Citation Nr: 21003763 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 15-40 253 DATE: January 22, 2021 ORDER Service connection for a disability manifested by right hand weakness, to include carpal tunnel syndrome, is denied. An initial rating in excess of 10 percent, prior to January 15, 2015, for degenerative arthritis of the lumbar spine, is denied. A 40 percent rating, effective from January 15, 2015, to February 4, 2019, for degenerative arthritis of the lumbar spine, is granted, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 20 percent, effective from February 4, 2019, for degenerative arthritis of the lumbar spine, is denied An initial rating in excess of 10 percent rating, prior to February 20, 2019, for calcaneal spurs, right foot and left foot, is denied. A rating in excess of 30 percent, effective from February 20, 2019, for bilateral pes planus with calcaneal spurs, right foot and left foot, is denied. A rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for right foot gout is remanded. FINDINGS OF FACT 1. The preponderance of the competent evidence of record is against a finding that the Veteran has a disability manifested by right hand weakness, to include carpal tunnel syndrome, that had an onset in service, or is otherwise related to service. 2. Prior to January 15, 2015, the Veteran’s service-connected lumbar spine disability was not manifested by forward flexion greater than 30 degrees but not greater than 60 degrees; combined range of motion not greater than 120 degrees; muscle spasm or guarding; or incapacitating episodes; moreover, other than the separately service-connected radiculopathy of the lower extremities, there was no objective evidence of other related neurological abnormalities. 3. Effective from January 15, 2015, to February 4, 2019, the Veteran’s service-connected lumbar spine disability was manifested by active lumbar motion limited by 75 percent in all planes; however, there were no findings of ankylosis or incapacitating episodes. 4. Effective from February 4, 2019, the Veteran’s service-connected lumbar spine disability has not been manifested by forward flexion of 30 degrees or less; favorable ankylosis; or incapacitating episodes; moreover, other than the separately service-connected radiculopathy of the lower extremities, there have been no objective evidence of other related neurological abnormalities 5. Prior to February 20, 2019, the Veteran’s calcaneal spurs, right foot and left foot, were manifested by pain on use. 6. Effective from February 20, 2019, the Veteran’s bilateral pes planus with calcaneal spurs, right foot and left foot, have been manifested by pain on manipulation and use accentuated and swelling on use. 7. The Veteran’s GERD has been manifested by reflux, heartburn, pyrosis, difficulty swallowing, and vomiting, however, there has been no indication that his symptoms are accompanied by substernal or arm or shoulder pain or productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability manifested by right hand weakness, to include carpal tunnel syndrome, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 10 percent, prior to January 15, 2015, for degenerative arthritis of the lumbar spine, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes (DCs) 5242, 5243. 3. Resolving reasonable doubt in favor of the Veteran, effective from January 15, 2015, to February 4, 2019, the criteria for a 40 percent rating, but no higher, for degenerative arthritis of the lumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.7, 4.71a, DCs 5242, 5243. 4. The criteria for a rating in excess of 20 percent, effective from February 4, 2019, for degenerative arthritis of the lumbar spine, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DCs 5242, 5243. 5. The criteria for a rating in excess of 10 percent rating, prior to February 20, 2019, for calcaneal spurs, right foot and left foot, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DC 5276. 6. The criteria for a rating in excess of 30 percent, effective from February 20, 2019, for bilateral pes planus with calcaneal spurs, right foot and left foot, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DC 5276. 7. The criteria for a rating in excess of 10 percent for GERD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.114, DC 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1986 to October 2010. In February 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ), seated at the Board’s Central Office in Washington, D.C. In July 2019, the Board remanded this matter for further development. The record shows that in the March 2012 rating decision, the Regional Office (RO) granted service connection for calcaneal spur, right foot (also claimed as bilateral plantar fasciitis) and for calcaneal spur, left foot, and assigned non-compensable ratings for each, effective from November 1, 2010. Thereafter, in a June 2019 rating decision, the RO granted service connection for bilateral pes planus and assigned a 0 percent rating, effective February 20, 2019. Finally, in a July 2020 rating decision, the RO granted a 10 percent rating for calcaneal spurs, right foot and left foot (also claimed as bilateral plantar fasciitis, right foot weakness and left foot weakness) effective November 1, 2010 to February 20, 2019, and granted a 30 percent rating for bilateral pes planus with calcaneal spurs (also claimed as plantar fasciitis, left foot weakness and right foot weakness), effective February 20, 2019. The issues on appeal have been characterized accordingly. Service Connection 1. Entitlement to service connection for a disability manifested by right hand weakness. The Veteran contends