran was in the Inactive (Ready) Reserve or Active Reserve. These matters come before the Board of Veterans’ Appeals (Board) on appeal from the October 2016 and May 2017 rating decisions by the San Juan, Puerto Rico Regional Office (RO) of the United States Department of Veterans Affairs (VA). In August 2019, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ), sitting at the RO in San Juan, Puerto Rico. A transcript of the hearing has been associated with the record on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 1. Entitlement to a compensable disability rating for circumcision scarring The Veteran asserts that he is entitled to a higher rating because it is still appealable for a compensable disability rating. The Veteran’s circumcision scarring is rated under Diagnostic Code 7802. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7802, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 was otherwise unchanged by the August 13, 2018, amendments. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under Diagnostic Code 7802 because the Veteran’s circumcision scar is not manifest by an area or areas of 144 square inches (929 sq. cm.) or greater. The Veteran was afforded a VA examination in March 2017. The March 2017 VA examination found that the Veteran had a scar around the circumference of the penis and the tip of the penis there is a linear scar that measured 9 cm long and 0.2 cm wide for a for a total measurement of 1.8 sq. cm. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s circumcision scar is not of the head, face, or neck, is not deep and non-linear, and is not associated with underlying soft tissue damage. Moreover, the Veteran’s circumcision scar is not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. During the August 2019 Board hearing, the Veteran testified that his scar does not cause pain but noted that there could be pain of the excessive skin in the scarring area due to friction after sexual intercourse. The Veteran described it as “…there is some irritation and sometimes even a little abrasion.” The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include pain from friction, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that the Veteran’s circumcision scar is manifest by an area or areas of 144 square inches (929 sq. cm.) or greater. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for circumcision scar. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a disability rating in excess of 40 percent for right shoulder rotator cuff tear, subacromial/subdeltoid bursitis acromioclavicular joint osteoarthritis claimed as right shoulder disability secondary to service-connected left ankle (aggravated by constant falls due to left ankle) associated with left ankle sprain with instability (previously evaluated as arthritis, left ankle) The Veteran asserts that he is entitled to a higher rating because his symptoms did not improve with therapy and he has opted to not have a surgical procedure to repair his right shoulder. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. The Veteran’s right shoulder rotator cuff tear is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5201, for limitation of motion of arm. Under Diagnostic Code 5010, arthritis due to trauma, substantiated by x-ray findings shall be rated as arthritis, degenerative. Arthritis, degenerative, is rated under Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion… In the present case, the Veteran is rated under limitation of motion with a 40 percent disability rating. Therefore, Diagnostic Code 5003 is not applicable to the present case because his disability is already compensable. Under Diagnostic Code 5201, limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The evidence of record shows that the Veteran is right-handed. See August 2019 Board Hearing transcript, April 2017 VA Shoulder Examination, and January 2017 VA Shoulder Examination. As the Veteran is in receipt of the highest schedular rating for limitation of motion of the arm of the major extremity, there is no basis to award a higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. As the Veteran already has the maximum schedular disability rating, the appeal is denied. Active Service Active duty for training includes full-time duty with the National Guard of any State under sections 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. See 38 U.S.C. § 101 (22)(C); 38 C.F.R. § 3.6 (c). Basically, this refers to the two weeks of annual training, which each Reservist or National Guardsman must perform each year. It can also refer to the Reservist’s or Guardsman’s initial period of training. Inactive duty training includes service with the National Guard of any State (other than full-time duty) under section 316, 502, 503, 504, or 505 of title 32, or the prior corresponding provisions of law. See 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d); see also Allen v. Nicholson, 21 Vet. App. 54, 57 (2007) (holding that in order to have basic eligibility for VA benefits based on a period of duty as a member of a state National Guard, a National Guardsman must have been ordered into Federal service by the President of the United States under 10 U.S.C. § 12401, or must have performed “full-time duty” under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505); Clark v. United States, 322 F.3d 1358, 1366 (Fed.Cir.2003) (explaining that “members of the National Guard only serve the [F]ederal military when they are formally called into the military service of the United States [and that at] all other times, National Guard members serve solely as members of the State militia under the command of a state governor.”). National Guard duty is distinguishable from other Reserve service in that a member of the National Guard may be called to duty by the governor of his or her state. “[M]embers of the National Guard only serve the Federal military when they are formally called into the military service of the United States [and a]t all other times, National Guard members serve solely as members of the State militia under the command of a state governor.” Allen v. Nicholson, 21 Vet. App. 54, 57 (2007). Therefore, to have basic eligibility as a veteran based on a period of duty as a member of a state National Guard, a guardsman must