Citation Nr: 21074177 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-43 130 DATE: December 14, 2021 ORDER Entitlement to an effective date earlier than July 15, 2013 for the grant of entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the thoracolumbar spine for the appeal period prior to December 29, 2020 is denied. Entitlement to a rating in excess of 40 percent for degenerative joint disease thoracolumbar arthritis for the appeal period beginning on December 29, 2020 is denied. Entitlement to an initial rating in excess of 10 percent for right knee meniscal tear for the appeal period prior to December 29, 2020 is denied. Entitlement to a rating in excess of 20 percent for right knee meniscal tear for the appeal period beginning on December 29, 2020 is denied. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome is denied. Entitlement to a compensable rating for residuals status post hemorrhoidectomy is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a rating in excess of 10 percent for tinnitus is denied. Entitlement to service connection for diabetes mellitus, type II, to include as due to exposure to herbicide agents, is denied. REMANDED Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for right upper extremity peripheral neuropathy is remanded. Entitlement to service connection for left upper extremity peripheral neuropathy is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) prior to July 15, 2013, is remanded. FINDINGS OF FACT 1. The Veteran's claim for entitlement to service connection for PTSD was denied in a September 2002 rating decision and it was not appealed by the Veteran. 2. The Veteran filed an informal claim to reopen entitlement to service connection for PTSD on July 15, 2013 and there were no formal claims, informal claims, or written intent to file a claim to reopen the previously denied claim of entitlement to service connection for PTSD following the September 2002 denial. 3. For the period on appeal prior to December 29, 2020, the Veteran's degenerative joint disease thoracolumbar arthritis was not manifested by forward flexion of 60 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without ankylosis, incapacitating episodes due to intervertebral disc syndrome or associated objective neurological abnormalities such as bowel or bladder impairments. 4. Throughout the appeal period, the Veteran's degenerative joint disease thoracolumbar arthritis has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes having a total duration of at least 6 weeks during any consecutive 12-month period on appeal. 5. For the appeal period prior to December 29, 2020, the Veteran's right knee meniscal tear was manifested by painful motion, flexion that was limited to, at worst, 100 degrees and normal extension even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without recurrent subluxation, lateral instability, effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 6. For the appeal period beginning on December 29, 2020, the Veteran's right knee meniscal tear was manifested by painful motion, flexion that was limited to, at worst, 100 degrees and normal extension even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without recurrent subluxation, effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum 7. For the appeal period beginning on December 29, 2020, the Veteran's right knee patellofemoral pain syndrome manifested as mild instability. 8. Throughout the period on appeal, the Veteran's left knee patellofemoral pain syndrome was manifested by painful motion, flexion that was limited to, at worst, 110 degrees and normal extension even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without recurrent subluxation, effusion, lateral instability, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 9. Throughout the period on appeal, the Veteran's residuals status post hemorrhoidectomy has not been manifested by evidence of large or thrombotic irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. 10. Throughout the appeal period, the Veteran's hearing impairment was no worse than Level II in the right ear and no worse than Level II in the left ear. 11. The Veteran is in receipt of a rating of 10 percent for tinnitus, which is the maximum schedular rating for that disability. 12. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of diabetes mellitus, type II. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date earlier than July 15, 2013 for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.155, 3.400. 2. The criteria for an initial rating in excess of 10 percent for degenerative joint disease of the thoracolumbar spine for the appeal period prior to December 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. The criteria for a rating in excess of 40 percent for degenerative joint disease of the thoracolumbar spine for the appeal period beginning on December 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 4. The criteria for an initial rating in excess of 10 percent for right knee meniscal tear for the appeal period prior to December 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.59, 4.71a, Diagnostic Code 5258. 5. The criteria for a rating in excess of 20 percent for right knee meniscal tear beginning December 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.59, 4.71a, Diagnostic Code 5258. 6. The criteria for a separate rating of 10 percent, but no higher, for right knee instability for the appeal period beginning December 29, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.71a, Diagnostic Code 5257. 7. The criteria for an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.59, 4.71a, Diagnostic Code2 5260-5261. 8. The criteria for entitlement to a compensable rating for residuals status post hemorrhoidectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.114, Diagnostic Code 7336. 9. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.85, Diagnostic Code 6100. 10. There is no legal basis for the assignment of a schedular rating in excess of 10 percent for tinnitus. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.102, 4.14.14, 4.87, Diagnostic Code 6260. 11. The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1969 to December 1970, to include service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by the Department of Veterans Affairs (VA). This case was before the Board in April 2019 and August 2019, at which times the issues currently on appeal were remanded for additional development. Specifically, Board remanded the instant matters to obtain Social Security Administration (SSA) records and to complete appropriate authorization forms to allow VA to obtain treatment records on his behalf as well as for scheduling of multiple VA examinations. Letters dated in August 2019 and July 2020 requested that the Veteran complete an Authorization to Disclose Information to VA (VA Form 21-4142) for various providers and a September 2019 response from SSA indicates there were no medical records related to the Veteran and that further efforts to obtain them would be futile. VA examinations were conducted in January 2021. The Board determines that there has been substantial compliance with its previous remands. The case has now been returned to the Board for further appellate action. In a January 2021 rating decision, the Veteran was assigned increased ratings for his service-connected thoracolumbar spine degenerative joint disease from 10 percent to 40 percent, effective December 29, 2020; right knee patellofemoral pain syndrome from 10 percent to 20 percent, effective December 29, 2020. As the Veteran is presumed to seek the maximum available benefits, those issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In the January 2021 rating decision, the agency of original jurisdiction (AOJ) also granted entitlement to service connection for right and left lower extremity radiculopathy, representing a full grant of the matters previously on appeal. Accordingly, those matters are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). In September 2020, the Veteran's private attorney withdrew representation after providing notice to the Veteran. In September 2021, the Veteran was notified of this withdrawal and advised that he could appoint another representative. To date, the record is silent as to a response from the Veteran indicating that a new representative has been appointed to assist with the present claim. Therefore, the Board will proceed with the Veteran's claim as a pro se (unrepresented) claim. Effective Date According to applicable law and regulation, except as otherwise provided, the effective date of an award of compensation based upon an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. The date of entitlement to an award of service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. a§ 3.400(b)(2)(i). The effective date of an evaluation and an award of compensation based on