Citation Nr: 21064210 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 11-24 650 DATE: October 19, 2021 ORDER Entitlement to an initial rating for a lumbar spine disorder greater than 10 percent prior to April 1, 2021, and greater than 40 percent thereafter is denied. Entitlement to a 10 percent initial disability rating for a cervical spine disability prior to April 12, 2011, is granted. Entitlement to a staged initial rating greater than 20 percent for a cervical spine disability from April 12, 2011, to March 31, 2021, and a staged initial rating greater than 40 percent from April 1, 2021 is denied. Entitlement to a separate 10 percent rating for right upper extremity radiculopathy is granted. Entitlement to a separate 10 percent rating for left upper extremity radiculopathy is granted. Entitlement to a compensable initial rating for allergic rhinitis is denied. Entitlement to a compensable initial rating for bilateral hearing loss is denied. Entitlement to an initial rating greater than 10 percent for a left foot disorder prior to April 1, 2021 is denied. Entitlement to a compensable initial rating for a right foot disorder prior to April 1, 2021, is denied. Entitlement to a staged initial rating of 30 percent, but no greater, for a bilateral foot disorder from April 1, 2021, is granted. REMANDED Entitlement to service connection for a disability of the left shoulder, arm, and/or hand is remanded. Entitlement to service connection for an eye disorder, to include strabismus, heterophoria, and/or esophoria is remanded. Entitlement to service connection for a disability manifested by joint swelling is remanded. FINDINGS OF FACT 1. Prior to April 1, 2021, the Veteran's thoracolumbar spine disability was manifested by forward flexion of the thoracolumbar spine to 75 degrees, combined range of motion of the thoracolumbar spine to 265 degrees, and no evidence of muscle spasm or guarding severe enough to result in abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. From April 1, 2021, the Veteran's thoracolumbar spine disability was not manifested by unfavorable ankylosis of the entire thoracolumbar spine. 3. Prior to April 12, 2011, the Veteran's cervical spine disability was manifested a combined range of motion of the cervical spine to 310 degrees. 4. From April 12, 2011 to March 31, 2021, the Veteran's cervical spine disability was manifested by forward flexion to no less than 18 degrees without evidence of cervical spine ankylosis. 5. From April 1, 2021, the Veteran's cervical spine disability was not shown to manifest ankylosis of the cervical spine. 6. The weight of the probative evidence of record demonstrates that the Veteran's cervical spine disability produces left upper extremity radiculopathy. 7. The weight of the probative evidence of record demonstrates that the Veteran's cervical spine disability produces right upper extremity radiculopathy. 8. Since the initial grant of service connection, the Veteran's allergic rhinitis has not been manifested by complete obstruction of one side of the nose, or greater than 50-percent obstruction of both nasal passages. 9. Since the initial grant of service connection, the Veteran's bilateral hearing loss has manifested no worse than Level II hearing loss in the right ear and Level II hearing loss in the left ear. 10. Prior to April 1, 2021, the Veteran's left foot disorder was not manifested by symptoms comparable to objective evidence of marked deformity, accentuated pain on manipulation and use, swelling on use, and characteristic callosities. 11. Prior to April 1, 2021, the Veteran's right foot disorder was not manifested by symptoms comparable to inward bowing of the tendo achillis, the weight-bearing line over or medial to the great toe, and pain on manipulation and use of the foot. 12. From April 1, 2021, the Veteran's bilateral foot disorder was manifested by severe symptoms but no evidence of marked pronation, extreme tenderness of the plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis on manipulation. CONCLUSIONS OF LAW 1. Prior to April 1, 2021, the criteria for an initial rating greater than 10 percent for degenerative disc disease of the thoracolumbar spine have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.71(a) Diagnostic Code 5242. 2. From April 1, 2021, the criteria for a staged initial rating greater than 40 percent for degenerative disc disease of the thoracolumbar spine have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.71(a) Diagnostic Code 5242. 3. Prior to April 12, 2011 the criteria for a 10 percent initial disability rating for degenerative disc disease of the cervical spine have been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.71(a) Diagnostic Code 5242. 4. From April 12, 2011 to March 31, 2021, the criteria for a staged initial disability rating greater than 20 percent for degenerative disc disease of the cervical spine have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.71(a) Diagnostic Code 5242. 5. From April 1, 2021, the criteria for a staged initial disability rating greater than 30 percent for degenerative disc disease of the cervical spine have not been met. 38 U.S.C. § 5107; 38 C.F.R. § 4.71(a) Diagnostic Code 5242. 6. The criteria for a separate 10 percent evaluation for left upper extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Code 8510. 7. The criteria for a separate 10 percent evaluation for right upper extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 4.71a, 4.124a, Diagnostic Code 8510. 8. The criteria for a compensable initial rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.31, 4.97, Diagnostic Code 6522. 9. The criteria for a compensable initial rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 10. The criteria for a compensable initial disability rating for a right foot disorder prior to April 1, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.101, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5276. 11. The criteria for an initial disability rating greater than 10 percent for a left foot disorder prior to April 1, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.101, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5284. 