he has right hand weakness related to service. In a November 2015 VA Form 9, he reported the right hand weakness was now diagnosed as carpal tunnel. In a February 2019 Fully Developed Claim Form, he indicated that the bilateral hand arthritis caused pain, reduced range of motion, and weakness. The question for the Board is whether the Veteran has a current disability that began during service or is related to an in-service injury, event, or disease. The Board concludes that, while the Veteran arguably has a current disability – as a diagnosis of carpal tunnel syndrome (CTS) was noted in his medical history – the preponderance of the evidence of record weighs against finding that his CTS, manifested by right hand weakness, began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records (STRs) show no report or finding of right hand weakness, a disability manifested by right hand weakness, or CTS. STRs show that in March 2000, the Veteran was seen for right wrist pain after an injury seven days prior. The assessment was rule out right wrist tendonitis. In October 2009, the Veteran was referred to rheumatology at the Naval Medical Center to determine whether he had bilateral hand arthritis due to complaints of hand pain and increased uric acid. A subsequent x-ray showed no radiographic evidence of arthritis in the hands. In October 2009, rheumatology findings for the hands showed joint spaces preserved, normal osseous mineralization, no osseous erosions, and soft tissues unremarkable. On a VA examination in November 2010, it was noted that for the Veteran’s claimed condition of right hand weakness, there was no diagnosis and no pathology to render any diagnosis. Private treatment records show that in July 2017, it was noted that the Veteran had mild CTS of the right wrist. On a VA examination in January 2020, a diagnosis of CTS, right wrist, 2016, was noted. The Veteran reported that his right hand condition started during active service due to repetitive activity, and that he currently had a diagnosis of carpal tunnel of the right wrist which caused weakness. The examiner rendered a negative opinion, noting the Veteran did not have diagnosis of right hand weakness, but had a diagnosis of CTS which caused right hand weakness. In August 2020, an addendum opinion was sought to specifically address whether the Veteran’s CTS was related to his treatment for tendonitis in service. A VA examiner again rendered a negative opinion noting for rationale that there was no confirmed diagnosis of right tendonitis found in the Veteran’s STRs and that following the March 2000 treatment, there was no further follow-up for that condition. The examiner also noted that during a November 2010 VA examination, conducted one day after the Veteran’s separation from service, the right wrist showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement; therefore, no diagnosis had been made for his complaint of right hand weakness. Finally, the examiner noted that there was no evidence in the file of when or how the diagnosis of CTS was made, noting that a June 2016 private treatment record noted a past medical history of CTS of the right wrist, mild, but that there was no EMG in records, and this was 6 years after service, and 16 years after his right wrist pain complaint during service. The Board finds the August 2020 VA examiner's opinion to be probative and persuasive because it is based on an accurate medical history and provides an explanation for the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Notably, the Veteran has not submitted any competent evidence contrary to the VA examiner's opinion. While the Veteran is competent to report having experienced right hand weakness and other right hand symptoms, he is not competent to provide a diagnosis for, or an opinion as to the etiology of, any such symptoms. Although lay persons are competent to provide opinions on some medical issues, the specific issue in this case falls outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24. Vet. App. 428 (2011). The issue is medically complex, as it requires specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board gives more probative weight to the competent medical evidence. Increased Rating Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which 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 there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. 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. 2. Entitlement to a rating in excess of 10 percent prior to February 4, 2019, and in excess of 20 percent, from that date for degenerative arthritis of the lumbar spine. The Veteran's service-connected lumbar spine disability has been rated pursuant to DC 5242, which pertains to degenerative arthritis and is rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. The record shows that his service-connected lumbar spine disability includes degenerative disc disease (DDD), thus, it may be rated under the General Rating Formula, or the Formula for Rating Intervertebral Disc Syndrome (IDS) Based on Incapacitating Episodes, whichever results in the higher rating. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, for a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, for muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, for a vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine limited 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. 38 C.F.R. § 4.71a, DC 5242. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The normal combined motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a. Under the Formula for Rating IDS, a 10 percent rating is assigned for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is for 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 is for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is for incapacitating episodes having a total duration of at least 6 weeks during a 12-month period on appeal. An incapacitating episode is a period of acute signs and symptoms due to IDS that requires bed rest prescribed by a physician and treatment by a physician 38 C.F.R. § 4.71a, DC 5243, Note (1). Prior to February 4, 2019, the record shows that on a November 2010 VA examination, the Veteran reported low back pain and stiffness. Examination revealed normal range of lumbar motion, no muscle spasm or tenderness, no guarding of movement, no weakness, and normal muscle tone. Repetitive motion was possible, but was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. No signs of lumbar IDS were noted. A treatment record from the Naval Medical Center in Portsmouth shows that in August 2010, the Veteran was seen for severe lower back pain. He reported having low back pain since the morning, and that he had lifted heavy concrete slabs over the weekend and moved tables. A past history of recurrent low back pain was noted. He denied radiation of pain, numbness, tingling, lower extremity weakness, or incontinence. Examination revealed tenderness on palpation, but no muscle spasm, and he demonstrated full range of motion of the thoracolumbar spine, with pain on flexion. The assessment was lumbar back strain. Private treatment records from the Spine Center at Chesapeake show that in March 2013, the Veteran was seen for moderate lumbar pain. He reported progressively worsened low back pain over the years since service. He reported the discomfort was most prominent in the lower left lumbar spine. He also reported that his pain worsened with flexion, extension, twisting movements, and sex. Examination of the lumbar spine revealed midline tenderness to palpation, normal muscle strength, and full active range of motion. The assessment included low back pain and DDD of the lumbar spine. In April 2013, the Veteran again reported constant lumbar pain that worsened with movement. Examination revealed normal gait, tone, strength. An MRI revealed HNP (herniated nucleus pulposus) at L4-5 and L5-S1, resulting in stenosis. The diagnoses included low back pain, sciatica, lumbar HNP, spinal stenosis lumbar region without neurogenic claudication. Back surgery was discussed. An MRI in December 2014, revealed disc bulge with superimposed nonfocal disc protrusion, increase in size, and stenosis, as well as L5-S1 disc protrusion with mild stenosis. On January 15, 2015, the Veteran was referred for physical therapy, and it was noted that he had lumbar radiculopathy. He reported chronic low back pain since the 1990s, and that he injured his back in service and that initially the pain was so severe he could not sit, stand, or lie down and he became incontinent. He was no longer incontinent of urine, but reported severe low back pain, at level 6 of 10, and increased with prolonged standing, sitting, or bending forward. Examination revealed “[t]runk/lumbar active range of motion is limited by 75% in all planes”, and that the was “halting secondary to complaints of pressure and pain”. It was noted that he ambulated without an assistive device, and a waddling gait pattern was noted. Private treatment records showed that in April 2016, the Veteran reported moderate low back pain that started a few days prior, and that he could weight bear but noted increased pain, as well as increased pain with bending, twisting, and certain positions. It was noted that he had not seen an orthopedic doctor in several years, had a limping gait and used a crutch, but no neurological deficits were. He denied radiation, loss of strength, or lower extremity paresthesia. Examination revealed no tenderness, spasm was present, range of low back motion limited due to pain, and normal strength. He was able to bear weight with an antalgic gait. After reviewing the record prior to February 4, 2019, and resolving doubt in favor of the Veteran, the Board concludes that the criteria for a 40 percent rating was met for his service-connected lumbar disability, effective January 15, 2015. On that date it was noted that he was seen at the Spine Center at Chesapeake, and the examiner found his active lumbar range of motion was limited by 75 percent in all planes. At a maximum of 90 degrees for forward flexion, a 75 percent decrease would be 22.5 degrees, which is sufficient to support the grant of a 40 percent rating, but no higher, effective from January 15, 2015, under the General Rating Formula. With regard to whether a rating in excess of 40 percent is warranted from January 15, 2015, the Board notes that the competent evidence fails to show or approximate unfavorable ankylosis of the thoracolumbar spine, or incapacitating episodes. While the Veteran clearly had ongoing pain and functional limitations due to pain and limited movement, and VA must in some circumstances consider functional impairment in addition to limitation of motion due to factors such as pain, this rule does not apply where, as here, he will be receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 8 (1997). Recognition is given to his reports of increased low back pain at all ranges of lumbar motion and with movement, there is no indication he has been prescribed bed rest by a physician, which is a requirement for VA purposes. Accordingly, the Board concludes that a rating in excess of 40 percent is not warranted at any point from January 15, 2015. The Board also finds that prior to January 15, 2015, the preponderance of the competent