a reopened claim is the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(2), (r). Thus, once a previous decision has become final, the earliest effective date of service connection generally is the date of the petition to reopen rather than the date of the initial claim. Exceptions to this rule include a later grant of service connection based in whole or in part on newly obtained service department records under certain circumstances, as provided in 38 C.F.R. § 3.156(c), and when the decision is revised or reversed on the basis of clear and unmistaken error (CUE), as provided in 38 U.S.C. § 5109A(a) and 38 C.F.R. § 3.105(a). Generally, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. A rating decision becomes final and binding if the veteran does not timely perfect an appeal of the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. Previous determinations that are final and binding, including decisions regarding service connection, will be accepted as correct in the absence of collateral attack by showing the decision involved CUE. The United States Court of Appeals for the Federal Circuit recently held that the creation of VA treatment records containing new and material evidence within one year of a legacy decision may vitiate the finality of that decision, without regard to whether VA adjudicators are notified of the existence of these records within one year of the issuance of that decision. See Lang v. Wilkie, 971 F.3d 1348, (Fed. Cir. 2020). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to an effective date earlier than July 15, 2013 for the grant of entitlement to service connection for PTSD The Veteran generally asserts that an effective date earlier than July 15, 2013 is warranted for the grant of service connection for PTSD. Specific argument in support of this appeal has not been submitted. The basic facts in this case are not in dispute. The Veteran was initially denied service connection for PTSD in a September 2002 rating decision as there was no evidence of a diagnosis of PTSD. The Veteran was informed of this decision in a subsequent September 2002 letter. The Veteran did not appeal that decision or submit new evidence within the one-year period and additional relevant service records were not received at any time after the issuance of the September 2002 rating decision. 38 U.S.C. § 3.156(b), (c); Lang v. Wilkie, 971 F.3d 1348 (2020). Therefore, the September 2002 rating decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. The Veteran filed an informal claim to reopen the previously denied claim of entitlement to service connection for PTSD on July 15, 2013. The claim was granted by the RO in June 2014 decision and subsequently assigned a rating in an October 2016 rating decision, effective August 12, 2016. In a June 2018 rating decision, the RO assigned an effective date of July 15, 2013. The Veteran has not identified nor has the Board's review of the record disclosed a formal or informal claim for benefits prior to July 15, 2013 and after the AOJ's September 2002 final decision. See 38 C.F.R. §§ 3.1(p), 3.155(a). See also Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). The evidence provides no basis for an award of service connection prior to July 15, 2013. While, under the provisions of 38 C.F.R. § 3.157(b)(1), the date of outpatient or hospital examination or the date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim, the Court of Appeals for Veterans Claims (Court) has held that this regulation only applies to a defined group of claims. See Sears v. Principi, 16 Vet. App. 244, 249 (2002) (section 3.157 applies to a defined group of claims, i.e., as to disability compensation, those claims for which a report of a medical examination or hospitalization is accepted as an informal claim for an increase of a service-connected rating where service connection has already been established). VA medical records cannot be accepted as informal claims for disabilities where service connection has not been established. The mere presence of medical evidence does not establish intent on the part of the Veteran to seek service connection for a condition. See Brannon v. West, 12 Vet. App. 32, 35 (1998). Merely seeking treatment does not establish a claim, to include an informal claim, for service connection. Thus, any record of VA treatment for the Veteran's PTSD during this period also cannot constitute a request to reopen a claim for service connection. Based on the analysis above and after reviewing the totality of the evidence, the Board finds that the effective date for the grant of service connection for a PTSD has been appropriately assigned as the date of the claim to reopen after the final disallowance of the claim, i.e., July 15, 2013. See 38 C.F.R. § 3.400(r). The Board is precluded by law from assigning effective dates prior to July 15, 2013 for the grant of service connection for PTSD. Accordingly, the preponderance of the evidence is against the claim for an effective date prior to July 15, 2013 for the award of service connection for PTSD, and, as such, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Increased Rating Claims 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. 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. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). 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.").] VA amended the criteria for rating musculoskeletal disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the Agency of Original Jurisdiction (AOJ) on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. As there is no evidence submitted subsequent to the effective date of the revised diagnostic criteria, the revised diagnostic criteria are not applicable to the instant claim. The Board also notes that the former and revised criteria under Diagnostic Code 5237 are identical. Thoracolumbar Degenerative Joint Disease The Veteran generally asserts that he should have higher ratings for his thoracolumbar degenerative joint disease as it is worse than contemplated by the currently assigned ratings. Specific argument in support of this appeal has not been submitted. At the outset, the Board acknowledges that the Veteran is in receipt of separate ratings for, in pertinent part, lumbar spine scars, as well as right and left lower extremity radiculopathy. These disabilities, and their assigned ratings, are not currently before the Board on appeal. Therefore, those ratings will not be discussed in this decision. This appeal stems from a claim dated in March 2012. During the period on appeal, the Veteran's thoracolumbar degenerative joint disease is rated 10 percent prior to December 29, 2020, and 40 percent thereafter under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Regulations specify that disabilities of the spine should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (Spinal Formula). 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. When intervertebral disc syndrome (IVDS) is present, it is to be evaluated under the Spinal Formula unless it is more favorable to rate under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula). Ratings under the Spinal Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. As relevant to the thoracolumbar spine, the General Rating Formula provides for a 10 percent rating when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, when the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, or when muscle spasm, guarding or localized tenderness is not severe enough to result in an abnormal gait or abnormal spinal contour. A 20 percent rating when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or when muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is assigned with unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is to 90 degrees and the normal combined range of motion is 240 degrees. Id., Note (2). Associated objective neurologic abnormalities should be rated separately under an appropriate diagnostic code. Id., Note (1). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Alternatively, the IVDS Formula provides for rating based on the total duration of incapacitating episodes. 