Citation Nr: 21065285 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 15-11 746 DATE: October 25, 2021 ORDER The petition to reopen the previously denied claim for entitlement to service connection for left Achilles tendon strain is denied. Entitlement to service connection for hemorrhoids is granted. Entitlement to service connection for left 2nd and 3rd finger frostbite residuals is denied. Entitlement to service connection for atrial fibrillation is denied. Entitlement to an initial rating of 10 percent for left ankle instability prior to December 8, 2016, is granted. Entitlement to an initial rating of 20 percent for left ankle instability from December 8, 2016, to December 6, 2019, is granted. Entitlement to an initial rating in excess of 10 percent prior to December 8, 2016, and from December 7, 2019, for left ankle instability is denied. Entitlement to an initial rating of 10 percent for right ankle instability prior to December 8, 2016, is granted. Entitlement to an initial rating of 20 percent for right ankle instability from December 8, 2016, to December 6, 2019, is granted. Entitlement to an initial rating in excess of 10 percent prior to December 8, 2016, and from December 7, 2019, for right ankle instability is denied. Entitlement to a rating of 10 percent, and no higher, for frostbite of the 3rd right finger is granted. Entitlement to a compensable rating for pruritis ani is denied. REMANDED Entitlement to a compensable rating for degenerative disc disease of the cervical spine is remanded. FINDINGS OF FACT 1. The Veteran did not timely appeal an October 1995 rating decision that denied his original claim for entitlement to service connection for left Achilles tendon strain. 2. New and material evidence has not been received since the October 1995 rating decision as to the claim for entitlement to service connection for left Achilles tendon strain. 3. The Veteran's hemorrhoids began during his active service. 4. The preponderance of the evidence of record is against finding that the Veteran has had residuals of left 2nd and 3rd finger frostbite at any time during or proximate to the pendency of the claim. 5. There is no probative evidence of record indicating that the Veteran's atrial fibrillation began during his active service or is etiologically related to an in-service event, injury, or disease. 6. During the rating period prior to December 8, 2016, and the period beginning December 7, 2019, the Veteran's left ankle instability was manifested by pain and motion limited, at most, to a moderate degree. 7. During the rating period from December 8, 2016, to December 6, 2019, the Veteran's left ankle instability was manifested in pain and motion limited to a marked degree. 8. During the rating period prior to December 8, 2016, and the period beginning December 7, 2019, the Veteran's right ankle instability was manifested in pain and motion limited, at most, to a moderate degree. 9. During the rating period from December 8, 2016, to December 6, 2019, the Veteran's right ankle instability was manifested in pain and motion limited to a marked degree. 10. The Veteran experiences pain, stiffness, and reduced strength as residuals of his frostbite of the 3rd right finger. 11. The Veteran's pruritus ani has been manifested by erythema covering less than 5 percent of the total body area and 0 percent of exposed areas. CONCLUSIONS OF LAW 1. The October 1995 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156, 19.20, 19.21, 19.52, 20.1103. 2. The criteria for reopening the previously denied claim for entitlement to service connection for left Achilles tendon strain have not been met. 38 U.S.C. §§ 1110, 1131, 5108; 38 C.F.R. §§ 3.156, 3.303. 3. The criteria for entitlement to service connection for hemorrhoids have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria for entitlement to service connection for left 2nd and 3rd finger frostbite residuals have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 5. The criteria for entitlement to service connection for atrial fibrillation have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 6. The criteria for entitlement to an initial rating of 10 percent for left ankle instability prior to December 8, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 7. The criteria for entitlement to an initial rating of 20 percent for left ankle instability from December 8, 2016, to December 6, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 8. The criteria for entitlement to an initial rating in excess of 10 percent prior to December 8, 2016, and from December 7, 2019, for left ankle instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 9. The criteria for entitlement to an initial rating of 10 percent for right ankle instability prior to December 8, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 10. The criteria for entitlement to an initial rating of 20 percent for right ankle instability from December 8, 2016, to December 6, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 11. The criteria for entitlement to an initial rating in excess of 10 percent prior to December 8, 2016, and from December 7, 2019, for right ankle instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Code 5271. 12. The criteria for entitlement to a rating of 10 percent, and no higher, for frostbite of the 3rd right finger have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, 4.104, Diagnostic Codes 5226, 5229, and 7199. 