Citation Nr: 21066345 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 18-30 194 DATE: October 29, 2021 ORDER Entitlement to an initial 50 percent disability rating for migraine headaches is granted. Entitlement to a rating in excess of 10 percent for a right wrist disability is denied. Entitlement to a 30 percent rating for a right ankle disability is granted. Entitlement to a 10 percent disability rating for hypertension is granted. Entitlement to service connection for diabetes mellitus is denied. REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to service connection for melena is remanded. FINDINGS OF FACT 1. For the entire period under appeal, the Veteran's headache disability has more likely been consistent with finding of very frequent prostrating and prolonged attacks that are capable of producing severe economic inadaptability. 2. The Veteran's right wrist disability is manifested by pain and limitation of motion but ankylosis is not shown. 3. The Veteran's right ankle disability is manifested by 0 degrees of dorsiflexion that is equivalent to ankylosis of the ankle between 0 and 10 degrees. 4. The Veteran's hypertension has required continuous medication, but has not manifested in diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 5. Diabetes mellitus was not shown in service, did not manifest to a compensable degree within one year of service separation, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 50 percent, but no higher, for a migraine headache disability have been met. 38 U.S.C. §§ 1155, 5103. 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2020). 2. The criteria for a disability rating in excess 10 percent for a right wrist disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5215 (2020). 3. The criteria for a 30 percent rating for a right ankle disability, but no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4. 1, 4.3, 4.7, 4.71a, Diagnostic Codes 5270, 5271 (2020), Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5271). 4. The criteria for a 10 percent disability rating, but no higher, for hypertension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7101 (2020). 5. Diabetes mellitus was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103(A) (2012); 38 C.F.R. §§ 3.303, 3.307 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1971 to September 1991. These matters are before the Board of Veterans' Appeals (the Board) on appeal of August 2015, March 2018 and April 2018 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021 the Veteran testified at a videoconference hearing in front of the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claim file. In the April 2018 rating decision, the RO granted a higher initial 30 percent disability rating for the Veteran's headache disability, effective September 15, 2014. The Board notes that the increase from 0 to 30 percent for headaches did not constitute a full grant of the benefits sought. Accordingly, the issue of entitlement to an initial rating in excess of 30 percent for migraine headaches remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Increased Ratings Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). 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 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his headache, ankle, wrist and hypertension disabilities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. 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. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Migraine Headaches The Veteran is currently in receipt of an initial 30 percent rating for migraine headaches pursuant to Diagnostic Code 8100. Under Diagnostic Code 8100, where migraine headaches occur with characteristic prostrating attacks on an average of once a month over the last several months, a 30 percent disability rating is appropriate. Migraine headaches with very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability warrant a maximum schedular 50 percent disability rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). The rating criteria do not define the term "prostrating." According to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." Essentially the same definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), which defines "prostration" as "extreme exhaustion or powerlessness." Factual Background and Analysis The Veteran underwent a VA examination in July 2015. The examiner noted that the Veteran had ongoing headache pain. He had pulsating or throbbing head pain, his pain worsened with physical activity and his headaches started out on the right side and then encircled his head. Other symptoms associated with his headaches included nausea, vomiting, sensitivity to light, sensitivity to sound and changes in vision. His typical headache pain lasted for less than 1 day. His headache pain usually lasted less than 1 day. He had characteristic prostrating attacks of headache pain with less frequent attacks. The pain was not productive of severe economic inadaptability. The examiner indicated that the Veteran's headaches impacted his ability to work as the Veteran worked part time as a driver for a company that transported mentally disabled patients back and forth to a development center. The Veteran reported that when he had a bad migraine, he was unable to work and had to call in sick. In the past 12 months he had missed about 10 days of work. At his hearing, the Veteran testified that he had migraines