38 C.F.R. § 4.71a, IVDS Formula. Incapacitating episodes are defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id., Note (1). There is no evidence that the Veteran experiences incapacitating episodes. In this regard, the July 2012, May 2017, June 2018 and December 2020 examiners reported that the Veteran did not experience IVDS of the thoracolumbar spine and the Veteran does not contend otherwise. In July 2012, the Veteran was afforded a VA examination. At that time, the examiner reported that the Veteran had a diagnosis of thoracolumbar arthritis, which was first diagnosed in 1999. The Veteran indicated that he experienced flare-ups that impacted his ability to walk and run. On range of motion testing, the Veteran demonstrated forward flexion to 90 degrees, with pain at 75 degrees; extension to 15 degrees, with pain at 15 degrees; right and left lateral flexion to 15 degrees, with pain at 15 degrees; and right and left lateral rotation to 20 degrees, with pain at 15 degrees. There was no additional functional loss following repetitive-use testing or during flare-ups. The examiner noted that range of motion was productive of weakened movement, excess fatigability and pain on movement. On examination, there was evidence localized tenderness and pain to palpation. Muscle strength testing showed normal hip flexion; active movement against gravity with right and left knee extension; active movement with gravity eliminated with right ankle plantar flexion; active movement against gravity with left ankle plantar flexion; and active movement with some resistance with right and left ankle dorsiflexion and great toe extension. There was no evidence of atrophy or ankylosis. Reflex and sensory examinations were normal. There was no evidence of radiculopathy or other neurological impairments. There was no evidence of IVDS. The Veteran reported regular use of a cane for assistance with ambulation. The examiner reported that the Veteran's lower back disability did not impact his ability to work. At a May 2017 VA examination, the Veteran reported that he experienced on and off back pain. He indicated that he did not use medication to treat back pain. The Veteran reported that flare-ups limited activities. On range of motion testing, the Veteran demonstrated forward flexion to 80 degrees; extension to 20 degrees; right and left lateral flexion to 25; and right and left lateral rotation to 30 degrees. Pain was noted with each range of motion measurement. The examiner noted that range of motion did not contribute to functional loss. On examination, there was no evidence of pain with weight-bearing, or of localized tenderness and pain to palpation. There was no additional functional loss following repetitive-use testing or during flare-ups. The examiner reported that he was unable to say without resorting to speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time and during flare-ups. The examiner noted that the Veteran's lumbar spine disorder was productive of less movement than normal, disturbances of locomotion, as well as interference with standing and sitting. Muscle strength testing was normal and there was no evidence of ankylosis or atrophy. Reflex and sensory examinations were normal. There was no evidence of radiculopathy or other neurological impairments. The Veteran reported that he did not use any devices for assistance with locomotion. There was no evidence of IVDS. The examiner reported that the Veteran's lower back disability impacted his ability to work in that he had to avoid prolonged walking and standing. At a June 2018 VA examination, the Veteran reported that his lumbar spine disorder had worsened and that he used over-the-counter and prescription medication to alleviate pain. The Veteran indicated that he experienced sharp pain, shooting pain, numbness, tingling, burning and discomfort. He reported experiencing flare-ups of intermittent severe back pain that lasted several hours in duration. With regard to functional loss, the Veteran stated that he experienced back pain following prolonged walking and standing. On range of motion testing, the Veteran demonstrated forward flexion to 75 degrees; extension to 20 degrees; right and left lateral flexion to 25; and right and left lateral rotation to 30 degrees. The examiner noted pain on each range of motion measurement but indicated hat that range of motion did not contribute to functional loss. On examination, there was evidence localized tenderness and pain to palpation. There was no evidence of pain with weight-bearing. There was no additional functional loss following repetitive-use testing or during flare-ups. The examiner reported that he was unable to say without resorting to speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time and during flare-ups. Muscle strength testing was normal and there was no evidence of ankylosis or atrophy. Reflex and sensory examinations were normal. There was no evidence of radiculopathy or other neurological impairments. The Veteran reported that he did not use any devices for assistance with locomotion. There was no evidence of IVDS. The examiner reported that the Veteran's lower back disability impacted his ability to work in that he had to avoid prolonged walking and standing, as well as with bending and lifting. At a December 2020 VA examination, the Veteran reported that his lumber spine disorder had worsened and that he experienced lower back pain that radiated to his legs. The Veteran denied flare-ups. With regard to functional loss, the Veteran stated that he experienced back pain following prolonged walking, sitting and standing. On range of motion testing, the Veteran demonstrated forward flexion to 30 degrees; extension to 10 degrees; right and left lateral flexion to 15; and right and left lateral rotation to 20 degrees. Pain was noted on forward flexion that resulted in functional loss. The examiner noted that range of motion contributed to functional loss in that the Veteran experienced staggering gait during range of motion testing. On examination, there was evidence localized tenderness and pain to palpation. There was evidence of pain with weight-bearing. The examiner noted that the Veteran was unable to perform repetitive-use testing due to fear of pain. The examiner reported that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time. The examiner estimated that range of motion following repeated use over time resulted in forward flexion to 20 degrees; extension to 10 degrees; right and left lateral flexion to 15; and right and left lateral rotation to 20 degrees. There was evidence of muscle spasm and guarding that resulted in abnormal gait or abnormal spinal contour. On muscle strength testing, the Veteran demonstrated active movement against some resistance with right and left hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. There was no evidence of atrophy or ankylosis. Reflex examination was normal. Sensory examination revealed normal right and left upper anterior thigh, and right and left thigh/knee, lower leg/ankle, and foot/toes decreased sensation. Straight leg testing was positive. The examiner reported that the Veteran experienced moderate constant pain, moderate paresthesia and/or dysesthesias, and numbness but no intermittent pain of the right and left lower extremities. The examiner reported that the overall severity of the Veteran's right and left lower extremity radiculopathy associated with the sciatic nerve was moderate. There was no evidence of other neurological impairments. There was no evidence of IVDS. The Veteran reported regular use of a cane for assistance with ambulation. The examiner reported that the Veteran's lower back disability impacted his ability to work in that he experienced pain following prolonged walking, sitting and standing. A review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities. However, there is no indication from the record that his lower back disability symptoms are manifestly different than those reported at the above-mentioned examinations. Upon review, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's thoracolumbar degenerative joint disease for the period on appeal prior to December 29, 2020. In that regard, a review of the record does not contain objective evidence that the Veteran experienced forward flexion worse than 75 degrees. Moreover, the combined range of motion has been shown to be, at worst, 205 degrees. Further, during this period on appeal there were no signs that the Veteran's lower back disorder was productive of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, and no incapacitating episodes were noted. The currently assigned 10 percent rating accurately reflects the Veteran's pain on movement of his lumbar spine, to include during flare-ups and after repetitive use over time. To that end, the July 2012, May 2017 and June 2018 examiners indicated that range of motion did not contribute to functional loss, and there was no evidence of additional loss of function or range of motion following repetitive-use or during flare-ups. Moreover, treatment notes reflect increased pain during flare-ups but there is no evidence that such pain was severe enough to result in forward flexion to 60 degrees or less, or a combined range of motion to 120 degrees or less. Here, the VA treatment records and VA examinations do not reveal additional functional impairment, including additional limitation of motion, on account of pain, weakness, etc, that is not already contemplated by the assigned 10 percent rating. 