Citation Nr: 21071363 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 10-49 378 DATE: November 30, 2021 ORDER Entitlement to service connection for a deviated septum is denied. Entitlement to an initial disability rating in excess of 20 percent for right wrist carpal tunnel syndrome and right elbow cubital tunnel syndrome is denied. Entitlement to an initial disability rating in excess of 10 percent for left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome prior to September 9, 2016; and in excess of 20 percent thereafter is denied. Entitlement to a separate 20 percent rating for left elbow cubital tunnel syndrome limitation of flexion, from February 12, 2021, but no earlier, is granted. Entitlement to a rating in excess of 20 percent for left elbow cubital tunnel syndrome limitation of flexion, from February 12, 2021, is denied. Entitlement to a separate 20 percent rating, for left elbow cubital tunnel syndrome impairment of pronation, from February 12, 2021, but no earlier, is granted. Entitlement to a rating in excess of 20 percent, for left elbow cubital tunnel syndrome impairment of pronation, from February 12, 2021, is denied. Entitlement to an initial disability rating in excess of 10 percent for varicose veins of the right leg is denied. Entitlement to an initial disability rating in excess of 10 percent for varicose veins of the left leg is denied. Entitlement to an initial compensable disability rating for leg length discrepancy is denied. Entitlement to an initial disability rating in excess of 10 percent for hiatal hernia with gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to service connection for a left ankle disability, to include degenerative arthritis is remanded. Entitlement to service connection for bilateral hammertoes is remanded. Entitlement to an initial compensable disability rating for bilateral pes planus with left plantar fasciitis prior to February 23, 2010; in excess of 10 percent from February 23, 2010, to September 9, 2016; and in excess of 30 percent since September 9, 2016, is remanded. Entitlement to an initial disability in excess of 10 percent for left knee degenerative arthritis is remanded. Entitlement to an initial disability rating in excess of 10 percent for right knee degenerative arthritis is remanded. Entitlement to an initial compensable disability rating for left hip degenerative arthritis prior to September 9, 2016; in excess of 10 percent thereafter is remanded. Entitlement to an initial disability rating in excess of 10 percent for right hip degenerative arthritis is remanded. Entitlement to an initial compensable rating for left hip arthritis limitation of extension is remanded. Entitlement to an initial compensable rating for right hip arthritis limitation of extension is remanded. Entitlement to an initial compensable rating for left hip arthritis limitation of adduction/abduction is remanded. Entitlement to an initial compensable rating right hip arthritis limitation of adduction/abduction is remanded. Entitlement to an initial disability rating in excess of 10 percent for thoracolumbar strain, degenerative disc disease (DDD) with segmental dysfunction of the lumbosacral, thoracic, and sacroiliac regions prior to July 24, 2009; in excess of 20 percent thereafter is remanded. FINDINGS OF FACT 1. The Veteran does not have a current deviated septum disability. 2. For the entire period on appeal, the Veteran's right elbow cubital tunnel syndrome with right wrist carpal tunnel syndrome most closely approximated mild incomplete paralysis of all radicular groups. 3. For the period prior to September 9, 2016, the Veteran's left elbow cubital tunnel syndrome with left wrist carpal tunnel syndrome most closely approximated mild incomplete paralysis of the ulnar nerve. 4. From September 9, 2016, the Veteran's left elbow cubital tunnel syndrome with left wrist carpal tunnel syndrome most closely approximated mild incomplete paralysis of all radicular groups. 5. For the period prior to February 12, 2021, the record is negative for evidence of the Veteran's left elbow cubital tunnel syndrome causing decreased flexion upon range of motion testing. 6. From February 12, 2021, affording the Veteran, the benefit of the doubt, her left elbow cubital tunnel syndrome results in limitation of flexion manifested by, at worst, flexion to 90 degrees based on flare-ups of left elbow pain. 7. For the entire appeal, the Veteran's left elbow cubital tunnel syndrome has been manifested by, at worst, pain, and limitation of flexion to 90 degrees with flare ups and repetitive use over time, but without symptoms equivalent to limitation of flexion to 55 degrees or less. 8. For the period prior to February 12, 2021, the record is negative for evidence of the Veteran's left elbow cubital tunnel syndrome causing decreased pronation upon range of motion testing. 9. From February 12, 2021, the Veteran's left elbow cubital tunnel syndrome, during flares and with repeated use over time, results in limitation of pronation of the minor arm with motion lost beyond the last quarter of arc and her hand not approaching full pronation. 10. For the entire appeal, the Veteran has not exhibited symptoms which show or more nearly approximate her left hand being fixed in supination or pronation. 11. For the entire appeal, the Veteran has not had persistent edema, incompletely relieved by elevation of the right leg, with or without beginning stasis pigmentation or eczema. 12. For the entire appeal, the Veteran has not had persistent edema, incompletely relieved by elevation of the left leg, with or without beginning stasis pigmentation or eczema. 13. For the entire appeal, the Veteran's leg length discrepancy has, at most, equated to 0.5 centimeters difference between leg lengths. 14. For the entire appeal, the Veteran's hiatal hernia with GERD has not been productive of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal pain, productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for a deviated septum are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial rating in excess of 20 percent for right elbow cubital tunnel syndrome with right wrist carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§3.102, 3.159, 4.1-4.14, 4.124a, Diagnostic Code (DC) 8513. 3. The criteria for an initial rating in excess of 10 percent for left elbow cubital tunnel syndrome with left wrist carpal tunnel syndrome, for the period prior to September 9, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§3.102, 3.159, 4.1-4.14, 4.124a, DC 8516. 4. The criteria for a rating in excess of 20 percent for left elbow cubital tunnel syndrome with left wrist carpal tunnel syndrome, for the period from September 9, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§3.102, 3.159, 4.1-4.14, 4.124a, DC 8513. 5. The criteria for a 20 percent rating effective February 12, 2021, but no earlier, for left elbow cubital tunnel syndrome limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5206. 