Citation Nr: 21070589 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-12 082 DATE: November 24, 2021 ORDER An evaluation in excess of 10 percent for a left wrist strain is denied. An evaluation in excess of 10 percent for a right wrist strain is denied. An evaluation in excess of 20 percent for a left shoulder strain is denied. An evaluation in excess of 20 percent for a right shoulder strain is denied. An evaluation in excess of 10 percent for a left ankle sprain is denied. An evaluation in excess of 10 percent for a right ankle sprain is denied. An evaluation in excess of 10 percent for a left knee strain is denied. An evaluation in excess of 10 percent for a right knee strain is denied. An evaluation in excess of 30 percent for gastroesophageal reflux disease (GERD) with irritable bowel syndrome (IBS) is denied. New and material evidence has been received, and a claim of service connection for bilateral leg disability (claimed as throbbing nerve pain from the buttocks to the ankles) is reopened. REMANDED Entitlement to service connection for bilateral leg pain, claimed as throbbing nerve pain from the buttocks to the ankles, to include radiculopathy secondary to a thoracolumbar spine disability. FINDINGS OF FACT 1. The Veteran's left wrist strain is not productive of ankylosis. 2. The Veteran's right wrist strain is not productive of ankylosis. 3. The Veteran's left shoulder strain is not productive of ankylosis, impairment of the humerus, impairment of the clavicle or scapula, motion limited to midway between the side and shoulder level, or the functional equivalent thereof. 4. The Veteran's right shoulder strain is not productive of ankylosis, impairment of the humerus, impairment of the clavicle or scapula, motion limited to midway between the side and shoulder level, or the functional equivalent thereof. 5. The Veteran's left ankle sprain is not productive of ankylosis, malunion of the os calcis or astragalus, astragalectomy, marked limited motion, or the functional equivalent thereof. 6. The Veteran's right ankle sprain is not productive of ankylosis, malunion of the os calcis or astragalus, astragalectomy, marked limited motion, or the functional equivalent thereof. 7. The Veteran's left knee strain is not productive of ankylosis, recurrent subluxation, lateral instability, dislocation or symptomatic removal of the semilunar cartilage, malunion or nonunion of the tibia and fibula, medial tibial stress syndrome (MTSS), genu recurvatum, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, or the functional equivalent thereof. 8. The Veteran's right knee strain is not productive of ankylosis, recurrent subluxation, lateral instability, dislocation or symptomatic removal of the semilunar cartilage, malunion or nonunion of the tibia and fibula, MTSS, genu recurvatum, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, or the functional equivalent thereof. 9. The Veteran's GERD with IBS is not productive of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or of other symptom combinations productive of severe impairment of health. His IBS is manifested by severe diarrhea with more or less constant abdominal distress. 10. Evidence received since a January 2010 final rating decision relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection for a bilateral leg disability (claimed as throbbing nerve pain from the buttocks to the ankles). CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for a left wrist strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5215 (2020). 2. The criteria for an evaluation in excess of 10 percent for a right wrist strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5215 (2020). 3. The criteria for an evaluation in excess of 20 percent for a left shoulder strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5201 (2020). 4. The criteria for an evaluation in excess of 20 percent for a right shoulder strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5201 (2020). 5. The criteria for an evaluation in excess of 10 percent for a left ankle sprain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5271 (2020). 6. The criteria for an evaluation in excess of 10 percent for a right ankle sprain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5271 (2020). 7. The criteria for an evaluation in excess of 10 percent for a left knee strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5260 (2020). 8. The criteria for an evaluation in excess of 10 percent for a right knee strain are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5260 (2020). 9. The criteria for an evaluation in excess of 30 percent for GERD with IBS are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.114, Diagnostic Codes 7346, 7319 (2020). 10. Evidence received since a January 2010 final rating decision is new and material; therefore, the Veteran's claim of entitlement to service connection for a bilateral leg disability (claimed as throbbing nerve pain from the buttocks to the ankles) is reopened. 38 U.S.C. §§ 5108, 7105(c) (2018); 38 C.F.R. §§ 3.156(a), 20.1103 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2002 to August 2006. This appeal is before the Board of Veterans' Appeals (Board) from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In November 2019, the Board denied the appeal to reopen a claim of service connection for bilateral leg pain. The Veteran appealed this denial to the United States Court of Appeals for Veterans Claims (Court), which vacated the denial in an April 2021 order granting a joint motion for partial remand (JMPR). The issue is therefore again before the Board. The November 2019 decision also remanded the other abovementioned issues with instruction to assist the Veteran in obtaining private treatment records and to provide him with adequate VA examinations. In a December 2019 letter, the Veteran was asked to identify any outstanding private treatment records. He did not reply. He underwent VA examinations in February 2020 and January 2021. The Board is therefore satisfied that the instructions in its November 2019 remand have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. 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. Consideration must also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria."). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the claimant 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. Medical records indicate that the Veteran is right-handed and therefore his right wrist and shoulder joints are evaluated under the "major" ratings and his left wrist and shoulder joints are evaluated under the "minor" ratings. 1. Entitlement to an evaluation in excess of 10 percent for a left wrist strain 2. Entitlement to an evaluation in excess of 10 percent for a right wrist strain The Veteran claims increased ratings for his bilateral wrist strains. The Veteran's bilateral wrist strains are evaluated for limitation of motion under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Under this code, limitation of dorsiflexion of the wrist to less than 15 degrees or limitation of palmar flexion of the wrist in line with the forearm is rated at 10 percent. This is the maximum rating under this code. As 10 percent is the maximum rating for limitation of motion, as opposed to ankylosis, the regulatory provisions pertaining to functional loss are not applicable. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202; Spencer v. West, 13 Vet. App. 376, 382 (2000); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Alternative and additional Diagnostic Codes for the wrists and hands are available under 38 C.F.R. § 4.71a, as follows: Under 38 C.F.R. § 4.71a, Diagnostic Code 5214, favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion is rated at 30 percent in the dominant extremity and at 20 percent in the nondominant extremity. Ankylosis of the wrist in any position neither favorable nor unfavorable is rated at 40 percent in the dominant extremity and at 30 percent in the nondominant extremity. Unfavorable ankylosis of the wrist in any degree of palmar flexion or with ulnar or radial deviation is rated at 50 percent in the dominant extremity and at 40 percent in the nondominant extremity. Normal range of motion in the wrist is dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. See 38 C.F.R. § 4.71, Plate I. The rating criteria for wrist disabilities were unchanged by the February 2021 amendments. The Veteran underwent a VA examination in July 2015. He reported pain that prevents him from performing any activity that stresses the joints. He reported flare-ups, stating that simple things like driving his car or writing caused pain. He stated that his wrists were weak and fatigued extremely quickly. All ranges of motion were full, with pain noted in palmar flexion and dorsiflexion bilaterally. Repetitive testing did not lead to any further loss of function or range. The examination was conducted during a flare-up and immediately after repeated use over time. There was no objective evidence of localized tenderness, pain on palpation, pain with weight bearing, or crepitus. There was no ankylosis. He was diagnosed with bilateral wrist strains. The examiner did not review the claims file. In his October 2016 notice of disagreement, the Veteran reported constant pain causing severe discomfort when performing very simple tasks. He stated that carrying lightweight grocery bags, driving a car, or simple typing caused severe discomfort. He stated that his wrists had become unstable with a high degree of flexion that can be mistaken for normal. He stated that fatigability occurred quickly when carrying a weighted load. The Veteran underwent another VA examination in April 2017. He denied flare-ups and did not report functional loss. Ranges of motion were full without pain in both wrists. There was no objective evidence of crepitus, pain with weight bearing, localized tenderness, or pain on palpation. Repetitive testing did not lead to loss of range or function. The examiner stated that there would be no additional functional limitation after repeated use over time. Muscle strength was full without atrophy. There was no ankylosis. X-rays did not show arthritis. He was diagnosed with bilateral wrist strains. VA treatment records reflect that in November 2017 the Veteran reported throbbing and persistent pain on all major joints, including his wrists. He reported some increased pain with weight bearing and stated that he thinks his joints are too flexible. Examination showed no crepitation, tenderness, effusions, decreased range of motion, atrophy, or abnormal strength. In his January 2018 substantive appeal, the Veteran argued that rating on the basis of limitation of motion did not take into consideration too much flexibility or lack of strength and stability, as well as the amount of pain. He reported that his joints are constantly achy and lack stability. He stated that his wrists constantly hurt and are unable to carry a load without making his pain more severe. VA treatment records reflect that at a January 2018 rheumatology consultation the Veteran reported joint pain in his wrists. He exhibited full ranges of motion in his joints. X-rays showed no significant arthritis in either wrist. The Veteran underwent another VA examination in January 2020. He reported sharp pain and achiness within the wrist and joint with reaching limitations and weakness. He reported that elevation of the arms caused more pain for typing, and carrying equipment, reaching equipment, placing equipment, driving, playing with his toddler, house chores, physical fitness, standing, sitting, and sleeping caused pain. He explained that he had constant pain, so everything caused some form of pain. He reported flare-ups every week and a half, from moderate to severe, and lasting a few days to a week. Flare-ups were precipitated by weight bearing, reaching, and typing on a computer. Palmar flexion was limited to 60 degrees bilaterally. Dorsiflexion was limited to 50 degrees bilaterally. Ulnar deviation and radial deviation were full bilaterally. Pain was noted in palmar flexion and in dorsiflexion. There was no evidence of pain with weight bearing, crepitus, localized tenderness, or pain on palpation. Repetitive testing further limited palmar flexion to 50 degrees and dorsiflexion to 40 degrees with contributing factors of pain and lack of endurance. The examiner stated that flare-ups and repeated use over time caused functional loss equivalent to the ranges of motion shown with repetitive testing. Muscle strength was full without atrophy. There was no ankylosis. He was diagnosed with chronic bilateral wrist strains. The Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's wrist strains. Higher ratings are available for ankylosis. The evidence weighs against such symptoms. There is no evidence in the record of ankylosis of the wrists even when considering the impact of flare-ups and repetitive use. The Board recognizes that the Veteran argues that his symptoms are severe and not adequately contemplated by the rating criteria. The evidence, however, shows that the Veteran routinely speaks of his musculoskeletal disabilities together, not as disabilities of the separate joints, both in his lay statements and when being treated by his physicians. While his wrist pain only warrants a 10 percent rating in each wrist, his joint pain ratings combine to 90 percent on their own, fully reflecting the significant disability that the Veteran reports. For these reasons, the Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's wrist strains. 