12. The criteria for a staged initial disability rating of 30 percent, but no greater, for a bilateral foot disorder from April 1, 2021 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.101, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1981 to September 2005. His service personnel records confirm active-duty service in Saudi Arabia from September 2001 to October 2002. The issue of entitlement to service connection for a right shoulder disorder was previously before the Board in August 2017, when it was remanded for further development of the evidence. While the Veteran's appeal was in remand status, his claim for entitlement to service connection for a right shoulder disorder was granted in an August 2021 rating decision. This action constitutes a full grant of the benefit sought on appeal with respect to that issue, and it is no longer before the Board. The Board has considered the Veteran's claims and decided entitlement based on the evidence or record. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Increased Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The primary concern in a claim for a higher evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an initial rating for a lumbar spine disorder greater than 10 percent prior to April 1, 2021 and greater than 40 percent thereafter Service connection for degenerative disc disease of the lumbar spine was awarded in a September 2008 rating decision, and a 10 percent disability rating was assigned, effective October 2, 2007, under 38 C.F.R. § 4.71a, Diagnostic Code 5242. In an August 2021 rating decision, the RO assigned a 40 percent disability rating from April 1, 2021. Under Diagnostic Code 5242, a 10 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is 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 evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5242. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. Id. at Note (1). In applying these regulations, VA should obtain examinations in which the examiner determines whether the disability is 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, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Board notes that, effective February 7, 2021, the rating schedule for evaluating musculoskeletal disabilities was amended in parts. Diagnostic Code 5242 was amended to make clear that its application was for degenerative arthritis/disc disease of the spine other than IVDS. Diagnostic Code 5243 was amended to clarify that it should only be applied for disc herniation with compression and/or irritation of the adjacent nerve root, and that all other disc diagnoses should be rated under Diagnostic Code 5242. As the regulations, as amended in February 2021, make the definition of incapacitating episodes even more restrictive than the former criteria, the Board will evaluate the lumbar spine disability under the former, more liberal, criteria. After thorough consideration of the evidence of record, the Board concludes that an initial rating greater than 10 percent is not warranted for the Veteran's lumbar spine disability prior to April 1, 2021, and a staged initial rating greater than 40 percent is not warranted from April 1, 2021. The preponderance of the evidence does not support the assignment of a rating in excess of 10 percent for a thoracolumbar spine disability prior to April 1, 2021. Prior to April 1, 2021, the evidence does not demonstrate range of motion of the thoracolumbar spine with flexion limited to 60 degrees or less; combined range of motion of the thoracolumbar spine to 120 degrees or less; 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. Specifically, a July 2008 VA examination reflects that there was forward flexion of the thoracolumbar spine to 75 degrees, extension to 30 degrees, right and left lateral flexion to 35 degrees, and right and left lateral rotation to 45 degrees. There was no pain on range of motion and the Veteran was able to complete repetitive use testing with no additional loss of motion, pain, fatigue, weakness, or incoordination. Also, the Veteran denied a history of incapacitating episodes and flare-ups. Additionally, a July 2009 VA treatment record notes that there was full range of motion of the lumbosacral spine without paraspinal tenderness, bulging, curvature, edema, or erythema. The Board recognizes the Veteran's dissatisfaction with the July 2008 VA examination and acknowledges the Veteran's reports that the VA examiner "did not use any device to measure flexation." However, because the July 2008 VA examination findings are consistent with the other medical evidence of record, the Board finds them to be probative in this case. Further, the Veteran cites medical records from his active-duty service to support his argument that his lumbar spine impairment warranted a rating higher than 10 percent prior to April 1, 2021. Nevertheless, because the medical findings in the service treatment records document the severity of the Veteran's lumbar spine disorder prior to the time period pertinent to the appeal, they are insufficient to establish entitlement to an increased rating in this case, particularly in light of the contemporaneous medical evidence which is contradictory to the findings during active-duty service. Consideration has been given to any functional impairment and any effects of pain on functional abilities due to the Veteran's service-connected back disability prior to April 1, 2021. The Board acknowledges the subjective complaints of pain made prior to April 1, 2021. However, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. In this case it does not. More specifically, there was no evidence of decreased range of motion with repetitive range of motion testing of the thoracolumbar spine or additional limitation of joint function due to pain, fatigue, weakness, lack of endurance, or incoordination during the July 2008 VA examination. Further, the Veteran denied a history of incapacitating episodes and flare-ups. In light of the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected thoracolumbar spine disability is not warranted prior to April 1, 2021 based on functional impairment. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-06. From April 1, 2021, the Veteran is in receipt of a 40 percent disability rating for his lumbar spine disorder. A rating higher than 40 percent is not warranted in the absence of evidence that the Veteran's lumbar spine disorder exhibited unfavorable ankylosis. There is no competent evidence of ankylosis, and neither the Veteran nor any medical provider has identified fixation of the thoracolumbar spine. An April 2021 VA examination reported that there was no ankylosis of the thoracolumbar spine on examination. Although the Board must consider functional factors when determining the impairment manifested by orthopedic disabilities, the provisions of 38 C.F.R. § 4.40 and 4.45 are not for consideration, as the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); DeLuca v. Brown, 8 Vet. App. 202 (1995). Therefore, the Board cannot conclude that the Veteran's disability most nearly approximates ankylosis when he has clearly retained some useful motion of the thoracolumbar spine. The Board finds that the competent evidence of record establishes that the Veteran's thoracolumbar spine was not ankylosed at any time, and a rating in excess of 40 percent is not warranted from April 1, 2021. Additionally, the Board has considered whether a separate evaluation is warranted for any neurological component of the Veteran's lumbar spine disability throughout each rating period. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). Although the June 2008 VA examiner noted that the Veteran experienced radiation of low back pain into the buttocks, the front of the thigh, and the calf, the examiner explained that a diagnosis of sciatic neuropathy could not be made because the presentation of radiation to the front of the thigh and the calf is not typical of sciatica. Similarly, the April 2021 VA examiner reported that there was no evidence of radiculopathy in the lower extremities. As there is no other evidence suggesting a neurological component to the Veteran's service-connected lumbar spine disability, a separate rating is not warranted. 2. Entitlement to a compensable initial rating for a cervical spine disorder prior to April 12, 2011, a staged initial rating greater than 20 percent from April 12, 2011 to March 31, 2021, and a staged initial rating greater than 40 percent from April 1, 2021 3. Entitlement to a separate 10 percent rating for right upper extremity radiculopathy 4. Entitlement to a separate 10 percent rating for left upper extremity radiculopathy Service connection for degenerative disc disease of the cervical spine was awarded in a September 2008 rating decision, and a noncompensable disability rating was assigned, effective October 2, 2007, under 38 C.F.R. § 4.71a, Diagnostic Code 5242. In a July 2011 rating decision, an increased rating of 20 percent was granted, effective April 12, 2011, and in an August 2021 rating decision, an increased rating of 30 percent was awarded, effective April 1, 2021. Under Diagnostic Code 5242, a 10 percent evaluation is warranted with forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, localized tenderness not resulting in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is present, or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted with forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, combined range of motion of the cervical spine is not greater than 170 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is present. A 30 percent evaluation is warranted if forward flexion of the cervical spine is 15 degrees or less or there is favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted if there is unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine. In applying these regulations, VA should obtain examinations in which the examiner determines whether the disability is 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, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Board notes that, effective February 7, 2021, the rating schedule for evaluating musculoskeletal disabilities was amended in parts. Diagnostic Code 5242 was amended to make clear that its application was for degenerative arthritis/disc disease of the spine other than IVDS. Diagnostic Code 5243 was amended to clarify that it should only be applied for disc herniation with compression and/or irritation of the adjacent nerve root, and that all other disc diagnoses should be rated under Diagnostic Code 5242. As the regulations, as amended in February 2021, make the definition of incapacitating episodes even more restrictive than the former criteria, the Board will evaluate the lumbar spine disability under the former, more liberal, criteria. After thorough consideration of the evidence of record, the Board concludes that an initial 10 percent disability rating is warranted for the Veteran's cervical spine disability prior to April 12, 2011, but that a staged initial rating greater than 20 percent is not warranted from April 12, 2011 to March 31, 2021, and a staged initial rating greater than 30 percent is not warranted from April 1, 2021. The preponderance of the evidence supports the assignment of a 10 percent initial disability rating for a cervical spine disability prior to April 12, 2011 under Diagnostic Code 5242. Prior to April 12, 2011, a July 2008 VA examination reflects range of motion of the cervical spine with forward flexion to 70 degrees, extension to 50 degrees, right and left lateral rotation to 60 degrees, and right and left lateral flexion to 35 degrees. There was no pain with neck range of motion, and there was no additional limitation of motion, fatigue, weakness, or incoordination following repeated use testing. The examiner noted that the Veteran had no incapacitating episodes of neck pain during the previous 12-month period, and that he had no flare-ups of the neck as indicated by acute pain, redness, swelling, or heat. As the pertinent medical evidence of record prior to April 12, 2011 shows