13. The criteria for entitlement to a compensable rating for pruritis ani have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.114, 4.118, Diagnostic Codes 7337 and 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1974 to June 1995. In October 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded this case in November 2019. Relevant to the issues denied herein, the remand directed the agency of original jurisdiction (AOJ) to obtain the Veteran's updated VA treatment records, provide the Veteran an examination as to his service-connected right and left ankle disabilities, provide the Veteran a VA examination as to his service-connected pruritis ani, and readjudicate the appeal in view of the expanded record. Pursuant to the remand, the AOJ obtained the Veteran's outstanding VA treatment records, afforded the Veteran VA examinations as to his service-connected ankle disabilities and pruritis ani that provide the information necessary to rate those disabilities, and readjudicated the appeal in an August 2020 supplemental statement of the case. Accordingly, the Board finds that VA at least substantially complied with the November 2019 remand. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Additional evidence, to include additional VA treatment records, was associated with the record following issuance of the August 2020 supplemental statement of the case. However, the additional evidence is not relevant to the issues denied herein. Accordingly, a remand for issuance of a supplemental statement of the case is not necessary, and the Board may proceed with appellate consideration. See 38 C.F.R. § 19.37. Neither the Veteran nor representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issue denied in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Reopening Issue 1. The petition to reopen the previously denied claim for entitlement to service connection for left Achilles tendon strain The Veteran seeks to reopen his previously denied claim for entitlement to service connection for left Achilles tendon strain. In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Under 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The question of whether new and material evidence has been received to reopen a previously denied claim must be addressed by the Board in the first instance because the issue goes to the Board's jurisdiction to reach and adjudicate the underlying claim on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). New evidence is existing evidence not previously considered by VA. Material evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In general, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The Veteran submitted his original claim for entitlement to service connection for a left ruptured Achilles tendon in July 1995. In the October 1995 rating decision, the AOJ denied the Veteran's claim because, although there is a record of treatment for the claimed condition in the service treatment records, the condition was not shown at separation from active service and was therefore considered resolved after treatment. The letter informing the Veteran of the October 1995 rating decision was enclosed with a VA Form 4107 that explained his right to appeal the decision. The Veteran did not submit a timely notice of disagreement as to the October 1995 rating decision's denial of entitlement to service connection for left Achilles tendon strain. In addition, new and material evidence as to that issue was not received within the one-year appeal period following issuance of the October 1995 rating decision. As such, the Veteran did not initiate a timely appeal of the October 1995 rating decision's denial of entitlement to service connection for left Achilles tendon strain, and the decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 19.20, 19.21, 19.52, 20.1103. Evidence that has been associated with the record since issuance of the final October 1995 rating decision and that is relevant to the issue of entitlement to service connection for left Achilles tendon strain includes the Veteran's assertions that he has left Achilles tendon strain due to in-service injuries, additional private and VA treatment records, and October 2012, December 2016, and December 2019 VA ankle conditions examinations. The Board finds that the evidence received since the final October 1995 rating decision is not new and material as to the previously denied claim for entitlement to service connection for left Achilles tendon strain. Regarding the Veteran's assertions that he has left Achilles tendon strain due to in-service injuries, such assertions are the same as those he made in support of his original claim denied in the final October 1995 rating decision. Those assertions are therefore redundant of evidence previously considered and are not considered to be new evidence. The additional medical treatment records show that the Veteran suffered a contusion to the left lower extremity in 2011 when he bumped his calf on furniture. He has also been diagnosed with conditions of the bilateral ankles, which are considered part of the already service-connected left and right ankle instability. The records do not show that the Veteran has been diagnosed with a disability of the left Achilles tendon. Thus, the additional medical treatment records are new in the sense that they were not previously considered by VA. However, they are not material because they do not relate to an unestablished fact necessary to substantiate the previously denied claim and/or do not raise a reasonable possibility of substantiating the previously denied claim, as they are cumulative of evidence previously considered and do not show a current left Achilles tendon disability. 38 C.F.R. § 3.156. The October 2012 VA examiner noted the Veteran's reported history of left Achilles tendon strain and checked a box indicating the Veteran either currently had or had at some point in the past left Achilles tendonitis or Achilles tendon rupture. However, he later clarified that the Veteran does not currently have a diagnosis of left Achilles tendon strain because "there is no pathology to render a diagnosis." The December 2016 and December 2019 VA examiners left blank the checkboxes for Achilles tendonitis and Achilles tendon rupture, and did not otherwise indicate that the Veteran has been diagnosed with a disability of the left Achilles tendon. Thus, the VA examinations are new in the sense that they were not previously considered by VA. However, they are not material because they do not relate to an unestablished fact necessary to substantiate the previously denied claim and/or do not raise a reasonable possibility of substantiating the previously denied claim, as they are cumulative of evidence previously considered and do not show a current left Achilles tendon disability. 