3. Entitlement to an evaluation in excess of 20 percent for a left shoulder strain 4. Entitlement to an evaluation in excess of 20 percent for a right shoulder strain The Veteran claims increased ratings for his bilateral shoulder strains. The Veteran's bilateral shoulder strains are evaluated for limitation of motion under 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under this code, limitation of motion of the arm is rated at 20 percent when limited to shoulder level. When motion is limited to midway between the side and shoulder level, a 30 percent rating is warranted in the dominant extremity and a 20 percent rating is warranted in the nondominant extremity. When motion is limited to 25 degrees from the side, a 40 percent rating is warranted in the dominant extremity and a 30 percent rating is warranted in the nondominant extremity. Alternative and additional Diagnostic Codes for the shoulder and arm are available as described below. Under 38 C.F.R. § 4.71a, Diagnostic Code 5200, ankylosis of scapulohumeral articulation in the dominant extremity is rated at 30 percent for favorable, with abduction to 60 degrees and the ability to reach the mouth and head; at 40 percent for intermediate between favorable and unfavorable; and at 50 percent for unfavorable, with abduction limited to 25 degrees from the side. For the nondominant extremity, all ratings under this code are decreased by 10 percent. Under 38 C.F.R. § 4.71a, Diagnostic Code 5202, ratings are available for impairment of the humerus. In the dominant extremity, a 20 percent rating is warranted for malunion of the humerus with moderate deformity or for infrequent episodes of dislocation of the humerus at the scapulohumeral joint with guarding at shoulder level. A 30 percent rating is warranted for malunion of the humerus with marked deformity or for frequent episodes of dislocation of the humerus at the scapulohumeral joint with guarding at all arm movements. A 50 percent rating is warranted for fibrous union of the humerus. A 60 percent rating is warranted for nonunion of the humerus (false flail joint). An 80 percent rating is warranted for loss of head of the humerus (flail shoulder). For the nondominant extremity, all ratings under this code are decreased by 10 percent, except for the 20 percent ratings which are the same in both extremities. Under 38 C.F.R. § 4.71a, Diagnostic Code 5203, ratings are available for impairment of the clavicle or scapula. A 10 percent rating is warranted for malunion of the clavicle or scapula or for nonunion of the clavicle or scapula without loose movement. A 20 percent evaluation is warranted for nonunion of the clavicle or scapula with loose movement or for dislocation of the clavicle or scapula. Normal range of motion of the shoulder is flexion and abduction from zero to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with zero degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. Id. DC 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to 'limitation of motion of' the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The February 2021 amendments to the ratings criteria for shoulder disabilities consisted of defining the limitation of motion in Diagnostic Code 5201 to the ranges of flexion and abduction and in Diagnostic Codes 5201 and 5202 defining "at shoulder level" to be 90 degrees and "midway between side and shoulder level" to be 45 degrees. The Board finds that these changes clarified but did not affect the substance of the criteria, and there is no scenario under which the amended criteria could be more favorable to the Veteran. The Veteran underwent a VA examination in July 2015. He reported pain that made lifting and holding things difficult. He reported flare-ups, stating that any activity with his shoulders causes pain no matter how small. He stated that lifting above his chest becomes very difficult depending on the weight and that reaching and stretching is also limited with pain. Flexion was limited to 175 degrees in the right shoulder and to 170 degrees in the left shoulder. Abduction was full to 180 degrees bilaterally. External rotation was full to 90 degrees in the right shoulder and limited to 80 degrees in the left shoulder. Internal rotation was full to 90 degrees bilaterally. Pain was noted in all ranges. Repetitive testing did not lead to any further loss of function or range. The examination was conducted during a flare-up and immediately after repeated use over time. There was no objective evidence of localized tenderness, pain on palpation, pain with weight bearing, or crepitus. Muscle strength was full without atrophy. There was no ankylosis. Tests for rotator cuff conditions were negative. There was no history or evidence of instability, dislocation, or lateral pathology. There were no conditions of the clavicle, scapula, acromioclavicular joint, sternoclavicular joint, or humerus. X-rays did not show arthritis. He was diagnosed with bilateral shoulder strains. The examiner did not review the claims file. In his October 2016 notice of disagreement, the Veteran stated that he could no longer lift anything over a few pounds without feeling pain. Depending on how much weight, he stated he could not life the weight above his shoulders. He reported that fatigability occurred quickly when carrying a weighted load. The Veteran underwent another VA examination in April 2017. He denied flare-ups and did not report functional loss. Ranges of motion were full without pain in both wrists. There was no objective evidence of crepitus, pain with weight bearing, localized tenderness, or pain on palpation. Repetitive testing did not lead to loss of range or function. The examiner stated that there would be no additional functional limitation after repeated use over time. Muscle strength was full without atrophy. There was no ankylosis. Rotator cuff conditions were not suspected. Instability, dislocation, or labral pathology was not suspected. There was no condition of the clavicle, scapula, acromioclavicular joint, sternoclavicular joint, or the humerus. X-rays did not show arthritis. He was diagnosed with bilateral shoulder strains. VA treatment records reflect that in November 2017 the Veteran reported throbbing and persistent pain on all major joints, including his shoulders. He reported some increased pain with weight bearing and stated that he thinks his joints are too flexible. Examination showed no crepitation, tenderness, effusions, decreased range of motion, instability, atrophy, or abnormal strength. In his January 2018 substantive appeal, the Veteran argued that rating on the basis of limitation of motion did not take into consideration too much flexibility or lack of strength and stability, as well as the amount of pain. He reported that his joints are constantly achy and lack stability. VA treatment records reflect that at a January 2018 rheumatology consultation the Veteran reported joint pain in his shoulders. He exhibited full ranges of motion in his joints. The Veteran underwent another VA examination in January 2020. He reported sharp pain and achiness within the shoulder joint with reaching limitations and weakness. He reported that elevation of the arms caused more pain for typing, and carrying equipment, reaching equipment, placing equipment, driving, playing with his toddler, house chores, physical fitness, standing, sitting, and sleeping caused pain. He explained that he had constant pain, so everything caused some form of pain. He reported flare-ups every week and a half, from moderate to severe, and lasting a few days to a week. Flare-ups were precipitated by weight bearing, reaching, and typing on a computer. Flexion was limited to 100 degrees and abduction was limited to 90 degrees bilaterally. External rotation was full to 90 degrees bilaterally. Internal rotation was limited to 75 degrees bilaterally. Pain was noted in all ranges except external rotation. There was no evidence of pain with