a combined range of motion to 310 degrees, a 10 percent initial disability rating is warranted for the Veteran's cervical spine disability prior to April 12, 2011. However, an initial rating greater than 10 percent is not warranted for the Veteran's cervical spine disability prior to April 12, 2011. Specifically, there is no evidence that the Veteran experienced cervical spine range of motion with forward flexion to 30 degrees or less; combined range of motion of the cervical spine to 170 degrees or less; or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Consideration has been given to any functional impairment and any effects of pain on functional abilities due to the Veteran's service-connected cervical spine disability prior to April 12, 2011. The Board acknowledges the subjective complaints of pain made prior to April 12, 2011. However, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. In this case it does not. More specifically, there was no evidence of decreased range of motion with repetitive range of motion testing of the thoracolumbar spine or additional limitation of joint function due to pain, fatigue, weakness, lack of endurance, or incoordination during the July 2008 VA examination. Further, the Veteran denied a history of incapacitating episodes and flare-ups. In light of the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected cervical spine disability prior to April 12, 2011 is not warranted based on functional impairment. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-06. From April 12, 2011 to March 31, 2021, the preponderance of the evidence does not support the assignment of a disability rating greater than 20 percent for the Veteran's cervical spine disability. In April 2011, a VA examination was conducted to evaluate the severity of the Veteran's cervical spine disability. At that time, the Veteran reported cervical spine pain with severe flare-ups every one to two months, lasting three to seven days. He noted symptoms including fatigue, decreased motion, stiffness, weakness, spasm, and constant pain. On physical examination, there was no evidence of gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, list, or scoliosis. There was also no evidence of cervical spine ankylosis. Range of motion of the cervical spine revealed forward flexion to 18 degrees, extension to 11 degrees, left lateral flexion to 32 degrees, right lateral flexion to 30 degrees, left lateral rotation to 35 degrees, and right lateral rotation to 40 degrees. The examiner noted that there was objective evidence of pain with active range of motion and following repetitive use testing. After repetitive motion, there was range of motion of the cervical spine with flexion to 20 degrees, extension to 12 degrees, left lateral flexion to 28 degrees, right lateral flexion to 20 degrees, left lateral rotation to 30 degrees, and right lateral rotation to 25 degrees. As the probative medical evidence from April 12, 2011 to March 31, 2021 does not reveal forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the cervical spine, a staged initial rating greater than 20 percent is not warranted for the Veteran's cervical spine disability from April 12, 2011 to March 31, 2021 under Diagnostic Code 5242. The Board has also considered the lay statements that the Veteran experienced symptoms and flare-ups that limited his ability to function from April 12, 2011 to March 31, 2021. However, as noted above, the objective evidence, including the results of repetitive motion testing, does not indicate a loss of motion consistent with a higher evaluation under the general rating formula. The Board concludes that the Veteran's reported impairments are contemplated by the current 20 percent evaluation. Thus, even with consideration of all relevant functional factors, the Board finds that a rating more than 20 percent for orthopedic impairment of the cervical spine is not warranted from April 12, 2011 to March 31, 2021. From April 1, 2021, the preponderance of the evidence does not support a staged initial rating greater than 30 percent for the Veteran's cervical spine disability. An April 2021 VA examination reflects that the Veteran reported neck pain and stiffness with weekly flare-ups of moderate severity. The Veteran also noted functional impairment described as limited range of motion. On physical examination, cervical spine active range of motion showed forward flexion to 30 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 50 degrees. There was pain with range of motion in each direction, but the examiner did not identify any additional limitation of motion specifically attributable to pain, weakness, fatigability, or incoordination. Passive range of motion was tested and was found to be the same as active range of motion with pain in each direction. The examiner noted that there was no evidence of pain with weight-bearing, but there was pain with active and passive motion which caused functional loss. After repetitive use testing, range of motion was further limited with forward flexion to 25 degrees, extension to 25 degrees, right and left lateral flexion to 25 degrees, and right and left lateral rotation to 45 degrees. The examiner noted that the Veteran was not examined after repeated use over time, but that pain would additionally limit range of motion with forward flexion to 20 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 40 degrees. With flare-ups, range of motion would be further limited with forward flexion to 15 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 35 degrees. There was no evidence of localized tenderness, guarding, or muscle spasm of the cervical spine. The April 2021 VA examiner reported that there was no ankylosis of the spine. As the probative evidence of record from April 1, 2021 does not reveal unfavorable ankylosis of the entire cervical spine, a staged initial rating greater than 30 percent is not warranted for the Veteran's cervical spine disability from April 1, 2021 under Diagnostic Code 5242. A higher rating for the cervical spine disability from April 1, 2021 is also not warranted