38 C.F.R. § 3.156. The Board notes that VA's duty to assist in providing an examination for requests to reopen a finally adjudicated claim applies only if new and material evidence is presented. 38 C.F.R. § 3.159(c)(4)(iii). In this case, the Board finds that no new and material evidence has not been received as to the Veteran's previously denied claim for entitlement to service connection for a left Achilles tendon disability. Therefore, any question as to the adequacy of the October 2012, December 2016, and December 2019 VA examination is not a viable issue. See also Woehlaert v. Nicholson, 21 Vet. App. 456, 461 (2007). Finally, the Board acknowledges the Veteran's Representative's arguments in a September 2021 written brief presentation that VA treatment records dated in April 2021 indicate that the Veteran was diagnosed with Achilles rupture tear (partial), which was later determined to be a calf tear. However, a review of those records reveals that they are for an individual other than the Veteran and were included in the Veteran's record by mistake. They are not for consideration in the Veteran's appeal, and VA has removed them from the Veteran's record. VA has not relied on those records in making any determination as to the Veteran's claims. In view of the foregoing, the Board finds that the evidence of record contains no new and material evidence received since the final October 1995 rating decision as to the previously denied claim for entitlement to service connection for a left Achilles tendon disability. Therefore, new and material evidence to reopen that finally denied claim has not been received, the doctrine of reasonable doubt is not for application, and the claim for entitlement to service connection for left Achilles tendon strain is not reopened. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service Connection Issues Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 2. Entitlement to service connection for hemorrhoids The Veteran seeks entitlement to service connection for hemorrhoids, which he contends began during his active service. The Board concludes that the Veteran has a current disability that began during his active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A January 1993 service treatment record shows that an examination revealed nonthrombosed external hemorrhoids at the 9 o'clock position with diffuse erythema but no fissures, bleeding, or masses. A December 2019 VA rectum and anus conditions examination revealed moderate hemorrhoids. Thus, the question becomes whether the current disability is related to service. The December 2019 VA examiner opined that that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, as a rationale for that opinion, the examiner explained, "If evidence of hemorrhoids can be found in the medical record from January 1993 as is noted, then a direct association is at least as likely to be present. However, I am unable to find these notes. In the absence of this confirmation, it is less likely than not that the current diagnosis of hemorrhoids is a continuation of hemorrhoids noted in service." As discussed above, the service treatment records do in fact include a January 1993 note documenting a finding of external hemorrhoids. Therefore, the Board accepts the December 2019 VA examiner's opinion as probative evidence that the current hemorrhoids are at least as likely as not related to the in-service hemorrhoids. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current hemorrhoids arose during his active service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for hemorrhoids is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for left 2nd and 3rd finger frostbite residuals The Veteran contends that he has residuals of frostbite of the left 2nd and 3rd fingers. At the October 2018 Board hearing, he testified that he had frostbite on those two fingers in 1987 or 1988 while working as a survival instructor in the cold. He treated the injury himself through rapid rewarming with water and did not go to sick call because "there's no sick call in the woods." He testified that he mentioned the injury at the time of his separation medical examination, and that the two fingers are painful, have limited motion, and are sensitive to heat and cold. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of left 2nd and 3rd finger frostbite residuals and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Specifically, the Veteran's service treatment records do not confirm that he reported frostbite to the left 2nd and 3rd finger at the time of his separation from active service. A June 1995 report of medical history indicates that the Veteran only reported frostbite of the right 3rd finger at that time. A June 1995 report of medical examination shows that the Veteran's upper extremities were normal except for scar tissue at the tip of the left finger. The medical treatment records do not show that the Veteran has been diagnosed with frostbite residuals of the left 2nd finger or left 3rd finger. Although the Veteran reported a history of frostbite of the left long and ring fingers at an August 2012 VA treatment visit, no findings related to that report were found and the assessment/plan portion of that treatment note merely repeats the Veteran's reported history. Because the assessment merely repeats the Veteran's reported history and is not based on any signs or symptoms found on examination, the Board finds that assessment not to be an indication that the Veteran has been diagnosed with frostbite residuals of the left 2nd finger or left 3rd finger