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, supra. Thus, a higher rating is not warranted for the Veteran's lower back disorder even in consideration of painful motion and other factors such as weakness, fatigability, lack of endurance, and incoordination. Moreover, there was no ankylosis. Therefore, a rating in excess of 10 percent prior to December 29, 2020 is not warranted. Next, the Board finds that a rating in excess of 40 percent is not warranted for the Veteran's thoracolumbar degenerative joint disease throughout the period on appeal. In this regard, there is no indication from the record that the Veteran has ankylosis of the thoracolumbar spine and the Veteran has not alleged such ankylosis. Therefore, a higher rating is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Moreover, when the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, 38 C.F.R. §§ 4.40 and 4.45 are not for application. Johnston v. Brown, 10 Vet. App. 80 (1997). With regard to disabilities of the spine, VA is to evaluate any associated objective neurologic abnormalities under appropriate diagnostic criteria. See Note (1) of the General Rating Formula. In this regard, while the Veteran has been awarded separate ratings for, in pertinent part, right and left lower extremity radiculopathy, and those ratings are not before the Board. The Board finds that his thoracolumbar degenerative joint disease does not result in any additional associated objective neurologic abnormalities, to include bladder or bowel incontinence. In this regard, neurologic abnormalities or findings related to the thoracolumbar degenerative joint disease such as bowel or bladder problems were not found on the various objective examinations of record. Therefore, absent evidence of objective neurologic abnormalities of bladder or bowel incontinence associated with the lumbar spine disorder, the Board finds that separate ratings for such conditions are not warranted. The Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, several VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The Board notes that the VA examinations did not test the opposite joint; however, the spine does not have an opposite joint. Although the June 2018 VA examination as well as the earlier examinations did not address passive range of motion, the Board notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Therefore, although the Board notes that the June 2018 VA examination as well as earlier examinations did not complete all the testing required under Correia v. McDonald, supra, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. Moreover, July 2012, May 2017 and June 2018 examiners indicated that range of motion did not contribute to functional loss, and there was no evidence of additional loss of function or range of motion following repetitive-use or during flare-ups. Therefore, the examinations of record are adequate for VA purposes. In reaching its conclusions, the Board acknowledges the Veteran's belief that his thoracolumbar degenerative joint disease is more severe than as reflected by the currently assigned ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his reports regarding the severity of his thoracolumbar degenerative joint disease. The Board has also considered whether further staged ratings under Fenderson v. West, 12 Vet. App. 119 (1999) are appropriate for the Veteran's service-connected thoracolumbar degenerative joint disease; however, the Board finds that his symptomatology has otherwise been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disability is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In this case, the preponderance of the evidence is against ratings in excess of 10 percent rating prior to December 29, 2020 and in excess of 40 percent thereafter, for the Veteran's thoracolumbar degenerative joint disease and the claims must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Right and Left Knees The Veteran generally asserts that he should have higher ratings for his right knee meniscal tear and left knee patellofemoral syndrome as each is worse than contemplated by the currently assigned ratings. Specific argument in support of these appeals has not been presented. At the outset, the Board acknowledges that the Veteran is in receipt of a separate rating for, in pertinent part, a right knee scar. This disability, and its assigned rating, is not currently before the Board on appeal. Therefore, that rating will not be discussed in this decision. The appeals stem from claims dated in March 2012. During the period on appeal, the Veteran's right knee patellofemoral syndrome is rated 10 percent prior to December 29, 2020 and 20 percent thereafter under 38 C.F.R. § 4.71a, Diagnostic Code 5258. His left knee patellofemoral syndrome is rated 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5260. 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), lateral instability or 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 zero 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). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can be assigned when the 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 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that she has tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. The Board acknowledges that at the April 2017 VA examination, the examiner reported that the Veteran had experienced shin splints. However, the examiner noted that the Veteran had no current shin splint symptoms, and the Veteran reported that he had not experienced shin splints since service. As such, those diagnostic codes are not for application. Turning to the evidence, the Veteran was afforded a VA examination in July 2012. At that time, the examiner diagnosed right knee meniscal tear and right and left knee patellofemoral syndrome. The Veteran reported that he experienced flare-ups that resulted in difficulty with walking and running. On range of motion testing, the Veteran demonstrated right knee flexion to 100 degrees and zero degrees of extension. The Veteran demonstrated left knee flexion to 110 degrees and zero degrees of extension. There was no evidence of painful motion on flexion or extension. The examiner reported that range of motion did not contribute to functional loss in the left knee, and that it contributed to functional loss in the right knee in that it resulted in less movement than normal, weakened movement, excess fatigability, and pain on movement. There was no evidence that the Veteran experienced additional functional loss following repetitive-use or during flare-ups. On examination, there was no evidence of bilateral knee localized tenderness and/or pain on palpation of the joint line. On muscle strength testing, the Veteran demonstrated active movement against gravity with right and left knee flexion and extension. The medial/lateral collateral ligaments stability test, anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all within normal limits. The examiner reported that the Veteran did not have ankylosis, and there was no objective evidence of subluxation or lateral instability, a semilunar cartilage condition, or recurrent patellar dislocation. The Veteran reported regular use of a cane for assistance with ambulation. With regard to functional impairment, the examiner reported that the Veteran's bilateral knee disabilities did not impact his ability to work. At a May 2017 VA examination, the Veteran reported that he experienced off and on right knee pain and indicated that his left knee did not bother him much. The Veteran reported flare-ups consisting of increased right knee pain and swelling. On range of motion testing, the Veteran demonstrated right knee flexion to 130 degrees and zero degrees of extension. The Veteran demonstrated left knee flexion to 140 degrees and zero degrees of extension. There was no evidence of painful motion on flexion. The examiner reported that range of motion did not contribute to functional loss. There was no evidence of bilateral knee localized tenderness and/or pain on palpation of the joint line, pain with weight bearing, or crepitus. There was no evidence that the Veteran experienced additional functional loss following repetitive-use or during flare-ups. The examiner reported that he was unable to say without resorting to speculation whether pain, weakness, fatigability or incoordination significantly limited right knee functional ability with repeated use over time and during flare-ups. Muscle strength testing was normal. The medial/lateral collateral ligaments stability test, anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all within normal limits. The examiner reported that the Veteran did not have ankylosis or atrophy, and there was no objective evidence of subluxation or lateral instability. The examiner reported that the Veteran had a right knee meniscus condition that was productive of frequent episodes of joint pain. The Veteran reported that he did not use and devices for assistance with ambulation. With