evidence of record weighs against the grant of an initial rating in excess of 10 percent for the service-connected lumbar disability. Despite the Veteran’s lay reports of chronic low back pain and increased pain with movement, as well as the objective findings of tenderness on palpation, objective testing revealed full range of lumbar motion on several occasions prior to January 15, 2015. Additionally, while tenderness was noted on two occasions, the competent evidence did not show muscle spasm or guarding. Therefore, even considering the Veteran’s reports of ongoing low back pain and noted functional loss due to increased low back pain on range of motion and with movement, the degree of additional limitation reflected by increased pain on movement would not result in limitation of motion more nearly approximating forward flexion greater than 30 degrees but not greater than 60 degrees or a combined range of motion not greater than 120 degrees. 38 C.F.R. §§ 4.40, 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995). Finally, the Board finds that effective from February 4, 2019, the preponderance of the competent evidence of record weighs against the grant of a rating in excess of 20 percent for the service-connected lumbar disability. Review of the record shows that a private physician, Dr. F.P., completed a Back Conditions DBQ (VA Form 21-0960M-14), dated February 4, 2019; it noted the Veteran’s reports of progressively worsening chronic back pain, and flare-ups that impacted functioning by causing difficulty with walking, standing, and sitting for prolonged periods, inability to climb up and down stairs, difficulty standing up from a seated position, and gait instability. The Veteran also reported muscle spasms and stiffness. Range of motion testing revealed lumbar flexion was to 45 degrees, extension to 15 degrees, and right and left lateral flexion and rotation were to 15 degrees, with pain on motion. He was able to perform repetitive-use testing with no change in range of lumbar motion. Tenderness was noted, as well as abnormal gait due to muscle spasms. Other contributing factors of disability included less movement than normal, weakened movement, excess fatigability, instability of station, disturbance of locomotion, and interference with sitting and standing. The examiner responded “yes” as to whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or when the joint is used repeatedly over a period of time. Muscle strength was slightly reduced, which was not entirely due to his lumbar disability. It was noted that he had incapacitating episodes over the last 12 months that lasted at least 2 weeks but less than 4 weeks. The examiner opined that the Veteran’s lumbar spine disability impacted his ability to perform any type of occupational task, noting he had decreased flexibility and limited mobility, and used a back brace when pain was excruciating. He reported taking time off of work to rest his back at least 2 to 3 times a month. The Board acknowledges that in the DBQ, Dr. F.P. checked a box noting the severity of ankylosis as “unfavorable ankylosis of entire thoracolumbar spine”. While this finding would meet the criteria for a higher rating under the General Rating Formula, the Board notes that such a finding is inconsistent with the rest of the DBQ, which found that the Veteran had some range of lumbar motion, albeit limited by pain. Further, the subsequent VA examination found that the Veteran had some range of lumbar motion, again limited by pain. Thus, a higher rating is not warranted based on this isolated and inconsistent finding of ankylosis. On a VA DBQ in January 2020, the Veteran reported constant aching low back pain with bilateral radiating pain. He was told to have a surgery but was indecisive due to conflicting opinions from specialists. He reported daily flare-ups of sharp stabbing pain, at level 10, lasting 30 minutes. He could not tolerate prolonged standing and sitting due to the pain. Range of lumbar motion was to 50 degrees on flexion, 15 degrees on extension, 20 degrees on left and right lateral flexion, and 25 degrees on left and right lateral rotation, with pain. There was pain with weight bearing. No tenderness, muscle spasm, guarding, or atrophy, was noted. Repetitive use testing was performed, with no addition loss of function or range of motion after three repetitions. The examiner opined that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time or with flare-ups. No ankylosis or IDS were noted. He did not use any assistive devices. On review of the record from February 4, 2019, the Board concludes the preponderance of the competent evidence weighs against the grant of a rating in excess of 20 percent for the Veteran's service-connected lumbar spine disability. In that regard, the evidence does not demonstrate ankylosis, forward flexion to 30 degrees or less, or incapacitating episodes lasting at least 4 weeks during the past 12 months. Rather, the clinical and reported findings more nearly approximated the criteria for a 20 percent rating. 38 C.F.R. § 4.7. The Board has considered the Veteran's reports of worsening low back pain, pain on range of motion, daily flare-ups, limitations on walking, standing, and sitting for prolonged periods, and difficulties with stairs and standing up from a seating position, as well as the potential additional limitation of functioning resulting therefrom. Although it is clear he has experienced functional limitations, the Board finds that there is insufficient objective evidence to conclude his pain and other symptoms have been associated with such additional functional limitation as to warrant a rating in excess of 20 percent. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. Moreover, the Board also notes that the 2019 examiner responded “yes” as to whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or when the joint is used repeatedly over a period of time, but did not provide any further specification, while the 2020 examiner more definitively opined that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time or with flare-ups. The Board also notes that, for the duration of the appeal period, other than the separately service-connected radiculopathy of the lower extremities, there is no objective evidence of other related neurological abnormalities. 3. Entitlement to a rating in excess of 10 percent rating, prior to February 20, 2019, for calcaneal spurs, right foot and left foot. The Veteran contends that a higher rating is warranted prior to February 20, 2019 for calcaneal spurs of both feet. As noted above, a 10 percent rating has been granted for calcaneal spurs, right foot and left foot (also claimed as bilateral plantar fasciitis, right foot weakness and left foot weakness) effective November 1, 2010 to February 20, 2019., under DC 5276, which evaluates impairment from flatfoot. Under DC 5276, flat foot (or pes planus), is assigned a 10 percent rating for moderate disability, with unilateral or bilateral involvement, with the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis (Achilles tendon), pain on manipulation and use of the feet. A severe disability is assigned a 20 percent rating for unilateral involvement, or 30 percent if it is bilateral, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A pronounced disability is assigned a maximum 30 percent rating if it is unilateral, or 50 percent if it is bilateral, with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Under DC 5284, a 10 percent rating is warranted for foot injuries indicative of a moderate disability. A 20 percent rating is warranted for foot injuries indicative of a moderately severe disability. A 30 percent rating is warranted for foot injuries indicative of a severe disability. With actual loss of use of the foot, a 40 percent rating is warranted. 38 C.F.R. §§ 4.71a, DC 5284. After review of the record prior to February 20, 2019, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for calcaneal spurs, right foot and left foot, under either DC 5276 or DC 5284. On a November 2010 VA examination, the Veteran reported bilateral plantar fasciitis since 2000, and that he had constant bilateral foot pain that was aching, exacerbated by physical activity, and relieved by rest. He reported pain with standing or walking, but denied pain, weakness, stiffness, swelling, and fatigue. Examination of the feet revealed no edema, disturbed circulation, weakness, atrophy, tenderness, heat, redness, instability, or signs of deformity. It was noted there was no functional limitation of standing and walking and he did not require the use of corrective shoe wear. The examiner indicated that for the claimed conditions of right and left plantar fasciitis, the diagnosis was calcanea spurs. In February 2019, the Veteran testified his arches had descended and he was treating conservatively with physical therapy and Motrin, but felt it was no longer working. He reported difficulty walking a distance and getting out of bed because the fascia area was still inflamed, but that by midday the pain went away. He testified he wore constant orthotics because of the cushion and with that he could manage to walk but that it was hard to stand or walk for a long period. The Board acknowledges the Veteran’s lay reports of symptoms and that he experienced functional loss due to pain, including in the morning and with walking or standing for a long period, but finds that prior to February 20, 2019, the symptomology associated with the service-connected calcaneal spurs more nearly approximates the criteria for a 10 percent rating. The evidence of record does not reveal that the Veteran's feet manifested moderately severe or severe disability, nor was there evidence of marked deformity, swelling on use, or characteristic callosities. While there was evidence of aching pain, exacerbated by activity, noted at the 2010 VA examination, there was no swelling or calluses noted. Moreover, he reported that the pain was relieved by rest, and he did not require the use of corrective shoe wear. Even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that he had daily difficulties getting out of bed and walking any distance would not result in symptoms more nearly approximating moderately severe or severe disability. In that regard, the Board notes that he indicated the pain in his feet went away midday, and that he wore orthotics to help with standing and walking. Thus, a higher rating is not warranted pursuant to 38 U.S.C. § § 4.40, 4.45, or Deluca, supra. Finally, the Board notes that the Veteran's disability is unlisted and rated by analogy. In this regard, DCs 5277 to 5283 are not applicable, as his service-connected foot symptoms are not manifested by weak foot, claw foot (pes cavus), metatarsalgia, hallux valgus, hallux rigidus, hammer toes, or malunion or nonunion of the tarsal or metatarsal bones. 