6. For the period from February 12, 2021, the criteria for a rating in excess of 20 percent for left elbow cubital tunnel syndrome limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5206. 7. The criteria for a 20 percent rating, effective February 12, 2021, but no earlier, for left elbow cubital tunnel syndrome limitation of pronation have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.59, 4.7, 4.71a, DC 5213. 8. For the period from February 12, 2021, the criteria for a rating in excess of 20 percent for left elbow cubital tunnel syndrome limitation of pronation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.59, 4.7, 4.71a, DC 5213. 9. The criteria for a disability rating in excess of 10 percent for right leg varicose veins have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, DC 7120. 10. The criteria for a disability rating in excess of 10 percent for left leg varicose veins have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, DC 7120. 11. The criteria for a compensable evaluation for left leg length discrepancy have not been met. 38U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.71a, DC 5299-5275. 12. The criteria for an evaluation in excess of 10 percent for hiatal hernia with GERD have not been met. 38U.S.C.§§1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.114, DC 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1982 to August 1986 and from October 1988 to May 2009. These matters are on appeal from November 2009, June 2010, and May 2013 rating decisions. In relevant part, in an August 2019 decision, the Board denied the Veteran's claims for initial increased ratings for her service-connected disabilities of bilateral pes planus with left plantar fasciitis, varicose veins of the left and right legs, right wrist carpal tunnel syndrome, right elbow cubital tunnel syndrome, left wrist carpal tunnel syndrome, left leg length discrepancy, and hiatal hernia with GERD. The Board also remanded claims for service connection for a deviated septum, a left ankle disorder, and bilateral hammertoes as well as claims for initial increased ratings for thoracolumbar strain and DDD, degenerative arthritis of the bilateral knees, and degenerative arthritis of the bilateral hips for further development. The Veteran appealed the August 2019 Board denials to the United States Court of Appeals for Veterans Claims (Court). For clarity, she did not appeal the Board's decision to grant separate initial 10 percent disability ratings for varicose veins of the left and right legs prior to September 9, 2016. In August 2020, the Court granted a Joint Motion for Partial Remand (JMPR) by the Veteran's representative and the VA General Counsel's Office. Pursuant to the JMPR, the Board remanded the appeal for further development in January 2021 and June 2021. All the claims remaining on appeal have been returned to the Board. During the pendency of the appeal, the Veteran has received increased and separate ratings, to include most recently in an April 2021 rating decision. As the Veteran has continued her appeals, the increased and separate ratings are reflected in the issues listed below. See AB v. Brown, 6 Vet. App. 35 (1993). That said, within the April 2021 rating decision, the Veteran received separate 20 percent ratings for right and left lower extremity radiculopathies associated with her service-connected lumbar spine. She has yet to express disagreement with these ratings or effective dates. As a result, the Board will not take jurisdiction over these issues at this time. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The presence of a current disability is the cornerstone of any service connection claim. Service connection is not warranted when there is no current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Current means near the time a claim is filed or at any time during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). Disability "refers to the functional impairment of earning capacity." See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that pain can constitute a current disability, even without an underlying diagnosis, if it causes sufficient functional impairment). 1. Entitlement to service connection for a deviated septum. The Veteran seeks service connection for a deviated septum, which she asserts is etiologically related to her service. She asserts suffering from symptomatology of difficulty breathing, a hoarse voice, painful watery eyes, nasal discharge, headaches, and congestion because of her deviated septum. Following consideration of the record, entitlement to service connection is denied due to lack of current disability. The presence of a current disability is the cornerstone of any service connection claim. Service connection is not warranted when there is no current disability. Brammer, 3 Vet. App. 223. Current means near the time a claim is filed or at any time during its pendency. Romanowsky, 26 Vet. App. 289; McClain, 21 Vet. App. 319. Disability "refers to the functional impairment of earning capacity." Saunders, 886 F.3d 1356. Here, service treatment records from 2005, document only a history of a deviated septum but do not indicate on-going residuals. Similarly, records in 2007 and 2009 document only a pertinent surgical history of a deviated septum. Moreover, a January 2009 VA examiner opined against a current diagnosis for a deviated septum because of a lack of pathology. This opinion was rendered following examination, in-person interview, and record review (including consideration of diagnostic testing, which revealed normal nasal cavities). That said, post-service treatment medical records throughout the period on appeal are negative for a current diagnosis of a deviated septum or residuals of said disability. Of note, records throughout the appeal almost entirely indicate the Veteran maintained a normal septum. Acknowledgment is given to an August 2016 record noting an "abnormal septum." This notation was not accompanied by a finding of a deviated septum following diagnostic testing or a general diagnosis of a deviated septum. Instead, the sole diagnosis was acute sinusitis. Given the above, entitlement to service connection is not warranted. In rendering this determination, the Board acknowledges the Veteran believes she has a current disability of a deviated septum that warrants service connection. Diagnosis of a deviated septum is medically complex, and it requires specialized medical education, experience, or training. Jandreau, 492 F.3d at 1377 n.4. The Veteran has not demonstrated that she has any medical training to offer a competent opinion as to whether she has a deviated septum. Of note, such training is critical, as per the record, the Veteran's purported deviated septum symptoms overlap with symptomatology associated with her already service-connected sinusitis, rhinitis, and migraine headache disabilities. That said, the VA examiner who conducted the 2009 VA examination has the medical expertise to make competent diagnoses and found that there is no current disability of a deviated septum. The Board finds that the examiner's opinion is probative evidence. The opinion is also supported by treatment medical records throughout the appeal which are negative for the condition. Absent evidence showing a current disability of, or a functional impairment of earning capacity (caused by symptoms separate from that associated with her already service-connected disabilities) service connection cannot be established. Given the lack of current disability, the Board need not consider the in-service incident or nexus elements of service connection. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. Accordingly, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate DCs identify the various disabilities. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58(1994). Where evidence indicates that the degree of disability increased or decreased during an appeal period following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126(1999). Regarding evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (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."). The Board notes that VA has amended the rating criteria for musculoskeletal system disabilities effective from February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. The DCs pertaining to the elbow and forearm were not changed by the February 7, 2021 amendments. Wrist/Elbow Relevant Rating Criteria DC 8513 pertains to paralysis of all radicular groups. Under this DC, mild incomplete paralysis is rated 20 percent disabling for the major and minor extremities. Moderate incomplete paralysis is rated 30 percent disabling for the major side and 20 percent disabling for the minor side. Severe incomplete paralysis is rated 50 percent disabling for the major side and 40 percent disabling for the minor side. Complete paralysis is 90 percent disabling for the major side and 80 percent disabling for the minor side. DC 8515 pertains to paralysis of the median nerve. Under this DC, mild incomplete paralysis is rated 10 percent disabling for the major and minor extremity. Moderate incomplete paralysis is rated 30 percent disabling on the major side and 40 percent disabling on the minor side. Severe incomplete paralysis of the median nerve is rated 50 percent disabling on the major side and 40 percent disabling on the minor side. Complete paralysis of the median nerve with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to the palm; flexion of wrist weakened; pain with trophic disturbances, warrants a maximum 70 percent evaluation for the major side and a 60 percent evaluation for the minor side. Under DC 8516, disability ratings of 10, 30, and 40 percent are assigned for mild, moderate, and severe incomplete paralysis of the ulnar nerve, respectively, in the major extremity. A disability rating of 60 percent is warranted for complete paralysis of the ulnar nerve in the major extremity, with griffin claw deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. 38 C.F.R. § 4.124a. DC 5205, rates ankylosis of the elbow. Favorable ankylosis at an angle between 90 and 70 degrees is rated at 40 percent for the major arm and 30 percent for the minor arm. Intermediate ankylosis of the elbow at an angle of more than 90 degrees or between 70 and 50 degrees is rated at 50 percent for the major arm and 40 percent for the minor arm; and unfavorable ankylosis of the elbow at an angle of less than 50 degrees or with complete loss of supination or pronation is rated at 60 percent for the major arm and 50 percent for the minor arm. 38 C.F.R. § 4.71a. DC 5206 rates limitation of the flexion of an elbow. A 10 percent disability rating is assigned when flexion is limited to 100 degrees, 20 percent assigned when flexion is limited to 90 degrees, 30 percent when flexion is limited to 70 degrees, 40 percent when flexion is limited to 55 degrees, and a 50 percent rating, the highest possible, when flexion is limited to 45 degrees. DC 5207 rates limitation of extension of an elbow. A 10 rating is assigned when extension is limited to 60 degrees, 20 percent rating is assigned when extension is limited to 75 degrees, 30 percent when extension is limited to 90 degrees, 40 percent when extension is limited to 100 degrees, and 50 percent, the highest possible, when extension is limited to 110 degrees. DC 5208 applies to disabilities where forearm flexion is limited to 100 degrees while the extension is limited to 45 degrees. Under DC 5208, only a 20 percent disability rating is possible. DC 5213 addresses the limitation of pronation and supination. For the non-dominant arm, a rating of 10 percent for limitation of supination to 30 degrees or less. A 20 percent rating is warranted for limitation of pronation with motion lost beyond last quarter of arc, where the hand does not approach full pronation. For limitation of pronation with motion lost beyond middle of arc, a 20 percent rating is warranted. For loss supination and pronation (bone fusion) with the hand fixed near the middle of the arc or moderate pronation, a 20 percent rating is warranted. For loss of supination and pronation (bone fusion) with the hand fixed in full pronation, a 30 percent rating is warranted. For loss of supination and pronation (bone fusion) with the hand fixed in supination or hyperpronation, a 20 percent rating is warranted. 2. Entitlement to an initial disability rating in excess of 20 percent for right elbow cubital tunnel syndrome with right wrist carpal tunnel syndrome (ulnar and median nerves). 3. Entitlement to an initial disability rating in excess of 10 percent for left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome (ulnar nerve) prior to September 9, 2016. 4. Entitlement to rating in excess of 20 percent for left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome (ulnar and median nerves) from September 9, 2016. The Veteran's right elbow and wrist disabilities are assigned a single 20 percent rating from June 1, 2009, pursuant to 38 C.F.R. § 4.124a, DC 8513. Her left elbow and wrist disabilities are in receipt of a single 10 percent rating from June 1, 2009 to September 9, 2016 under DC 8516. Thereafter, they are in receipt of a single 20 percent rating under DC 8513. In this case, the Veteran is right-handed. Therefore, her right upper extremity is considered major, and her left upper extremity is minor for rating purposes. On January 2009 VA examination, the Veteran reported that she had constant pain in her right wrist and a tingly feeling in her fingers. The examiner explained the Veteran's symptomatology of tingling, numbness, pain, and weakness were due to nerve disease. There was abnormal sensation, anesthesia, and paralysis of the affected parts. A physical examination revealed bilateral full ROM. Joint