Citation Nr: 21071500 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-01 926 DATE: November 30, 2021 ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected chronic epididymo-orchitis, is denied. Entitlement to a compensable rating for chronic epididymo-orchitis is denied. Entitlement to a rating in excess of 10 percent for a left knee disability is denied. REMANDED Entitlement to service connection for a respiratory disorder is remanded. Entitlement to service connection for headaches, to include as secondary to a respiratory disability or service-connected cervical spine disability, is remanded. Entitlement to service connection for a bilateral foot disorder, claimed as plantar fasciitis, is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to rating in excess of 10 percent for residuals of a fractured vertebra (a cervical spine disability) is remanded. FINDINGS OF FACT 1. The evidence is against finding that the Veteran's hemorrhoids began during active service, or is otherwise related to an in-service event, injury, or disease. 2. The evidence is against finding that the Veteran's ED is secondary to service-connected chronic epididymo-orchitis, or is otherwise related to an in-service event, injury, or disease. 3. During the appeal period, the Veteran's chronic epididymo-orchitis has been manifested by testicular pain and discomfort; the disability did not result in tubercular infections, renal dysfunction, or the need for yearly or more frequent hospitalizations, long-term drug therapy or intermittent intensive management. 4. During the appeal period, the Veteran's left knee disability was manifested by, at worst, flexion limited to 90 degrees with normal extension. CONCLUSIONS OF LAW 1. The criteria for service connection for hemorrhoids have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for ED have not been satisfied. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for a compensable rating for chronic epididymo-orchitis have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7525. 4. The criteria for a rating in excess of 10 percent for a service-connected left knee disability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1978 to March 1999, to include service in Southwest Asia. This matter is before the Board of Veterans' Appeals (Board) from ratings decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The issues were previously before the Board in January 2019, along with the additional claim of service connection for an acquired psychiatric disorder. In July 2020, the Veteran's service connection claim for an acquired psychiatric disorder was granted and is no longer on appeal. The remaining issues return for further appellate review. The Veteran testified before the undersigned Veterans Law Judge during in March 2017. A transcript is of the hearing is of record. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 1. Service connection for hemorrhoids. The Veteran seeks service connection for hemorrhoids that he asserts began in service. During his March 2017 Board hearing, the Veteran reported that he had been treated, by observation only, for hemorrhoids during service, and that he has experienced such since that time, with continued observation. He reported that his private treatment records dated in the years immediately after service had been destroyed, and that he had been observed for hemorrhoids, and that his physicians still observe his hemorrhoids. His service treatment records (STRs) dated in March 1987 indicate that the Veteran did have external hemorrhoids at that time. On his November 1998 Report of Medical History, the Veteran reported a history of hemorrhoids, and the examiner, in a contemporaneous Report of Medical Examination, noted recurrent hemorrhoids. Post-service, a hemorrhoid disability is not shown until September 2012 with the Veteran complaining of rectal bleeding due to a history of hemorrhoids. A May 2014 private treatment record notes an internal hemorrhoid. The Veteran presented for a VA examination in January 2015, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner opined that it was less likely than not that the Veteran had a hemorrhoid disability that was related to service. In support of this conclusion, the examiner explained that there was no current objective evidence of a current hemorrhoid condition. While the Veteran, the examiner continued, reported a history of hemorrhoids during service and that such came and went, private treatment for a colonoscopy and biopsy of a mass were both negative for treatment for hemorrhoids. As the Board noted in its previous remand, however, internal hemorrhoids were again observed upon private examination in March 2016. Thus, while the January 2015 VA examiner did not find evidence of a current hemorrhoid condition, the Veteran had clearly been diagnosed with such during private treatment. As such, a new VA examination to determine the etiology of any hemorrhoids over the course of the appeal was provided in January 2020. While the January 2020 VA examiner diagnosed internal hemorrhoids, he opined in the negative regarding their etiology to the Veteran's military service. The examiner explained that the Veteran was diagnosed in service with thrombosed external hemorrhoids, rather than his current internal hemorrhoids, which resolved at the time without surgical intervention. The Board finds this opinion highly probative as it was made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. There is also no medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. 