4. Entitlement to a rating in excess of 30 percent, effective from February 20, 2019, for bilateral pes planus with calcaneal spurs, right foot and left foot. The Veteran contends that a higher rating is warranted from February 20, 2019 for bilateral pes planus with calcaneal spurs of both feet. As noted above, a 30 percent rating has been granted under DC 5276. After review of the record, however, the Board finds the preponderance of the evidence is against a rating in excess of 30 percent, from February 20, 2019, under either DC 5276 or DC 5284. In that regard, received on February 20, 2019, was a Foot Conditions, Including Flatfoot (Pes Planus), DBQ (Form 21-0960M-6), completed by a private doctor, in which the Veteran reported excruciating foot pain in the morning with feelings of stabbing pain. He reported flare-ups involving difficulty walking, standing, and climbing stairs, decreased flexibility of the feet with limited mobility causing gait instability and him to trip. He reported stiffness, swelling, and cramping of his foot and toes. Examination revealed pain in both feet, accentuated with manipulation, swelling on use, and characteristic calluses. He tried arch supports, built-up shoes, and orthotics, but his feet remained symptomatic. It was noted he had extreme tenderness of the plantar surfaces, not improved by orthopedic shoes or appliance; decreased longitudinal arch height on weight-bearing; objective evidence of marked deformity, and marked pronation of both feet. It was also noted that he had inward bowing, marked inward displacement, severe spasms of the Achilles tendons of both feet, and metatarsalgia of both feet. The examiner characterized plantar fasciitis as severe on the right and moderately severe on the left, and opined that his foot condition chronically compromised weight-bearing, that arch supports and orthotics gave partial relief, that pain was worse in the morning, and that the condition worsened throughout the day, making walking difficult and painful. Functional impairment was noted due to pain, less movement than normal, weakened movement, pain on movement and weight-bearing, deformity, instability of station, disturbance of locomotion, and interference with standing. The examiner opined the Veteran’s functional ability was significantly impaired during flare-ups or when the feet were used repeatedly over a period of time, noting he had difficulty walking, standing, and climbing up and down steps. Received in June 2019 was another DBQ completed by a private doctor, Dr. S., on which the Veteran reported foot pain with walking in the morning and long-distance walking, and that it was hard to walk around his workspace. He reported flare-ups of pain in the morning and evening, and that he had functional impairment of the foot including, inability to do a lot of lifting, standing, or walking, and inability to run. He did not have pain or swelling on use of the feet or characteristic callouses, but did have pain on manipulation. He used arch supports for both feet, with relief of symptoms. It was also noted that he had extreme tenderness on the plantar surfaces of both feet, but that the tenderness was improved by orthopedic shoes or appliances. There was no evidence of marked deformity, marked pronation, marked inward displacement, or severe spasm of the Achilles’ tendon. He did not have inward bowing of the Achilles tendon of either foot. It was noted that that he had foot pain that did not contribute to functional loss because he was able to walk, but that he experienced functional impairment due to disturbance of locomotion and difficulty walking 2 blocks. On a VA examination in January 2020, the Veteran reported aching pain, stiffness, and weakness in his feet. He reported pain every day, especially in the morning. He denied flare-ups impacting the function of the foot, but did report not being able to walk or stand for a prolonged period of time. He had accentuated pain on use of the feet, pain on manipulation of the feet, and swelling on use of the feet. He used arch supports for both feet, but the feet remained symptomatic. Extreme tenderness of the plantar surfaces was not noted, nor was there marked inward displacement or severe spasm of the Achilles tendon on manipulation, but he did have decreased longitudinal arch height of both feet on weight-bearing. Examination revealed right and left foot pain that contributed to functional loss, as well as pain on movement, swelling, and interference with standing. The examiner opined that the Veteran’s functional ability was significantly impaired during flare-ups or when the feet were used repeatedly over a period of time, noting that he reported pain and weakness in the right and left foot due to overlapping foot conditions. The examiner also opined that his foot condition impacted his ability to work, noting that the Veteran reported he was unable to tolerate prolonged standing and walking due to bilateral pes planus, plantar fasciitis, calcaneal spurs, hallux valgus, status post Haglund procedure and removal of Morton's neuroma, right foot. The examiner noted that the Veteran’s status-post Haglund procedure was a progression of the service-connected foot disability, but that status-post removal of Morton’s neuroma was not related to the service-connected foot disability. In order for a higher rating to be granted under DC 5276, the Veteran’s service-connected foot disability must result in or approximate bilateral pronounced disability with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo-achilles on manipulation, not improved by orthopedic shoes or appliances. Review of the evidence shows that the Veteran's symptoms have progressed gradually over time, and that overall, effective from February 20, 2019, he has significant symptoms that meet or approximate the criteria for a 30 percent rating under DC 5276. With regard to a 50 percent rating, however, the competent medical evidence is conflicting as to the level of severity of the Veteran's symptoms and consequent impairment, and as to whether the criteria have been met or approximated, effective