have been ordered into Federal service by the President of the United States under 38 U.S.C. §§ 316, 502, 503, 504, or 505. Hence, for the appellant’s service in the National Guard, only periods of Federalized service are qualifying service for the purpose of VA compensation benefits. Although the record contains some of the Veteran’s military records, they do not clearly identify periods of qualified military service. The record does contain an injury report from September 1989 in the Puerto Rico Army National Guard identifying an injury that occurred on Wednesday, September 27, 1989 at or about 1439 hours (2:39 pm, local). However, the memorandum of “Report of Investigation in Case of Sickness or Injury (State Active Military Duty)” clearly identifies that the active service was not Federal service. See Service Personnel Records received on November 14, 2012, pp. 5-8. Service Connection Service connection may be granted for a 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(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially 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). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of the disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). As a preliminary matter, the Board notes that the Veteran’s Waseca Federal Prison treatment records reflects an August 28, 2001 and July 30, 2002 record that the Veteran had no medical complaints, no allergies, no current medications, no lice, and the medical provider determined that the Veteran was a healthy male. Subsequently, the next record in the Veteran’s Waseca Federal Prison treatment records was two years later for a complaint of right eye irritation. Finally, in the Veteran’s intake worksheet into Waseca Federal Prison (August 2001), and prior at the Federal Prison Camp in Duluth, Minnesota (January 2000), the Federal Transfer Center (December 1998), he reported chronic ear infections and recurrent back pain, but no other disabilities. However, prior federal records from January 1997 do not reflect any complaints of ear problems with the first history of ear infections in April 1998. 3. Entitlement to service connection for dental/gum problem The Veteran asserts that he required dental treatment and since he did not have dental treatment, he filed this claim. Furthermore, the Veteran asserted in the August 2019 Board hearing that since has previously been rated at 100 percent disabled (effective November 20, 2014), the issue has become moot. First, the Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). As the Veteran noted during his Board testimony, there is no current disability and that he was seeking dental treatment that has since been performed. Furthermore, the Board notes that the record does not reflect a current dental/gun disability at any point during the period on appeal. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. At the core of service connection is functional impairment, which can be a disability even if there is no underlying diagnosis. Consideration should be given to the impact of functional limitation. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no assertion of functional limitation due to the need of dental treatment. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for bilateral ear fungus 5. Entitlement to service connection for bilateral dry eyes Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that he “spent a lot of time in swimming pools; contaminated and uncontaminated lakes; and so on and so forth; and was an instructor for the Red Cross in conjunction with the military…” and that due to the exposure to the contaminated and uncontaminated water, it has caused intermittent bilateral ear fungus and intermittent bilateral dry eye. First, affording the Veteran the benefit of the doubt, the Board finds that there are current disabilities. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran’s VA treatment records reflect that he has been diagnosed with dry eyes and ear infections during the period on appeal. However, even if there was a current disability, the Board finds that there was not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran does not assert, nor does the record reflect an in-service onset of bilateral ear fungus. The Veteran’s STRs, entrance examination, and separation examination reflect a normal clinical evaluation with no complaints of ear fungus disabilities. The Board notes that although the Veteran indicated “Yes” for ear, nose, or throat trouble in his separation examination, the notes in box 25 indicated that the positive indication was an error and the Veteran noted that he was in good health in box 8. See October 1978 Separation Examination. Finally, the Board notes that when asked when his disabilities first manifested, the Veteran testified that his disabilities had been an issue for a while, but worsened approximately 1993 and never asserted or implied that they began in service. The Veteran’s service personnel records reflect that the Veteran trained and certified youths in the Recreation Services Learn To Swim Programs with additional duties to supervise the daily maintenance, sanitation, safety, and overall operation of the swimming pool; noting that the Veteran’s initiative, job knowledge, and attitude towards his job made him an outstanding assert to the Recreation Services Learn to Swim Programs and the United States Army. See Enlisted Evaluation Report (AR 600-200); Fort Hood, Texas (prepared August 1978, signed September 1978). Thus, without more, the preponderance of the evidence is against a finding of an in-service incurrence of ear fungus or dry eye disabilities. The Board notes that the mere act of swimming in a pool does not rise to the level of an in-service event nor is there evidence of exposure to water contamination. Furthermore, the Board notes that the Veteran’s service personnel records reflect that he was responsible for the maintenance of the pool, his September 1978 Enlisted Evaluation Report notes that the Veteran’s performance of these duties resulted in an evaluation superior to most and there was no documentation of pool contamination. Finally, there is no evidence in the record that the Veteran is qualified to determine contamination of water or that he was exposed to contaminated water beyond his lay testimony. The second element of service connection has not been met, and an award of service connection is not warranted. See Holton, supra. Accordingly, service connection is denied. The Board has considered the Veteran’s reports attributing his bilateral ear fungus and bilateral dry eye disabilities to in-service exposure to contaminated water, but the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Therefore, the Veteran is not competent to provide an opinion on the etiology of his bilateral ear fungus nor bilateral dry eye. