Citation Nr: 21072801 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 11-23 195 DATE: December 6, 2021 ORDER Service connection for a disability manifested by blood in urine is denied. Service connection for a disability of the testicle, to include right hydrocele and right spermatocele is denied. Service connection for gout is denied. Service connection for a cervical spine disability (claimed neck disability) is denied. A rating greater than 10 percent for temporomandibular joint (TMJ) pain is denied. REMANDED The issue of service connection for a headache disorder is remanded. The issue of service connection for a left leg disability is remanded. The issue of service connection for a right shoulder disability is remanded. The issue of service connection for a sleep disorder, to include obstructive sleep apnea (OSA) and a disability manifested by interrupted sleep is remanded. The issue of a total disability rating based on individual unemployability due to service-connected disability (TDIU) for the period before September 16, 2020 is remanded. FINDINGS OF FACT 1. The Veteran's genitourinary disability did not onset due to disease or injury sustained during his period of service. 2. The Veteran's gout did not onset due to disease or injury sustained during his period of service. 3. The Veteran's current cervical spine disability did not onset due to disease or injury sustained during his period of service. 4. The Veteran's TMJ has not manifested with limited motion of the inter-incisal range of 21 millimeters (mm) to 30 mm during the appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a disability manifested by blood in urine have not been met. 38 U.S.C. §§ 1110, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a disability of the testicle, to include right hydrocele and right spermatocele have not been met. 38 U.S.C. §§ 1110, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for gout have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for a rating greater than 10 percent for TMJ pain have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.150, Diagnostic Code (DC) 9905. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1978 to March 1978. These matters came before the Board of Veterans' Appeals (Board) on appeal from July 2009, May 2011, February 2013, and May 2015 rating decisions issued by the RO. The Board last remanded the appeal in April 2021 for additional development. Specifically, the Board instructed the RO to review the record, to include all the evidence added to the claims file since the April 2018 Supplemental Statement of the Case (SSOC) and re-adjudicate the claims for service connection for disability manifested by blood in the urine, gout, a sleep disorder manifested by OSA and interrupted sleep, a testicle disability, a cervical spine disability; a claim for an increased rating for TMJ pain; and a claim for a TDIU. If any benefit sought was not granted, the RO was to furnish the Veteran an SSOC and afford him an opportunity to respond. The RO re-adjudicated the claims for service connection for disability manifested by blood in the urine, gout, a sleep disorder manifested by OSA and interrupted sleep, a testicle disability, a cervical spine disability; a claim for an increased rating for TMJ pain; and a claim for a TDIU in a June 2021 SSOC. The requested development has been completed and the claims have been returned to the Board for further appellate adjudication. In June 2021, the RO granted an increased 10 percent rating for the TMJ pain, effective January 22, 2009. As a higher schedular rating for TMJ pain is possible and the Veteran did not withdraw the appeal, the claim remains pending on appeal before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Finally, the Veteran testified before a Veterans Law Judge (VLJ) in a video-conference hearing in February 2015. A transcript of the hearing is of record. The VLJ who conducted the February 2015 hearing has retired from the Board. The law requires that the VLJ who conducted a hearing shall participate in making the final determination of the claim. 38 U.S.C. § 7107 (c) (2012); 38 C.F.R. § 20.707 (2017). In a September 2021 letter, the Veteran was given the opportunity to request another Board hearing. He was advised that if he did not respond within 30 days, the Board would assume that he did not want a hearing. The Veteran has not responded to the letter and another Board hearing is not warranted. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, degenerative arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, arthritis is a chronic disease. 38 U.S.C. § 1101. Therefore, section 3.303(b) is potentially applicable. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). 