at least 3 to 4 times a week. At times the migraines were so bad that he had to go to the back of his house and put a pillow over his head for relief. The Veteran testified that sometimes his headaches incapacitated him to such a degree that he could not leave his house. When he most recently was not on medication, his headache symptoms were at an increased level for 2 weeks. Based on a review of the record, the Board finds that a maximum 50 percent rating is warranted under Diagnostic Code 8100 for the entire period on appeal. As noted above, in order to be entitled to a rating exceeding 30 percent, the evidence must show that the Veteran has headaches of very frequent completely prostrating intensity, and prolonged attacks productive of (or capable of producing) severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board observes that the July 2015 VA examiner described his headaches as prostrating in nature as it was noted that the Veteran had characteristic prostrating attacks of headache pain with less frequent attacks. However, the Veteran has credibly testified that his headaches have increased in frequency and severity which included episodes of incapacitation where he had to go into a dark room and cover his face to shield himself from the light. Accordingly, the evidence of record supports a finding that he has had very frequent and prolonged prostrating headaches. The Board also concludes that the evidence of record likely demonstrates that the severity of the Veteran's headache disability is productive (or capable of producing) severe economic inadaptability. Notably, the July 2015 VA examiner found that the Veteran's migraine headaches impacted his ability to work as the Veteran reported that when he had a bad migraine, he was unable to work and had to call in sick. Additionally, in the past 12 months he reported that he had missed about 10 days of work. Based on the foregoing, the evidence shows that the Veteran has very frequent completely prostrating and prolonged headache attacks that are capable of producing severe economic inadaptability. Consequently, the Board finds that the Veteran's headache disability merits an initial 50 percent rating. The Board has considered entitlement to an initial evaluation in excess of 50 percent but notes that a rating higher than 50 percent is not supported by regulation. As the maximum scheduler evaluation under the rating code for migraine headaches is in now effect, no additional discussion is necessary. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board has also considered the use of other rating codes but finds that there are no appropriate codes that provide for an evaluation in excess of 50 percent for headaches. Wrist The Veteran filed a claim for an increased rating for his service-connected right wrist disability which was received by VA in February 2018. The Veteran is currently assigned a 10 percent disability rating for his right wrist disability, effective July 17, 2013 under Diagnostic Code 5215. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Pursuant to Diagnostic Code 5215, a 10 percent rating is warranted where palmar flexion is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. This is the maximum schedular rating based on limitation of motion of the wrist under this diagnostic code. Diagnostic Code 5214 applies to ankylosis of the wrist. Diagnostic Code 5214 provides the following ratings for a major extremity: 30 percent for favorable ankylosis in 20 degrees to 30 degrees dorsiflexion; 40 percent for ankylosis in any other position except favorable; and 50 percent for unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation. Diagnostic Code 5214 notes that extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a. Normal range of motion for the wrist is 80 degrees palmar flexion and 70 degrees dorsiflexion. 38 C.F.R. § 4.71, Plate I. Factual Background and Analysis The Veteran underwent a VA examination in February 2018. It was noted that the Veteran had degenerative arthritis of the right wrist after a right wrist fracture. The Veteran reported that his pain had progressed which limited his range of motion. He now wore a brace which helped. He also had a weakened grip secondary to pain. He did not report flare-ups of the wrist. He had functional limitations as he could not move his wrist much went it hurt and he drove and did most things with his left hand. Palmar flexion was from 0 to 40 degrees, dorsiflexion was from 0 to 20 degrees, ulnar deviation was from 0 to 20 degrees and radial deviation was from 0 to 15 degrees. Loss of range of motion contributed to functional loss as there was slow movement and limited range of motion secondary to pain. There was pain on examination that caused functional loss as well as tenderness to palpation. There was evidence of pain with weight bearing but no crepitus. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion after 3 repetitions. The examiner was unable to say without resorting to mere speculation whether pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over a period of time or during flare ups as there was no conceptual or empirical basis for making such a determination in terms of range of motion without directly observing function under these conditions. There were no additional factors contributing to the disability. Muscle strength testing was normal. There was no ankylosis. The Veteran regularly used a brace on his right wrist. The Veteran's right wrist disability impacted his ability to work as driving with his right hand was difficulty due to pain and difficulty with gripping items. The Veteran underwent a VA examination in February 2020. It was noted that the Veteran had degenerative arthritis of the right wrist after a right wrist fracture. The Veteran reported that he had an increase in pain and stiffness and could not hold objects in his right hand when he had a flare up of pain. During these flare ups he lost an additional 10 degrees of motion. He could not write or do fine motor tasks with his right hand. He could not carry weight in his right hand/wrist. Palmar flexion was from 0 to 25 degrees, dorsiflexion was from 0 to 30 degrees, ulnar deviation was from 0 to 35 degrees and radial deviation was from 0 to 20 degrees. Loss of range of motion contributed to functional loss as he could not torque or twist well and had problems with fine motor function. There was pain on examination that caused functional loss as well as tenderness to palpation. There was evidence of pain with weight bearing and crepitus. The Veteran was able to perform repetitive use testing with additional loss of function or range of motion after 3 repetitions as palmar flexion was from 0 to 15 degrees, dorsiflexion was from 0 to 20 degrees, ulnar deviation was from 0 to 25 degrees and radial deviation was from 0 to 20 degrees. Pain, weakness and fatigability, lack of endurance and incoordination caused the additional functional loss of 10 degrees with repeated use over time and after flare ups. There were no additional factors contributing to the disability. Muscle strength testing demonstrated active movement against some resistance (4/5) in flexion and extension. There was no ankylosis. The Veteran did not use any assistive devices. The Veteran's right wrist disability impacted his ability to work as he had difficulty with the steering wheel and turning due to his wrist condition. Passive range of motion was the same as active range of motion. Based on the evidence, the Board does not find that the Veteran is entitled to an evaluation in excess of the current 10 percent disability rating for his right wrist disability. With respect to the applicable rating criteria, the Veteran is currently assigned a 10 percent disability rating under Diagnostic Code 5215. A 10 percent disability rating is the highest schedular rating available. As such, the Board is unable to grant a higher schedular rating under these criteria. The Board notes that Diagnostic Code 5214 (wrist, ankylosis of), which is the only other diagnostic code which specifically references the wrist, is not appropriate for application in this case because, as is discussed below, there is no evidence of ankylosis in the record. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). As noted above, in evaluating any disability on the basis of limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). A review of the record therefore demonstrates that the Veteran experiences functional loss and limitation of motion due to his right wrist disability as demonstrated by the additional 10 degrees of limitation in motion as documented by the February 2021 VA examination. However, ankylosis of the right wrist is not shown. As a result, while higher disabilities ratings are contemplated for ankylosis of the wrist under Diagnostic Code 5214, the evidence does not show that the Veteran's right wrist has been manifested by symptoms consistent with ankylosis at any time during the course of the appeal, even upon consideration of the actual degree of functional impairment due to factors such as pain, weakness, fatigability, incoordination, and lack of endurance. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As a result, the Board finds that rating in excess of 10 percent is not warranted for a right wrist disability. Ankle The Veteran filed a claim for an increased rating for his service-connected right ankle disability which was received by VA in February 2018. The Veteran is currently assigned a 10 percent disability rating for his right ankle disability under Diagnostic Code 5271 which are the criteria used for disabilities due to limited motion of the ankle joint. Notably, the criteria for limited motion of the ankle joint under Diagnostic Code 5271 have changed during the period covered by this appeal, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes, 5257, 5055). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied Under the previous criteria of Diagnostic Code 5271, a 10 percent disability rating is assigned where the evidence shows moderate loss of ankle motion. A 20 percent disability rating is assigned where there is evidence of marked loss of ankle motion. Id. Under the revised criteria of Diagnostic Code 5271, a 20 percent rating is warranted for marked limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion), and a 10 percent rating is warranted for moderate limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion). See 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2021). Limitation of motion of the ankle is rated under Diagnostic Codes 5270 and 5271. Normal ranges of motion of the ankle are dorsiflexion from zero degrees to 20 degrees, and plantar flexion from zero degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The terms "moderate" and "marked" are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (2020). Factual Background