function of the wrist and elbow bilaterally were deemed not to be limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There was normal motor, sensory, and reflex function of the upper extremities. The Veteran reported right wrist functional impairment of being unable to type but denied functional impairment of her right elbow. During a February 2010 VA examination, the Veteran reported weakness, stiffness, and pain in her left upper extremity present for 3 or 4 years previous. The Veteran denied experiencing swelling, heat, redness, giving way, lack of endurance, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation, and dislocation. Flares were reported as occurring once per month and lasting a day with pain 6/10 in severity. The Veteran reported that during flare-ups she experienced functional impairments of pain, limitation of motion of the elbow, and limited ROM of the left arm. She denied weakness. Flares were precipitated by physical activity and "always arch." The examiner indicated the Veteran's nerve disease caused tingling, numbness, and pain. The examiner opined there was no abnormal sensation, anesthesia, weakness, or paralysis of the affected parts. Symptoms were described as occurring constantly. The Veteran denied treatment for her elbow condition but noted functional impairment of it being extremely painful to try to type or even use the left arm in an extended position. As to the left wrist/carpal tunnel syndrome, the Veteran reported the condition being present for 3 years, experiencing tingling and numbness and weakness of fingers of the left hand. She reported symptoms were constant. Treatment was a wrist brace. She reported functional impairment of painful typing or even writing for a prolonged period. Physical examination of the elbow revealed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement bilaterally. Examination of the wrists and hands revealed Tinel's sign present on the left, but negative Phalen's test bilaterally. Neurologic examination showed normal motor and sensory function and normal reflexes of the upper extremities. ROM was full bilaterally in wrists and elbows. Muscle strength, reflex, and sensory examinations were normal. On May 2013 VA peripheral nerve examination, the Veteran was negative for diagnosis and for symptoms attributable to peripheral nerve condition, to include intermittent/chronic pain, paresthesias and/or dysesthesias, and numbness. On May 2014 VA peripheral nerve examination, symptoms attributable to a peripheral nerve condition were moderate left upper extremity paresthesias and/or dysesthesias and numbness. The right upper extremity was negative for report of symptoms. Muscle strength testing, reflex exam, and sensory exam were normal bilaterally. Radial, median, and ulnar nerves were deemed normal. Examination was negative for assistive devices. No functional impact was associated with the Veteran's disability. Impression was left mild ulnar neuropathy. On September 2016 VA nerve examination, the Veteran reported moderate pain and severe numbness bilaterally. The Veteran denied paresthesias and/or dysesthesias bilaterally. Muscle strength testing was normal without muscle atrophy. Reflex and sensory exam were also normal. Median nerve Phalen and Tinel sign testing was positive bilaterally. Bilaterally the median nerves had incomplete paralysis that was moderate in severity. Comparatively, the ulnar nerve had mild incomplete paralysis in the right and moderate incomplete paralysis in the left. Examination was negative for assistive devices. Functional impact of the Veteran's condition was wrist pain aggravated with typing. On September 2016 VA elbow and forearm examination, flare-ups were described as pain increasing and a constant feeling of hitting her "elbow funny bone." During flare she reported being unable "to drive and place her elbow on the windowsill" because of pain. She reported altering her method of steering to accommodate her condition. Functional loss/impairment were cannot use left hand and elbow when driving. ROM bilaterally was full. Pain was present in flexion and extension but did not result in/cause functional loss in the right elbow. Pain was present in flexion, forearm supination, and extension in the left elbow, but was not noted to result in/cause functional loss. There was no change in ROM following repetition and no estimated change in ROM with repetitive use over time or with flare ups. Pain, weakness, fatigability, and incoordination did not significantly limit the Veteran's functional ability with flare-ups. Muscle strength was normal and there was no evidence of ankylosis, atrophy, or assistive devices. Examination was also negative for flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. No functional impact was associated with the Veteran's condition. On February 2021 VA examination, peripheral nerves were negative for right upper extremity symptomatology. The left upper extremity experienced numbness, intermittent pain, and paresthesias and/or dysesthesias which were mild. Muscle strength testing and reflex and sensory exam were normal and there was no muscle atrophy. The median and ulnar nerve were deemed normal in the right upper extremity. The median nerve was deemed normal in the left with only mild incomplete paralysis of the ulnar nerve in the left. Examinations were negative for assistive devices. No functional impact was associated with the Veteran's conditions. On February 2021 elbow/forearm VA examination, the Veteran denied experiencing flare-ups and instead reported constant pain 8/10 in severity. Diagnosis was left elbow cubital tunnel syndrome with painful supination and left elbow cubital tunnel syndrome with painful flexion. ROM was full on the right with no reported pain and no changes in ROM following repetition or with estimated repeated use over time or flare-ups. Left ROM was 110 flexion, 0 extension, 80 supination, and 80 pronation. Pain was present only in left flexion and extension. Passive ROM and ROM following repetition mirrored the above. There was evidence of pain on active motion. Pain and lack of endurance were noted to significantly limit functional ability with repeated use over time and with flare. Left ROM with repeated use over time was estimated as 100 flexion, 0 extension, 70 supination, and 60 pronation. Left ROM with flare-ups was estimated as 90 flexion, 0 extension, 60 supination, and 50 pronation. Examination was negative for assistive devices, atrophy, ankylosis, flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. Functional impact was having to take breaks every 15 minutes due to pain. Treatment medical records do not reflect symptomatology worse than indicated above. Following consideration of the record, the Board finds a rating in excess of 10 percent is not warranted prior to September 9, 2016, for the Veteran's left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome. To