weight bearing or crepitus with excess fatigability and disturbance of locomotion. There was objective evidence of mild tenderness at the acromioclavicular tendons. Repetitive testing further limited flexion to 90 degrees, abduction to 80 degrees, and internal rotation to 70 degrees with contributing factors of pain and lack of endurance. The examiner stated that flare-ups and repeated use over time caused functional loss equivalent to the ranges of motion shown with repetitive testing. Muscle strength was full without atrophy. There was no ankylosis. Tests for rotator cuff conditions were negative. There was no history or evidence of instability, dislocation, or lateral pathology. There were no conditions of the clavicle, scapula, acromioclavicular joint, sternoclavicular joint, or humerus. Cross-body adduction tests were negative. He was diagnosed with chronic bilateral shoulder strains. In a September 2020 statement, the Veteran stated that he agreed with his current ratings for his shoulder disabilities. The Board finds that this statement does not constitute unambiguous withdrawal of the appeal as to these issues, and in any event the Veteran's representative continued to pursue them in a September 2021 informal hearing presentation. See Hembree v. Wilkie, 33 Vet. App. 1, 7 (2020). The Board finds that evaluations in excess of 20 percent are not warranted for the Veteran's shoulder strains. The Veteran is assigned the minimum compensable rating for painful motion in both shoulders, which contemplates additional functional limitations like weakness, premature or excess fatigability, and incoordination. Critically, even when considering additional functional limitation during flare-ups and on repeated use, at no time during the appeal period is there limitation of motion midway between the side and shoulder of either arm. Higher ratings are available for ankylosis, impairment of the humerus, impairment of the clavicle or scapula, motion limited to midway between the side and shoulder level, or the functional equivalent thereof. The evidence weighs against such symptoms. There is no evidence in the record of ankylosis even when considering the impact of flare-ups and repetitive use. There is also no evidence of impairment of the humerus, or impairment of the clavicle or scapula. Rather, the symptoms reported were limited to painful motion, limited motion, and difficulty lifting. At no time was flexion or abduction measured as limited to less than 80 degrees, nor did any examiner find further limitation of range during flare-ups or with repeated use over time. Furthermore, in his September 2020 statement, the Veteran indicated that he agreed with his current 20 percent ratings for his shoulder disabilities. For these reasons, the Board finds that evaluations in excess of 20 percent are not warranted for the Veteran's shoulder strains. 5. Entitlement to an evaluation in excess of 10 percent for a left ankle sprain 6. Entitlement to an evaluation in excess of 10 percent for a right ankle sprain The Veteran claims increased ratings for his bilateral ankle sprains. The Veteran's bilateral ankle disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Ratings under this code are available at 10 percent for moderate limited motion and 20 percent for marked limited motion. Normal range of motion of the ankle is measured as 0-20 degrees of dorsiflexion and 0-45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. The February 2021 amendments to the ratings criteria for ankle disabilities only affected Diagnostic Code 5271. In the amended criteria, moderate limited motion is defined as less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion, and marked limited motion is defined as less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. The Board finds that these changes clarified but did not affect the substance of the criteria, and there is no scenario under which the amended criteria could be more favorable to the Veteran. Alternative and additional Diagnostic Codes for the ankle are available under 38 C.F.R. § 4.71a, as follows: Under 38 C.F.R. § 4.71a, Diagnostic Code 5270, ankylosis of the ankle in plantar flexion less than 30 degrees is rated at 20 percent; ankylosis in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 and 10 degrees is rated at 30 percent; and ankylosis in plantar flexion at more than 40 degrees, in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion, or eversion deformity is rated at 40 percent. Under 38 C.F.R. § 4.71a, Diagnostic Code 5272, ankylosis of the subastragalar or tarsal joint is rated at 10 percent for ankylosis in good weight-bearing position and at 20 percent for ankylosis in poor weight-bearing position. Under 38 C.F.R. § 4.71a, Diagnostic Code 5273, malunion of the os calcis or astragalus is rated at 10 percent for moderate deformity and 20 percent for marked deformity. Under 38 C.F.R. § 4.71a, Diagnostic Code 5274, astragalectomy is rated at 20 percent. The Veteran underwent a VA examination in July 2015. He reported pain with very little stability, stating that he could not stand or walk for long periods. He reported flare-ups, stating that his ankles constantly have pain no matter what. He stated that lack of strength prevented him from performing activities which required strength. Dorsiflexion and plantar flexion were full to 20 degrees and 45 degrees but exhibited pain. Repetitive testing did not lead to any further loss of function or range. The examination was conducted during a flare-up and immediately after repeated use over time. There was no objective evidence of localized tenderness, pain on palpation, pain with weight bearing, or crepitus. Muscle strength was full without atrophy. There was no ankylosis. Instability or dislocation tests were not conducted. There was no history of shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, astragalectomy, or malunion of the calcaneus or talus. He was diagnosed with bilateral ankle sprains. The examiner did not review the claims file. In his October 2016 notice of disagreement, the Veteran reported overextension movement in his ankles, with tendons and ligaments stretched beyond recovering to their normal limitations. He reported extreme instability, causing him constantly to roll or rotate when walking on flat ground. Uneven surfaces greatly increased his instability, leading to spraining that immobilized him. He reported constant pain causing distress and discomfort, and he stated fatigability occurs quickly while standing for a short time or walking short distances. The Veteran underwent another VA examination in April 2017. He reported daily ongoing pain. He stated that he walks his dog one mile daily. He reported pain with prolonged walking. He denied flare-ups. Ranges of motion were full without pain in both ankles. There was no objective evidence of crepitus, pain with weight bearing, localized tenderness, or pain on palpation. Repetitive testing did not lead to loss of range or function. The examiner stated that there would be no additional functional limitation after repeated use over time. Muscle strength was full without atrophy. There was no ankylosis. Ankle instability