1. The issue of service connection for a disability manifested by blood in urine 2. The issue of service connection for a disability of the testicle, to include right hydrocele and right spermatocele The Veteran asserts that he has disability manifested by blood in the urine and/or a testicle disability that onset from injury sustained during his period of service. A March 1978 service treatment record documents the Veteran's complaint of testicle pain with bleeding during urination. He also experienced some burning during urination. An additional March 1978 service treatment record also reflects the Veteran's complaint of burning on urination. He reported he experienced two episodes of "dark" urine. After service, the July 2009 VA genitourinary examination report reflects the Veteran's report that he started passing blood in his urine after sustaining a back injury during basic training. He reported that it cleared up after a couple of months, but he continued to have recurrent hematuria once a year. He was treated with Keflex which helped clear the blood and he used Keflex every time he had the episodes of blood in the urine. He denied experiencing any other symptoms and denied experiencing back or abdominal pain, frequency, urethral burning, dysuria, or painful urination. Objectively, the Veteran had normal bladder, urethra, testicle, prostate, epididymis/spermatic cord/scrotum, and seminal vesicles examinations. Creatinine testing was normal and urine analysis testing showed no blood in the urine. The examiner concluded that genitourinary examination was normal. A July 2011 private treatment record reflects the Veteran's complaint that his testicles hurt and were getting bigger. He complained of testicular swelling ongoing for several years that had increased in severity in the last year. On physical examination, he had swelling of the right testicle. The clinical impression was hydrocele. Scrotal testicular ultrasound findings showed large complex right hydrocele. An April 2012 VA operative report documents that the Veteran underwent right spermatocelectomy for right spermatocele. A subsequent April 2012 treatment record reflects the Veteran's complaint of bilateral testicular pain status-post surgery for hydrocele. He complained of pain and swelling of the testicles/scrotum and reported that he had run out of pain medication. The April 2012 scrotal ultrasound findings showed no evidence of testicular mass or testicular torsion; interval evacuation of a large complex right hydrocele; edematous hyperemic right epididymis suggesting epididymitis; and bilateral epididymal cysts. A May 2012 VA urology clinic note reflects that the Veteran had undergone right hydrocelectomy that was complicated by right epididymitis that had resolved. The Veteran was doing well. A subsequent May 2012 VA urology clinic note reflects the Veteran's complaint of erectile dysfunction status post right spermatocelectomy performed in April 2012. The Veteran had no hematuria, prostatitis, or urolithiasis. The December 2012 VA male reproductive system conditions examination report documents diagnosis of erectile dysfunction and spermatocele. The Veteran asserted his testicle disability onset from injury sustained in March 1978. On examination, the examiner opined that the erectile dysfunction and spermatocele disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran did not receive diagnosis or treatment for erectile dysfunction or spermatocele during his period of service. The examiner acknowledged that he did receive treatment for complaints of testicle pain associated with hematuria during service but noted that the disorder resolved in 1978 and the Veteran had no further testicle pain with hematuria during his period of service. An April 2013 and September 2014 VA urology clinic notes reflect that the Veteran had erectile dysfunction status post right spermatocelectomy. Genitourinary examination showed normally developed scrotum; nontender, bilaterally descended, normally oriented testicles without masses or induration and normal cord structure; and, appropriately positioned epididymis with no tenderness or induration. A December 2014 private treatment record reflects the Veteran received treatment for hematuria exacerbated by sexual intercourse. The risk factor for the Veteran's hematuria was diabetes mellitus. Instrumentation, trauma, catheter, anticoagulated, and frequent urinary tract infections were not risk factors for his hematuria. The record shows this was the Veteran's third episode of post-coital hematuria in the last 3 weeks. Urine analysis was normal. January 2015 VA urology clinic note reflects the Veteran received treatment for intermittent hematospermia. Genitourinary examination showed normally developed scrotum; nontender, bilaterally descended, normally oriented testicles without masses or induration and normal cord structure; and, appropriately positioned epididymis with no tenderness or induration. The assessment was hematuria/hematospermia. March 2015 VA cystourethroscopy findings showed benign prostatic hyperplasia (BPH). The October 2015 VA urology clinic note documents assessment of erectile dysfunction treated by Sildenafil and resolved hematospermia. The March 2017 VA male reproductive system conditions examination report documents diagnoses of erectile dysfunction, BPH, bilateral spermatocele status post right spermatocelectomy, acute prostatitis (resolved without residuals), and hematospermia (resolved October 2015). The Veteran complained his testicle disability onset due to injury sustained during service in March 1978. On physical examination, the examiner opined that the Veteran's genitourinary disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran was diagnosed with acute prostatitis in March 1978 but the condition resolved without residuals. The examiner explained that there was no objective evidence of a chronic recurrent condition since the Veteran's discharge from service. In addition, the examiner reported that the Veteran's erectile dysfunction and