achieve the next highest, 20 percent rating, under DC 8516, the record must reflect moderate ulnar symptomatology. Here, records largely indicate the Veteran's impairments were, at worst, mild in severity. In that regard, examination reports throughout this portion of the appeal document normal sensory, reflex, and muscle testing results. Such findings are representative of a condition that is only mild in severity/impairment. Additionally, no examiner has opined that the Veteran suffers from overall moderate incomplete paralysis. Notably, despite the 2014 examiner indicating the presence of moderate paresthesias and/or dysesthesias and numbness, the Veteran's overall condition was nevertheless deemed to be only equivalent to mild incomplete paralysis. This determination was predicated on in-person examination, consideration of lay assertions, diagnostic testing, and review of the record. The determination also corresponds with treatment medical records from the period which are negative for a finding of more than mild symptomatology, let alone, a finding of moderate incomplete paralysis by a clinician. In that regard, physicians throughout this period indicated the presence of neurologic symptomatology, by way of testing, but not moderate impairment. Given the above, the Veteran's symptoms are not equivalent to moderate incomplete paralysis, as such a rating in excess of 10 percent is not warranted prior to September 9, 2016. Furthermore, a rating in excess of 20 percent is not warranted for either the right or the left elbow/wrist disabilities for any portion of the period on appeal under DC 8513. From the outset, the Board acknowledges that the 2016 VA examination contains notations of severe numbness bilaterally, moderate constant pain, and findings of moderate incomplete paralysis of the median nerves bilaterally and of the left ulnar nerve. Such findings are generally suggestive that the Veteran's disabilities warrant a higher rating. However, here, increased ratings are not warranted as the above findings stand in stark contrast to the remaining evidence of record. To that end, although the Veteran reported severe/moderate symptomatology, actual testing on 2016 VA examination revealed normal deep tendon reflexes, sensation, and muscle strength. Such findings are not indicative of any impaired functionality, and thus weigh against a finding of moderate incomplete paralysis. Moreover, contemporaneous treatment medical records, from both prior to, and after, VA examination are negative for findings of neurologic impairment. In that regard, although these records confirm clinicians conducted abbreviated neurologic examinations, they are silent for any discussion/findings of decreased sensation or reflexes. They are also negative for reports of numbness or decreased grip strength (to include any reports of dropping objects). Such negative findings, again, weigh against a moderate rating and more closely align the conditions being, at most, mild in severity. Finally, records for the remainder of the appeal, to include 2021 examination, are negative for abnormal or decreased reflexes, sensation, or muscle strength. These records also do not reference the kind of moderately severe symptomatology found solely on the 2016 VA examination. In considering the totality of the record, the Board finds Veteran's disabilities have remained akin to mild incomplete paralysis as evidenced by the aforementioned treatment medical providers and testing. As a result, increased ratings are not warranted under DC 8513. In rendering this determination, the Board has considered the Veteran's arguments that she should be rated separately for ulnar and median nerve impairment under DC 8515 and DC 8516, instead of having a single rating under DC 8513. In the instant case, separate ratings are not appropriate. First, although the record documents incomplete paralysis of both the median and ulnar nerves, it is negative for a distinction, from any clinician or examiner, in the symptomatology between the two disabilities. Rather symptoms appear to overlap. Importantly, if symptoms of two conditions cannot be sufficiently distinguished, entitlement to the benefit sought is determined based on the overlapping symptoms, which are attributed in whole to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998). The Board finds to award a separate rating would be impermissible pyramiding, as it would compensate the Veteran for the same symptoms twice. See 38 C.F.R. § 4.14. Second, the Veteran's symptomatology has been deemed to be only mild in severity throughout the period on appeal. Therefore, even if separate ratings were provided under DC 8515 and 8516, mild incomplete paralysis under those DCs warrants only 10 percent ratings. Thus, a combined rating would not be higher than 20 percent. See 38 C.F.R. § 4.25. That said, the Board has also considered the application of other codes to allow for separate ratings. The Board finds that a separate compensable rating is warranted for limitation of flexion of the left forearm under DC 5206. February 12, 2021, VA examination establishes that during flare ups the Veteran's forearm flexion is limited to 90 degrees, this warrants a separate rating of 20 percent. A rating in excess of 20 percent is not warranted as the record, to include examinations, are negative for findings of flexion limited to 70 percent even during flare up or with repeated use over time. Additionally, the claims file is negative for evidence of ROM testing documenting decreased flexion prior to February 17, 2021, such as to warrant a compensable rating earlier. To the contrary, ROM prior to this period was determined to be full. The Board also finds that a separate 20 percent rating is warranted from February 12, 2021, for limitation of pronation due to left elbow cubital tunnel syndrome. Per the 2021 VA examiner, during flare and with repetitive use over time, pronation was limited to 50 and supination to 60 degrees. Such findings are commensurate with limitation of motion, of a non-dominate arm, warranting a 20 percent under DC 5213. A higher rating of 30 percent is not warranted as the record lacks evidence of the hand being fixed in supination or hyperpronation. Again, an earlier separate rating is not warranted as the record, to include VA examinations, reflects full ROM prior to February 12, 2021. A compensable rating is not warranted under DC 5207 as extension has remained full throughout the period on appeal. Additionally, a rating under DC 5208 is not for application as forearm flexion has not been limited to 100 degrees while the extension is limited to 45 degrees. Finally, the record is negative for evidence of decreased ROM associated with the right forearm or elbow such as to warrant the award of a separate compensable rating for any portion of the appeal. In summary, entitlement to an initial disability rating in excess of 20 percent