based upon functional impairment, as the Veteran is already in receipt of the highest disability rating based upon limitation of motion under the pertinent rating criteria. Under the General Rating Formula for Diseases and Injuries of the Spine, any associated objective neurologic abnormalities are to be evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For the reasons discussed below, separate 10 percent ratings for radiculopathy of the right and left upper extremities are granted. During his June 2008 VA examination, the Veteran reported cervical spine pain that radiated down to the top of his shoulders. Similarly, the April 2011 VA examination notes that the Veteran reported neck pain which radiated to his shoulders, arms, hands, and fingertips. Neither VA examiner assessed whether the Veteran's radiating pain constituted radiculopathy. In a December 2019 private medical record, the Veteran reported neck pain which spread to both his arms and head. The physician diagnosed "[c]ervical spondylosis with radiculopathy." Although the April 2021 VA examiner reported that the Veteran did not have radiculopathy of the upper extremities, the examiner does not appear to have considered the Veteran's previous reports of radiating pain, as no such complaints were noted in the examination; thus, the Board does not afford significant probative value to the April 2021 VA examiner's opinion that there was no radiculopathy. Based upon the December 2019 private treatment record diagnosing cervical radiculopathy, and with consideration of the benefit of the doubt, the Board concludes that separate 10 percent ratings are warranted for radiculopathy of the right and left upper extremities. 5. Entitlement to a compensable initial rating for allergic rhinitis The Veteran contends that a compensable initial rating is warranted for allergic rhinitis. Service connection for allergic rhinitis was granted by the RO in a September 2008 rating decision, and a noncompensable rating was assigned, effective October 2, 2007, under 38 C.F.R. § 4.97, Diagnostic Code 6522. Under Diagnostic Code 6522, allergic or vasomotor rhinitis warrants a 10 percent rating where there are no polyps, but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6522. A maximum 30 percent rating is for application when there are polyps. Id. After thorough consideration of the evidence of record, the Board concludes that a compensable initial rating is not warranted for allergic rhinitis. During a July 2008 VA examination, the Veteran reported that he experienced symptoms including intermittent post-nasal drip, nasal congestion, and sinus headaches which were worse during the spring and fall. He noted that he took Claritin and Flonase to relieve his symptoms. In an April 2011 VA examination, the Veteran complained of having sinus infections or upper respiratory infections at least once per year. He noted occasional headaches and swelling with postnasal drip, bad breath, cough, sneezing, and bronchitis. Physical examination was normal. An April 2021 VA examination reflects the Veteran's reports of nasal congestion, sneezing, and itchy eyes with occasional episodes throughout the year. On physical examination, there was permanent hypertrophy of the nasal turbinates but there was not greater than 50 percent obstruction of the nasal passages; there was not complete obstruction of the right or left side; and there were no nasal polyps. Private treatment records from 2014 through 2017 reflect diagnoses of and treatment for allergic rhinitis. The records reflect that the Veteran was "doing good on current meds without any side effects . . . ." Based upon review of the evidence of record, the Board finds that the Veteran is not entitled to a compensable rating for his service-connected allergic rhinitis. The evidence of record fails to demonstrate allergic rhinitis with either greater than 50 percent obstruction of the nasal passage on both sides or with complete obstruction on one side. Despite the Veteran's complaints, the treatment records and VA examinations of record do not reflect symptomatology meeting the rating criteria for a 10 percent rating pursuant to Diagnostic Code 6522. As such, a compensable rating for allergic rhinitis must be denied. The Board has considered other potentially applicable diagnostic codes, including Diagnostic Codes 6510 through 6514 pertaining to sinusitis. However, the medical evidence of record does not contain a diagnosis of sinusitis. Thus, there is no basis for assignment of a rating pursuant to the sinusitis diagnostic criteria. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) ("[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy."). Accordingly, as the preponderance of the evidence is against the claim for an initial compensable rating for the service-connected allergic rhinitis disability, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to a compensable initial rating for bilateral hearing loss Service connection for bilateral hearing loss was granted in a September 2008 rating decision, and a noncompensable disability rating was assigned, effective October 2, 2007. VA disability compensation for impaired hearing is derived from the application in sequence of two tables. See 38 C.F.R. § 4.85(h), Table VI and Table VII. Table VI correlates the average pure tone sensitivity threshold, derived from the sum of the 1000, 2000, 3000, and 4000 Hertz (Hz) thresholds divided by four, with the ability to discriminate speech, providing a Roman numeral to represent the correlation. Each Roman numeral corresponds to a range of thresholds in decibels and of speech discriminations in percentages. The table is applied separately for each ear to derive the values used in Table VII. Table VII prescribes the disability rating based on the relationship between the values for each ear derived from Table VI. See 38 C.F.R. § 4.85. When the puretone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hz is 55 decibels or more, the Roman numeral designation for hearing impairment is determined from either Table VI or Table VIa, whichever results in a higher number. Each ear is evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz, the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results is the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear is evaluated separately. 