2. Service connection for ED. The Veteran, during his March 2017 Board hearing, asserted that he has ED was secondary to his service-connected chronic epididymo-orchitis. He reported that while he underwent a vasectomy during service in 1996, giving rise to the epididymo-orchitis, his erectile dysfunction did not begin immediately after the procedure. The Veteran essentially reported the same upon VA examination in January 2015 that he underwent an in-service vasectomy and developed orchitis as a result, as well as cysts, and reported that he has since developed erectile dysfunction. Indeed, his STRs note no complaints, diagnosis, or treatment related to ED. On VA examination in January 2015, while the examiner noted the use of prescription medication known to treat ED, the examiner did not diagnose the Veteran with ED and noted that private treatment records were silent for a diagnosis of such. Private treatment records dated in 2016, however, indicate that the Veteran was diagnosed with ED, including a March 2016 record that notes prescription medication to treat ED "for prostate surgery." Thus, as the Board noted in its prior remand, while the VA examiner did not find evidence of ED, the Veteran had been diagnosed with such during private treatment, and a new VA examination was afforded in January 2020 to determine the etiology of any ED over the course of the appeal. The examiner acknowledged the Veteran's diagnosis of ED but opined, in both the January 2020 examination report as well as in a June 2020 addendum, that it was neither caused nor aggravated by his epididymo-orchitis. In support of this conclusion, the examiner explained that 1) epididymo-orchitis does not cause or aggravate ED, and 2) the Veteran's medical treatment records actually indicate that he developed ED as a result of a radical prostatectomy. The Board finds the above opinion highly probative as they were made by a medical professional with consideration of the specific facts in this case and after examination of the Veteran. The opinion is also supported by other evidence of record, including no evidence of ED during service or until many years after service, following a prostatectomy. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinion. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. As to both service connection claims denied above, the Board has considered the Veteran's statements, to include his assertions that his hemorrhoids and ED are related to service or a service-connected disability. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., hemorrhoid pain and bleeding, erectile issues; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (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."). 3. A compensable rating for chronic epididymo-orchitis. The Veteran is service connected for chronic epididymo-orchitis which is currently rated as noncompensable under Diagnostic Code 7525. Epididymitis is inflammation of the epididymis, which is the elongated cordlike structure along the posterior border of the testis. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 632 (32nd Ed. 2012). Orchitis is an inflammation of a testis. Id. at 1333. Diagnostic Code 7525 provides that epididymo-orchitis should be rated as a urinary tract infection. 38 C.F.R. § 4.115a provides that a 10 percent rating should be assigned for urinary tract infections with long-term drug therapy, one to two hospitalizations per year, and/or requiring intermittent intensive management, and that a 30 percent rating should be assigned for recurrent symptomatic infection requiring drainage, frequent hospitalization (greater than two times per year), and/or requiring continuous intensive management. No higher ratings are provided. If urinary tract infections result in poor renal function, the disability should be rated as renal dysfunction. Diagnostic Code 7525 also states that, for tubercular infections, rating should be rated according to 38 C.F.R. § 4.88b (infectious diseases, immune disorders, and nutritional deficiencies) or 38 C.F.R. § 4.89 (ratings for inactive non-pulmonary tuberculosis in effect on August 19, 1968), whichever is appropriate. See 38 C.F.R. § 4.115b, Diagnostic Code 7525. The Veteran was afforded a VA examination for his increased rating claim in In a January 2015 VA examination, the Veteran reported that he had vasectomy in service and that he developed chronic epididymo-orchitis as a result which is treated with anti-inflammatories. The examination report notes that the Veteran did not have any history of recurrent episodes of a urinary tract infection, a voiding dysfunction, renal dysfunction, or ED. Physical examination of the genitalia was normal, and the Veteran did not have any other pertinent physical findings, complications, or conditions. Pursuant to the Board's remand, an additional examination was afforded in January 2020. The Veteran reported symptoms of constant testicular pain, aggravated by prolonged sitting. There again was no voiding or renal dysfunction, and the veteran has not required continuous medication. While ED was noted, as the Board has explained above the evidence