regard to functional impairment, the examiner reported that the Veteran's bilateral knee disabilities did not impact his ability to work. At a June 2018 VA examination, the Veteran reported that his bilateral knee disability was productive of aching pain, popping and swelling. He stated that he treated his symptoms with prescription pain medication and heating pads. The Veteran reported occasional flare-ups productive of moderate to severe pain that lasted several hours in duration. The Veteran indicated that he experienced difficulty with prolonged sitting, walking and standing. On range of motion testing, the Veteran demonstrated right knee flexion to 120 degrees and zero degrees of extension. The Veteran demonstrated left knee flexion to 125 degrees and zero degrees of extension. There was no evidence of painful motion on flexion or extension of the right knee, and there was evidence of painful motion on flexion and extension of the left knee. The examiner reported that range of motion did not contribute to functional loss. There was no evidence that the Veteran experienced additional functional loss following repetitive-use or during flare-ups. There was no evidence of bilateral knee localized tenderness and/or pain on palpation of the joint line, pain with weight bearing, or crepitus. The examiner reported that he was unable to say without resorting to speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time and during flare-ups. Muscle strength testing was normal. The medial/lateral collateral ligaments stability test, anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all within normal limits. The examiner reported that the Veteran did not have ankylosis or atrophy, and there was no objective evidence of subluxation or lateral instability. There was evidence of bilateral knee recurrent patellar dislocation that did not affect range of motion of the knee or ankle. The examiner reported that the Veteran had a right knee meniscus condition productive of meniscal tear, and frequent episodes of joint locking and pain. The Veteran indicated that his right knee locks approximately once every 2 to 3 months. The Veteran reported occasional use of a brace for assistance with ambulation. With regard to functional impairment, the examiner reported that the Veteran's bilateral knee disabilities impacted his ability to work in that he was unable to stand or walk for prolonged periods of time. At a December 2020 VA examination, the Veteran reported that he experienced right knee pain at a 5 out of 10 on a 1-10 scale, with 10 being the most severe pain. He indicated that his right knee occasionally gives out and stated that his knee gave out a couple weeks prior causing him to fall. He reported that he did not experience any problems with his left knee. The Veteran denied flare-ups. He indicated that he was unable to stand or walk for prolonged periods of time due to right knee pain. On range of motion testing, the Veteran demonstrated right knee flexion to 110 degrees and zero degrees of extension. The Veteran demonstrated left knee flexion to 130 degrees and zero degrees of extension. Pain was noted with right and left knee flexion. The examiner reported that range of motion contributed to right knee functional loss in that the Veteran had difficulty with flexion. With regard to the right knee, there was evidence of localized tenderness and/or pain on palpation of the joint line, pain with weight bearing, and crepitus. With regard to the left knee, there was evidence of localized tenderness and/or pain on palpation of the joint line, and no evidence of pain with weight bearing, or crepitus. With regard to the right knee, the examiner reported that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time. Following repeated use over time testing, the Veteran demonstrated right knee flexion to 100 degrees and zero degrees of extension. There was no evidence that the Veteran experienced additional functional loss related to his left knee following repetitive-use or during flare-ups. On muscle strength testing, the Veteran demonstrated active movement against gravity with right and left knee flexion and extension. The medial/lateral collateral ligaments stability test, anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all within normal limits. The examiner reported that the Veteran did not have ankylosis or atrophy, and there was no objective evidence of subluxation or lateral instability. There was no evidence of recurrent patellar dislocation. The examiner reported that the Veteran had a right knee meniscus condition productive of meniscal tear, and frequent episodes of joint locking, effusion and pain. The Veteran reported regular use of a cane for assistance with ambulation. With regard to functional impairment, the examiner reported that the Veteran's bilateral knee disabilities impacted his ability to work in that he was unable to stand or walk for prolonged periods of time. A review of the record shows that the Veteran receives treatment at the VA Medical Center as well as private providers for various disabilities. However, there is no indication from the record that his right and left knee symptoms are manifestly different than those reported at above-mentioned examinations. Right Knee Analysis The Veteran has right knee meniscal tear and is currently assigned a 10 percent rating prior to December 29, 2020 and a 20 percent rating thereafter under Diagnostic Code 5258. Based on a review of the evidence, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent under Diagnostic Code 5258 prior to December 29, 2020. As for the period on appeal beginning December 29, 2020, the Board notes that the 20 percent rating is the highest schedular rating available under this diagnostic code. Therefore, the Board will consider whether higher or separate ratings are available under other potential diagnostic codes. As noted above, right knee range of motion testing was performed during VA examinations in July 2012, May 2017, June 2018 and December 2020, and the Veteran was shown to have, at worst, 100 degrees of flexion and zero degrees of extension. However, the evidence does not show that the Veteran would be entitled to the next higher 20 or 30 percent ratings for the respective appeal periods. In this regard, the reports do not suggest that the specific findings on examination and throughout the period on appeal, in terms of range of motion, would change to the degree required for an even higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. With regard to the period prior to December 29, 2020, the July 2012, May 2017 and June 2018 VA examiners reported that the Veteran did not experience additional functional loss following repetitive-use or during flare-ups. Therefore, Board finds that such factors do not result in functional loss more nearly approximating flexion limited to 45 degrees or extension limited to 20 degrees in the right knee. See DeLuca v. Brown, supra; Mitchell v. Shinseki, supra. With regard to the period beginning December 29, 2020, the Veteran denied right knee flare-ups and flexion was measured to, at worst, 100 degrees following repetitive use. Therefore, such range of motion findings, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination or as a result of repetitive motion and/or flare-ups, do not meet the requirements for a compensable rating under Diagnostic Code 5260 or 5261. Additionally, the Board notes that assigning separate ratings based on limitation of motion, in addition to the currently assigned 20 percent rating under Diagnostic Code 5258, is tantamount to pyramiding. In this regard, the Court held that rating a knee disability under Diagnostic Codes 5257 or 5260/5261 or both, does not, as a matter of law, preclude the assignment of a separate rating for a meniscal disability of the same knee under Diagnostic Code 5258 or 5259, or vice versa. Lyles v. Shulkin, 29 Vet. App. 107 (2017). However, the Board finds that Diagnostic Code 5258 and Diagnostic Code 5260/5261 both are rated based on limitation of motion and knee pain, as a cause of limitation of motion. In the case of Diagnostic Code 5258, limitation of motion is reflected by the symptoms or findings of pain, locking, and effusion into the joint. In the case of Diagnostic Code 5260/5261, such limitation of motion is encompassed by the limitation of flexion or extension, as applicable, including limitation of motion due to pain. Both Diagnostic Codes overlap in "locking" as a form of limitation of motion that is usually accompanied by pain. Thus, both are rated based on knee pain and limitation of motion due to pain. Thus, to assign separate ratings under Diagnostic Code 5258 and Diagnostic Code 5260/5261 would compensate the Veteran twice for the same symptomatology, which would result in impermissible pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Therefore, as the Veteran is in receipt of the 10 and 20 percent ratings pursuant to Diagnostic Code 5258, the Board finds that the Veteran would not be entitled to a higher rating pursuant to Diagnostic Code 5260 or 5261 for the reasons stated above. Next, the Board has also analyzed the currently assigned separate 10 percent rating under Diagnostic Codes 5257, and if this assignment along with the 10 and 20 percent assignments under Diagnostic Code 5258 violates the rule against pyramiding. Diagnostic Code 5258 contemplates dislocation, effusion, and locking of the knee while Diagnostic Code 5257 pertains to knee instability and subluxation. The evaluation of the same disability or the same manifestations under various diagnoses is prohibited. 