Citation Nr: 21073566 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-00 681 DATE: December 9, 2021 ORDER New and material evidence having been received, the claim for entitlement to service connection for a heart disability is reopened. Service connection for headaches is denied. Entitlement to a rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to an effective date prior to November 3, 2014, for an increased rating of 10 percent for right knee disability is denied. Entitlement to a rating in excess of 10 percent for chronic left knee tendinitis with left patellar dish involvement is denied. Entitlement to a rating in excess of 10 percent for left ankle degenerative joint disease with calcaneal spur is denied. Entitlement to compensable rating for right heel calcaneal spur prior to January 4, 2020 and a rating in excess of 10 percent thereafter is denied. REMANDED Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for high blood pressure is remanded. Entitlement to service connection for an acquired psychiatric condition, to include anxiety disorder and depressive disorder is granted. Entitlement to service connection for hearing loss is remanded. FINDINGS OF FACT 1. The claim for service connection for a heart disability was previously denied by the RO in a decision dated February 1999. The Veteran did not appeal that decision and no new evidence pertinent to that claim was received by VA within one year from the date that the RO mailed the notice of the determination to the Veteran. 2. 2. New evidence received since the time of the final February 1999 decision relates to an unestablished fact necessary to grant the Veteran's claim of entitlement to service connection for a heart disability. 3. The Veteran does not have a current headache disability that onset in or is causally related to his service. 4. The Veteran's right knee patellofemoral pain syndrome does not result in loss of flexion to less than 135 degrees. 5. The Veteran filed his claim for an increased rating for his right knee disability on November 3, 2014 and the evidence does not support a worsening of the condition in the 12 months prior to that filing. 6. The Veteran's chronic left knee tendinitis with left patellar dish involvement does not result in loss of flexion to less than 135 degrees. 7. The Veteran's left ankle degenerative joint disease with calcaneal spur does not cause dorsiflexion to less than 20 degrees or plantar flexion to less than 40 degrees. 8. Prior to January 4, 2020, the Veteran's right heel calcaneal spur manifest with no symptoms. 9. As of January 4, 2020, the Veteran's right heel calcaneal spur manifest with moderate limitation of motion. CONCLUSIONS OF LAW 1. The February 1999 rating decision denying service connection for a heart disability is final. 38 U.S.C. § 7015(c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 2. Evidence submitted to reopen the claim of entitlement to service connection for a heart disability is new and material. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for a headache disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304. 4. The criteria for a rating in excess of 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 5. The criteria for entitlement to an effective date prior to November 3, 2014, for an increased rating of 10 percent for right knee disability have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 6. The criteria for a rating in excess of 10 percent for left knee tendinitis with left patellar dish involvement have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 7. The criteria for a rating in excess of 10 percent for left ankle degenerative joint disease with calcaneal spur have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 8. The criteria for a compensable rating for right heel calcaneal spur prior to January 4, 2020 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 9. The criteria for a rating in excess of 10 percent for right heel calcaneal spur as of January 4, 2020 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal comes to the Board of Veterans' Appeals (Board) from an April 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In an August 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted a 10 percent rating for right heel calcaneal spur effective January 4, 2020. The increased rating constitutes a partial grant of benefits, such that the issue remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993). Claim to Reopen 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a heart disability The Board is neither required nor permitted to analyze the merits of a previously denied claim if new and material evidence has not been submitted. Butler v. Brown, 9 Vet. App. 167, 171 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). In a February 1999 rating decision, the RO denied service connection for a heart condition diagnosed as status post myocardial infarction. The RO found that the evidence did not support that the condition onset in service or was causally related to the Veteran's service. The Veteran did not file a timely notice of disagreement and no new evidence pertinent to the claim was received by VA prior to the expiration of the appeal period. In addition, VA has not received or associated with the claims file any relevant official service department records that existed and had not been associated with the claims file at the time of the February 1999 decision. Therefore, the February 1999 decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(b) and (c), 20.302, 20.1103. Evidence added to the record since the February 1999 decision, includes a June 2017 private opinion that the Veteran's prehypertension and high cholesterol that developed in service more likely than not aided in the development of the Veteran's hypertension, coronary artery disease, and stroke. The Board finds that the evidence constitutes new and material evidence sufficient to reopen the Veteran's claim for entitlement to service connection for a heart disability. On this basis, the issue is reopened. Service Connection 2. Entitlement to service connection for headaches The Veteran has claimed service connection for headaches. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Veteran has not offered a specific statement on whether he alleges he has a current headache condition that onset in service or whether he has a current headache condition that was caused by his service. The Veteran's service treatment records do not reflect a diagnosis of a headache condition in service. Post-service treatment records include a January 2008 record of the Veteran reporting a headache lasting two to three hours. He reported not having a similar episode previously. He was assessed with a tension headache by history. Records do not reflect a diagnosis of a chronic headache condition or current ongoing complaint of headache. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). In the absence of evidence of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Even if it were conceded that the Veteran has a current headache condition, a preponderance of the evidence is against finding that the condition onset in or is related to his service. As noted above, there is a lack of an event or symptoms during service and furthermore, there is no evidence which links any current headaches to any event in service. Therefore, the Board finds that service connection for a headache condition is not warranted. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. 3. Entitlement to a rating in excess of 10 percent for right knee disability The Veteran currently has a 10 percent rating for right knee patellofemoral pain syndrome under Diagnostic Code 5260. The Veteran contends that he is entitled to a higher rating. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5261. The Board notes that regulations regarding the musculoskeletal system changed effective February 7, 2021. While DCs 5260 and 5261 remained the same, DC 5257 changed as follows: Recurrent subluxation or instability: Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation 30 One of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation 20 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation 10 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 30 A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker 20 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 10 Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): 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). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004 ; 69 Fed. Reg. 59,990 (2004). 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent. On VA examination in April 2015, the Veteran's right knee range of motion was tested to be from 0 to 140 degrees flexion. He was noted to have pain with flexion but no additional functional loss. No pain was noted on weight bearing. No additional loss of function was shown on repetitive use testing. The examiner indicated that the Veteran's reported pain causing functional loss with repeated use over time but noted normal range of motion. The Veteran reported mild flare ups three times a month for an hour with pain causing functional loss but normal range of motion. On VA examination in January 2020, the Veteran's right knee range of motion was tested to be from 0 to 135 degrees flexion in active, passive, weight and nonweight bearing. No pain was noted on examination. There was no additional loss of function or range of motion on repetitive use testing. The examiner stated that pain, weakness, fatigability or incoordination do not significantly limit functional ability with repeated use over a period of time. The Veteran did not report flare ups. There is no other evidence suggesting that the Veteran has loss of flexion to less than 135 degrees in his right knee, either range of motion testing or lay evidence. The Board acknowledges the Veteran's reports that his knee pain is worse with running and during cold weather. However, even considering the Veteran's lay reports, the degree of additional limitation reflected by the Veteran's statements does not result in limitation of motion more nearly approximating flexion limited to 30 degrees as is required for a 20 percent rating. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg but finds that none are applicable. As noted above, range of motion testing reflected extension was to 0 even after repetition. The examinations also did not reflect any giving way or instability of the knee to warrant a rating under DC 5257. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for right knee patellofemoral pain syndrome. 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. 4. Entitlement to an effective date prior to November 3, 2014, for an increased rating of 10 percent for right knee disability The April 2015 rating decision granted the Veteran an increased, 10 percent rating, for his right knee patellofemoral pain syndrome effective November 3, 2014. The Veteran contends he is entitled to an earlier effective date for the increased rating. In general, the effective date of a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation, the effective date of the award shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). The record here reflects that the Veteran first filed an increased rating claim on November 3, 2014. The Board has reviewed the evidence but finds none that supports that a factually ascertainable increase in disability occurred within the one-year period preceding November 3, 2014. Based on the forgoing, the Board finds that an effective date for the increased, 10 percent rating, is not warranted prior to November 3, 2014. 5. Entitlement to a rating in excess of 10 percent for left knee disability The Veteran currently has a 10 percent rating for chronic left knee tendinitis with left patellar dish involvement under Diagnostic Code 5260-5024. Diagnostic Code 5024 applies to tenosynovitis, tendinitis, tendinosis or tendinopathy and states that the condition should be rated as degenerative arthritis, based on limitation of motion of affected parts. Diagnostic Code 5260 applies to limitation of leg flexion. On VA examination in April 2015, the Veteran's left knee range of motion was tested to be from 0 to 140 degrees flexion. No pain was noted but he was noted to have mild tenderness to palpation of the lateral knee joint. No pain was noted on weight bearing. No additional loss of function was shown on repetitive use testing. The examiner indicated no functional loss with repeated use over time. The Veteran reported mild flare ups three times a month for an hour with pain causing functional loss but normal range of motion. On VA examination in January 2020, the Veteran's left knee range of motion was tested to be from 0 to 135 degrees flexion in active, passive, weight and nonweight bearing. No pain was noted on examination. There was no additional loss of function or range of motion on repetitive use testing. The examiner stated that pain, weakness, fatigability or incoordination do not significantly limit functional ability with repeated use over a period of time. The Veteran did not report flare ups. There is no other evidence suggesting that the Veteran has loss of flexion to less than 135 degrees in his left knee, either range of motion testing or lay evidence. The Board acknowledges the Veteran's reports that his knee pain is worse with running and during cold weather. However, even considering the Veteran's lay reports, the degree of additional limitation reflected by the Veteran's statements does not result in limitation of motion more nearly approximating flexion limited to 30 degrees as is required for a 20 percent rating. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg but finds that none are applicable. As noted above, range of motion testing reflected extension was to 0 even after repetition. The examinations also did not reflect any giving way or instability of the knee to warrant a rating under DC 5257. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for chronic left knee tendinitis with left patellar dish involvement. 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. 6. Entitlement to a rating in excess of 10 percent for left ankle disability The Veteran currently has a 10 percent rating for left ankle degenerative joint disease with calcaneal spur under Diagnostic Code 5010-5271. The Veteran contends that he is entitled to a higher rating. Effective February 7, 2021, VA amended the rating criteria for Diagnostic Code 5271. 85 Fed. Reg. 76,453 (Nov. 30, 2020). As this regulatory change was enacted during the pendency of this appeal, the Board will consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. Under the prior criteria, a 10 percent rating is warranted for moderate limited motion of the ankle and a 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension." See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character." See www.merriam-webster.com/dictionary/marked. Under the new criteria, a 10 percent rating is warranted for moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion). A 20 percent rating is warranted for marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). 38 C.F.R. § 4.71a, Diagnostic Code 5271. On VA examination in April 2015, range of motion testing showed the Veteran to have dorsiflexion to 20 degrees and plantar flexion to 40 degrees. No pain was noted on examination, but the Veteran was noted to have pain on weight bearing. No additional loss of function was found after three repetitions. The examiner indicated that the Veteran would have pain with repeated use over time but no additional loss of range of motion. The Veteran reported mild flare ups two to three times a week for an hour. Pain was noted but no additional loss of range of motion. The Veteran reported that he is not able to put his full weight on his ankle, and when he has pain that affects his walking. On VA examination in January 2020, range of motion testing again showed dorsiflexion to 20 degrees and plantar flexion to 40 degrees on both active and passive motion with no objective evidence of pain. He had no additional functional loss after three repetitions. The examiner further indicates that pain, weakness, fatigability or incoordination would not significantly limit functional ability with repeated use over a period of time or during a flare up. The Veteran reported left ankle pain worse with prolonged walking and during bad weather. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for his left ankle degenerative joint disease with calcaneal spur under the pre-February 7, 2021 rating criteria. The Board acknowledges the Veteran's lay reports of symptoms, including pain that affects his weight bearing especially after prolonged walking. However, even considering the Veteran's lay reports of symptoms and functional loss, the Board finds that the degree of additional limitation would not result in symptoms more nearly approximating marked limited motion. The Board further finds that the preponderance of the evidence is against a rating in excess of 10 percent under the new rating criteria effective February 7, 2021 because dorsiflexion measured 20 degrees and plantar flexion measured 40 degrees on both VA examinations and no other evidence suggests more limited motion. Thus, the evidence does not support that the criteria corresponding to a higher 20 percent rating is warranted. Even considering the Veteran's lay reports of symptoms and functional loss, the Board finds that the degree of additional limitation would not result in symptoms more nearly approximating less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 10 percent for left ankle degenerative joint disease with calcaneal spur. 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. 7. Entitlement to a compensable for a right heel disability prior to January 4, 2020 and a rating in excess of 10 percent thereafter The Veteran currently has a noncompensable rating for right heel calcaneal spur prior to January 4, 2020 and a 10 percent rating thereafter under Diagnostic Code 5299-5271. The Veteran underwent a VA foot examination in February 2015. The examiner found no right foot pain on physical examination. The Veteran also underwent a VA ankle examination in January 2020. Range of motion testing showed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. No pain was noted on examination. The examiner indicated no additional loss of function or range of motion after three repetitions, after repetitive use over time, or during a flare up. A review of the Veteran's medical treatment records do not reflect any symptomatology attributable to his right heel calcaneal spur. As calcaneal spur is not specifically contemplated by the rating criteria, the Board will consider all potentially applicable diagnostic codes. First, the Board finds that a preponderance of the evidence is against a compensable rating prior to January 4, 2020 under any diagnostic code. The earliest evidence reflecting any right foot or ankle symptoms at all, including pain, is the January 2020 VA examination. Thus, prior to that date there is no basis on which to grant a compensable rating for right heel calcaneal spur. The Board has further specifically considered the criteria for a rating under Diagnostic Code 5271. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent as of January 4, 2020 under either the pre-February 7, 2021 or the current rating criteria. On VA examination in January 2020, the Veteran's right ankle range of motion was tested to be normal with no pain noted. Thus, the Board finds that his condition does not more nearly approximate marked limited motion. The Board has considered ratings assigned for the feet, including Diagnostic Code 5276 for flat foot. A 20 percent rating under Diagnostic Code 5276 applies where there is objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. The Board finds that the The Board finds that a preponderance of the evidence is against a compensable rating for right heel calcaneal spur prior to January 4, 2020 and a rating in excess of 10 percent thereafter. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability is remanded. As discussed above, the Board finds that new and material evidence has been submitted to reopen the issue of entitlement to service connection for a heart disability. As the AOJ has not adjudicated the issue in the first instance, the Board finds that the issue must be remanded to allow such. 2. Entitlement to service connection for high blood pressure In a June 2017 statement, a private examiner opined that the Veteran's prehypertension and elevated cholesterol in service contributed to his subsequent diagnosis of hypertension. No VA opinion has been obtained as to whether it is at least as likely as not that the Veteran's hypertension onset in or is causally related to his service or any service-connected disability. On remand, such an opinion should be obtained. 3. Entitlement to service connection for an acquired psychiatric condition, to include anxiety disorder and depression In a February 2017 statement, a private examiner opined that the Veteran has an anxiety disorder secondary to his tinnitus, knee disabilities, ankle disabilities, calcaneal spurs, condyloma acuminate, congestive heart condition, and stroke residuals. The Board notes that the Veteran is not currently service-connected for a heart disability and his claim for such has been remanded herein. Therefore, his claim for service connection for an acquired psychiatric condition is potentially intertwined with his claim for service connection for a heart condition. In addition, the Board notes that the Veteran underwent a VA examination in January 2020 at which he was diagnosed with major depressive disorder with anxious distress. The examiner opined that the Veteran's psychiatric condition is not secondary to any of his service-connected disabilities because his psychiatric symptoms onset in 1997 but none of his service-connected disabilities onset at that time. The record reflects that the Veteran had a stroke in 1997. On remand, an addendum VA opinion should be obtained as to whether the Veteran's service-connected disabilities at least as likely as not aggravated his psychiatric condition. 4. Entitlement to service connection for hearing loss The Veteran underwent a VA audiological examination in March 2015. The VA examiner opined that the Veteran's hearing loss is not as least as likely as not caused by or as a result of an event in service. The examiner explained that the Veteran had a significant threshold shift at 4000 Hz in the right ear during service, suggesting exposure to hazardous levels of noise but no hearing loss was incurred during service. The Board finds the March 2015 VA opinion to be inadequate as it offers no rationale for why the Veteran's right ear hearing loss is not causally related to the Veteran's service beyond stating that no hearing loss was incurred in service. See in Hensley v. Brown, 5 Vet. App. 155, 157 (1993). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A new VA opinion as to the etiology of the Veteran's hearing loss should be obtained on remand. The rationale for the opinion must include a complete discussion of all potential factors so as to determine whether there is a relationship between the Veteran's current hearing loss and service. The matters are REMANDED for the following action: 1. Obtain a VA opinion as to whether it is at least as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran has a heart condition and/or hypertension that onset in or is causally related to his service or was caused or aggravated by any service-connected disability. There is no need to schedule further examination of the Veteran, unless the reviewer concludes such is necessary. All relevant records, to include a copy of this remand, must be made available to and reviewed by the reviewer/examiner in conjunction with the examination or review. The examiner should comment on the June 2017 private opinion report. 2. Obtain a VA opinion as to whether it is at least as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran's psychiatric condition, to include anxiety disorder and major depressive disorder, was aggravated by any service-connected disability. There is no need to schedule further examination of the Veteran, unless the reviewer concludes such is necessary. All relevant records, to include a copy of this remand, must be made available to and reviewed by the reviewer/examiner in conjunction with the examination or review. The examiner should comment on the February 2017 private opinion report. 3. Obtain a VA medical opinion addressing the likelihood of a relationship between the Veteran's hearing loss and his service. There is no need to schedule further examination of the Veteran, unless the reviewer concludes such is necessary. All relevant records, to include a copy of this remand, must be made available to and reviewed by the reviewer/examiner in conjunction with the examination or review. Based on review of the record, the reviewer/examiner should render an opinion as to whether it is at least as likely as not (i.e., to a 50 percent degree of probability or greater) that the Veteran's hearing loss had its onset during military service or is otherwise causally or etiologically related to the Veteran's active service, to include noise exposure, or whether such a relationship to service is unlikely (i.e., a probability of less than 50 percent). In so doing, the examiner should discuss causes of hearing loss and describe how hearing loss that results from noise exposure generally presents or develops in most cases, in determining the likelihood that any current hearing loss was caused by noise exposure in service as opposed to some other cause. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Christensen 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.