Citation Nr: 21065399 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 16-30 090 DATE: October 26, 2021 ORDER Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to an evaluation in excess of 10 percent for right ankle strain with tendonitis is denied. Entitlement to an evaluation in excess of 10 percent for left ankle strain with tendonitis is denied. Entitlement to a compensable evaluation for erectile dysfunction is denied. REMANDED Entitlement to service connection for a right wrist disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for residuals of a cholecystectomy is remanded. Entitlement to an evaluation in excess of 10 percent for right knee strain is remanded. Entitlement to an evaluation in excess of 10 percent for left knee strain is remanded. FINDINGS OF FACT 1. The Veteran is a Persian Gulf veteran with a current disability of IBS, which manifested to a degree of at least 10 percent, and chronically persisted for at least six months. 2. The Veteran's right ankle strain with tendonitis is manifested by no more than moderate limited motion of the ankle. 3. The Veteran's left ankle strain with tendonitis is manifested by no more than moderate limited motion of the ankle. 4. The Veteran does not have a deformity of the penis. CONCLUSIONS OF LAW 1. The criteria for service connection for IBS have been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.317, 4.114, Diagnostic Code 7319. 2. The criteria for a rating in excess of 10 percent for right ankle strain with tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 3. The criteria for a rating in excess of 10 percent for left ankle strain with tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 4. The criteria for a compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.115b, Diagnostic Codes 7599-7522. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty for training from September 1987 to February 1988, and served on active duty from September 1990 to May 1991, January 2008 to May 2010, and November 2017 to May 2019, to include service in the Southwest Asia theater of operations during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal of January 2014 (bilateral knee, erectile dysfunction, and residuals of a cholecystectomy) and December 2014 rating decision (right wrist, bilateral elbow, bilateral ankle, IBS) issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2019, the Board reopened the claims for service connection a right wrist disability, bilateral elbow disability and a right shoulder disability and remanded these claims on the merits for further development. In September 2019, the Board also remanded the claims for service connection for residuals of a cholecystectomy, IBS, and increased rating claims for erectile dysfunction, bilateral ankle disability, and bilateral knee disability, for further development. These issues, with the exception of entitlement to service connection for a right shoulder disability, now return for appellate review. As to the issue of entitlement to service connection for a right shoulder disability, a September 2020 rating decision granted service connection for right shoulder strain with impingement syndrome. Accordingly, this claim is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). In June 2016 VA Forms 9, Appeal to Board of Veterans' Appeals, which, in part, perfected the issues herein, the Veteran requested a Board hearing. However, in August 2017 correspondence, the Veteran withdrew his hearing requests. 38 C.F.R. § 20.704 (e). Accordingly, the Veteran's hearing requests are withdrawn, and the Board will proceed with appellate review. As a final initial matter, the Board has found that an inferred claim for a total disability rating for compensation purposes based on individual unemployability (TDIU) has not been raised in relation the Veteran's increased rating claims for his erectile dysfunction, bilateral ankle, and bilateral knee disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, the record reflects the Veteran has been employed during the appeal period. Specifically, most recently, a March 2021 VA treatment record documented Veteran reported that he had been working as a mechanic; however, he had been moved to the office due to pain issues. An April 2021 VA treatment record documented the Veteran was employed full-time. Moreover, neither the Veteran nor or his representative has indicated that the Veteran's erectile dysfunction, bilateral ankle and/or bilateral knee disabilities prevented gainful employment, nor is such otherwise reflected in the record. SERVICE CONNECTION Generally, service connection may be established for 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. To establish service connection on a direct incurrence basis, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, when a veteran has served in the Southwest Asia theater of operations during the Persian Gulf War, presumptive service connection may alternatively be established under 38 U.S.C. § 1117. In such cases, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that manifested during active service in the Southwest Asia theater of operations during the Persian Gulf War, or manifested to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnoses. 38 C.F.R. § 3.317(a). Objective indications of chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. MUCMIs include functional gastrointestinal disorders; IBS is a functional gastrointestinal disorder. 38 C.F.R. § 3.317. 