or dislocation was not suspected. There was no evidence or history of shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, astragalectomy, or malunion of the calcaneus or talus. X-rays did not show arthritis. He was diagnosed with bilateral ankle sprains. VA treatment records reflect that in November 2017 the Veteran reported throbbing and persistent pain on all major joints, including his ankles. He reported some increased pain with weight bearing and stated that he thinks his joints are too flexible. Examination showed no crepitation, tenderness, effusions, decreased range of motion, instability, atrophy, or abnormal strength. In his January 2018 substantive appeal, the Veteran argued that rating on the basis of limitation of motion did not take into consideration too much flexibility or lack of strength and stability, as well as the amount of pain. He reported that his joints are constantly achy and lack stability. He stated that he constantly rolls his ankles from lack of stability, spraining them and rendering him immobile. VA treatment records reflect that at a January 2018 rheumatology consultation the Veteran reported about two hours of ankle pain and stiffness in the mornings. He reported that he walks for about 45-60 minutes per day. He exhibited full ranges of motion in his joints. X-rays showed no significant arthritis in either ankle. The Veteran underwent another VA examination in January 2020. He reported sharp pain and achiness in the ankle joint with reaching limitations and weakness. He reported that playing with his toddler, house chores, physical fitness, standing, sitting, and sleeping caused pain. He explained that he had constant pain, so everything caused some form of pain. He reported flare-ups every week and a half, from moderate to severe, and lasting a few days to a week. Flare-ups were precipitated by weight bearing, reaching, and typing on a computer. Dorsiflexion was limited to 15 degrees bilaterally. Plantar flexion was limited to 40 degrees bilaterally. Pain was noted in all ranges. There was evidence of mild tenderness in the lateral collateral ligaments and pain with weight bearing. There was no evidence of crepitus. Repetitive testing further limited plantar flexion to 35 degrees and dorsiflexion to 10 degrees with contributing factors of pain and lack of endurance. The examiner stated that flare-ups and repeated use over time caused functional loss equivalent to the ranges of motion shown with repetitive testing. Muscle strength was full without atrophy. There was no ankylosis. Stability tests were normal. There was no evidence or history of shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, astragalectomy, or malunion of the calcaneus or talus. He was diagnosed with chronic lateral collateral ligament sprains. In a September 2020 statement, the Veteran reported that when walking or standing still his ankles might buckle or give out causing him to fall. The Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's ankle sprains. Higher ratings are available for ankylosis, malunion of the os calcis or astragalus, astragalectomy, marked limited motion, or the functional equivalent thereof. The evidence weighs against such symptoms. There is no evidence in the record of ankylosis even when flare-ups and repetitive use are considered. There is no also no evidence of astragalectomy, or malunion of the os calcis or astragalus. Dorsiflexion has not been measured as limited to less than 10 degrees, and plantar flexion has not been measured as limited to less than 35 degrees. The January 2020 VA examiner found that flare-ups and repeated use over time caused the same limitations as those measured after repetitive testing. Moreover, at multiple times during the appeal period the Veteran's ranges of motion were found not to be limited at all. The Board recognizes that the Veteran argues that his symptoms are severe and not adequately contemplated by the rating criteria. The evidence, however, shows that the Veteran routinely speaks of his musculoskeletal disabilities together, not as disabilities of the separate joints, both in his lay statements and when being treated by his physicians. While his ankle pain only warrants a 10 percent rating in each ankle, his joint pain ratings combine to 90 percent on their own, fully reflecting the significant disability that the Veteran reports. For these reasons, the Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's ankle sprains. 7. Entitlement to an evaluation in excess of 10 percent for a left knee strain 8. Entitlement to an evaluation in excess of 10 percent for a right knee strain The Veteran claims increased ratings for his bilateral knee strains. The Veteran is currently in receipt of a 10 percent rating for limitation of flexion for each knee under 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under this code, flexion of the leg is rated noncompensable when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. Alternative and additional Diagnostic Codes for the leg and the knee are available under 38 C.F.R. § 4.71a, as follows: Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis of the knee with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, is rated at 30 percent; ankylosis in flexion between 10 and 20 degrees is rated at 40 percent; ankylosis in flexion between 20 and 45 degrees is rated at 50 percent; and extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, is rated at 60 percent. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, recurrent subluxation or lateral instability is rated at 10 percent for slight instability, 20 percent for moderate instability, and 30 percent for severe instability. As of February 7, 2021, under the amended criteria, a 10 percent rating is warranted for a diagnosed condition with recurrent instability that does not require a prescription for a brace, cane, or walker; or for a sprain, incomplete ligament tear, or complete ligament tear causing persistent instability without a prescription for an assistive device or bracing for ambulation. A 20 percent rating is warranted for a diagnosed condition with recurrent instability after surgical repair that requires a prescription for a brace, cane, or walker; or for a sprain, incomplete ligament tear, or complete ligament tear causing persistent instability with a prescription for an assistive device or bracing for ambulation. A 30 percent rating is warranted for a diagnosed condition with recurrent instability after surgical repair that requires a prescription for a brace and either a cane or a walker; or for an unrepaired or failed repair of a complete ligament tear causing persistent instability with a prescription for both an assistive device and bracing for ambulation. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocation of semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint is rated at 20 percent. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, symptomatic removal of the semilunar cartilage is rated at 10 percent. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, extension of the leg is rated noncompensable when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, malunion of the tibia and fibula is rated at 10 percent with slight disability, 20 percent with moderate disability, and 30 percent with marked disability. Nonunion of the tibia and fibula, with loose motion and requiring a brace, is rated at 40 percent. As of February 7, 2021, under the amended criteria, malunion of the tibia and fibula is to be evaluated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. In addition, the code provides criteria for MTSS or shin splints. Treatment for less than 12 consecutive months warrants a 0 percent rating. A disability requiring treatment for no less than 12 consecutive months and unresponsive to either shoe orthotics or other conservative treatment warrants a 10 percent rating. A disability requiring treatment for no less than 12 consecutive months unresponsive to surgery and either shoe orthotics or other conservative treatment warrants a 20 percent rating in one lower extremity and a 30 percent rating for both lower extremities. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, acquired traumatic genu recurvatum, with objectively demonstrated weakness and insecurity in weight-bearing is rated at 10 percent. The Veteran underwent a VA examination in July 2015. He reported pain that decreased his ability to bend, exercise, walk, or stand for lengths of time. He reported flare-ups, stating that his knees always have pain that is determined by his amount of activity. He stated that weakness prevents him from activities requiring strength. Flexion was limited to 130 degrees in the right knee and to 135 degrees in the left knee. Extension was full to 0 degrees bilaterally. Pain was noted in all ranges. Repetitive testing did not lead to any further loss of function or range. The examination was conducted during a flare-up and immediately after repeated use over time. There was no objective evidence of localized tenderness, pain on palpation, pain with weight bearing, or crepitus. Muscle strength was full without atrophy. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability tests were normal. There was no evidence or history of any tibial or fibular impairment. There were no meniscal conditions or history thereof. There was no ankylosis. X-rays did not show arthritis. He was diagnosed with bilateral knee strains. The examiner did not review the claims file. In his October 2016 notice of disagreement, the Veteran reported recurrent lateral instability while performing normal daily activities. He stated that his knees give out from simple activities such as walking. He reported constant pain. He stated that fatigability occurs quickly while standing for a short time or walking a short distance. The Veteran underwent another VA examination in April 2017. He denied flare-ups and did not report any functional loss. Flexion and extension were full without pain bilaterally. There was no objective evidence of crepitus, pain with weight bearing, localized tenderness, or pain on palpation. Repetitive testing did not lead to loss of range or function. The examiner stated that there would be no additional functional limitation after repeated use over time. Muscle strength was full without atrophy. There was no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability tests were normal. There was no evidence or history of any tibial or fibular impairment. There were no meniscal conditions or history thereof. X-rays did not show arthritis. He was diagnosed with bilateral knee strains. VA treatment records reflect that in November 2017 the Veteran reported throbbing and persistent pain on all major joints, including his knees. He reported some increased pain with weight bearing and stated that he thinks his joints are too flexible. Examination showed no crepitation, tenderness, effusions, decreased range of motion, instability, atrophy, or abnormal strength. In his January 2018 substantive appeal, the Veteran argued that rating on the basis of limitation of motion did not take into consideration too much flexibility or lack of strength and stability, as well as the amount of pain. He reported that his joints are constantly achy and lack stability. He reported that his knees pop and move inside the joint. VA treatment records reflect that at a January 2018 rheumatology consultation the Veteran reported joint pain in his knees. He reported that he walks for about 45-60 minutes per day. He exhibited full ranges of motion in his joints. In November 2018 his rheumatologist noted hyperextension of the knees. The Veteran underwent another VA examination in January 2020. He reported sharp pain and achiness within the knee joints with reaching limitations and weakness. He reported that driving, playing with his toddler, house chores, physical fitness, standing, sitting, and sleeping caused pain. He explained that he had constant pain, so everything caused some form of pain. He reported flare-ups every week and a half, from moderate to severe, and lasting a few days to a week. Flare-ups were precipitated by weight bearing, reaching, and typing on a computer. Flexion was limited to 100 degrees and extension was full to 0 degrees bilaterally. Pain was noted in flexion. There was no evidence of crepitus, localized tenderness, or pain on palpation. There was evidence of pain with weight bearing. Repetitive testing further limited flexion to 90 degrees with contributing factors of pain, lack of endurance, and incoordination. The examiner stated that flare-ups and repeated use over time caused functional loss equivalent to the ranges of motion shown with repetitive testing. Muscle strength was full without atrophy. There was no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability tests were normal. There was no evidence or history of any tibial or fibular impairment. There were no meniscal conditions or history thereof. X-rays did not show arthritis. He was diagnosed with chronic bilateral knee strains. In a September 2020 statement, the Veteran reported that when walking or standing still his knees might buckle or give out causing him to fall. The Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's knee strains. Higher ratings are available for ankylosis, recurrent subluxation, lateral instability, dislocation or symptomatic removal of the semilunar cartilage, malunion or nonunion of the tibia and fibula, MTSS, genu recurvatum, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, or the functional equivalent thereof. The evidence weighs against such symptoms. There is no evidence in the record of ankylosis even when flare-ups and repetitive use are considered. There is also no evidence of dislocation or symptomatic removal of the semilunar cartilage, malunion or nonunion of the tibia and fibula, MTSS, genu recurvatum, or limitation of extension. As to instability, in November 2016 and September 2020 lay statements the Veteran described routine giving out of the knees causing falls. These isolated complaints do not rise to the level of minimum slight lateral instability under DC 5257. Additionally, there is no medical evidence of him being treated after such falls, and multiple examiners and a VA treating nurse practitioner have found no instability through testing and examination. His flexion has not been measured as limited to less than 90 degrees, and the January 2020 examiner found that flexion was limited to 90 degrees during flare-ups and after repeated use over time. The Board recognizes that the Veteran argues that his symptoms are severe and not adequately contemplated by the rating criteria. The evidence, however, shows that the Veteran routinely speaks of his musculoskeletal disabilities together, not as disabilities of the separate joints, both in his lay statements and when being treated by his physicians. While his knee pain only warrants a 10 percent rating in each knee, his joint pain ratings combine to 90 percent on their own, fully reflecting the significant disability that the Veteran reports. For these reasons, the Board finds that evaluations in excess of 10 percent are not warranted for the Veteran's knee strains. 