is against a finding that it is related to his epididymo-orchitis, but instead, a nonservice-connected prostatectomy. The examination report is negative for (and the Veteran did not report), urinary tract infections, long-term drug therapy, hospitalizations, or infection related to his epididymo-orchitis. The Veteran's medical treatment records are not in significant conflict with the findings upon VA examination. Based on the above, a compensable rating for the Veteran's chronic epididymo-orchitis is not warranted. Throughout the appeal period, the evidence does not reflect that the Veteran's epididymo-orchitis caused urinary tract infections. Furthermore, VA examinations and treatment records for this period are devoid of any indication he was prescribed long-term drug therapy, experienced 1 to 2 (or more) hospitalizations per year, or underwent intermittent intensive management to treat his testicle disability. Furthermore, the Veteran has not been diagnosed with a tubercular infection, nor an infectious disease, immune disorder, or nutritional deficiency. Thus 38 C.F.R. § 4.88b and § 4.89 are not applicable. As the preponderance of the evidence reflects that the Veteran's symptomatology does not rise to the level of impairment contemplated by a 10 percent rating, a noncompensable evaluation is appropriate. The appeal is denied. 4. A rating in excess of 10 percent for a left knee disability. The Veteran contends that he is entitled to a higher rating for his service-connected left knee disability. The Board notes that while the Veteran's left knee rating had been noncompensable since May 1999, subsequent to the Board's previous remand the RO awarded an increased, 10 percent rating effective the date of his increased rating claim on March 19, 2014 in a July 2020 rating decision. As higher ratings are available for the knee, the claim has remained on appeal. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can be assigned when a knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 94 (32nd ed. 2012). In this case the evidence does not reflect, and the Veteran does not allege, that he has a meniscal condition, tibia or fibula impairment, genu recurvatum, or ankylosis of the knee. See Chavis v. McDonough, 34 Vet. App. 1, 20 (2021). As such, those diagnostic codes are not for application. Ratings can be also assigned for knee instability or subluxation under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). "Slight," as relevant to a physical condition, is defined as "small of its kind or in amount." Merriam-Webster's Dictionary, https://www.merriam-webster.com/dictionary (last visited September 24, 2021). It is similar to "mild," which is defined as "not severe" or temperate" with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." Id. "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary, https://www.merriam-webster.com/dictionary (last visited September 24, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id., Note (2). Turning to the evidence, range of motion (ROM) testing was performed during VA examinations in January 2015 and January 2020 and was at worst 90 degrees of flexion and 0 degrees of extension. At these examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiners, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. During each examination, the Veteran denied flare-ups, and both examiners indicated that that pain, weakness, fatigability, or incoordination did not significantly limit functional ability of the left knee with repeated use over a period of time. The Veteran's treatment records do not show greater limitation of motion than the examination findings. Given the above, a higher rating is not warranted based on limitation of motion absent flexion limited to at least 30 degrees or extension limited to at least 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Regarding instability and subluxation of the knee, the Board notes that there are specific medical tests that are designed to reveal instability of the joints. These tests were administered by medical professionals in this case during each of the above VA knee examinations during the appeal, and testing revealed no instability. Given the tests performed are generally recognized in the medical community, the results are afforded high probative value. In addition, the Veteran has not contended that his left knee disability is manifested by instability. Id.; see also English v. Wilkie, 30 Vet. App. 347, 349 (2018) (holding that Diagnostic Code 5257 does not require objective medical evidence of instability). The objective medical evidence of no left knee instability, in combination with the Veteran's repeated lack of complaint of such, is consistent with the current lack of a separate rating for left knee instability during the appeal. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a rating for recurrent subluxation or instability is not warranted because the evidence is against a finding of persistent instability. Notably, diagnostic testing for stability at the above examinations did not reveal any instability, which is strong evidence against a finding of persistent instability. Put another way, when multiple medical tests for instability fail to detect instability, constant instability is not present. A compensable rating is not warranted for patellar instability either. The evidence does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon), and, as discussed above, the evidence is against a finding of recurrent instability. Moreover, the record does not contain a diagnosed condition involving the patellofemoral complex; that is, the quadriceps tendon, the patella, or the patellar tendon. The Veteran, as a lay person, is not competent to provide the required diagnosis. Based on the foregoing, the Veteran's claim for an increased disability rating for his service-connected left knee disability must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71a. The Board is sympathetic to the Veteran's lay statements that his disability is worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disability have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disability is evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND While the Board regrets further delay, the Veteran's remaining claims must be remanded for additional development. 1. Service connection for a respiratory disability. 2. Service connection for headaches. The Board previously remanded the Veteran's claim in January 2019 for a new VA examination to determine whether the Veteran has respiratory disability, originally claimed as sinusitis, that is related to in-service sinus problems. Of note, during his hearing before the undersigned, the Veteran asserted that he first noticed problems with his sinuses beginning in the first couple of years of service, and that he had nose bleeds, treated with medication. He reported that he believed that a confirmed diagnosis of sinusitis was noted in his service treatment records but did not recall if he noted such on his service separation examination. He reported that he continued self-treatment for the same, with medications, and blew his nose a lot after separation from service. In a March 2017 statement, the Veteran's spouse reported that the Veteran often wakes up with a bloody nose and sinus problems, that he constantly blows his nose, and that his nose bleeds take a long time to stop. She asserted that the Veteran has sinus drainage, and his sinus condition is impacted by the weather. The Veteran's STRs dated in November 1978 do indicate that he presented with a cough, fever, and runny nose. Later that month, he had a nose bleed and was diagnosed with an upper respiratory infection. Subsequent STRs dated through October 1993 note a sinus headache, a sore throat, a cold, sinus drainage, acute pharyngitis, hay fever, and an upper respiratory infection. On his November 1998 Report of Medical Examination at separation, the examiner noted a history of sinus/muscular headaches. On VA examination in January 2015, while the Veteran reported constant drainage of the sinuses and that he had been diagnosed with sinusitis during service. the examiner determined that there was no current objective evidence of sinusitis. Thus, while the VA examiner, in January 2015, did not find evidence of current sinusitis, it remained unclear if the Veteran's symptoms, reported as nosebleeds and constant sinus drainage, are manifestations of a disorder other than sinusitis. As such, in its previous remand, the Board ordered the RO to afford the Veteran a new VA examination to determine the precise nature and the etiology of any respiratory disorder, including to specifically determine if the Veteran has a respiratory disorder other than sinusitis. While an additional examination was afforded in January 2020, it continues to remain unclear as to whether the Veteran's complaints re manifestations of a disorder other than sinusitis, with the examiner simply noting that there are no STRs nor post separation medical records consistent with the diagnosis of chronic sinusitis. As such, the claim must again be remanded for an addendum opinion. Additionally, as the evidence of record suggest that the Veteran's headache complaints may be related to a respiratory disability on a secondary basis, the Veteran's headache claim is intertwined with the respiratory claim and must also be remanded. The Board notes that, while a separate headache examination was also afforded in January 2020, the examiner provided no diagnosis despite noting the Veteran's reported history and symptoms, noting only that the requested opinion was "moot" as there are not STRs or post separation medical record indicating a chronic headache condition. As noted in the Board's last remand, STRs dated in January 1980 indicate that the Veteran had a sinus headache. A December 1989 Report of Medical History indicates that the Veteran reported history of a head injury, with an illegible note by the examiner. In October 1990, the Veteran reported that he got headaches when he did not wear his glasses and reported a history of a childhood motor vehicle accident at age eight, with head trauma. In September 1993, the Veteran reported eye pain radiating to the left temporal area, and in October 1993, he reported a severe headache, with dizziness and kidney pain, and a history of headaches. In January 1997, coincident to a motor vehicle accident, the Veteran complained of a headache, and on his November 1998 Report of Medical History and contemporaneous Report of Medical Examination, the Veteran reported a history of frequent or severe headaches and the examiner noted sinus/muscular headaches. While on remand, the examiner's opinion should also address whether the Veteran's headaches are a residual of his already-service-connected cervical spine disability. 