38 C.F.R. § 4.86(b). In October 2008, the Veteran underwent an audiological examination. On the authorized audiological testing, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 45 LEFT 5 5 5 40 45 The average puretone threshold for the relevant frequencies was 15 in the right ear and 24 in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 92 percent in the left ear. The examiner reported that the Veteran's hearing disability caused difficulty hearing and understanding speech in a noisy environment. The Veteran underwent another VA audiological examination in May 2011. On the authorized audiological testing, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 20 15 40 LEFT 10 5 15 45 45 The average puretone threshold for the relevant frequencies was 23 in the right ear and 28 in the left ear. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 84 percent in the left ear. The examiner reported that the Veteran's hearing disability caused difficulty hearing soft voices and people behind him. He noted that he often had to ask people at work to repeat things. In April 2021, the Veteran underwent another VA audiological examination. On the authorized audiological testing, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 20 45 70 LEFT 10 15 20 40 60 The average puretone threshold for the relevant frequencies was 38 in the right ear and 34 in the left ear. Speech audiometry revealed speech recognition ability of 86 percent in the right ear and 92 percent in the left ear. The examiner reported that the Veteran's hearing disability caused difficulty hearing and understanding in background noise and asking others to repeat themselves. The audiometric results of the October 2008 audiogram result in Level I hearing acuity in the right ear and Level I hearing acuity in the left ear. The results of the May 2011 VA audiogram result in Level II hearing acuity in the right ear and Level II hearing acuity in the left ear. The results of the April 2021 VA audiogram result in Level II hearing acuity in the right ear and Level I hearing acuity in the left ear. With each of such findings, the point of intersection on Table VII requires the assignment of a noncompensable evaluation under Diagnostic Code 6100. 38 C.F.R. § 4.85. Additionally, the Veteran's hearing loss disability does not satisfy the "exceptional pattern" defined in 38 C.F.R. § 4.86. After review of the evidence of record, there is no evidence that would warrant a compensable rating for the Veteran's bilateral hearing loss during the rating period on appeal. 38 U.S.C. § 5110. While there have been day-to-day fluctuations in the manifestations of the Veteran's hearing loss, the evidence shows no distinct periods of time during which the Veteran's bilateral hearing loss has varied to such an extent that staged ratings would be warranted. Cf. 38 C.F.R. § 3.344 (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). The assignment of disability evaluations for hearing impairment is a purely mechanical application of the rating criteria from which the Board cannot deviate. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992); see also Massey v. Brown, 7 Vet. App. 204, 208 (1994) (finding the Board may only consider the specific factors as are enumerated in the applicable rating criteria). The Board is sympathetic to the Veteran's complaints related to his hearing loss but finds that there is no schedular basis for granting a compensable rating. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.7, 4.21. 7. Entitlement to an initial rating greater than 10 percent for a left foot disorder prior to April 1, 2021; entitlement to a compensable initial rating for a right foot disorder prior to April 1, 2021; and entitlement to a staged initial rating greater than 20 percent for a bilateral foot disorder April 1, 2021 Service connection for right and left foot plantar fasciitis was granted in a September 2008 rating decision, and an initial noncompensable rating was assigned for right foot plantar fasciitis with an initial 10 percent rating assigned for left foot plantar fasciitis, effective October 2, 2007, under 38 C.F.R. § 4.71a, Diagnostic Code 5276. In an August 2021 rating decision, the RO combined the right and left foot plantar fasciitis disability ratings and assigned a 20 percent disability rating for bilateral plantar fasciitis, effective April 1, 2021, under 38 C.F.R. § 4.71a, Diagnostic Code 5284. Plantar fasciitis is not explicitly provided for in the diagnostic criteria. Nonetheless, it is traditionally rated under Diagnostic Code 5276, which rates for acquired flatfoot, and by analogy rates the typical symptoms of plantar fasciitis. Under Diagnostic Code 5276, a 10 percent disability rating is warranted for moderate bilateral or unilateral flatfoot, with the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A 30 percent rating is warranted for severe bilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances, is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Terms such as "mild," "moderate," "severe," and "pronounced" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It is noted, however, that the rating criteria in this matter do give some description of those terms. The Board finds that a compensable rating is not warranted for the Veteran's right foot disability prior to April 1, 2021. Upon VA examination in June 2008, the Veteran reported pain in his feet with walking. The Veteran's right foot manifested tenderness and pain to palpation with mild varus rotation of the fifth digit and mild splaying of the second and third digit. Range of motion of the fifth distal interphalangeal joint was absent. There was no decrease in the height of the medial longitudinal arch and no pain or crepitus with range of motion of the ankle joint. There was no decrease in the height of the medial longitudinal arch with mild decrease upon