and Analysis The Veteran underwent a VA examination in February 2018. The examiner noted that the Veteran had osteoarthritis of the right ankle. The Veteran reported an increase in sharp, shooting pains in the last year. The pains were 5-6/10 on the pain scale and were aggravated with movement and walking. He did not report flare-ups. He had functional loss as he could not walk as much when his ankle hurt and walked slower because of the pain. Walking up steps was also hard. Right ankle plantar flexion was from 0 to 40 degrees. Dorsiflexion as from 0 to 20 degrees. The range of motion itself contributed to functional loss as there was slow movement and limited movement due to pain. There was pain to palpation as there was guarding and facial grimacing with palpation of the medial malleolus. There was evidence of pain with weight bearing but no evidence of crepitus. He was able to perform repetitive-use functioning with no additional loss of motion. The examiner was unable to say without resorting to mere speculation whether pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over a period of time or during flare ups as there was no conceptual or empirical basis for making such a determination in terms of range of motion without directly observing function under these conditions. Muscle strength was normal. There was no ankylosis. Ankle instability or dislocation was not suspected. He did not use any assistive devices. The examiner indicated that the Veteran's right ankle disability impacted the Veteran's ability to work as walking or standing on his ankles for long periods of time caused ankle pain. There was no objective evidence of pain on passive range of motion testing. The Veteran underwent a VA examination in February 2020. The examiner noted that the Veteran had osteoarthritis of the right ankle as well as chronic instability syndrome. The Veteran reported stiffness, instability and pain. He also lost an additional 5 degrees of motion during his reported flare-ups as he had increased pain and stiffness. He had functional loss or impairment as he could not run or jump. Right ankle plantar flexion was from 0 to 15 degrees and dorsiflexion was from 0 to 5 degrees. The range of motion itself contributed to functional loss as it affected the foot and ankle sequence in ambulation limiting the stride. There was pain to palpation as there was severe pain of the lateral malleolus. There was evidence of pain with weight bearing and evidence of crepitus. He was able to perform repetitive-use functioning with additional loss of motion as plantar flexion was from 0 to 10 degrees and dorsiflexion was from 0 to 0 degrees after 3 repetitions. Pain, weakness and fatigability and lack of endurance caused the additional functional loss with repeated use over time and after flare ups as again plantar flexion was from 0 to 10 degrees and dorsiflexion was from 0 to 0 degrees. There were no additional factors contributing to the disability. Muscle strength testing demonstrated active movement against some resistance (4/5) in flexion and dorsiflexion. There was no ankylosis. There was ankle instability. The Veteran did not use any assistive devices. The Veteran's right ankle disability impacted his ability to work as he could not run, jump, squat or put all of his weight on his right foot. He could not walk for long periods of time. Passive range of motion was the same as active range of motion. Under the circumstances of this case, and with resolution of all reasonable doubt in the Veteran's favor, the Board concludes that an increased 30 percent rating for a right ankle disability is warranted. In light of the Veteran's competent and credible reports of pain and stiffness to which the Board has accorded significant probative value, and the fact that at a point during the appeal period the Veteran's right ankle dorsiflexion was from 0 to 0 degrees during his February 2021 VA examination (compared to a normal range of 0 to 20 degrees) and his plantar flexion was from 0 to 01 degrees (compared to a normal range of 0 to 45 degrees), the Board affords the Veteran the benefit of the doubt and finds that his overall disability picture more nearly approximates the criteria for a 30 percent rating. Notably, according to both the old and revised 38 C.F.R. § 4.71a, Diagnostic Code 5271, the maximum schedular evaluation available for limited motion of the ankle is a 20 percent evaluation. However, Diagnostic Codes 5270 and 5272 for ankle disorders offer a potentially higher rating is for ankylosis of the ankle. The Board notes that the results of the February 2021 VA examination demonstrated marked limitation of dorsiflexion as there was actually a finding of 0 degrees of dorsiflexion after repetitive movement over a period of time and during flare-ups. The Board finds this to be consistent with a finding that the Veteran could not move his foot in dorsiflexion to any measurable extent. Therefore, while the February 2021 examiner did not specifically find the presence of ankylosis, the Board will consider this evidence in a light most favorable to the Veteran and conclude that it warrants a finding of ankylosis of the right ankle in dorsiflexion between 0 degrees and 10 degrees, and the assignment of a 30 percent, but no greater, rating under 38 C.F.R. § 4.71a, Diagnostic Code 5270. However, as the evidence does not reflect findings consistent with ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity, a