3. Service connection for a bilateral foot disability. The Veteran seeks service connection for a foot disability, initially claimed as one for plantar fasciitis. Similar to the above respiratory disability claim, a January 2015 VA examiner found no current objective evidence of plantar fasciitis. However, the Veteran reported pain in his heels and across the arches of his feet since service and, as noted in the Board's previous remand, his STRs reflect treatment with arch supports, muscle bruise, calcification in the achilles tendon, pes cavus, and plantar fasciitis. As it remained unclear if the Veteran's symptoms of foot pain are manifestations of a disability other than plantar fasciitis, the claim was remanded for an additional examination. However, the January 2020 VA examiner provided a negative opinion based, in part, on the absence of plantar fasciitis, without addressing whether any other bilateral foot disability existed during the appeal. The Board notes that pain alone that results in functional impairment may be considered a disability for VA compensation purposes, and the examination did note that the Veteran's foot pain resulted in difficulty walking long distances. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As such, the claim must again be remanded for an addendum opinion. 4. Service connection for a low back disability. During his March 2017 Board hearing, the Veteran asserted that he had low back pain during service, treated with pain medication. His STRs indicate that the Veteran complained of low back pain in December 1987. In March 1990, he complained of low back pain after physical training that morning and was diagnosed with musculoskeletal spasm, and an additional March 1990 treatment records show a diagnosis of mechanical low back pain from injury. On his November 1998 Report of Medical History, he reported recurrent low back pain, and the examiner, in a contemporaneous Report of Medical Examination, noted mechanical low back pain. Post-service, and despite the Veteran reporting continued back problems since service with private treatment, a low back disability is not shown until a September 2012 diagnosis of lumbago after a complaint of low back pain. At a VA examination in January 2015, the Veteran reported a history of low back pain since service, without an injury or accident reported, and complained of pain and stiffness that came and went. The examiner opined that it was less likely than not that the Veteran had a low back disability that was related to service, as there was no current diagnosis of a low back disability. As the Board noted in its previous remand, however, the Veteran sought private treatment for low back pain in February 2015 and was again diagnosed with lumbago. A March 2015 X-ray examination revealed mild degenerative endplates sclerosis, spurring and facet arthrosis, and exaggerated lumbar lordosis. In June 2016, during private treatment, the Veteran was diagnosed with lower multilevel degenerative disc disease. Thus, while the January 2015 VA examiner did not find evidence of a current low back disability, the Veteran has clearly been diagnosed with such during private treatment. As such, a new VA examination to determine the etiology of any low back disability over the course of the appeal was provided in January 2020. While the January 2020 VA examiner diagnosed the Veteran with lumbar disc disease and spondylosis, he opined in the negative regarding their etiology to the Veteran's military service, explaining, in part, that "there are no STRs indicating a chronic lumbar condition." As the Board has noted above, however, the Veteran's STRs contain multiple reports of low back pain. The examiner did not explain with any rationale why these reports of pain and their treatment did not represent a chronic lumbar condition. As such, the claim must again be remanded for an addendum opinion. 5. A rating in excess of 10 percent for residuals of a fractured vertebra. The Veteran seeks a rating in excess of 10 percent for residuals of an in-service cervical spine injury. During the appeal period the Veteran underwent VA examinations in January 2015 and, pursuant to the Board's previous remand, January 2020. While range of motion testing in January 2015 showed forward flexion to 45 degrees and a combined range of motion no less than 340 degrees, range of motion was significantly more reduced in January 2020, with forward flexion noted by the examiner to be only 10 degrees. The examiner noted in the "Remarks" section of the examination report, in explaining this marked reduction in flexion, that "given that the patient now has a NSC condition of disc disease and spondylosis the ROMs are representative of the NSC condition and not the S/C mildly displaced C5 fracture." The Board interprets this statement to suggest that the ROM findings during the January 2020 cervical spine examination are not indicative of the actual functional loss in the Veteran's cervical spine, with the examiner somehow incorporating the Veteran's nonservice-connected lumbar spine disability into the cervical spine findings. While the RO attempted to clarify the examiner's findings in June 2020, the