squatting. X-ray of the right foot and ankle was normal. The right foot disorder caused no functional limitations on standing or walking and there was no medial inward bowing of the right Achilles tendon. The diagnoses were right foot plantar fasciitis, sesamoiditis, neuroma, and right ankle arthralgia. Although the evidence demonstrates pain on use of the feet, in the absence of evidence of deformity or abnormality of the right Achilles tendon, the Veteran's right foot disorder prior to April 1, 2021 most nearly approximates the criteria contemplated by the current noncompensable evaluation for a mild disability under Diagnostic Code 5276. Accordingly, a compensable initial disability rating for right foot plantar fasciitis prior to April 1, 2021 is not warranted. The Board also finds that an initial rating greater than 10 percent is not warranted for the Veteran's left foot disability prior to April 1, 2021. A June 2008 VA examination of the left foot notes the Veteran reported pain in his feet with walking. Examination showed pain and tenderness to palpation with mild varus rotation of the fifth digit and absent range of motion of the fifth distal interphalangeal joint. There was no decrease in the height of the medial longitudinal arch. There was no pain or crepitus with range of motion of the ankle joint. There was no decrease in the height of the medial longitudinal arch with mild decrease upon squatting. X-ray of the right foot and ankle was normal. The left foot disorder caused no functional limitations on standing or walking, but there was mild medial inward bowing of the left achilles tendon. The diagnoses were left foot plantar fasciitis and sesamoiditis. Because the probative evidence of record prior to April 1, 2021 does not reflect objective evidence of marked deformity such as pronation or abduction, accentuated pain on manipulation and use, evidence of swelling on use, or characteristic callosities, the Board finds that the Veteran's left foot disorder most nearly approximates the criteria contemplated by the current 10 percent evaluation for a moderate disability under Diagnostic Code 5276 prior to April 1, 2021. Accordingly, an initial disability rating greater than 10 percent is not warranted for left foot plantar fasciitis prior to April 1, 2021. Beginning April 1, 2021, the Veteran's right and left foot plantar fasciitis was combined and rated as 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5284 for other foot injuries. Under Diagnostic Code 5284, a moderate foot injury warrants a 10 percent disability evaluation. A moderately severe foot injury warrants a 20 percent disability evaluation and a severe foot injury is assigned a 30 percent disability evaluation. A 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. As noted above, terms such as "mild," "moderate," "severe," and "pronounced" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In April 2021, the Veteran underwent a VA foot conditions examination. The Veteran reported pain and tenderness with prolonged standing or walking. He stated that he experienced moderate to severe flare-ups of right and left foot pain on a weekly basis. The Veteran reported accentuated pain on use and manipulation of both feet. There was no indication of swelling on use and there were no characteristic calluses. The Veteran reported that he used arch supports for both feet, but that he remained symptomatic. There was extreme tenderness of the plantar surfaces of both feet and that the tenderness was not improved by orthopedic shoes or appliances. There was not decreased longitudinal arch height of either feet on weight-bearing, there was not objective evidence of marked deformity of one or both feet, and there was not marked pronation of one or both feet. The weight-bearing line was not over or medial to the great toe of either foot and there was not a lower extremity deformity causing alteration of the weight-bearing line. Additionally, there was not inward bowing of the Achilles' tendon of one or both feet and there was not marked inward displacement and severe spasm of the Achilles' tendon. The examiner reported that non-surgical treatment did not relieve the Veteran's plantar fasciitis symptoms, but that he did not have any functional loss of the feet due to plantar fasciitis. The Veteran also had Morton's neuroma, but there was no evidence of metatarsalgia. The examiner also noted that the Veteran had sigmoiditis of both feet, which was of mild severity. The examiner reported that the foot condition chronically compromised weight bearing and that it required arch supports, custom orthotic inserts, or shoe modifications. The examiner stated that there was pain on physical examination of both feet, and that the pain contributed to functional loss, which was identified as interference with standing and pain. The evidence suggested that pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or with repeated use over time, including pain and tenderness with prolonged standing and walking. The examiner noted that there was evidence of pain in both feet with active motion and with weight-bearing described as pain and tenderness with prolonged standing and walking. The examiner explained that the Veteran had difficulty standing for more than 30 minutes and walking for more than one quarter of a mile. The diagnoses included bilateral plantar fasciitis, right foot Morton's neuroma, and bilateral sigmoiditis. Based upon the evidence of record, the Board concludes that an increased rating of 30 percent is warranted for the Veteran's bilateral foot disorder from April 1, 2021. Review of the April 2021 VA examination reflects that the Veteran experienced moderate to severe flare-ups of foot symptomatology as well as accentuated pain on use and manipulation. Additionally, the Veteran's bilateral foot disorder causes functional loss including interference with standing and walking. Given this evidence, the weight of the probative evidence of record is at least in equipoise as to whether the Veteran's bilateral foot disorder is severe. Accordingly, an increased rating