by a competent medical source. An October 2012 VA examiner noted the Veteran's reports of cold weather exposure during his active service, but found that there is no pathology to render a diagnosis as to the left 2nd and 3rd fingers because current physical examination of that hand was normal aside from mild degenerative joint disease shown on X-ray that was consistent with normal aging. A December 2016 VA hand and finger conditions examiner found the Veteran's strength testing to be normal bilaterally and representative of the expected results for the Veteran's current age and general physical condition. Range of motion at that examination was also normal for the left hand with no pain noted on examination. Accordingly, the competent medical evidence of record does not show that the Veteran has been diagnosed with frostbite residuals of the left 2nd finger or left 3rd finger. The October 2012 VA examiner attributed the Veteran's current degenerative joint disease of the left hand to the normal aging process rather than to a frostbite injury. The Veteran is competent and credible in his reports of being exposed to cold conditions during his active service and to rapidly warming his hands using water. The Board also acknowledges his belief that his current pain and other symptoms in his left hand are related to an in-service cold injury. However, he is not competent to provide a diagnosis in this case or to relate his symptoms to an in-service event. The issue is medically complex, as it requires specialized medical education and knowledge of the lasting effects of cold injuries and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, his assertions are not entitled to probative value and do not weigh against the competent medical evidence of record, to include the October 2012 VA examiner's finding that the Veteran's current left hand degenerative joint disease is attributable to the normal aging process and not to a frostbite injury. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for left 2nd and 3rd finger frostbite residuals. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 4. Entitlement to service connection for atrial fibrillation The Veteran seeks entitlement to service connection for atrial fibrillation. At the October 2018 Board hearing, he testified that he believes the strep throat he had during his active service caused his atrial fibrillation, that his sleep apnea and atrial fibrillation are likely connected, and that he included the issue in his claim because his representative told him that the in-service strep throat is "a possibility as the genesis of your problem." His doctor has told him that the atrial fibrillation "is likely prolonged persisted because of sleep apnea." In a November 2018 statement, the Veteran also asserted that he had in-service transient heart problems, viral infections, and stress from training that may have caused his atrial fibrillation. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, although the Veteran has a current diagnosis of atrial fibrillation, the evidence shows that the Veteran had strep throat during his active service, and the Veteran is credible in his reports that his in-service work as a survival instructor was stressful, there is no probative evidence of record etiologically relating his current disability to his active service. The Veteran's service treatment records do not show diagnosis of atrial fibrillation or any other cardiovascular condition. April 1995 service treatment records show that the Veteran complained of pain in the left upper lateral chest. He was evaluated, including through an ECG, and it was determined that the chest pain was noncardiac in nature. The June 1995 report of medical examination for retirement from active service indicates that the Veteran had normal clinical evaluations of the heart and vascular system. A VA treatment note dated in August 2006, more than 21 years after the Veteran's separation from active service, indicates that the Veteran was diagnosed with recent onset atrial fibrillation, and that prior to the recent atrial fibrillation he had had no history of cardiovascular condition. Thus, the medical treatment records show that the Veteran was not diagnosed with atrial fibrillation until many years after his separation from active service, and that he did not have a history of cardiovascular condition prior to the recent onset of that condition. Regarding the Veteran's assertions that his atrial fibrillation may be related to his diagnosed sleep apnea, he submitted a claim for entitlement to service connection sleep apnea in December 2016, and the claim was denied in a March 2017 rating decision. That rating decision became final because he did not timely appeal it. Thus, he is not service connect for sleep apnea. Furthermore, the issue of whether new and material evidence has been received as to the issues of service connection for sleep apnea since the March 2017 rating decision is beyond the scope of the appeal for service connection for atrial fibrillation. Therefore, the Veteran may not be service connected for atrial fibrillation on a secondary basis as due to or aggravated by sleep apnea. Finally, the Veteran is not considered competent to associate his current atrial fibrillation with his in-service strep throat, noncardiac chest pain, viral infections, and stress. The issue is medically complex, as it requires specialized knowledge in the interpretation of complicated diagnostic medical testing, which the Veteran has not been shown to possess. Jandreau, 492 F.3d at 1377 n.4. Furthermore, the Veteran has not submitted any competent evidence indicating that there may be an etiological between the atrial fibrillation first diagnosed many years after his separation from active service and the in-service strep throat, noncardiac chest pain, viral infections, and stress. The Board acknowledges that an opinion was not obtained as to whether the Veteran's