BPH were diagnosed approximately 35 to 37 years after his discharge from service. Finally, the examiner found that the Veteran's spermatocele status post right spermatocelectomy and hematospermia were diagnosed in 2011 and 2013, respectively, resolved without residuals and were not causally related to injury sustained during service. A May 2018 VA urology clinic note reflects that the Veteran had multiple episodes of hematospermia over the past year. CT scan findings of the urinary system were unremarkable. Though the Veteran has current genitourinary disabilities, the preponderance of the evidence is against a finding of a linkage between the onset of the current genitourinary disabilities and a period of service, to include any injury sustained in March 1978. Rather, the competent medical evidence shows that the current genitourinary disabilities onset many years after the Veteran's discharge from service. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). The Veteran's erectile dysfunction and BPH were diagnosed approximately 35 to 37 years after his discharge from service. The Veteran's spermatocele status post right spermatocelectomy and hematospermia were diagnosed in 2011 and 2013, respectively, resolved without residuals and were not causally related to injury sustained during service. (See March 2017 VA examination report and opinions). The December 2012 VA examination report documents that though the Veteran did receive treatment for complaints of testicle pain associated with hematuria during service, the condition resolved, and he had no further testicle pain with hematuria during his period of service. He did not receive diagnosis or treatment for erectile dysfunction or spermatocele during his period of service. The examiner opined that the erectile dysfunction and spermatocele disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Thus, the evidence shows that the current genitourinary disabilities had no etiological relationship to any injury sustained during the Veteran's period of service from January 1978 to March 1978, having onset many years after his discharge from service. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current genitourinary disabilities and a period of the Veteran's service. The Veteran is competent to report his in-service injury, but he is not competent to link his current genitourinary disabilities to a period of service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). The Veteran is not competent to establish that his current genitourinary disabilities onset due to any injury sustained during a period of service. The Veteran is not competent to offer opinion as to etiology of any current genitourinary disabilities. The question regarding the etiology of such disabilities is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claims for service connection for disability manifested by blood in urine and a disability of the testicle, to include right hydrocele and right spermatocele spine must be denied. The preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. The issue of service connection for gout 4. The issue of service connection for a cervical spine disability (claimed neck disability) The Veteran asserts that his gout and cervical spine disabilities onset from injury sustained during his period of service. February 1978 service treatment records reflect that the Veteran injured his back in a motor vehicle accident (MVA) 6 months earlier. The assessment was low back pain. There are no complaints, treatment for, or diagnosis of gout or a cervical spine (neck) disability. After service, an August 2001 private treatment record reflects, in pertinent part, the Veteran complained of pain, discomfort, spasms, and impaired mobility of the cervical spine with pain radiating into the upper extremities due to injury sustained in an MVA in March 2001. MRI findings of the cervical spine showed straightening of the normal cervical lordosis; disc herniations at the C3/4, C4/5, and C5/6 levels; and mild degenerative changes. July 2004 right knee x-ray findings (ordered for clinical history of pain and gout) showed no significant plain film abnormalities. July 2005 left foot x-ray findings (ordered for clinical history of pain, swelling and gout) showed swelling of the soft tissues in the left foot. Bones and joints were unremarkable, and no traumatic bony lesions were suspected. March 2006 right ankle x-ray findings (ordered for clinical history of pain and gout) showed no significant bony or joint space abnormalities. April 2010 cervical spine x-ray findings showed degenerative changes. November 2011 private treatment records reflect the Veteran received treatment for gout in his right knee. October 2012 MRI findings of the cervical spine showed multilevel mild degenerative change at C3-C4 through C5-C6; 3 millimeters (mm) central and right paramedian disc protrusion at C3-C4; 3mm left paramedian disc protrusion at C5-C6; and no evidence of bony central canal stenosis. A November 2015 VA treatment record documents the Veteran's report that he was experiencing a flareup of his gout on the right. The March 2017 VA non-degenerative arthritis and foot conditions examination reports documents diagnosis of gout. The March 2017 VA knee and lower leg conditions examination report documents diagnoses of degenerative arthritis and gout. The Veteran reported his gout onset during his