examiner did not appear to understand the question posed, and no further development was accomplished prior to the issuance of the most recent Supplemental Statement of the Case that continued the denial of the Veteran's claim. Unfortunately, the Board requires accurate ROM testing in the Veteran's cervical spine in order to properly adjudicate his increased rating claim. As such, the claim must be remanded for a new VA examination of the cervical spine. The matters are therefore REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his respiratory, headache, bilateral foot, low back, and cervical spine claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner, preferably one other than the examiner who provided the January 2020 opinion, to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current respiratory disability, to include sinusitis, onset during service or is otherwise related to an in-service injury, event, or disease. (a) The examiner must specifically determine if the Veteran has a respiratory disorder, considering his symptoms of nosebleeds and constant sinus drainage. (b) The examiner must opine whether it is at least as likely as not that the Veteran's respiratory disorder, if any, is related to an in-service injury, event, or disease, specifically, his in-service cough, nose bleeds, sore throats, congestion, drainage, colds, upper respiratory infections, pharyngitis, and hay fever. The need for an additional examination is left to the discretion of the examiner. A complete rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, the claims file should be sent to an appropriate examiner, preferably one other than the examiner who provided the January 2020 opinion, to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current headache disability onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether any current headache disability is at least as likely as not (a) caused, or (b) aggravated (i.e., worsened beyond natural progression) by any respiratory disability, to include sinusitis, or the Veteran's service-connected cervical spine disability. In offering the above opinions, the examiner is asked to specifically consider whether, if headaches are not diagnosed on a current examination, are those reported by the Veteran and his spouse during the current appellant period related to an in-service injury, event, or disease, specifically, his in-service headaches, reported eye pain radiating to the left temporal area, severe headache, with dizziness and kidney pain, and sinus/muscular headache. The need for an additional examination is left to the discretion of the examiner. A complete rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, the claims file should be sent to an appropriate examiner, preferably one other than the examiner who provided the January 2020 opinion, to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current foot disability onset during service or is otherwise related to an in-service injury, event, or disease. (a) The examiner must specifically determine if the Veteran has a bilateral foot disability, considering his symptoms of pain in his heels and across the arches of his feet, and whether the foot pain of which he has complained results in functional impairment such that the foot pain may be considered a disability for VA compensation purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). (b) The examiner must opine whether it is at least as likely as not that the Veteran's bilateral foot disability, if any, is related to an in-service injury, event, or disease, specifically, his in-service treatment with arch supports, muscle bruise, calcification in the achilles tendon, pes cavus, and plantar fasciitis. The need for an examination is left to the discretion of the examiner. A complete rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 5. After records development is completed, the claims file should be sent to an appropriate examiner, preferably one other than the examiner who provided the January 2020 opinion, to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current low back disability onset during service or is otherwise related to an in-service injury, event, or disease, specifically, his in-service low back pain, musculoskeletal spasm, and mechanical low back pain. The need for an examination is left to the discretion of the examiner. A complete rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 6. After records development is completed, schedule the Veteran for a VA neck examination to determine the current symptoms, level of severity, and functional impairment associated with his service-connected cervical spine disability. The claims file should be reviewed by the examiner. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and after repetitive use over time. If it is not possible to specifically estimate range of motion during flare-up and after repetitive use over time without speculation, the examiner is asked to opine as to whether, during these conditions, forward flexion of the cervical spine would be limited to 30 degrees or less, or the combined range of motion of the cervical spine would be 170 degrees or less. If this cannot be accomplished without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and explain why that is the case. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.