for right elbow cubital tunnel syndrome with right wrist carpal tunnel syndrome impairment of the ulnar and median nerves under DC 8513 is denied. Entitlement to an initial disability rating in excess of 10 percent for left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome with impairment of the ulnar nerve, prior to September 9, 2016, under DC 8516, is denied. Entitlement to rating in excess of 20 percent for left wrist carpal tunnel syndrome and left elbow cubital tunnel syndrome with impairment of the ulnar and median nerves from September 9, 2016, under DC 8513, is denied. Entitlement to a separate 20 percent rating, but no higher, for left elbow cubital tunnel syndrome limitation of flexion, under DC 5206, is granted from February 12, 2021, but no earlier. Entitlement to a 20 percent rating, but no higher, for left elbow cubital tunnel syndrome impairment of pronation is granted from February 12, 2021, but no earlier, pursuant to the provisions of 38 C.F.R. § 4.59; DC 5213. Varicose Vein Relevant Rating Criteria DC 7120, a noncompensable evaluation is assigned for asymptomatic palpable or visible varicose veins. A 10 percent evaluation is warranted for intermittent edema of an extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. A 20 percent evaluation is assigned for persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent evaluation is warranted for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent evaluation is assigned for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent evaluation is warranted with the following findings attributable to the effects of varicose veins: massive board-like edema with constant pain at rest. The note associated with DC 7120 indicates that these evaluations are for the involvement of a single extremity. If more than one extremity is involved, each extremity should be evaluated separately and combines (under 38 C.F.R. § 4.25), using the bilateral factor (38 C.F.R. § 4.26), if applicable. 5. Entitlement to an initial disability rating in excess of 10 percent for varicose veins of the left leg. 6. Entitlement to an initial disability rating in excess of 10 percent for varicose veins of the right leg. The Veteran is currently assigned initial individual ratings of 10 percent for her varicose veins of her right and left legs, pursuant to 38 C.F.R. § 4.104, DC 7120. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the disability picture is more consistent with a 10 percent rating throughout the period on appeal. During a January 2009 VA examination, the Veteran reported that her legs were painful after excessive walking and that she was treated with scalar therapy. Examination was negative for symptoms of pain, edema, dark pigmentation of the skin, eczema, or ulceration. Physical examination revealed varicose veins bilaterally with no ulcer, edema, or statis pigmentation. In addition, in a July 2013 statement, the Veteran reported that she had pain after prolonged standing. She noted that her varicose veins were getting worse and caused her to sit for a majority of the day. She also indicated that she elevated her legs and wore support stockings. During a September 2016 VA examination, the VA examiner noted that the Veteran's varicose veins were asymptomatic palpable and visible varicose veins. The examiner noted that the Veteran's symptoms, included aching and fatigue in both legs after prolonged standing, were relieved by compression hosiery. She had no persistent edema, stasis pigmentation, or eczema in either leg. There was no function impairment associated with her condition. Similarly, treatment medical records throughout the appeal do not reflect worse symptomatology. Therefore, the criteria for the next higher rating of 20 percent have not been met or approximated for either leg. 38 C.F.R. § 4.104, DC 7120. The Veteran is competent to report her symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). There is also no reason to doubt the credibility of her statements. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Indeed, the Veteran's statements were considered in the previous award of her 10 percent ratings. However, upon reviewing all of the pertinent evidence of record, the Board finds that entitlement to a disability rating in excess of 10 percent, for the Veteran's bilateral lower extremity varicose veins is not warranted. In this regard the evidence of record does not reveal symptomatology that is severe enough for a rating in excess of 10 percent. Specifically, the evidence does not show that the Veteran experienced persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema; persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration; or, massive board-like edema with constant pain at rest. Thus, a rating in excess of 10 percent for the Veteran's right or left lower extremity varicose veins is not warranted. Leg Length Discrepancy Relevant Rating Criteria Under DC 5275, shortening of the bones of the lower extremity that measure 1 1/4 to 2 inches (3.2 cms. to 5.1 cms.) warrants a 10 percent evaluation. Shortening of the bones of the lower extremity that measure 2 to 2 1/2 inches (5.1 cms. to 6.4 cms.) warrants a 20 percent evaluation. Shortening of the bones of the lower extremity that measure 2 1/2 to 3 inches (6.4 cms. to 7.6 cms.) warrants a 30 percent evaluation. Shortening of the bones of the lower extremity that measure 3 to 3 1/2 inches (7.6 cms. to 8.9 cms.) warrants a 40 percent evaluation. Shortening of the bones of the lower extremity that measure 3 1/2 to 4 inches (8.9 cms. to 10.2 cms.) warrants 50 percent evaluation. Shortening of the bones of the lower extremity that measure over 4 inches (10.2 cms) warrants a 60 percent evaluation. The amendments did not affect this Diagnostic Code. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). The note associated with DC 5275 indicates that both lower extremities should be measured from the anterior superior spine of the ilium to the internal malleolus of the tibia. The Note also states that this DC should not be combined with other ratings for fracture or faulty union in the same extremity. 7. Entitlement to an initial compensable disability rating for leg length discrepancy. The Veteran is currently assigned a noncompensable evaluation for her left leg length discrepancy, pursuant to 38 C.F.R. § 4.71a, DC 5299-5275. Hyphenated diagnostic codes, including a DC ending in the digits "99," are used when there is no specifically applicable DC and the disability is rated by analogy. 38 C.F.R. § 4.27. Here, the Veteran's left leg length discrepancy is rated by analogy using the criteria for shortening of bones of the lower extremity under DC 5275. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a compensable evaluation for her left leg length discrepancy at any point during the pendency of the appeal. Throughout the appeal period, the evidence did not show that the Veteran's left leg was shortened by between 1 1/4 to 2 inches (3.2 cms. to 5.1 cms.). In fact, a January 2009 VA examiner reported that the Veteran's leg length from the anterior superior iliac spine to the medial malleolus was 90 centimeters on the right and 90.5 centimeters on the left, which equates to 0.5 centimeters discrepancy between the Veteran's leg lengths. Thereafter September 2016 and April 2021 knee/leg VA examinations were negative for a finding of a current leg discrepancy. Treatment medical records do not document symptomatology greater than reported on examination. Thus, after consideration of all the evidence of record, the Board finds that a compensable evaluation is not warranted for the Veteran's left leg length discrepancy. See 38 C.F.R. § 4.71a, DC 5275. Hiatal Hernia/GERD Relevant Rating Criteria Under DC 7346, a 10 percent disability rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal pain, productive of considerable impairment of health. A 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 8. Entitlement to an evaluation in excess of 10 percent for hiatal hernia with GERD. The Veteran is currently assigned a 10 percent evaluation for hiatal hernia with GERD throughout the appeal period, pursuant to 38 C.F.R. § 4.114, DC 7346. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for hiatal hernia with GERD at any point during the pendency of the appeal. Throughout the entire appeal period, the evidence does not show that the Veteran had persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal pain, productive of considerable impairment of health. In that regard, on February 2010 VA examination, the Veteran reported that she had a painful burning in her stomach, as well as constant heartburn, epigastric pain, scapular pain, and reflux and regurgitation of her stomach contents. However, she denied dysphagia, arm pain, hematemesis, passing of black tarry stools, and nausea and vomiting. She also denied experiencing any overall functional impairment from her hiatal hernia with GERD. Moreover, treatment medical records throughout the appeal are negative for symptomatology warranting a 30 percent rating. Correspondingly, the Board also finds that the record does not demonstrate that the Veteran's hiatal hernia with GERD is consistent with a 60 percent rating during the appeal period. There is no evidence of vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Based on the aforementioned, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 10 percent for a GERD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 9. Entitlement to service connection for a left ankle disability. Remand is appropriate to obtain VA opinions addressing secondary service connection. The Veteran is now in receipt of service-connection for a right ankle disability. In addition, she is service-connected for an array of low back and lower extremity disabilities of the feet, knees/legs, and hips. The record is negative for an opinion addressing whether these service-connected disabilities individually or combined caused or aggravated her claimed left ankle disability. Such an opinion is warranted as these back/lower extremity conditions are known to impair/alter the Veteran's mobility/movements which in turn could impact her left ankle. Furthermore, an opinion is warranted as service medical records reflect the Veteran's knee, ankle, and spine symptomatology improved following being prescribed the same course of custom orthotics, personal training, and chiropractic intervention. Given the above, a VA examination opinion must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 10. Entitlement to service connection for bilateral hammertoes. 11. Entitlement to an initial compensable disability rating for bilateral pes planus with left plantar fasciitis prior to February 23, 2010; in excess of 10 percent from February 23, 2010, to September 9, 2016; and in excess of 30 percent since September 9, 2016. Remand is also required to clarify the nature and etiology of the Veteran's claimed bilateral hammertoe disabilities. In brief, the majority of VA examinations throughout the appeal appear to be negative for the condition. However, February 2010 VA examination and treatment records thereafter repeatedly document the condition following in-person examination. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). These conflicting findings leave the record unclear as to current disability. VA adjudicators are not free to simply ignore or disregard the medical conclusions of a VA or private physician and then substitute their own judgment on a medical matter. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). A clarifying opinion and examination are warranted to address this discrepancy. In addition, no opinion has been obtained as to the nature and etiology of any diagnosed hammertoe disability, to include secondary service connection. Such an opinion must be obtained. As stated, the Veteran is being afforded a new VA examination to address her toe disabilities. The information obtained during examination might prove relevant to her claims for increase rating for bilateral pes planus and plantar fasciitis. As a result, the claims are remanded as inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 12. Entitlement to an initial disability in excess of 10 percent for left knee degenerative arthritis. 13. Entitlement to an initial disability rating in excess of 10 percent for right knee degenerative arthritis. 14. Entitlement to an initial compensable disability rating for left hip degenerative arthritis prior to September 9, 2016; in excess of 10 percent thereafter. 15. Entitlement to an initial disability rating in excess of 10 percent for right hip degenerative arthritis. 16. Entitlement to an initial compensable rating for left hip arthritis limitation of extension. 17. Entitlement to an initial compensable rating for right hip arthritis limitation of extension. 18. Entitlement to an initial compensable rating for left hip arthritis limitation of adduction/abduction. 19. Entitlement to an initial compensable rating right hip arthritis limitation of adduction/abduction. 