1. Entitlement to service connection for IBS is granted. The Veteran's service records indicate that he served in the Southwest Asia theater of operations during the Persian Gulf War from November 1990 to April 1991. Accordingly, he qualifies as a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The Veteran contends that service connection is warranted for his IBS. Specifically, in a January 2015 notice of disagreement, he reported abdominal pain, and diarrhea or constipation, associated with stress for 20 years. Further, an intestinal conditions disability benefits questionnaire (DBQ) was obtained in March 2021 and noted the Veteran reported his symptoms onset in 2005, specifically he developed gas and abdominal pain with constipation and diarrhea, which worsened depending on his mental health status and stress level. The March 2021 intestinal conditions DBQ also documented a diagnosis of IBS, with an initial diagnosis date in 2014. In this regard, a July 2014 VA treatment record documented a history of present illness which included IBS. The Board finds that the Veteran's IBS is presumptively related to his Gulf War service. IBS is listed as a MUCMI (functional gastrointestinal disorder) under 38 C.F.R. § 3.317, which essentially replaces the nexus element, and there is not sufficient affirmative evidence to outweigh this presumption. In this regard, a March 2021 VA examiner found the Veteran's IBS symptoms did not manifest until more than 20 years after Southwest Asia service, and there was no documentation, evidence, or link between his IBS and his Southwest Asia exposures. However, the March 2021 VA examiner's opinion is factually inaccurate as a December 1993 medical record noted the Veteran had little fluid in the stomach at the beginning of the examination suggesting mild gastric hypersecretion. In this regard, the Board observes that the December 1993 medical record is only a few years after the Veteran's service in the Southwest Asia theater of operations during the Persian Gulf War. Moreover, while evidence of a direct nexus bolsters the Veteran's case, it is not necessary to grant service connection under § 3.317. Finally, a 10 percent evaluation is warranted for moderate IBS, defined as frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Here, the March 2021 intestinal conditions DBQ documented, in part, the Veteran had alternating diarrhea and constipation. Thus, the evidence shows that the condition is at least compensably disabling under 38 C.F.R. § 4.114, Diagnostic Code 7319. Thus, after resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's IBS is a result of Persian Gulf War service as a MUCMI. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection for IBS is warranted. INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA must consider whether to "stage" the rating, meaning assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. Consideration of the appropriateness of a staged rating is required for increased rating claims, irrespective of whether it is an initial rating at issue or instead an established rating. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 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 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to an evaluation in excess of 10 percent for right ankle strain with tendonitis is denied. 2. Entitlement to an evaluation in excess of 10 percent for left ankle strain with tendonitis is denied. The Veteran contends that he is entitled to higher ratings for his right and left ankle disabilities. Specifically, in a January 2015 notice of disagreement, the Veteran reported, in part, that his ankles hurt all the time. The initial question before the Board is determining the appropriate appeal period for consideration in order to determine the appropriate rating for the Veteran's right and left ankle disabilities. The current claim for increase stems from an April 18, 2014 informal claim for increase. The Board has considered in particular the evidence of record from April 17, 2013, one year prior to the date of receipt of the claim for increase, to determine if it is factually ascertainable that an increase occurred during that period. Further, although in September 2019, the Board characterized the Veteran's claims for increased ratings for his right and left ankle disabilities, as initial rating claims, these claims are properly characterized as increased rating claims. Specifically, the December 2014 rating decision at issue continued 10 percent ratings for these disabilities based on the April 18, 2014 informal claim for increase. Further, service connection for the Veteran's right and left ankle disabilities were granted in a June 2012 rating decision which assigned initial evaluation of 10 percent each. The Veteran did not submit a notice of disagreement as to the ratings or effective dates assigned for these disabilities and no new and material evidence was received, or constructively received, within the appeal period that suggested higher ratings were warranted. Accordingly, the Board finds that the June 2012 rating decision is final as to these issues. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 20.302, 20.1103. Consequently, these claims are not initial rating claims. Throughout the appeal period, the Veteran's left and right ankle disabilities have been 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. 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.) As this regulatory change was enacted during the pendency of this appeal, the Board will consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. For the version of the rating criteria in effect prior to February 7, 2021, 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. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). After reviewing the evidence, as to the Veteran's right ankle disability and his left ankle disability, the Board finds the evidence does not support a rating higher than 10 percent under either version of Diagnostic Code 5271 based on the orthopedic manifestations. In this regard, a November 2014 ankle conditions DBQ revealed that the Veteran had ankle dorsiflexion to 20 degrees and plantar flexion to 25 degrees, bilaterally. A May 2015 ankle conditions DBQ found the Veteran had right ankle dorsiflexion to 10 degrees and plantar flexion to 25 degrees and left ankle dorsiflexion to 5 degrees and plantar flexion to 20 degrees. Most recently, a September 2020 ankle conditions DBQ found that the Veteran had ankle dorsiflexion to 20 degrees and plantar flexion to 45 degrees, bilaterally. Additionally, the findings documented during the November 2014, May 2015 and September 2020 DBQs include consideration of additional functional loss associated with the onset of pain and repetitive motion testing. Concerning the range of motion findings of the Veteran's bilateral ankle disability, the Board notes that the November 2014 and May 2015 DBQs do not include passive range of motion and do not specify range of motion with and without weight-bearing. See Correia, 28 Vet. App. at 170. However, the November 2014 VA examiner found there was no evidence of pain with weight bearing and the May 2015 VA examiner found there was evidence of pain with weight bearing. Further, the September 2020 DBQ specifically found as to each ankle, there was no objective evidence of pain on non-weight bearing and measurements for passive range of motion testing were the same as with active range of motion testing. Moreover, generally, active range of motion testing produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. There is no indication that the range of motion testing in these examinations was performed other than on weight-bearing. Therefore, there is no prejudice to the Veteran in relying on November 2014 and May 2015 DBQs that involved active range of motion testing because such results tend to produce the "worst case scenario" of impairment and thus would tend to support the highest possible rating. Other medical records also documented complaints of bilateral ankle pain; however, such records did not provide range of motion testing in degrees to support a higher evaluation. For instance, an August 2014 private medical record noted, in part, the Veteran had obvious tendinosis nodules on the mid portion of his Achilles tendon bilaterally, which was tender to the touch but he had good range of motion of the ankles and feet. Additionally, a May 2016 VA treatment record noted, in part, increased right ankle pain with swelling over the past three weeks, which started about three weeks ago and was worse after he got up to walk after he had been sitting awhile. An April 2017 medical record noted the Veteran sustained an injury to the right ankle prior day and that he was experiencing mild pain. A June 2017 VA treatment record documented the Veteran reported increased right ankle pain for about one year and that if he had to walk a long way, it took him a long time, and that his right ankle was worse than the left ankle. October 2017 and November 2017 service records reflected the Veteran received a physical profile, in part, for bilateral ankle pain and/or injury. Additionally, a June 2018 VA treatment record documented the Veteran reported his right ankle was still hurting, had not improved, and was worse if he walked a long distance. A November 2018 service record documented the Veteran reported he was not able to run or jog two miles due to right ankle pain but could engage in aerobic alternatives of walking, and bicycling. August 2019 and September 2019 VA treatment records also found that there was no reduction in muscle strength with plantar flexion documented as of 5 out of 5 and dorsiflexion documented as of 5 out of 5. A September 2019 service record documented the Veteran reported he was not able to run or jog two miles due to bilateral ankle/foot injury/pain but could engage in aerobic alternatives of walking, swimming, and bicycling. A September 2020 VA treatment record noted, in part, the Veteran complained his ankles swelling. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for either ankle under the rating criteria prior to February 7, 2021 or the criteria thereafter. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to include decreased tolerance for weightbearing, avoidance of strenuous exercise, disturbance of locomotion, daily pain including with swelling by the end of the day and/or swelling off and on, localized pain to the posterior and lateral ankles, including worse pain after he got up to walk after he had been sitting awhile or worse pain if walking long distance, and if he had to walk a long way, it took him a long time, interference with standing, feelings of instability and being "twisted", weak and like the " bone is out of place". However, even considering the Veteran's lay reports of symptoms and functional loss, the preponderance of the evidence is against a finding that the degree of additional limitation reflected by the Veteran's statements resulted in symptoms more nearly approximating limitation so distinctive or emphasized that it would approximate marked limited motion. Specifically, the November 2014 VA examiner documented the Veteran did not report flare-ups of either ankle. The September 2020 VA examiner documented the Veteran did not report flare-ups of either ankle but instead described the problem was always the same. Thus, the record reflects the Veteran did not consistently describe flare-ups