of 30 percent is warranted under Diagnostic Code 5284, effective April 1, 2021. An increased rating greater than 30 percent is not warranted under Diagnostic Code 5284, as 30 percent is the highest schedular rating available. The Board has also considered the application of other diagnostic codes pertaining to the feet, but increased ratings greater than 30 percent are not provided for under any diagnostic code pertaining to the feet except for Diagnostic Code 5276. An increased rating greater than 30 percent is not warranted under Diagnostic Code 5276, as there is no evidence of marked pronation, extreme tenderness of the plantar surfaces, or marked inward displacement and severe spasms of the tendo achillis on manipulation. Accordingly, an increased rating greater than 30 percent is not warranted under Diagnostic Code 5276. REASONS FOR REMAND 1. Entitlement to service connection for a disability of the left shoulder, arm, and/or hand is remanded. In an April 2021 VA opinion, a VA examiner opined that it was less likely than not that the Veteran's diagnosed left shoulder strain was related to his active duty service because "there are no medical records showing diagnosis, treatment for the left shoulder condition during active duty." Review of the service treatment records, however, document complaints of and treatment for a tight and painful left shoulder and left shoulder pain with active and passive cross-chest adduction, pain on palpation, and a painful shoulder arc. Accordingly, because the April 2021 VA opinion is based upon an inaccurate factual basis, a new VA examination is required. 2. Entitlement to service connection for an eye disorder, to include strabismus, heterophoria, and/or esophoria is remanded. In April 2021, a VA examiner diagnosed dry eye syndrome, nuclear sclerotic cataract, and vitreous floaters. The examiner also concluded that the Veteran does not meet the diagnostic criteria for right or left eye strabismus. The VA examiner, however, did not provide an opinion as to whether the Veteran's dry eye syndrome, nuclear sclerotic cataract, or vitreous floaters were caused by or incurred during the Veteran's active-duty service. Towards that end, the Board observes that the Veteran's service treatment records document numerous complaints of blurry vision, poor distance focus, and poor night vision. In light of this evidence, a new VA examination is warranted to determine the etiology of the Veteran's diagnosed eye disorders. 3. Entitlement to service connection for a disability manifested by joint swelling is remanded. In an April 2021 VA examination, the examiner opined that the Veteran did not have a diagnosed disability associated with his complaints of joint swelling. The VA examiner, however, did not address the possibility that the Veteran's symptoms of joint swelling were manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness of unknown etiology associated with his service in the Persian Gulf. Accordingly, a new VA examination is warranted to determine whether the Veteran's joint swelling symptoms constitute an undiagnosed illness or a medically unexplained chronic multisymptom illness. Additionally, the Board observes that the Veteran's service treatment records document complaints of joint swelling in the fingers, hands, wrists, and fingers. As there is evidence of in-service symptomatology of joint swelling symptoms, the examiner should also provide an opinion as to whether any currently diagnosed disorder associated with the Veteran's reports of joint swelling symptoms were incurred in or caused by his active-duty service. The matters are REMANDED for the following action: 1. Provide the Veteran with a new VA examination by an appropriate physician to determine the etiology of the Veteran's left shoulder disorder. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that any left shoulder disorder currently diagnosed, or diagnosed during the appeal, even if currently resolved, was caused by or incurred as a result of the Veteran's active-duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the service treatment records and the Veteran's lay statements regarding in-service and post-service symptomatology. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 2. Provide the Veteran with a new VA examination by an appropriate clinician to determine the etiology of the Veteran's eye disorders. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that any eye disorder currently diagnosed, or diagnosed during the appeal, even if currently resolved, was caused by or incurred as a result of the Veteran's active-duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the service treatment records and the Veteran's lay statements regarding in-service and post-service symptomatology. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 3. Schedule the Veteran for a new VA examination to assess the etiology of the Veteran's joint swelling. After a thorough review of all evidence in the claims file, to include the Veteran's service treatment records, the post-service treatment records, and the Veteran's lay statements, the examiner should address the following: (a.) Can the Veteran's joint swelling symptoms be attributed to a known clinical diagnosis (other than a symptom-based diagnosis)? (b.) For any diagnosed disability, the examiner is asked to opine whether it is at least as likely as not (e.g., a 50 percent probability or greater) that the Veteran's disability was caused by or incurred during service, to include whether it first manifested during service. (c.) Are the Veteran's joint pain symptoms a manifestation of: (i) an undiagnosed illness; (ii) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology; (iii) a diagnosable chronic multisymptom illness with a partially explained etiology; or (iv) a disease with a clear and specific etiology? A complete rationale for all opinions must be provided. The examiner is advised that the Veteran is competent to report observable symptomatology. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Katz, 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.