from February 20, 2019. In that regard, on the DBQ in February 2019, Dr. P. noted the Veteran had extreme tenderness, marked pronation, marked inward displacement, and severe spasms of the Achilles tendons, but that arch supports and orthotics gave partial relief. In June 2019, Dr. S. noted extreme tenderness, improved by orthopedic shoes or appliances, but noted no evidence of marked pronation, marked inward displacement, or severe spasm of the Achilles tendon. Finally, in January 2020, the VA DBQ examiner noted the Veteran used arch supports, but his feet remained symptomatic, and extreme tenderness was not noted, nor was there marked inward displacement or severe spasm of the Achilles tendon on manipulation. The Board finds that while these three DBQ examinations reflect that the Veteran’s service-connected bilateral foot disability resulted in essentially the same degree of pain and limitations (including limits on standing, walking, and using stairs), as well as the wearing of arch supports/orthopedic appliances, there has not been any discernable consistency as to whether he has marked pronation, marked inward displacement and severe spasm of the Achilles tendon, or whether his symptoms are improved by orthopedic shoes or appliances. Even viewing these examinations separately, the Board concludes that a 50 percent rating is not warranted pursuant to DC 5276 because at no time did his service-connected bilateral foot disability manifest marked pronation, extreme tenderness, marked inward displacement, and severe spasms of the Achilles tendon, not improved by orthopedic shoes or appliances. The Board also notes that to warrant the next higher rating under DC 5284, there must be actual loss of use of the foot. Although the Veteran has consistently reported foot pain and limitations on functioning, there has been no assertion or indication that he had loss of use of either foot to an extent that he would be equally well served by an amputation with prosthesis. Therefore, the criteria for higher rating under DC 5284 have not been met or approximated. The Board acknowledges it must consider whether a higher rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement. 38 U.S.C. §§ 4.40, 4.45; DeLuca, supra. However, even considering the Veteran's reports of foot pain that was worse in the morning, and in the 2019 DBQs that flare-ups impacted the functioning of the foot, including walking and standing, there has been no finding approaching actual loss of use of foot or marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo-achilles on manipulation to warrant higher ratings under DC 5276 or DC 5284. Therefore, from February 20, 2109, his bilateral foot condition more nearly approximates a 30 percent disability rating. Finally, the Board has considered the Veteran’s lay statements and acknowledges that he is competent to report any foot symptoms he experiences. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In that regard, his statements regarding foot pain, swelling, and interference with standing and walking, are consistent with the rating assigned, and to the extent he argues his symptoms are more severe, his statements must be weighed against the other competent evidence of record. The Board finds, however, that the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's more general (though competent and credible) lay assertions regarding the severity of his service-connected right and left foot disabilities. 5. Entitlement to a rating in excess of 10 percent for GERD. The Veteran contends that a higher rating is warranted for GERD, which has been rated under DC 7346 which provides the criteria for rating hiatal hernia. After review of the record, however, the Board finds the preponderance of the evidence is against a rating in excess of 10 percent for GERD. Under DC 7346, a 10 percent rating is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is for when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. On a VA examination in November 2010, it was noted that the Veteran’s GERD did not affect his general body health or body weight, and he denied difficulty swallowing, heartburn, epigastric pain, reflux, arm pain, haematemesis, melena, scapular pain, nausea, or vomiting. An upper GI series was noted to be abnormal with a small polyp in the gall bladder lumen, but no calculi or cholecystitis. There was mild distal esophageal dysmotility with moderate reflux and a small sliding hiatal hernia. It was noted that the hiatal hernia/GERD condition did not cause anemia and there were no findings of malnutrition. VA treatment records show that in February 2012, the Veteran reported chronic upper abdominal pain for several months, without nausea or vomiting. Private treatment records from the Spine Center at Chesapeake show that on a review of systems in March 2013, the Veteran reported abdominal pain, difficulty swallowing, and heart burn, but denied nausea and vomiting. At the February 2019 hearing, the Veteran testified that he took medication twice a day because of the burning from GERD, and that the burning woke him up at night. He reported he had difficulty swallowing antacids, and had to really push with a lot of water, which caused problems if he did it too quickly. He testified he had chest pain and vomiting, described as acid reflux and coughing up. He took Zantac that helped with GERD and pain, and noted that he had increased the Zantac to twice a day. On the January 2020 VA DBQ examination, the Veteran reported acid reflux, chest tightness, epigastric pain, and nausea. It was noted that he had pyrosis, reflux, nausea, and vomiting, but no substernal or arm or shoulder pain was noted, nor were his symptoms found to be productive of considerable impairment of health. The examiner opined that the Veteran’s GERD impacted his ability to work, noting he reported reflux and heartburn at night that caused discomfort. After reviewing the foregoing, the Board finds that the competent evidence of record shows that the Veteran’s GERD symptoms have included reflux, heartburn, pyrosis, difficulty swallowing, and vomiting, and he has reported having chest pain tightness; however, there has been no showing that his symptoms are productive of considerable impairment of health. While it is clear he has had ongoing symptoms related to GERD, these symptoms are not shown to meet or approximate the criteria for a rating in excess of 10 percent. 