9. Entitlement to an evaluation in excess of 30 percent for GERD with IBS The Veteran claims an increased rating for his digestive disability. The Veteran's digestive disability is currently rated as irritable colon syndrome under 38 C.F.R. § 4.114, Diagnostic Code 7319. His current 30 percent evaluation is warranted for severe irritable colon syndrome, defined as diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. This is the maximum schedular rating available under this code. GERD may alternatively be rated as analogous to a hiatal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7346. Under this code, a maximum 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or for other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. Diagnostic Codes 7319 and 7346 cannot be combined. Rather, a single evaluation may be assigned under the code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Private treatment records reflect that in March 2015 the Veteran reported intermittent treatment for IBS with some loose bowel movements. He was diagnosed with GERD and diarrhea. The Veteran underwent a VA examination in July 2015. He reported epigastric burning pain, heartburn, reflux, and occasional nausea, improved with Nexium. The examiner noted infrequent episodes of epigastric distress, heartburn, reflux, and sleep disturbance occurring 4 or more times per year but lasting less than one day. There was no dysphagia, regurgitation, substernal arm or shoulder pain, anemia, weight loss, nausea, vomiting, hematemesis, or melena. There was no esophageal stricture, spasm or acquired diverticulum. The examiner noted that a March upper endoscopy showed GERD. He was diagnosed with GERD. In his October 2016 notice of disagreement, the Veteran reported severe GERD, including pain around his heart and left shoulder with severe burning in his esophagus and throat. He stated that acid is constantly present in the back of his mouth in the form of regurgitation. He argued that he persistently had recurrent epigastric distress, pyrosis with dysphagia, and regurgitation causing discomfort and pain in his everyday life. He also reported that his IBS was a separate disability, causing multiple episodes daily and in the middle of the night of diarrhea with severe stomach pain. The Veteran underwent another VA examination in April 2017. He reported reflux treated with Nexium. No other symptoms were noted. He was diagnosed with GERD. The Veteran underwent a separate examination for intestinal conditions in May 2017. He reported longstanding diarrhea due to IBS, treated continuously with loperamide. He reported loose stools 5-7 times daily with cramping, daily painful abdominal distention after meals, and weekly nausea with abdominal pain. The examiner noted more or less constant abdominal distress with seven or more exacerbations over the prior year. There was no weight loss, malnutrition, complications, or other general health effects. He was diagnosed with IBS. VA treatment records reflect that in November 2017 the Veteran reported worsening GERD symptoms after changing medication to Prilosec for insurance reasons. He also reported wet diarrhea, 4-5 bowel movements per day with intermittent pain and cramping in the stomach. He was diagnosed with GERD and with chronic diarrhea. In October 2018 he reported 4-7 bowel movements per day, varying between solid to soft to diarrhea. There was no weight loss, dysphagia, or odynophagia. In November 2018 he was diagnosed with chronic defecatory dysfunction labelled as IBS-D. A July 2019 x-ray showed a moderate amount of stool predominantly in the ascending colon. In September 2019 he reported bad cramps in the mid-lower abdomen which wake him up at night. A November 2019 colonoscopy showed no evidence of microscopic colitis. In January 2020 he reported 2-7 loose-to-watery stools per day with incomplete evacuations and daily heartburn. X-rays showed mild-to-moderate stool burden throughout the colon. The Veteran underwent another VA examination for intestinal disabilities in January 2020. He reported pain, 5-7 bowel movements per day, bloating, gas, constant bleeding, and nighttime pain with waking up and spending an hour on the toilet. He reported that he takes continuous medication, specifically Immodium as needed. The examiner noted diarrhea, abdominal distention, and nausea and identified frequent episodes of bowel disturbance with abdominal distress. There was no weight loss, malnutrition, complications, or other general health effects. He was diagnosed with IBS. The Veteran underwent another VA examination for esophageal disabilities in January 2020. He reported pain in his arm and chest, pain in his ear and head, burning in his throat and esophagus, and regurgitation. He reported daily use of Prilosec. The examiner noted symptoms of pyrosis, reflux, regurgitation, substernal arm and shoulder pain, sleep disturbance at least four times per year lasting less than one day, and nausea at least four times per year lasting less than one day. There was no dysphagia, regurgitation, substernal arm or shoulder pain, anemia, weight loss, nausea, vomiting, hematemesis, or melena. There was no esophageal stricture, spasm or acquired diverticulum. He was diagnosed with GERD. In a September 2020 statement, the Veteran stated that he agreed with his current rating for his GERD and IBS. The Board finds that this statement does not constitute unambiguous withdrawal of the appeal as to these issues, and in any event the Veteran's representative continued to pursue them in a September 2021 informal hearing presentation. See Hembree v. Wilkie, 33 Vet. App. 1, 7 (2020). The Veteran underwent another VA examination for esophageal disabilities in December 2020. He reported infrequent episodes of epigastric distress, dysphagia, substernal pain, and both nausea and sleep disturbance caused by esophageal reflux occurring 4 or more times per year and lasting 1-9 days. He was diagnosed with GERD. The Veteran underwent another VA examination for intestinal disabilities in December 2020. He reported diarrhea 7 times per day and daily alternating diarrhea and constipation. He reported episodes of bowel disturbance and more or less constant abdominal distress with exacerbating episodes of spasm and pain occurring 