Citation Nr: 21074402 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 17-17 219A DATE: December 15, 2021 ORDER An initial rating in excess of 10 percent for residuals of a right wrist injury is denied. An initial rating in excess of 10 percent prior to September 1, 2016 for cervical spine degenerative disc disease (DDD) is denied. An initial 20 percent rating from September 1, 2016 to March 3, 2017 for cervical spine DDD is granted, subject to the rules and regulations governing the award of monetary benefits. An initial rating in excess of 20 percent from March 3, 2017 for cervical spine DDD is denied. REMANDED Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hypertension. Entitlement to service connection for right leg shin splints is remanded. Entitlement to service connection for left leg shin splints is remanded. Entitlement to an initial compensable rating prior to April 12, 2017 and a 10 percent rating therefrom for the left knee disability is remanded. Entitlement to an initial compensable rating for headaches is remanded. FINDINGS OF FACT 1. Throughout the appeal period, residuals, right wrist injury, has been manifested in limitation of motion, pain on movement and tenderness on palpation; there is no evidence of ankylosis. 2. For the period prior to September 1, 2016 the Veteran's cervical spine disability has been manifested by pain and stiffness with motion without forward flexion limited to 30 degrees or less; combined range of motion limited to 170 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 3. For the period from September 1, 2016 to March 3, 2017, the evidence is at least in equipoise as to whether the Veteran's cervical spine was manifested by forward flexion to less than 30 degrees but not less than 15 degrees. 4. For the period from September 1, 2016, the Veteran's cervical spine disability has been manifested by pain and stiffness with motion and forward flexion has not been limited to greater than 30 degrees; and there is no ankylosis. CONCLUSIONS OF LAW 1. Throughout the appeal period, the criteria for a rating in excess of 10 percent, for residuals, right wrist injury, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5215. 2. For the period prior to September 1, 2016, the criteria for an initial rating in excess of 10 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.59, 4.71a, DC 5242. 3. For the period from September 1, 2016 to March 3, 2017, the criteria for an initial 20 percent rating, but no higher, for a cervical spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.59, 4.71a, DC 5242. 4. For the period from March 3, 2017, the criteria for an initial rating in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.59, 4.71a, DC 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1997 to June 2005 and from March 2006 to March 2013. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). During the pendency of the appeal, in a March 2017 rating decision, the RO granted a higher initial 20 percent rating for the cervical spine disorder, effective March 3, 2017. In a March 2019 rating decision, the RO also granted a higher initial 20 percent rating for the right knee disability, effective April 12, 2017. These grants do not constitute a full grant of the benefits sought and the claim for higher ratings remain on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board previously remanded the case for further development in August 2019. The case has since been returned to the Board for appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. §§ 4.40. It is important that when evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. §§ 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. §§ 4.45. It is the intent of the schedule to recognize painful motion with joint or periarticular pathology as productive of disability. It is also the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. §§ 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). 1. Entitlement to a higher initial rating for the right wrist disorder. The Veteran is service-connected for a right wrist disorder under DC 5215. The record reflects that the Veteran is left handed. As such, the service-connected right wrist disability affects his minor extremity. 38 C.F.R. § 4.69. During the pendency of the appeal, portions of the rating schedule for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). However, the rating criteria applicable to the Veteran's right wrist disability under DC 5215 was not changed by the new regulation. As a result, the amendment of the rating criteria will not have an impact on Veteran's right wrist increased rating claim. Under DC 5215, the Veteran has been in receipt of a maximum 10 percent rating for the duration of this appeal. Pursuant to DC 5215, a maximum 10 percent evaluation is warranted for either the major or minor extremity if dorsiflexion is less than 15 degrees or palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a. At a January 2012 VA examination, findings revealed palmar flexion to 80 degrees, dorsiflexion to 70 degrees, ulnar deviation to 45 degrees and radial deviation to 20 degrees. He was assigned a 10 percent rating based on painful motion. At a March 2017 VA examination, findings revealed palmar flexion to 60 degrees, dorsiflexion to 60 degrees, ulnar deviation to 35 degrees and radial deviation to 20 degrees. There was no ankylosis. At an August 2020 VA examination, findings revealed palmar flexion to 80 degrees, dorsiflexion to 70 degrees, ulnar deviation to 40 degrees and radial deviation to 20 degrees. There was no ankylosis. A higher than 10 percent rating is simply not feasible under Code 5215 even considering functional loss due to pain and other factors since the maximum rating assignable under DC 5215 is 10 percent. See Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). In order for the Veteran to receive a disability rating in excess of 10 percent