20. Entitlement to an initial disability rating in excess of 10 percent for thoracolumbar strain, DDD with segmental dysfunction of the lumbosacral, thoracic, and sacroiliac regions prior to July 24, 2009; in excess of 20 percent thereafter. In April 2021, a VA examiner conducted examinations to address the current severity of the Veteran's disabilities of the hips, knees, and low back. The examiner was also tasked with providing retrospective opinions as to the degrees of ROM on active, passive, weightbearing, and non-weightbearing at the time of previous February 2009 and September 2016 VA examinations. In response, the 2021 examiner indicated being unable to provide said retrospective opinions without resorting to mere speculation. Problematically, no further rationale was provided. When an examiner determines that an opinion cannot be provided without resorting to mere speculation, an examiner must explain why it is not feasible to provide a medical opinion, stating what, if any, additional evidence would permit such an opinion to be made. See Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). An examiner should also indicate whether they have exhausted the limits of current medical knowledge in providing an answer to that particular question(s). As this information was not provided by the 2021 examiner for any of the Veteran's hip, knee, or spine disabilities, a remand for addendum opinions is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the etiology of the Veteran's left ankle disability. If it is determined that an additional physical examination of the Veteran is required to offer this opinion, such an examination should be scheduled. After reviewing the claims file and considering the Veteran's contentions, the examiner should opine whether it is at least as likely as not (that is, a 50 percent or greater probability) that the Veteran's left ankle disability: (a.) is caused by her service-connected disabilities of the feet, right ankle, hips, legs, lumbar spine, and/or sciatic nerve, either individually or in combination. (b.) underwent any incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected disabilities of the feet, right ankle, hips, legs, lumbar spine, and/or sciatic nerve, either individually or in combination. 2. Obtain a VA examination and opinion as to the nature and etiology of the Veteran's claimed bilateral hammertoes. Following consideration of the record and examination of the Veteran's feet. The examiner must: (a.) Identify any current hammertoe disabilities present during the appeal. Note: previous VA examinations, except February 2010 examination, were negative for the condition, however treatment medical records note repeat diagnosis for the condition. These positive and negative findings were made following in-person inspection. These conflicting findings must be addressed. After reviewing the claims file and considering the Veteran's contentions, the examiner should opine whether it is at least as likely as not (that is, a 50 percent or greater probability) that any diagnosed hammertoe disability: (b.) is caused by or incurred in service. (c.) is caused by her service-connected disabilities of the feet, either individually or in combination. (d.) underwent any incremental increase in disability, regardless of its permanence, due to the Veteran's the service-connected disabilities of the feet either individually or in combination. Note: The examiner must address the significance of the Veteran's back/lower extremity conditions impairing/altering her mobility/movements and in turn impacting her left ankle. Note: the examiner must address the significance of service medical records indicating the Veteran's knee, ankle, and spine symptomatology, including pain, improved following being prescribed a shared course of treatment, which relied upon custom orthotics, personal training, and chiropractic intervention. Such is suggestive of the conditions being intertwined. 3. Forward the claims file to appropriate VA examiner(s) to obtain a retrospective opinion as to the severity of the Veteran's hip conditions. If it determined that an additional physical examination of the Veteran is required to offer this opinion, such an examination should be scheduled. (a.) The examiner is asked to provide a retrospective opinion to estimate the degree of range of motion for passive motion, weight-bearing, and non-weight-bearing at the time of the January 2009, February 2010, and September 2016 VA hip examinations. (b.) The examiner is asked to estimate, if possible, the additional impairment (in terms of range of motion) due to pain based on the evidence of record and the Veteran's statements for the 2009, 2010, and 2016 VA examinations. (c.) The examiner should also address the Veteran's reports of flare-ups during the 2009, 2010, and 2016 examinations. (d.) The examiner is asked to describe whether pain significantly limited functional ability during flares, and indicate range of motion during flares (the examiner must glean information regarding the flares' severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources). (e.) A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 4. Forward the claims file to appropriate VA examiner(s) to obtain retrospective opinions as to the severity of the Veteran's knee conditions. If it determined that an additional physical examination of the Veteran is required to offer this opinion, such an examination should be scheduled. (a.) The examiner is asked to provide a retrospective opinion to estimate the degree of range of motion for passive motion, weight-bearing, and non-weight-bearing at the time of the January 2009, February 2010, and September 2016 VA knee examinations. (b.) The examiner is asked to estimate, if possible, the additional impairment (in terms of range of motion) due to pain based on the evidence of record and the Veteran's statements for the 2009, 2010, and 2016 VA examinations. (c.) The examiner should also address the Veteran's reports of flare-ups during the 2009, 2010, and 2016 examinations. (d.) The examiner is asked to describe whether pain significantly limited functional ability during flares, and indicate range of motion during flares (the examiner must glean information regarding the flares' severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources). (e.) A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 5. Forward the claims file to appropriate VA examiner(s) to obtain retrospective opinions as to the severity of the Veteran's spine condition. If it determined that an additional physical examination of the Veteran is required to offer this opinion, such an examination should be scheduled. (a.) The examiner is asked to provide a retrospective opinion to estimate the degree of range of motion for passive motion, weight-bearing, and non-weight-bearing at the time of the February 2010 and September 2016 VA spine examinations. (b.) The examiner is asked to estimate, if possible, the additional impairment (in terms of range of motion) due to pain based on the evidence of record and the Veteran's statements for the 2010 and 2016 VA examinations. (c.) The examiner should also address the Veteran's reports of flare-ups during the 2010 and 2016 examinations. (d.) The examiner is asked to describe whether pain significantly limited functional ability during flares, and indicate range of motion during flares (the examiner must glean information regarding the flares' severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources). (e.) A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. Marissa Caylor Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Burroughs, 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.