but instead consistently reported pain, which was present during the Veteran's range of motion testing in all DBQs. The September 2020 VA examiner found also to each ankle, pain, weakness, fatigability, or incoordination did not significantly limited functional ability of each ankle with repeated use over a period of time. Moreover, the September 2020 VA examiner found the current ankle disabilities did not impact the Veteran's ability to perform occupational tasks. The examiner explained, as the Veteran's right and left ankle disabilities, the functional impact was derived from history only, and that there was medical documentation of current abnormality and on abnormal physical examination findings. The September 2020 VA examiner explained the Veteran denied change in functional loss via repetitive use or flare-ups and at baseline just "deals with it", had no current medical care for it, no imaging, on current physical therapy to indicate his previous tendonitis (a self-limiting inflammatory condition) was still present. The September 2020 VA examiner also explained by history functional loss was more "I am concerned they will give out and I will fall" vs true daily falling or actual functional loss. Further, applying the most recent September 2020 DBQ findings regarding the Veteran's dorsiflexion and plantar flexion, bilaterally, to the new rating criteria, these measurements would not meet the criteria corresponding to a higher 20 percent rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating at any point during the appeal period. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The Veteran's bilateral ankle disability does not warrant a separate or higher disability rating under Diagnostic Codes 5270 or 5272 at any time during the appeal period because he has never demonstrated or been diagnosed with ankylosis of either ankle or its functional equivalent. In this regard, the November 2014 VA examiner did not endorse ankylosis of either ankle. Similarly, the May 2015 and September 2020 VA examiners found the Veteran did not have ankylosis of either ankle. Further, there is no diagnosis related to malunion of the os calcis or astragalus of either ankle, or the Veteran did not have an astragalectomy of either ankle. In this regard, the November 2014, May 2015 and September 2020 VA examiners found the Veteran did not have now have or had not ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). Thus, Diagnostic Codes 5273 and 5274 are not for application. 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, 5274. Further, while the Veteran, as a layperson, is competent to report the symptoms he has experienced, he has not been shown to have the requisite knowledge or training to be deemed competent to identify a specific level of disability for either ankle disability according to the rating criteria, which is a medically complex determination that cannot be based on lay observation alone. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Such competent evidence concerning the nature and extent of the Veteran's bilateral ankle disability has been provided by the November 2014, May 2015 and September 2020 VA examiners' findings which directly address the criteria under which his disabilities are evaluated. The Board finds the November 2014, May 2015 and September 2020 VA examiners' findings to be competent, objective, and probative evidence of record, and are therefore accorded greater weight than the Veteran's subjective complaints of symptomatology for his bilateral ankle strain with tendonitis. Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with his respect to his bilateral ankle disability. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claims, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to an evaluation in excess of 10 percent for right ankle strain with tendonitis and entitlement to an evaluation in excess of 10 percent for left ankle strain with tendonitis are not warranted. 3. Entitlement to a compensable evaluation for erectile dysfunction is denied. The Veteran contends that he is entitled to compensable rating for erectile dysfunction. Specifically, in a January 2015 notice of disagreement, the Veteran reported, in part, he was stressed and unable to have sex with his wife because of his sexual dysfunction, he further described he had been married twice and his sex life does not exist anymore. The initial question before the Board is determining the appropriate appeal period for consideration in order to determine the appropriate rating for the Veteran's erectile dysfunction. The current claim for increase stems from an April 23, 2013 claim for increase. The Board has considered whether it is factually ascertainable that there was evidence of increase within the year prior to that date and has found that there is not. [As there was a final September 2012 rating decision on this issue, any effective date earlier than the date of that rating decision would need to be based on evidence not considered in that rating decision.] Further, although in September 2019, the Board characterized the Veteran's claim for a compensable rating for his erectile dysfunction, as an initial rating claim, this claim is properly characterized as an increased rating claim. Specifically, the January 2014 rating decision at issue continued noncompensable rating for the Veteran's erectile dysfunction based on April 23, 2013 claim for increase. Further, the September 2012 rating decision which awarded service connection for the Veteran's erectile dysfunction is final as to this issue. Consequently, this claim is not an initial rating claim. Throughout the appeal period, the Veteran's erectile dysfunction been rated under 38 C.F.R. § 4.115b, Diagnostic Codes 7599-7522. Unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." 