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for diverticulitis The Veteran asserts that he is entitled to service connection for diverticulitis due to his military occupational specialty (MOS) of long history of mechanized infantry field exposure. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran’s VA treatment records reflect a diagnosis of diverticulitis during the period on appeal. See San Juan, Puerto Rico VAMC treatment records. Second, the Board finds that there was not an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran does not assert, nor does the record reflect an in-service onset of diverticulitis. The Veteran’s STRs, entrance examination, and separation examination reflect normal clinical evaluation with no complaints of diverticulitis disabilities. Thus, without more, the preponderance of the evidence is against a finding of an in-service incurrence of diverticulitis. The second element of service connection has not been met, and an award of service connection is not warranted. See Holton, supra. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to service connection for left leg calf atrophy secondary to the service-connected left ankle disability The Veteran asserts that his left leg calf atrophy is secondary to his service-connected disabilities. First, the Board finds that there is not evidence of a current disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran was afforded a VA examinations in January and October 2016. The VA examiner opined that the Veteran does not have a current diagnosis of left leg calf atrophy. The October 2016 VA examiner opined that after review of the e-file, CPRS charts, the medical literature, and the interview of the Veteran, he determined that the Veteran does not have a diagnosis of left leg calf atrophy and therefore a nexus opinion cannot be rendered. The Board notes that in August 2011, the VA examiner found that the VA examiner found that the Veteran had 5 cm of left calf atrophy. However, that disability appears to have resolved prior to this period on appeal. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. At the core of service connection is functional impairment, which can be a disability even if there is no underlying diagnosis. Consideration should be given to the impact of functional limitation. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no assertion of functional limitation due to left calf atrophy. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 8. Entitlement to service connection for skin discoloration of the bilateral legs, to include secondary to his service-connected discogenic disease, lumbar spine also claimed as back condition associated with residuals of left ankle sprain with instability is remanded. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, has a presumptive disease during the pertinent presumptive period, or is service-connected for a disability that may have caused or aggravated the Veteran’s disability; and (3) indicates that the claimed disability may be associated with the in-service event, injury, disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the Veteran has documented skin discoloration within his VA treatment records during the period on appeal and he is service connected for disabilities that may be related. Because there is evidence of currently diagnosed disabilities, service-connected disabilities, and an indication that the current disabilities may be associated with the service-connected disabilities, remand for a VA examination is required. 9. Entitlement to service connection for right knee disability, to include as secondary to the service-connected left ankle disability is remanded. The Veteran asserts that his right knee disability is caused by falls related to his left ankle disability. The Veteran was afforded a VA examination in January 2016. The January 2016 VA examiner opined that the Veteran’s right knee disability is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s back or left ankle disabilities. The January 2016 VA examiner opined that the Veteran’s right knee disability is most likely due to aging and/or trauma (meniscal tear), which had its onset years after service. However, the January 2016 VA examiner did not address the Veteran’s assertion that his right knee disability is due to the falls caused by his left ankle disability and if the meniscal tear is at least as likely as not due to a fall caused by the Veteran’s service-connected left ankle disability. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For the above reasons, remand is required. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his discoloration of his bilateral legs. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the Veteran’s discoloration of his bilateral legs at least as likely as not proximately due to his service-connected disabilities? Is the Veteran’s discoloration of his bilateral legs at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected disabilities? 2. Obtain an addendum opinion regarding the etiology of the right knee disability from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right knee disability had onset in, or is otherwise related to, active service; including but not limited to secondary to his service-connected back disability and/or his service-connected left ankle disability. The examiner must specifically address the following: (a) The Veteran’s assertion that his service-connected left ankle disability causes him to fall and injury is right knee. (b) The 2015 right knee meniscal tear. (c) The 2008 diagnosis of knee joint osteoarthritis. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, 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.