38 C.F.R. § 4.14; Lyles v. Shulkin, supra. Moreover, the Board notes that that every symptom contemplated by Diagnostic Code 5258 (dislocated semilunar cartilage, episodes of locking, and effusion in the joint) is distinct and separate from the criteria for a rating under Diagnostic Codes 5257, which contemplate instability of the knee. Separate ratings under Diagnostic Code 5257 and 5258 are therefore permissible in this instance and do not amount to impermissible pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, supra; VAOPGCPREC 9-2004. Resolving reasonable doubt in the Veteran's favor, the Board will award a separate 10 percent rating for slight right knee instability under Diagnostic Code 5257 beginning December 29, 2020, the date of the VA examination and earliest date from which it is factually ascertainable that the Veteran experienced slight right knee instability. In this regard, the December 2020 VA examination report shows complaints of left knee giving way, and he indicated that he recently fell. Prior to this date, there are no complaints of right knee instability or evidence of suck on examination. The Board finds that a next-higher 20 percent rating is not warranted. To that end, there are specific objective tests that are designed to reveal instability and laxity of the joints. These tests were administered by a medical professional during July 2012, May 2017, June 2018 and December 2020 VA examinations, and the testing revealed no instability or laxity. Given the objective testing performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value. If subluxation or lateral instability were present to a moderate degree, as required for a 20 percent rating, the Board would expect that this would have been identified during the multiple tests that were performed. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257. Therefore, the most probative evidence is against a separate rating prior to December 29, 2020 or for a rating in excess of 10 percent beginning December 29, 2020 under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or additional separate rating under 5259, 5256, 5262, or 5263, respectively, for his right knee meniscal tear. Moreover, the Board notes that a higher rating under Diagnostic Code 5258 prior to December 29, 2020 is not warranted, as there is no evidence prior to this date that the Veteran experienced frequent episodes of locking, pain and effusion into the joint. To that end, there is no evidence prior to December 29, 2020 that the Veteran experienced effusion into the joint. The Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. In this case, several VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The Board notes that the Veteran is service connected for both the left and right knees; therefore, there is not an undamaged joint to test. Although the June 2018 VA examination as well as the earlier examinations did not address passive range of motion, the Board notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, supra; Robinson v. Peake, supra; Scott v. McDonald, supra. Therefore, although the Board notes that the June 2018 VA examination as well as earlier examinations did not complete all the testing required under Correia v. McDonald, supra, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. Moreover, July 2012, May 2017 and June 2018 examiners indicated that range of motion did not contribute to functional loss, and there was no evidence of additional loss of function or range of motion following repetitive-use or during flare-ups. Therefore, the examinations of record are adequate for VA purposes. The Board acknowledges the Veteran's statement that his right knee meniscal tear is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds, however, that neither the Veteran's statements nor medical evidence demonstrates that the criteria for higher ratings have been met. The Board also acknowledges that the Veteran's VA treatment records and private treatment records note complaints of and treatment for his right knee disability. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether further staged ratings under Hart v. Mansfield, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the periods on appeal. Therefore, assigning additional staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. As noted above, a separate 10 percent rating, but no higher, is warranted for right knee instability beginning December 29, 2020. The preponderance of the evidence is against a rating in excess of 10 percent prior to December 29, 2020 and in excess of 20 percent beginning December 29, 2020 for his right knee meniscal tear and the claims must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Left Knee Analysis As noted above, left knee range of motion testing was performed during VA examinations in July 2012, May 2017, June 2018 and December 2020, and the Veteran was shown to have, at worst, 110 degrees of flexion and zero degrees of extension. The reports do not suggest that the specific findings on examination and throughout the period on appeal, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's statements. In this regard, the record does not show greater functional loss following repetitive use and during flare-ups. Therefore, Board finds that such factors do not result in functional loss more nearly approximating flexion limited to 45 degrees or extension limited to 15 degrees in the left knee. See DeLuca v. Brown, supra; Mitchell v. Shinseki, supra. While the Veteran has essentially stated that he has reduced motion in his left knee, he has not described a range of motion less than that found of record. In this regard, he reported that he experienced pain and tenderness, as well as difficulty with prolonged walking and standing. The Veteran's statements do not show the requisite limitation of motion necessary for higher or additional separate ratings. Treatment records do not show greater limitations of motion than the above examination findings. Given the above, even when considering the left knee pain's impact on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. With respect to Diagnostic Code 5257, the Board finds that an additional separate rating is not warranted for instability of the left knee. 38 C.F.R. § 4.71a. In this regard, there are specific objective tests that are designed to reveal instability and laxity of the joints. These tests were administered by a medical professional during July 2012, May 2017, June 2018 and December 2020 VA examinations, and the testing revealed no instability or laxity. Given the objective testing performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value. If subluxation or lateral instability were present to a slight degree, as required for a separate compensable rating, the Board would expect that this would have been identified at least once during the multiple tests that were performed or by the Veteran himself during examination. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257. Instead, the examiners stated that there was no history of left knee recurrent subluxation and lateral instability and that joint testing revealed no instability. Therefore, the most probative evidence is against a separate rating for the left knee under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to demonstrate a meniscus injury, ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or additional separate rating under 5258, 5259, 5256, 5262, or 5263, respectively, for his left knee disorder. The Board acknowledges the Veteran's statement that his left knee disability is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statements nor medical evidence demonstrates that the criteria for a rating in excess of 10 percent have been met. The Board also acknowledges that the Veteran's VA treatment records and private treatment records note complaints of and treatment for his left knee disability. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. In this case, several VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The Board notes that the Veteran is service connected for both the left and right knees; therefore, there is not an undamaged joint to test. Although the June 2018 VA examination as well as the earlier examinations did not address passive range of motion, the Board notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, supra; Robinson v. Peake, supra; Scott v. McDonald, supra. Therefore, although the Board notes that the June 2018 VA examination as well as earlier examinations did not complete all the testing required under Correia v. McDonald, supra, the range of motion findings are still the most probative evidence concerning the Veteran's functional limitation at such times. Moreover, July 2012, May 2017 and June 2018 examiners indicated that range of motion did not contribute to functional loss, and there was no evidence of additional loss of function or range of motion following repetitive-use or during flare-ups. Therefore, the examinations of record are adequate for VA purposes. The Board has considered whether a staged rating under Hart v. Mansfield, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. In this case, the preponderance of the evidence is against ratings in excess of 10 percent for left knee patellofemoral syndrome and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Residual Status Post Hemorrhoidectomy The Veteran generally asserts that he should have a higher rating for his residual status post hemorrhoidectomy as his disability is worse than contemplated by the currently assigned rating. Specific argument in support of this appeal has not been submitted. This appeal stems from a claim dated in March 2014. During the period on appeal, the Veteran's residuals status post hemorrhoidectomy is rated noncompensable under Diagnostic Code 7336. Under Diagnostic Code 7336, a noncompensable rating is assigned for mild or moderate hemorrhoids; a 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences; and a 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia or with fissures. The maximum rating permitted for hemorrhoids is 20 percent. 38 C.F.R. § 4.114, Diagnostic Code 7336. Turning to the evidence, the Veteran was afforded a VA examination in September 2018. At that time, the examiner noted that the Veteran underwent a hemorrhoidectomy in 1972. The Veteran reported that he experienced painful hemorrhoids and that he was undergoing banding treatment. He indicated that he also used stool softener to alleviate hemorrhoid pain. On examination, the examiner reported that the Veteran experienced moderate external hemorrhoids. The examiner indicated that the Veteran's hemorrhoids impacted his ability to work in that he could not perform occupations that required prolonged sitting. No other pertinent findings were noted. Based on the evidence of record, the Board finds that a compensable rating residual status post hemorrhoidectomy is not warranted. The record does not establish, and the record does note establish, hemorrhoids that are large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences, persistent bleeding, secondary anemia or fissures. Therefore, a compensable rating is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7336. The Board acknowledges the Veteran's statement that his residual status post hemorrhoidectomy is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statements nor medical evidence demonstrates that the criteria for a compensable rating have been met. The Board also acknowledges that the Veteran's VA treatment records and private treatment records note complaints of and treatment for his residual status post hemorrhoidectomy. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether a staged rating under Hart v. Mansfield, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. In this case, the preponderance of the evidence is against a compensable rating for residuals status post hemorrhoidectomy and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Bilateral Hearing Loss The Veteran generally asserts that he should have a higher rating for his bilateral hearing loss as his disability is worse than contemplated by the currently assigned rating. Specific argument in support of this appeal has not been submitted. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second. To rate the degree of disability for service-connected hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. The Veteran asserts that he should have a compensable rating for his bilateral hearing loss because his disability is worse than contemplated by the currently assigned rating. A July 2012 VA audiological evaluation was conducted. At that time, the examiner noted that the Veteran's hearing loss included difficulty hearing conversations and having to turn volumes up on listening devices. Audiological testing results at that time were as follows: Hertz 1000 2000 3000 4000 Average Right Ear 30 50 75 85 60 Left Ear 30 45 55 60 48 Speech recognition ability was 94 percent in the right ear and 100 percent in the left ear. The examiner diagnosed bilateral hearing loss. Applying those values to the rating criteria results in a numeric designation of Level II in the right ear and Level I in the left ear. 38 C.F.R. § 4.85, Table VI. Application of the levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 produces a noncompensable rating. An exceptional pattern of hearing loss was not shown. 38 C.F.R. § 4.86. A September 2018 VA audiological evaluation was conducted. At that time, the examiner noted that the Veteran's hearing loss included difficulty hearing conversations and that the Veteran often spoke loudly. Audiological testing results at that time were as follows: Hertz 1000 2000 3000 4000 Average Right Ear 40 65 85 85 69 Left Ear 35 55 70 75 59 Speech recognition ability was 96 percent in each ear. The examiner diagnosed bilateral hearing loss. Applying those values to the rating criteria results in a numeric designation of Level II in the right ear and Level II in the left ear. 38 C.F.R. § 4.85, Table VI. Application of the levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 produces a noncompensable rating. An exceptional pattern of hearing loss was not shown. 38 C.F.R. § 4.86. In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The July 2012 and September 2018 VA examiners reported that the Veteran's hearing loss did not impact ordinary conditions of daily life. Therefore, the Board finds that the audiology evaluation reports are in compliance with the requirements of Martinak. The Board also finds that the Veteran is not entitled to a compensable rating for his bilateral hearing loss. There is no indication from the record that the Veteran's hearing impairment was worse than Level II in the right ear or Level II in the left ear. 38 C.F.R. § 4.86. The result of the Veteran's VA examination falls within the schedular criteria for, at worst, a noncompensable rating. Therefore, the criteria for an initial compensable rating have not been met. 38 C.F.R. § 4.85, Diagnostic Code 6100. To the extent that the Veteran and contends that his hearing loss is more severe than currently evaluated during any period on appeal, the Board observes that the Veteran, while competent to report symptoms, is not competent to report that his hearing acuity is of sufficient severity to warrant higher evaluations under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that the remainder of his symptomatology has been stable throughout the appeal. Therefore, assigning a staged rating is not warranted. In Doucette v. Shulkin, 28 Vet. App. 366 (2017), the Court held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday environment as these are the effects that VA's audiometric tests are designed to measure. The Veteran has not otherwise described functional effects that are considered exceptional or, that are not otherwise contemplated by the assigned rating. Id. Thus, his complete disability picture is compensated under the rating schedule. Further, neither he nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. Id. (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds that the preponderance of the evidence is against the claims of entitlement to a compensable rating for bilateral hearing loss. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Tinnitus The Veteran generally asserts that his service connected tinnitus warrants a higher rating. Specific argument in support of this appeal has not been submitted. The Veteran was granted entitlement to service connection for tinnitus in a January 2016 rating decision and assigned a 10 percent rating, effective August 20, 2015 under Diagnostic Code 6260. 38 C.F.R. § 4.87. Diagnostic Code 6260 provides a maximum disability rating of 10 percent for tinnitus, whether the ringing is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260; see also Smith v. Nicholson, 451 F.3d 1344, 1350 (Fed. Cir. 2006). As there is no adequate legal basis upon which to award a rating in excess of 10 percent for tinnitus, the Veteran's claim for a higher schedular rating must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 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; 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, such as diabetes mellitus, type II. 