atrial fibrillation may be related to in-service strep throat, noncardiac chest pain, viral infections, and stress. However, the Veteran has not submitted or identified any competent evidence that his diagnosed atrial fibrillation may be related to his active service. Although medically competent evidence is not always required to trigger VA's duty to assist by providing a VA examination, a conclusory generalized lay statement suggesting a nexus between a current disability and service does not suffice to meet the standard of 38 C.F.R. § 3.159 (c)(4)(i)(B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010). In this case, the only evidence that the Veteran's atrial fibrillation may be related to his active service is the Veteran's own conclusory generalized lay statements. Accordingly, the Board finds that there is no evidence establishing a sufficient indication that the atrial fibrillation may be related to an in-service event, injury, or disease such that VA's duty to assist has been triggered. See also McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) (whether a claimant suffered an "in-service event, injury, or disease" under the second prong involves "a classic factual assessment, involving the weighing of facts"). In summary, the evidence does not show that the Veteran's atrial fibrillation was diagnosis during service or for many years after his separation from active service. There is no probative evidence of record indicating that the Veteran's atrial fibrillation began during his active service or is etiologically related to an in-service event, injury, or disease. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for atrial fibrillation. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. Increased Rating Issues Disability ratings are determined by the application of 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). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 5. Entitlement to higher initial ratings for left ankle instability 6. Entitlement to higher initial ratings for right ankle instability The Veteran seeks compensable initial ratings prior to December 8, 2016, and initial ratings in excess of 10 percent from that date for left ankle instability and right ankle instability. The applicable rating period is from July 2012, the effective date for the award of service connection for those disabilities, through the present. See 38 C.F.R. § 3.400. The Veteran's service-connected left and right ankle disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle and a 20 percent rating is warranted for marked limited motion of the ankle. Id. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. Effective February 7, 2021, VA amended the rating criteria for Diagnostic Code 5271. 85 Fed. Reg. 76,453 (Nov. 30, 2020). Under the new criteria, a 10 percent rating is warranted for moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion.) A 20 percent rating is warranted for marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion.). Because this regulatory change became effective only after the relevant rating, the new criteria do not strictly apply in this case. Nevertheless, in proposing the amendment to Diagnostic Code 5271, VA noted that, "VA currently uses these standards to define marked and moderate, this change is intended as a clarification of current policy and would ensure consistent application of these criteria among rating personnel." 82 Fed. Reg. 35,723 (August 1, 2017). Accordingly, in making changes to Diagnostic Code 5271, VA was codifying a previous policy to ensure more uniformity among its rating personnel. As such, even prior to February 7, 2021, marked limited motion of the ankle would mean less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. Such measurements are consistent with the dictionary definitions of "moderate" and "marked". According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character". See www.merriam-webster.com/dictionary/marked. In view of the foregoing, the Board will consider ankle motion limitation to be moderate if it is limited to less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion. The Board will consider ankle motion limitation to be marked if it is limited to less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. The Board finds that, for each ankle, the criteria for an initial rating of 10 percent, and no higher, were met during the relevant period prior to December 8, 2016, and the period beginning on December 7, 2019, and that the criteria for a rating of 20 percent were met from December 8, 2016, to December 6, 2019. At an October 2012 VA examination, the Veteran reported pain and swelling in his ankles. On examination, he had right ankle dorsiflexion to 20 degrees or greater and plantar flexion to 45 degrees or greater and left ankle dorsiflexion to 20 degrees or greater and plantar flexion to 45 degrees or greater. He did not have additional loss of motion following repetitive-use testing. At a December 2016 VA examination, the Veteran reported that his service-connected left and right ankle disabilities result in trips and falls, as well as pain with walking. On examination, the Veteran had right ankle dorsiflexion to 5 degrees and plantar flexion to 30 degrees on both active motion and passive motion and left ankle dorsiflexion to 5 degrees and plantar flexion to 30 degrees on both active motion and passive motion. He did not have additional loss of motion following repetitive-use testing, and the examiner indicated that the Veteran would have no additional loss of motion on repeated use over time. The examiner indicated that pain would significantly limit the Veteran's functional ability during flareups, but declined to describe any additional functional loss in terms of range of motion because "Veteran was not being examined during a flareup and was not able to replicate the associated range of motion loss." At the December 2019 VA examination, the Veteran reported