38 C.F.R. § 4.27. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. The Veteran's erectile dysfunction is thus ultimately rated by application of the provisions Diagnostic Code 7522, for penis, deformity, with loss of erectile power. Under Diagnostic Code 7522, a 20 percent rating when the evidence shows both loss of erectile power and a physical deformity of the penis. Simply stated, the condition is not compensable in the absence of penile deformity. Although the rating schedule does not provide a zero percent evaluation for Diagnostic Code 7522, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Based upon the evidence of record, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to a compensable disability rating for erectile dysfunction for the entirety of the rating period on appeal. Specifically, proximate to the appeal period, a July 2012 VA examiner found the Veteran had erectile dysfunction but also found, upon physical examination, his penis was normal. Similarly, during the pendency of the claim, June 2013 and March 2021 VA examiners found the Veteran had erectile dysfunction, but upon physical examination, found his penis was normal. In the present case, the evidence of record does not reveal any physical deformity of the Veteran's penis. He has not alleged, nor does the evidence show, that he has penile deformity. As such, there is no lay or medical support for a compensable disability rating for erectile dysfunction under Diagnostic Code 7522. Moreover, the Board notes that the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ throughout the period on appeal and is also service-connected for left spermatocele throughout the appeal period. Further, while the Veteran, as a layperson, is competent to report the symptoms he has experienced; however, he has not been shown to have the requisite knowledge or training to be deemed competent to identify a specific level of disability for his erectile dysfunction according to the rating criteria, which is a medically complex determination that cannot be based on lay observation alone. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Such competent evidence concerning the nature and extent of the Veteran's erectile dysfunction has been provided by the July 2012, June 2013 and March 2021 VA examiners' findings which directly address the criteria under which his disabilities are evaluated. The Board finds the July 2012, June 2013 and March 2021 VA examiners' findings to be competent, objective, and probative evidence of record, and are therefore accorded greater weight than the Veteran's subjective complaints of symptomatology for his erectile dysfunction. Additionally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with respect to the Veteran's erectile dysfunction. See Doucette, 28 Vet. App. at 369-70. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 4.3, 4.7; Gilbert, 1 Vet. App. at 54-56. Accordingly, entitlement to a compensable evaluation for erectile dysfunction not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a right wrist disability is remanded. 2. Entitlement to service connection for a right elbow disability is remanded. 3. Entitlement to service connection for a left elbow disability is remanded. Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). A September 2020 elbow and forearm conditions DBQ found the Veteran did not have a current diagnosis of either elbow. Similarly, a September 2020 wrist conditions DBQ found the Veteran did not have a current diagnosis of the right wrist. However, these DBQs noted imaging was not conducted, as relevant to a diagnosis of degenerative or traumatic arthritis of the right wrist or either elbow. In this regard, a November 2013 VA treatment record noted, in part, left wrist/elbow arthritis. Additionally, the September 2020 wrist conditions DBQ noted, in part, the Veteran the Veteran had stiffness in his wrist and with use of his wrist there was pain and that he also reported numbness and tingling and symptoms consistent with carpal tunnel syndrome, which was outside the scope of the DBQ. However, the Veteran's carpal tunnel syndrome of the right wrist, if diagnosed, is within the scope of this claim as he has generally reported wrist pain. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may adequately identify the disability for which compensation benefits are sought by referring to a body part or system that is disabled, or by describing the symptoms of that disability). Thus, as this point, the Veteran has not been fully evaluated to determine whether or not there is a diagnosis for his right wrist or bilateral elbow symptoms. Further, the Veteran had active service in Southwest Asia from November 1990 to April 1991. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The Veteran reports experiencing joint pain of the right wrist and bilateral elbow. Additionally, in terms of the Veteran's left elbow disability, an April 2010 service record reflects, in part, a complaint of left elbow pain; however, no VA opinion has addressed this claim on a direct incurrence basis. Accordingly, on remand, the Veteran should be scheduled for an examination to determine the nature and etiology of his claimed right wrist and bilateral elbow disabilities. 