38 C.F.R. § 4.7. The Board therefore concludes that the preponderance of the evidence is against the claim for the assignment of a rating in excess of 10 percent for the Veteran's GERD. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for right foot gout. The Veteran contends his right foot gout is related to service. Service connection has been established for left foot gout only. In July 2019, the Board remanded in part to obtain a VA examination with opinion to determine whether it was at least as likely as not that any current gout disability had an onset in or was otherwise related to service. A January 2020 disability benefits questionnaire (DBQ) noted a diagnosis of gout, left great toe, and 1999 was listed as the date of diagnosis. The Veteran reported he was diagnosed with acute gout on active duty due to pain in his bilateral great toes, and that since then he had persistent gout attacks. The examiner noted that the claims file showed that in service in April 1999, the Veteran complained of left foot gout. In May1999, he reported left foot pain, and it was noted he was originally treated for acute gout, but the assessment was persistent gout, left great toe. At the DBQ the Veteran reported swelling, erythema, and pain in his bilateral great toes, and reported having gout attacks 2-3 times a year. It was noted that there was evidence in the claims file that the Veteran was treated for left great toe gout, but that he does not receive any treatment for the right great toe and there was no current pathology to render a diagnosis of gout, right great toe. In the DBQ medical opinion, it was noted that review of the claims file showed that in July 2017, the Veteran reported a history of gout and that the prior Friday he started having right 1st metatarsophalangeal pain and swelling. The diagnosis was acute gout. The examiner rendered a positive opinion, but did not specify either foot, just referring to the disability as “gout”, and noting for rationale that the Veteran had no issues related to the claimed gout prior to service, that the onset of the condition was during service and documented in STRs, that there is evidence of current, chronic, and continuous treatment and care, and that the Veteran had 2 attacks during service and was diagnosed as persistent gout. It appears the examiner provided an addendum opinion, clarifying that a nexus had been established for the left great toe only, again citing for rationale that the Veteran had no issues prior to service, and that the onset of the condition was during service and documented in STRs, but that he only had left great toe affected for his gout diagnosis. The examiner also noted that the claims file was silent for right great toe gout attacks, and that physical examination did not show any abnormality on his bilateral great toes which meant he did not have any acute gout symptoms. The Board notes that in the DBQ, the VA examiner indicated that the claims file showed that in July 2017 the Veteran was treated for acute gout in the right 1st MTP, but then indicated in the rationale that the claims file was silent for right great toe gout attacks, and that current physical examination did not show any abnormality in his bilateral great toes. The Board finds that since the Veteran was treated for acute gout of the right great toe (1st MTP) in July 2017, it appears he did have a right great toe diagnosis or disability during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Once VA undertakes the effort to provide an examination when developing a service connection claim, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, in light of these apparent inconsistencies in the rationale, the Board determines a VA addendum opinion is warranted. The matter is REMANDED for the following action: (Continued on the next page)   Forward the claim for service connection for right foot gout to the 2020 VA examiner for a supplemental opinion. The examiner should opine as to whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that any current right foot gout had an onset in or is otherwise related to service. The examiner should note that the Veteran was treated for acute gout in July 2017, and that at that time he reported a history of gout and that the prior Friday he started having right 1st metatarsophalangeal pain and swelling. The examiner must explain the rationale for any opinions given, and, if unable to provide any requested opinion without resorting to speculation, the examiner should so state and should provide an explanation as to the reason(s) therefor. If the original VA examiner (from 2020) is not available, please forward this request to another qualified examiner. If deemed necessary by the examiner, a physical examination of the Veteran should be conducted. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Casula 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.