preponderance of the evidence is against a rating higher than 30 percent under Diagnostic Code 5270. The Board has also considered whether an increased or additional disability rating may be assigned for the Veteran's right ankle disability under alternative diagnostic codes pertaining to disability of the ankle. Diagnostic Code 5273 pertains to malunion of os calcis or astragalus, which has not been shown at any time during the appeal. Finally, as there is no evidence that the Veteran's right talus bone has been removed, Diagnostic Code 5274 for astragalectomy is not applicable. Thus, the Veteran is not entitled to an increased or additional rating under Diagnostic Codes 5003, 5010, 5270, 5272, 5273, or 5274. Accordingly, the Veteran's right ankle disability is manifested by 0 degrees of dorsiflexion that is equivalent to ankylosis of the ankle between 0 and 10 degrees. However, ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity, is not shown. As a result, the Board finds that a 30 percent rating, but no higher, is warranted for a right ankle disability. Hypertension In this case, the Veteran currently has a noncompensable disability rating for hypertension under Diagnostic Codes Diagnostic Code 7101. Diagnostic Code 7101 provides that a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent rating is warranted for diastolic pressure predominantly 120 or more. A 60 percent rating is warranted for diastolic pressure predominantly 130 or more. In every instance where the rating schedule does not provide for a noncompensable evaluation, a noncompensable evaluation shall be assigned where the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2020). Factual Background and Analysis The Veteran filed a claim for an increased rating that was received by VA in February 2018. The Veteran underwent a VA examination in February 2018. The examiner noted that the Veteran's hypertension was well controlled and the Veteran was on two blood pressure medications as he had been on continuous medication for his hypertension. The examiner indicated that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's current blood pressure readings were 130/78, 120/70 and 115/70. The examiner found that the Veteran's hypertension did not impact his ability to work. The Veteran underwent a VA examination in February 2020. The examiner noted that the Veteran had been on continuous medication for his hypertension. The examiner indicated that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's current blood pressure readings were 140/80, 130/80 and 135/80. The examiner found that the Veteran's hypertension impacted his ability to work as he reported that when he exerted himself moderately, he got very tired and light-headed which caused him to stop his exertion. The Veteran felt that this resulted from his hypertension medications. Upon review, the Board finds that a 10 percent disability rating, but no higher, is warranted for hypertension. In that regard, the Board notes that the Veteran's diastolic pressure occasionally ranged near or above 100, and that he required medication to control his pressures. The Board cannot find, however, that a rating in excess of 10 percent is warranted as the evidence does not demonstrate diastolic pressures predominantly 110 or more, or any systolic pressures over 200. Accordingly, the Board finds that a disability rating in excess of 10 percent is not warranted. Accordingly, the Board finds that a 10 percent rating, but no higher, is warranted for the Veteran's service-connected hypertension. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include type II diabetes mellitus may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as type II diabetes mellitus is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Factual Background and Analysis The Veteran contends that that his diabetes mellitus was incurred during his service. The Veteran specifically testified that his diabetes was the result of him eating poorly in the service. The Veteran's service treatment records are negative for complaints or treatments of diabetes mellitus. A December 2007 VA treatment note reported that the Veteran was prediabetic. A May 2016 VA treatment report indicated that the Veteran had a past history of diabetes mellitus. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for diabetes mellitus is not warranted. As there is a current diagnosis of diabetes mellitus, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including diabetes mellitus, if such disabilities are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for diabetes mellitus on a presumptive basis is not warranted as the record does not show evidence of diabetes mellitus within one year of the Veteran's separation from active duty. To the extent that the Veteran is asserting that he experienced continuing symptoms of diabetes mellitus thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, as the Veteran was not diagnosed with diabetes mellitus until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of diabetes mellitus, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board notes that the Veteran's service treatment records are negative for complaints or treatments of diabetes mellitus. Further, there is no competent evidence or opinion even suggesting that there exists a medical nexus between current diabetes mellitus and the Veteran's service and the Veteran has not presented or identified any such existing medical evidence or opinion. The Board finds that the competent evidence of record, while showing the currently diagnosed diabetes mellitus disability, does not demonstrate that the Veteran's diabetes mellitus is related to the Veteran's service. The Board also notes that the Veteran was not provided with VA examination and opinions to assess the current nature and etiology of his claimed diabetes mellitus disability. However, VA need not conduct an examination with respect to the claims on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claims. See 38 C.F.R. § 3.159(c) (4). Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case as there is no credible evidence that the diabetes mellitus manifested in service or within a year of separation from service, there is no credible evidence that the diabetes mellitus manifested in service. There is also no competent evidence suggesting that this disability is otherwise associated to service. Thus, remand for a VA examination is not necessary. The Board notes the Veteran's contentions regarding the etiology of his claimed diabetes mellitus disability. To the extent that the Veteran himself contends that a medical relationship exists between his claimed diabetes mellitus and his service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that diabetes mellitus is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran does not have the medical expertise to provide an opinion regarding the claimed diabetes mellitus etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran's assertions that there is a relationship between his claimed diabetes mellitus and his service are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. The Board notes that VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012). The threshold for finding a link between current disability and disease or injury in service is low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the Veteran's claim for service connection for a lumbar spine disability, at the July 2021 hearing, the Veteran indicated that his current lumbar spine disability was incurred during his service as he routinely during service had to lift heavy ATM batteries all day long. He testified that his service involved lots of amounts of bending and lifting. He also testified that his lumbar spine disability aggravated his service-connected right ankle disability. Notably, the Veteran has yet to undergo a VA examination regarding the etiology of his lumbar spine disability. Accordingly, the Board finds that a VA examination is needed to determine whether the Veteran has a current lumbar spine disability that is related to service to include as being caused or aggravated by service-connected right ankle disability. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c) (4). Regarding the Veteran's gastrointestinal disability and melena claims, the Veteran testified that he had abnormal, pink stools while in service on multiple occasions and also suffered in-service heartburn. Notably, a November 2002 VA treatment note indicated that the Veteran had a diagnosis of melena while a February 2013 VA treatment report noted blood in the Veteran's stool. Additionally, the Board notes that the Veteran has yet to undergo a VA examination regarding the etiology of his current gastrointestinal or melena disabilities. An examination or opinion is necessary to make a decision on a claim if the evidence of record contains competent evidence that the claimant has a current disability, and indicates that the disability or symptoms may be associated with the claimant's active military history, but does not contain sufficient medical evidence to make a decision on the claim. See 38 U.S.C. § 5103A (d) (2); 38 C.F.R. § 3.159(c) (4). Accordingly, the Board finds that he should be scheduled for a VA examination and opinion to determine whether the Veteran has current gastrointestinal or melena disabilities that are related to service. The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Schedule the Veteran for a VA examination to determine the etiology of the claimed lumbar spine disability. Based on a review of the record and an examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran has current lumbar spine disability that is related to any incident of the Veteran's service to include his contentions regarding performing repetitive bending and lifting during service. The examiner should also opine as to whether if it is at least as likely as not (at least a 50 percent probability) that the Veteran has current lumbar spine disability that is caused or aggravated by a service-connected right ankle disability. If the examiner finds that the Veteran has a lumbar spine disability that has been permanently aggravated/worsened by a service-connected disability, to the extent feasible, the degree of worsening should be identified. All opinions expressed by the examiner must be accompanied by a complete rationale. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 3. Schedule the Veteran for a VA examination to determine the etiology of the claimed gastrointestinal and melena disabilities. Based on a review of the record and an examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has current gastrointestinal and melena disabilities that are related to any incident of the Veteran's service. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 4. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.