4. Entitlement to service connection for residuals of a cholecystectomy is remanded. As to the Veteran's residuals of a cholecystectomy, a March 2021 VA examiner found it was less likely as not that there were signs or symptoms present that led up to the diagnosis and surgery (laparoscopic cholecystectomy) in June 2013 during the Veteran's first or second period of service. As a rationale, the March 2021 VA examiner explained, in part, the Veteran's records were negative for gallbladder or gallbladder symptoms such as pain, nausea or vomiting, fever or chills, chronic diarrhea, jaundice, unusual stools or urine. However, this is factually inaccurate, as a May 2010 service treatment record noted, in part, that the Veteran reported frequent small amounts of urine six times during the day and incomplete emptying of the bladder for two months. Thus, an addendum opinion addressing the claim on direct incurrence basis is warranted. 5. Entitlement to an evaluation in excess of 10 percent for right knee strain is remanded. 6. Entitlement to an evaluation in excess of 10 percent for left knee strain is remanded. VA treatment records reflect the Veteran's bilateral knee disabilities may have disabilities may have increased in severity since the Veteran was last examined by VA. Specifically, a January 2021 VA treatment record noted the Veteran had a ramp added to his home to prevent the Veteran from using the stairs, as he was a fall risk due to chronic knee pain and vertigo. English v. Wilkie, 30 Vet. App. 347 (2018). The January 2021 VA treatment record also noted, in part, the Veteran reported being on light duty due to chronic back and knee pain and wore a knee brace. However, the most recent September 2020 knee and lower leg conditions DBQ did not endorse a finding of instability of station as to either knee, found there was no history of recurrent subluxation or recurrent effusion for either knee, joint stability testing was normal as to each knee, and did not note any current use of a knee brace. Accordingly, the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of right knee strain and left knee strain, to include whether there is instability or subluxation of either knee. The matters are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination for his right wrist claim and bilateral elbow claims. The clinician must review the claims file. The clinician is asked to provide a response to the following: (a.) Identify the Veteran's objective indications of a disability for his right wrist and bilateral elbows. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. (b.) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a right wrist and/or bilateral elbow disability be attributed to a known clinical diagnosis, to include carpal tunnel syndrome of the right wrist or arthritis of either elbow? Please explain. If the signs and symptoms are not characteristic of a known clinical diagnosis, the clinician should so indicate. There is no requirement that the clinician provide a diagnosis of undiagnosed illness. (c.) If the Veteran's objective indications of his right wrist and/and bilateral elbow cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? Please explain. The clinician should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. (d.) If the Veteran's objective indications of his right wrist and/and bilateral elbow can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? Please explain. This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. (e.) If both the etiology and pathophysiology of a right wrist and/and bilateral elbow diagnosis are partially understood or fully understood (or if diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment), then is it at least as likely as not that the Veteran's diagnosed condition(s) was incurred in, or is otherwise related to, his active service, to include, as to the left elbow, consideration of an April 2010 service record which reflects, in part, a complaint of left elbow pain? Please explain. 2. Obtain an opinion from an appropriate clinician regarding the nature and etiology of the Veteran's residuals of a cholecystectomy, with examination only if deemed necessary by the clinician. After review of the claims file, the clinician asked to provide a response, with a rationale to support the proffered opinion, to the following: Is it at least as likely as not that the Veteran's cholecystectomy, and residuals thereof, was incurred in, or is otherwise related to, his active service, to include consideration of a May 2010 service treatment record which noted, in part, that the Veteran reported frequent small amounts of urine six times during the day and incomplete emptying of the bladder for two months? Please explain. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right knee strain and left knee strain. The clinician should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. In so doing, the clinician should explain whether there is instability or subluxation of either knee and express an opinion as to the severity of such instability or subluxation. The clinician must also test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing for each knee. If it is not possible to provide a specific measurement without speculation, the clinician 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 clinician does not have the knowledge or training. The clinician must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups for each knee. If it is not possible to provide a specific measurement based on direct observation, the clinician 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 clinician 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 clinician does not have the knowledge or training. 4. Thereafter, readjudicate the issues remaining on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Espinoza, 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.