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). Further, the veteran was presumed to have been exposed to herbicide agents while serving in the Republic of Vietnam. VA laws and regulations provide that if a veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) lists the diseases covered by the regulation. The Secretary of VA has determined that there is no positive association between exposure to herbicide agents and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32, 395-32, 407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21, 260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). Diabetes Mellitus The Veteran generally asserts that he has diabetes mellitus that is related to his period of active service, to include in-service herbicide agent exposure or secondary to service-connected disabilities. In his August 2016 VA Form 21-526EZ (Application for VA disability benefits), the Veteran indicated that he was applying for VA benefits related to diabetes mellitus, type II. The application did not contain any additional detail with regard to his claimed diabetes. The Veteran's service treatment records are unremarkable for any complaints of, treatment for, or diagnosis of a diabetes during active service. In his December 1970 separation examination report, clinical evaluation revealed no abnormalities of the endocrine system. A review of the Veteran's post-service medical records shows no diagnosis or treatment for diabetes mellitus. In December 2020, the Veteran was afforded a VA examination with regard to the etiology of any currently present diabetes mellitus. At that time, the Veteran reported that he had never been diagnosed with diabetes mellitus, type II. The Veteran indicated he did not experience any symptoms attributable to diabetes mellitus. Following examination, the examiner reported that the Veteran did not have a diagnosis of diabetes mellitus and that the Veteran did not experience functional impairment related to diabetes mellitus. As the record does not reflect a current diagnosis related to diabetes mellitus the cornerstone element of service connection has not been met, and service connection is not warranted. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). No further discussion of the remaining elements is necessary. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of diabetes mellitus. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). Moreover, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). In reaching this determination, the Board has also considered the lay assertions of record, including the contentions of the Veteran in support of a medical nexus. The Veteran contends that his diabetes mellitus, type II is due to his service. As a lay person, the Veteran is competent to report observable symptoms. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability"); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology); Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent on a variety of matters concerning the nature and cause of disability. Jandreau, 492 F.3d at 1377 n.4. However, while the Veteran is competent to report having experienced symptoms of dizziness or thirst, he is not competent to opine on the etiology of the condition and/or to determine that these symptoms are somehow related to his active service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Therefore, as the preponderance of the evidence is against the Veteran's claim for service connection for diabetes mellitus, type II, the Board finds that the Veteran's claim must be denied. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND The Board finds that additional information is required before the remaining claims on appeal are decided. Service Connection Erectile Dysfunction The Veteran asserts that his diagnosed erectile dysfunction is the result of service in his August 2016 Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ). A January 2021 VA examiner opined that it was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected thoracolumbar arthritis as no recent Magnetic Resonance Imaging (MRI) scan was noted to detect compression of the cauda equina nerve that might lead to erectile dysfunction. However, the examiner did not address whether the Veteran's erectile dysfunction was aggravated by his service-connected thoracolumbar arthritis. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Moreover, the examiner did not provide an opinion related to service connection on a direct basis. See 38 C.F.R. § 3.303. Therefore, the Board finds that an additional medical opinion is warranted to address the nature and etiology of his erectile dysfunction. Cervical Spine The Veteran asserts that he has a cervical spine disorder as a result of his active duty service. At a December 2020 VA examination, the examiner diagnosed cervical spondylosis and opined that it was less likely than not related to service. In reaching this conclusion, the examiner commented that that the Veteran's service treatment records and December 1970 separation examination were silent for complaints of a cervical spine condition. The Board is unable to decide the claim based on the December 2020 opinion. In this regard, the examiner relied solely on the absence of in-service treatment as well as post-service treatment for several years as the sole rationale for the negative nexus opinion. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Moreover, the opinions were provided without an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, the Board finds that an additional medical opinion is warranted to address the nature and etiology of his cervical spine disorder. Right and Left Upper Extremity Peripheral Neuropathy The issues of entitlement to service connection for right and left upper extremity peripheral neuropathy are inextricably intertwined with the claim of entitlement to service connection for a cervical spine disorder remanded herein, as the December 2020 VA examiner opined that the Veteran's upper extremity peripheral neuropathy is caused by his cervical spine condition. Hence, a determination on these claims should be deferred pending final disposition of the claim for entitlement to service connection for a cervical spine disorder. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). TDIU prior to July 15, 2013 The issue of entitlement to TDIU prior to July 15, 2013is inextricably intertwined with the claims remanded herein. Harris v. Derwinski, supra. Hence, a determination on the claim for TDIU prior to July 15, 2013should be deferred pending final disposition of the claims of entitlement to service connection for a cervical spine disorder, erectile dysfunction, and right and left upper extremity peripheral neuropathy. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and her representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran's erectile dysfunction. The need for physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the review of the record, the examiner must provide an opinion as to the following: (A) Is at least as likely as not (50 percent or better probability) that the Veteran's erectile dysfunction had its onset during her active service, or is otherwise etiologically related to such service, to include in-service exposure to herbicide agents (notwithstanding the fact that there may not be a presumed association).? (B) Is at least as likely as not (50 percent or better probability) that the Veteran's erectile dysfunction was caused OR aggravated by his service-connected thoracolumbar degenerative joint disease? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, 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). 3. Following the receipt of outstanding records, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran's cervical spine disorder. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the review of the record, the examiner provide an opinion as to the follow: Is it at least as likely as not (50 percent or better probability) that any currently present cervical spine disorder, to include cervical spondylosis, had its onset during his active service, or is otherwise etiologically related to such service? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, 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). 4. Following the completion of the above, the Agency of Original Jurisdiction should consider whether additional development is warranted as a result of the above (e.g., development for right and left upper extremity peripheral neuropathy and entitlement to a TDIU prior to July 15, 2013). KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher O'Donnell, 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.