period of service. The March 2017 VA neck (cervical spine) conditions examination report documents diagnoses of degenerative arthritis of the spine, cervical spine spondylosis, and calcific tendinitis of the neck. The Veteran reported that he sustained injury to his neck in February 1978 during a 20-mile march. The examiner opined that the Veteran's gout was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that despite the Veteran's assertion that he had gout since his period of service, the service treatment records made no reference to the Veteran having gout or arthritic condition. Thus, the examiner concluded there was no evidence that the Veteran had gout during service. Rather, the Veteran's gout onset many years after his discharge from service. Similarly, the examiner opined that the Veteran's cervical spine disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the service treatment records documented that the Veteran had a clicking pain in both TMJs after falling while running down a hill in February 1978; however, there were no complaints of a cervical spine disorder documented in any service treatment records. The examiner concluded there was no evidence that the Veteran sustained any neck or cervical spine injury during service (in the fall after running in February 1978). Rather, the Veteran's cervical spine disability onset many years after his discharge from service. The examiner reiterated that if any written documentation of a cervical spine disability had been documented in the service treatment records, the benefit of the doubt would have been given to the Veteran and the opinion would have been in his favor. Noting several different types of memory errors for discounting the Veteran's report that his cervical spine disability onset from the injury sustained in a fall while running down a hill, the examiner concluded that the Veteran's cervical spine disability less likely than not onset due to that in-service injury in February 1978. Though the Veteran has current gout and cervical spine disabilities, the preponderance of the evidence is against a finding of a linkage between the onset of those disabilities and a period of service. Rather, the competent medical evidence shows that the gout and cervical spine disabilities onset many years after the Veteran's discharge from service. Despite the Veteran's report that he had gout since his period of service, the service treatment records made no reference to gout or any other arthritic condition. Thus, the examiner concluded there was no evidence that the Veteran had gout during service. Similarly, despite the Veteran's report that he sustained his cervical spine disability in a fall after running in February 1978, there was no evidence that the Veteran sustained any neck or cervical spine injury during service (in the fall after running in February 1978). The examiner reiterated that if any written documentation of a cervical spine disability had been documented in the service treatment records, the benefits of the doubt would have been given to the Veteran and the opinion would have been in his favor. (See March 2017 VA examination reports and opinions). The August 2001 private treatment record reflects, in pertinent part, the Veteran's complaint of pain, discomfort, spasms, and impaired mobility of the cervical spine with pain radiating into the upper extremities due to injury sustained in an MVA in March 2001. Beginning in July 2004, the Veteran received x-rays for various extremities due to a reported clinical history of pain and gout. Thus, the evidence clearly shows that the current gout and cervical spine disabilities had no etiological relationship to any injury sustained during the Veteran's period of service or otherwise onset during the Veteran's period of service, having onset many years after his discharge from service. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current gout and cervical spine disabilities and a period of the Veteran's service. In addition, there is no evidence of gout or cervical spine arthritis in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303 (b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of arthritis within one year of separation from service. Regardless, the Veteran did not serve on active duty for 90 days or longer. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303 (b), 3.307, 3.309. The Veteran is not competent to establish that his current gout and cervical spine disabilities onset during or due to any injury reportedly sustained during a period of service. The Veteran is not competent to offer opinion as to etiology of any current gout or cervical spine disabilities. The question regarding the etiology of such disabilities is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claims for service connection for gout and cervical spine disabilities must be denied. The preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disabilities and their ratings are listed in Diagnostic Codes (DCs). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 5. The issue of a rating greater than 10 percent for TMJ) pain The Veteran's TMJ pain is assigned a 10 percent rating. Under DC 9905, a 10 percent rating is assigned for range of lateral excursion from 0 to 4 mm or limited motion of the inter-incisal range from 31 to 40 mm. A 20 percent rating is assigned for limited motion of the inter-incisal range from 21 to 30 mm. A 30 percent rating is assigned for limited motion of the inter-incisal range from 11 to 20 mm. A 40 percent rating is assigned for limited motion of the inter-incisal range from 0 to 10 mm. 38 C.F.R. § 4.150, Diagnostic Code 9905. The note to DC 9905 provides that the ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. The November 2010 VA dental and oral examination report documents the Veteran's complaint of progressively worsening jaw pain. He reported that when he slept at night his jaw locked up and he had to wiggle his jaw to put it back into position. On physical examination, there was 25 to 50 percent loss of bone of the maxilla not replaceable by prosthesis and loss of the bone of the mandible. There was no malunion or nonunion of the maxilla, nonunion or malunion of the mandible, loss of motion at the temporomandibular articulation, loss of bone of the hard palate, evidence of osteomyelitis, or tooth loss due to loss of substance of body of maxilla or mandible. X-ray findings showed chronic adult periodontal disease. The Veteran's TMJ appeared within normal limits and was nontender to touch or palpation. The Veteran had no pain on opening, no crepitus, and no limitation on opening or closing. The February 2011 VA dental and oral examination report documents the Veteran's complaint of bilateral clicking of the TMJ upon mandibular movement. On physical examination, there was no loss of bone of the maxilla, malunion or nonunion of the maxilla, nonunion or malunion of the mandible, loss of bone of the hard palate, evidence of osteomyelitis, evidence of osteoradionecrosis, or tooth loss due to loss of substance of body of maxilla or mandible. The Veteran did experience loss of motion at the temporomandibular articulation. The Veteran was partially edentulous and due to the lack of teeth, the examiner was unable to measure jaw movements. However, subjectively, the Veteran displayed mild limitation upon maximum opening and there was no limitation in left or right lateral excursions or protrusions. He experienced mild bilateral TMJ clicking only perceived upon auscultation with a stethoscope and had moderate tenderness of buccinator and masseter muscles bilaterally. The March 2017 VA TMJ conditions examination report reflects the Veteran's report that his jaw clicked, popped, and would occasionally lock up. The Veteran demonstrated 11 mm of right and left lateral excursion without pain. There was no evidence of pain with chewing or localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of crepitus or clicking of joints or soft tissue of the right TMJ but not the left TMJ. Inter-incisal distance was 45 mm. The Veteran was able to perform repetitive use testing without additional functional loss or range of motion. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a time in the right or left TMJ. The examiner remarked that the Veteran had only maxillary teeth numbers 2 and 13 and was missing mandibular posterior teeth. The examiner explained that because of the missing teeth, there was no occlusal plane, and the Veteran was over closing with loss of vertical dimension which created stress on the TMJ laxity in the muscles and ligaments and could lead to clicking of the joints. However, there was no worsening of the condition and the condition did not appear severe. Further, there was no evidence of pain on passive range of motion or when the joint was used in non-weight-bearing. The November 2020 VA TMJ conditions examiner reported that Veteran's range of motion and functional limitations were unable to be tested because the Veteran had no upper teeth - his right and left inter-incisal measurements could only be estimated and right and left inter-incisal estimated distance was 40 centimeters (cm) (i.e., 400 mm), respectively. He was able to perform repetitive use testing without additional loss of function or range of motion. Pain significantly limited functional ability with repeated use over time and during a flare-up, but the examiner was not able to describe the additional limitation in terms of range of motion because the Veteran had no upper teeth so inter-incisal measurements could only be estimated. The examiner estimated that inter-incisal distance remained at 40 cm (400 mm) and the Veteran had right and left lateral excursion over 4 mm, bilaterally. The Veteran complained of pain on both right and left TMJ but worse on the right side. The Veteran reported that during flareups he was unable to open his mouth as normally but the examiner noted that this was an expected complaint of a patient who had a TMJ disorder, especially during periods when the pain was worse or the jaw locked. The examiner remarked that there was evidence of pain on passive range of motion and non-weight-bearing testing of the left and right TMJ. At worst, the Veteran displayed 11 mm of right and left lateral excursion without pain and Inter-incisal distance of 45 mm. (see March 2017 VA examination report). Though pain significantly limited functional ability with repeated use over time and during flareups (see November 2020 examination report), the manifestations that can be associated with the TMJ pain - even after considering DeLuca (orthopedic) factors indicated at 38 C.F.R. §§ 4.40, 4.45, 4.59, and in consideration of the complaints of pain on motion, do not support a finding of inter-incisal range of motion 21 to 30 mm. The Board reiterates that in the November 2020 TMJ conditions examination report, the examiner estimated that inter-incisal distance remained at 40 cm (400 mm) and the Veteran had right and left lateral excursion over 4 mm, bilaterally. In addition, though there was evidence of pain on passive range of motion and non-weight-bearing testing of the left and right TMJ, this functional loss was not productive of additional limitation of motion. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The 10 percent rating for the TMJ pain adequately contemplates the severity of his disability during the appeal period. Accordingly, a rating greater than 10 percent for TMJ pain is not warranted. REASONS FOR REMAND 1. The issue of service connection for a headache disorder is remanded. 2. The issue of service connection for a left leg disability is remanded. 3. The issue of service connection for a right shoulder disability is remanded. 4. The issue of service connection for a sleep disorder, to include obstructive sleep apnea (OSA) and a disability manifested by interrupted sleep is remanded. 5. The issue of a TDIU for the period before September 16, 2020 is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends that his left leg, right shoulder, and headache disabilities onset due to injury sustained during his period of service. In the May 2015 rating decision, the RO denied these claims on appeal. His Notice of Disagreement (NOD) was received in August 2015, a Statement of the Case (SOC) was issued in June 2018 and he perfected his appeal in July 2019. Additional VA treatment records, including VA examinations, have been added to the claims file since issuance of the June 2018 SOC. Remand is required for the RO to consider the evidence first. With respect to the Veteran's claim for service connection for a sleep disorder, to include OSA and an interrupted sleep disorder, the Veteran submitted an article suggesting an association between OSA and PTSD (i.e., he now asserts his OSA is secondary to his service-connected psychiatric disorder). The examination report of record is insufficient for determining whether service connection may be granted. Remand is warranted to determine if the Veteran's diagnosed OSA or any other sleep disorder is caused or aggravated by his service-connected psychiatric disorder. The claim for a TDIU prior to September 16, 2020 is inextricably intertwined with the claim of service connection for a sleep disorder, to include OSA and an interrupted sleep disorder and the Board will defer the issue until the requested development below has been completed. THE REMAND DIRECTIVES FOLLOW. 2. After undertaking any additional development that may be warranted based on additional information or evidence received, readjudicate the issues of service connection for left leg, right shoulder, and headache disabilities. In particular, the RO must consider the VA treatment records added to the claims file since the June 2018 SOC. If the benefits sought are not granted, the Veteran should be furnished with a Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity to respond to the SSOC before the record is returned to the Board for further review 3. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed sleep disorder, including OSA and interrupted sleep disorder. The claims file must be reviewed by the examiner. All indicated tests and studies should be performed and the clinical findings should be reported in detail. THE EXAMINER IS ADVISED THAT THE Veteran asserts that his sleep disorder onset secondary (i.e., caused or aggravated by) to his service-connected other specified trauma and stressor related disorder with subthreshold posttraumatic stress disorder (PTSD) and cocaine and alcohol disorder. A comprehensive clinical history should be obtained, to include a discussion of the Veteran's documented medical history and assertions. After reviewing the entire record, the examiner should provide an opinion WITH SUPPORTING EXPLANATIONS as to the following: Was the Veteran's current sleep disorder CAUSED OR AGGRAVATED (worsened) by service-connected other specified trauma and stressor related disorder with subthreshold PTSD and cocaine and alcohol disorder? If aggravation of any sleep disorder by service-connected other specified trauma and stressor related disorder with subthreshold PTSD and cocaine and alcohol disorder is shown, the examiner should objectively quantify, to the extent possible, the degree of aggravation beyond the level of impairment had no aggravation occurred. THE EXAMINER MUST CONSIDER AND EXPLAIN WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF THE DISORDERS IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE, ACCOUNTING FOR FACTS AND CIRCUMSTANCES SPECIFIC TO THE VETERAN. As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *February 2006 sleep study findings showed mild obstructive sleep apnea. *The March 2017 VA sleep apnea examination report documents diagnosis of obstructive sleep apnea. The examiner opined that the OSA was less likely than not incurred in or caused by an in-service injury or illness. The examiner explained that there was no objective evidence in the service treatment records that the OSA onset during a period of service and noted that the Veteran's OSA was diagnosed 37 years after his separation from service. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.