that he had pain and decreased range of motion in both ankles and that he takes acetaminophen daily to treat his symptoms. The Veteran denied flare-ups in his left and right ankle symptoms. On examination, the Veteran had right ankle dorsiflexion to 5 degrees and plantar flexion to 10 degrees and left ankle dorsiflexion to 5 degrees and plantar flexion to 10 degrees. He did not have additional loss of motion following repetitive-use testing additional loss of motion following repetitive-use testing. The examiner indicated that the Veteran would have no additional loss of motion on repeated use over time. The examiner also indicated that there was no objective evidence of pain on passive range-of-motion testing or when the joints were used in non-weight bearing. Based on the foregoing, the Board concludes that, for the relevant period prior to December 8, 2016, the record shows the Veteran had painful motion of the left and right ankles due to his service-connected disabilities. Therefore, under 38 C.F.R. § 4.59, those painful joints resulting from healed injury are entitled to at least the minimum compensable rating for the joint. Under Diagnostic Code 5271, the minimum compensable rating for limited motion of the ankle is 10 percent. Accordingly, the Board concludes that the criteria for ratings of 10 percent for the service-connected left and right ankle disabilities were met during the relevant period prior to December 8, 2016. The Board further finds that the criteria for ratings of 20 percent for the service-connected left and right ankle disabilities were met during the period from December 8, 2016, the date the Veteran submitted a VA Form 21-526b, Veteran's Supplemental Claim for Compensation, on which he reported a worsening in his ankles, through December 6, 2019. Specifically, at the December 2016 VA examination, the Veteran had dorsiflexion to 5 degrees bilaterally on initial testing, and the examiner opined that the Veteran's functional ability would be reduced during flare-ups. Thus, affording the Veteran the benefit of the doubt, during flare-ups, the Veteran would have dorsiflexion to less than 5 degrees in both ankles, which under Diagnostic Code 5271 constitutes a "marked" limitation. As such, a rating of 20 percent was warranted from December 8, 2016, to December 6, 2019. The Board also finds that the criteria for a rating in excess of 10 percent were not met during the relevant periods prior to December 8, 2016, and from December 7, 2019, the date of the December 2019 VA examination. Specifically, the record does not show that the Veteran had left ankle motion or right ankle motion limited to less than 5 degrees of dorsiflexion or 10 degrees of plantar flexion at any time during either of those periods. Regarding the period beginning December 7, 2019, at the December 2019 VA examination, the Veteran had 5 degrees of dorsiflexion and 10 degrees of plantar flexion in both ankles with no further decrease in motion following repetitive-use testing or on repeated use over time. In addition, he denied having flare-ups in his ankle symptoms at that examination. Thus, the Veteran had dorsiflexion of 5 degrees or greater and plantar flexion of 10 degrees or greater bilaterally, which constitutes "moderate" limitation and warrants no higher than a 10 percent rating under Diagnostic Code 5271. The Board acknowledges that the effective dates for changes in ratings depend on when a change in disability level can be ascertained and should not be assigned mechanically as of the date of an examination or particular record. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015); see also 38 C.F.R. § 3.400(o). However, in this case the record does not show that the criteria for a rating of 20 percent were met for either ankle during the relevant period prior to the December 8, 2016 VA Form 21-526b. Therefore, a change in the disability level of the service-connected left and right ankle disabilities cannot be ascertained at a date prior to December 8, 2016, and the 20 percent ratings assigned as of December 8, 2016, cannot be assigned at an earlier date. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the Veteran's symptoms would warrant a higher rating under a different Diagnostic Code. The record does not show that the Veteran has ankylosis of the either ankle, malunion of the os calcis or astragalus due to the service-connected left and right ankle disabilities, or an astragalectomy on either the left or the right. See 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, and 5274. Finally, the Board has considered the Veteran's reports of instability and giving way in his bilateral ankles. For all musculoskeletal disabilities, the Rating Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the Rating Schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. It also considers pain, instability, and malaligned joints. 38 C.F.R. § 4.59. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss, and the Veteran's bilateral ankle instability is considered through his compensable rating under Diagnostic Code 5271. Neither the Veteran nor his representative has raised any other issues with regard to the ratings for the service-connected left and right ankle disabilities, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). In summary, the Board finds that the Veteran's service-connected left ankle instability and right ankle instability should each be rated at 10 percent prior to December 8, 2016; at 20 percent from December 8, 2016, to December 6, 2019; and at 10 percent from December 7, 2019. To the extent that the Veteran seeks ratings higher than those assigned previously or in this decision, the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 7. Entitlement to a compensable rating for frostbite of the 3rd right finger The Veteran seeks compensable rating for frostbite of the 3rd right finger. The applicable rating period is from December 10, 2011, one year prior to receipt of the claim for increase, through the present. See 38 C.F.R. § 3.400(o)(2). The Veteran's frostbite of the 3rd right finger is currently assigned a noncompensable rating under Diagnostic Code 7199-5226. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. In this case, the use of Diagnostic Code 7199-5226 reflects that the Veteran's specific service-connected disability is not listed in the Schedule and that a diagnostic code was therefore "built-up" using 71, one of the two-digit codes used for disabilities of the cardiovascular system under 38 C.F.R. § 4.104, and 99. Id. The Veteran's frostbite of the 3rd right finger has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5226, which pertains to ankylosis of the long finger. Under Diagnostic Code 5226, a 10 percent rating is warranted for unfavorable or favorable ankylosis of the long finger. Also relevant to the issue on appeal is 38 C.F.R. § 4.71a, Diagnostic Code 5229, which pertains to limitation of motion of the index or long finger. Under Diagnostic Code 5229, a noncompensable rating is warranted when there is a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is warranted when there is a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. At the October 2012 VA examination, the Veteran had normal motion and no functional loss in the 3rd right finger. At the December 2016 VA hand and finger conditions examination, the Veteran reported stiffness, a mushy sensation, and reduction in strength in the 3rd right finger. On examination, he had normal range of motion in the right hand. At the October 2018 Board hearing, the Veteran testified that the residuals of frostbite in the 3rd right finger are manifested by pain, sensitivity to heat and cold, limited motion, swelling, and a "mushy" feeling. Upon considering the evidence of record, the Board finds that a rating of a 10 percent since December 10, 2012, the date of the claim, is warranted for the Veteran's frostbite of the 3rd right finger. The Veteran has competently and credibly reported that his 3rd right finger is painful. Therefore, under 38 C.F.R. § 4.59, that painful joint resulting from healed injury is entitled to at least the minimum compensable rating based on limited motion. Under Diagnostic Code 5229, the minimum compensable rating for limited motion of the index or long finger is 10 percent. The record does not contain evidence dating during the one-year prior to December 10, 2012, that makes the severity of the Veteran's frostbite of the 3rd right finger factually ascertainable. Therefore, the Board concludes that a compensable rating is not warranted during that period, and that the date of the claim is therefore the appropriate effective date for the award of the 10 percent rating under Diagnostic Code 5229. See 38 C.F.R. § 3.400(o)(2). Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected frostbite of the 3rd right finger, nor have any other such issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. In summary, the Board finds that a compensable rating was not warranted for the Veteran's frostbite of the 3rd right finger during the relevant period prior to December 10, 2012, but that a rating of 10 percent, and no higher, was warranted from that date under Diagnostic Code 5229. To the extent the Veteran seeks ratings higher than those previously assigned or those assigned herein, the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. 8. Entitlement to a compensable rating for pruritis ani The Veteran seeks a compensable rating for pruritis ani. The applicable rating period is from December 10, 2011, one year prior to receipt of the claim for increase, through the present. See 38 C.F.R. § 3.400(o)(2). The Veteran's pruritis ani is rated under 38 C.F.R. § 4.114, Diagnostic Code 7337, which directs that the disability be rated for the underlying condition. At an October 2012 VA rectum and anus conditions examination, the Veteran reported that his pruritis ani causes itching of the anus. On examination, the Veteran did not have any findings, signs, or symptoms attributable to his pruritis ani. The examiner indicated that the Veteran's pruritis ani does not have a functional impact. At the October 2018 Board hearing, the Veteran testified that his pruritis ani is a "persistent issue", but that he had last been treated for the condition in 2005 or 2006. At a December 2019 VA rectum and anus conditions examination, the Veteran reported itching and bleeding with use of Preparation H, a topical steroid, and medicated pads daily. The examiner did not complete the portion of the examination pertaining to pruritis ani. Therefore, in August 2020, the AOJ obtained an addendum statement from the examiner as to the underlying condition of the pruritis ani. In that addendum, the examiner indicated that the Veteran's claim file was again reviewed, and that the Veteran's pruritis ani was manifested by an erythematous area around the anus totalling less than 5 percent of the total body area and 0 percent of the exposed area. Given the December 2019 VA examiner's description of the Veteran's pruritis ani in the examination report and the August 2020 addendum, the Board finds that the underlying condition of the Veteran's pruritis ani is most comparable to a condition of the skin, such as dermatitis or eczema, and is ratable under 38 C.F.R. § 4.118, Diagnostic Code 7806. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806 a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or the disability was to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. For claims filed prior to August 13, 2018, a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Code 7806. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or the disability is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating under the pre-August 13, 2018 regulations because the Veteran's disability does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The Veteran has treated the condition with topical pads and medications, to include a topical steroid, applied to the affected area. There is no indication that the disability has required medications that are applied in such a way that they affect the body as a whole. In addition, the VA examiner indicated in his August 2020 addendum that the condition covered less than 5 percent of the total body area and none of the exposed areas. Finally, there is no indication that the condition was comparable to a scar with underlying soft tissue damage, that the condition had an area of 144 square inches or greater, or that the condition was comparable to an unstable or painful scar such that a compensable rating was warranted under the diagnostic codes pertaining to scars. The Board further finds that the preponderance of the evidence is against the assignment of a compensable rating under the regulations in effect since August 13, 2018. Specifically, the Veteran has required no more than topical therapy for the condition, and the condition has been manifested by involvement of less than 5 percent of the total body area and less than 5 percent of exposed areas. In addition, there is no indication that the condition was comparable to a scar with underlying soft tissue damage, that the condition had an area of 144 square inches or greater, or that the condition was comparable to an unstable or painful scar. The Board acknowledges the Veteran's assertion in a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, received in July 2020 that his pruritis ani causes incontinence three times per week. The Veteran is competent to report symptoms that are observable through the senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not considered competent to attribute those symptoms to a particular cause. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1376-77. The December 2019 VA examiner was asked in August 2020 to again review the record, which at that time would have included the July 2020 VA Form 21-526EZ, and to describe the underlying condition of the Veteran's pruritis ani and describe it. The examiner did not attribute the Veteran's reported incontinence to his pruritis ani. Rather, the examiner found that the pruritis ani is manifested by erythema covering less than 5 percent of the total body area and 0 percent of exposed areas. Based on the VA examiner's August 2020 addendum, the Board finds that the Veteran's reported incontinence is not for consideration in rating his pruritis ani. Finally, the Board acknowledges the Veteran's representative's argument in the September 2021 written brief presentation that because the December 2019 VA examiner stated in the August 2020 addendum that the underlying etiology of the Veteran's pruritis ani was unable to be determined, "we recommend that the disability of pruritis be considered on an extra-schedular basis." Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran's disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy, 27 Vet. App. at 495. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. In this case, the instructions for the August 2020 addendum asked that the December 2019 VA examiner "to indicate the underlying condition and describe it". In response to those instructions, the examiner described the condition as being manifested by erythema covering less than 5 percent of the total body area and 0 percent of exposed areas. Such symptoms are explicitly considered in the rating criteria for Diagnostic Code 7806. Thus, in regard to the first element of Thun, comparison of the Veteran's symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. Moreover, there is not a requirement in the rating criteria that the underlying etiology of the condition be considered. Rather, Diagnostic Code 7337 only directs that the disability be rated based on the underlying condition, which, as previously stated, was thoroughly described by the VA examiner in the August 2020 addendum. Accordingly, the Veteran's pruritis ani manifestations are reasonably contemplated by Diagnostic Codes 7337 and 7806, the threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for pruritis ani. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Entitlement to a compensable rating for degenerative disc disease of the cervical spine is remanded. Although the record contains a contemporaneous December 2016 VA examination regarding the Veteran's degenerative disc disease of the cervical spine, the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiner stated that the Veteran has flare-ups in his cervical spine symptoms and that pain significantly limits his functional ability with flare-ups. However, the examiner declined to describe that limit in functional ability in terms of range of motion because "Veteran was not being examined during a flare-up and as ot able to replicate the associated range of motion loss." The examiner did not explain why an estimate of loss of motion could not be made based on the Veteran's description of his increased symptoms during flare-ups. See Id. Therefore, the issue must be remanded so that the Veteran may be afforded another VA examination to determine the current severity of his service-connected degenerative disc disease of the cervical spine disability, and to determine the likely functional loss the Veteran had during flare-ups at the time of the December 2016 VA examination. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected degenerative disc disease of the cervical spine. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). To the extent possible, the examiner must provide an estimate of the additional impairment due to flare-ups at the time of the December 2016. In that regard, the examiner should consider the Veteran's contemporaneous descriptions of his increased symptoms during flare-ups and any other relevant evidence. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. J. Anthony, 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.