7 or more times per year. He attributed 10 pounds of weight loss to his condition. He was diagnosed with IBS. The Board finds that an evaluation in excess of 30 percent is not warranted for the Veteran's GERD with IBS. As discussed above, regulations prohibit separate ratings for these disabilities. Alternative higher ratings for GERD are available for pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or for other symptom combinations productive of severe impairment of health. The evidence weighs against such a finding. There is no evidence in the record of hematemesis, melena, or moderate anemia. Indeed, the Veteran's symptoms reports routinely focus on his IBS disability, not the GERD. However, a 30 percent rating under DC 7319 is the maximum schedular rating and, thus, a higher rating under such DC is not warranted. The Board has also considered alternative ratings under the codes for colitis or diverticulitis, but higher ratings under such codes require findings of malnutrition or a history of operative or other traumatic or infectious process, neither of which is present here. Furthermore, in his September 2020 statement, the Veteran indicated that he agreed with his current 30 percent rating for his GERD with IBS. For these reasons, the Board finds that an evaluation in excess of 30 percent is not warranted for the Veteran's GERD with IBS. 10. Whether new and material evidence has been received to reopen a claim of service connection for bilateral leg pain, claimed as throbbing nerve pain from the buttocks to the ankles The Veteran seeks to reopen his claim of service connection for bilateral leg pain, claimed as throbbing nerve pain from the buttocks to the ankles. VA may reopen a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New" evidence is evidence not previously submitted to agency decision makers and "material" evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether the evidence presented or secured since the prior final disallowance of the claim is new and material, the credibility of the evidence is generally presumed. Cox v. Brown, 5 Vet. App. 95, 98 (1993); Justus v. Principi, 3 Vet. App. 510, 513 (1992). VA is required to review for newness and materiality only the evidence submitted by a claimant since the last final disallowance of the claim on any basis, whether a decision on the underlying merits or, a petition to reopen. Evans v. Brown, 9 Vet. App. 273, 283 (1996). In Shade v. Shinseki, 24 Vet. App. 100 (2010), the United States Court of Appeals for Veterans Claims (Court) held that § 3.159(c)(4) does not require new and material evidence as to each previously unproven element of a claim for the claim to be reopened and the duty to provide an examination triggered. In a fact pattern where a prior denial was based on lack of current disability and nexus, the Court found that newly submitted evidence of a current disability was, in concert with evidence already of record establishing an injury in service, new and material and sufficient to reopen the claim and obtain an examination. Regardless of any RO determinations that new and material evidence has been submitted to reopen service connection, the Board must still determine whether new and material evidence has been submitted in this matter. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). The Veteran's claim was originally denied in a January 2010 rating decision based on a finding that the evidence did not establish a current diagnosis or any in-service event, disease, or injury. He neither appealed this denial nor submitted any evidence during the one-year appeal period, and the decision therefore became final. The Veteran next submitted a claim to reopen in July 2014. The claim was denied in an October 2014 rating decision based on a finding that new and material evidence had not been submitted. He filed the claim on which this appeal is based in March 2015, within the one-year appeal period of the October 2014 rating decision. The Board therefore finds that the October 2014 rating decision did not become final and will make a finding as to whether new and material evidence has been received since January 2010, the date of the last final rating decision. The JMPR instructs that the Board consider whether lay evidence submitted since the final January 2010 rating decision is new and material, specifically, a statement accompanying his October 2016 notice of disagreement. In this statement, the Veteran reported that while on active duty he was trained in the Marine Corps Mixed Martial Arts Program, which included training in "body hardening," consisting of deadening the body's nerves. Since then, he stated that he has had constant throbbing pain in both legs, preventing him from sitting longer than a few minutes. He attached an excerpt from the martial arts program describing the body hardening nerve strike exercises. In his January 2018 substantive appeal, he again described his martial arts training, stating that he trained roughly once per month. He stated that because they did the training so rarely, they failed to deaden the nerves and merely damaged them. He stated that he always feels some form of pain in his legs. These statements are cumulative of a December 2009 statement considered in the original January 2010 denial. Since the Court vacated the Board's decision, however, new medical evidence has been associated with the Veteran's claims file. VA treatment records from January 2018 indicate that he exhibits sciatica in his lower extremities which may be associated with his service-connected thoracolumbar spine disability. The Board finds that this evidence relates to an unestablished fact, is not cumulative or redundant of the evidence previously of record, and is sufficient to raise a reasonable possibility of substantiating the claim of service connection. The Veteran's claim is therefore reopened. REASONS FOR REMAND Entitlement to service connection for bilateral leg pain, claimed as throbbing nerve pain from the buttocks to the ankles, to include radiculopathy secondary to a thoracolumbar spine disability. As discussed above, the Veteran's claim of service connection for nerve pain is herein reopened by the Board based on VA treatment records from January 2018 indicating that he exhibits sciatica in his lower extremities which may be associated with his service-connected thoracolumbar spine disability. While his VA examinations for his thoracolumbar spine disability show no such radiculopathy, he has not been examined since May 2017, prior to the January 2018 findings. Remand for a new examination is therefore required. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine whether the Veteran exhibits radiculopathy associated with his service-connected thoracolumbar spine disability. The examiner should report the extent of the Veteran's disability in accordance with VA rating criteria. The claims file must be reviewed by the examiner. All opinions are to be accompanied by a complete rationale. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. 2. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. REBECCA N. POULSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.