for his right wrist disability, he would have to meet the criteria under Diagnostic Code 5214 for ankylosis of the right wrist. A review of the medical and lay evidence of record does not establish ankylosis of the wrist. In this regard, the Veteran was specifically noted by the March 2017, and August 2020 VA wrist examiners to not have ankylosis of the right wrist. The Board notes that, while VA must in some circumstances considers functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination, see DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); 38 C.F.R. §§ 4.40, 4.45, this rule does not apply where, as here, the Veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. Similarly, Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016) are not for application because those decisions pertain to the adequacy of examinations as they relate to range of motion findings, but range of motion findings are not relevant here because they cannot result in a higher rating. The Board has considered the Veteran's belief that he is entitled to a higher rating for his wrist disability. However, as the current evaluation contemplates pain, limitation of motion, and the absence of ankylosis, there is simply no basis for a higher evaluation. The Board has also considered the whether the Veteran is entitled to a higher/separate rating for numbness and tingling of his right hand. This symptom, however, appears to overlap with the symptomatology attributed to his already service-connected right upper extremity radiculopathy. As such, additional compensation for these symptoms under a separate disability rating would violate the rule against pyramiding because the Veteran would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14. As such, higher/separate ratings are not warranted for this symptomatology. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine is not for application and the claim is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 49 (1990). 2. Entitlement to a higher initial rating for cervical spine DDD. The Veteran has asserted that he is entitled to a higher rating for his cervical spine disability as his symptoms are worse than those contemplated by the currently assigned rating. The Veteran's cervical spine disorder is currently rated at 10 percent prior to March 3, 2017 and 20 percent therefrom under DC 5242. VA regulations provide spine disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever would result in a higher rating. 38 C.F.R. § 4.71a. As noted above, while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the diagnostic codes as they pertain to the Veteran's cervical spine were not changed. Under the General Rating Formula, a 10 percent rating is warranted where there is forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees, or combined range of motion of the cervical spine not greater than 170 degrees, or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. See Plate V, 38 C.F.R. § 4.71a. At a January 2012 VA examination, the Veteran reported that he had constant moderate to severe cervical pain. He reported that cold weather exacerbated his symptoms. Further, that he had periodic stiffness and spasms. He reported that pain radiated to his right arm and left leg. The Veteran did not have any incapacitating episodes of cervical pain the last 12 months. The examiner noted that the Veteran's spinal disability did not affect his activities of daily living. Upon physical examination, range of motion (ROM) testing revealed forward flexion to 45 degrees; extension to 35 degrees; right and left lateral flexion to 30 degrees each; right lateral rotation to 30 degrees and left lateral rotation to 35 degrees. There was evidence of pain on testing. The Veteran was able to perform ROM three times without further limitation due to fatigue, weakness, or incoordination. The examiner noted that the Veteran walked with a cane but had a normal gait. In a November 2013 statement, the Veteran reported that he suffered from muscle spasms with guarding that resulted in abnormal gait. A review of the record shows that the Veteran received treatment at the VA Medical Center and from private providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has a cervical spine impairment that is worse than that reported in his various statements and the examination reports of record, to specifically include additional findings of limitation of motion. Further, although it was noted that the Veteran utilized a cane, it was further noted that on short walk, he had normal gait and his medical records consistently indicate that he had a normal gait. Based on the foregoing, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for his cervical spine disability prior to September 1, 2016. In this regard, there is no indication from the record that the Veteran had flexion greater than 15 degrees but not greater than 30 degrees. In fact, the Veteran's flexion was limited to, at worst, 45 degrees. Moreover, while the Veteran appears to have had muscle spasms, there is no indication that he had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. As indicated above, the Veteran's VA treatment records consistently show that he had a normal gait. Therefore, the Board finds that a rating in excess of 10 percent for the period prior to September 1, 2016, for the Veteran's cervical spine disability is not warranted at this time. 38 C.F.R. § 4.71a, DC 5242. At a March 2017 VA thoracolumbar examination, the Veteran reported that he continued to have radiating pain from his neck and right upper back. Indeed, the Veteran denied any lower back pain or problems, but reported that tingling and numbness feeling starts from the neck and the right upper back, then radiated from his right upper back to the right arm down to his pinky and left leg down to his left toe. The Veteran reported that his upper back pain occurs four to five hours every day. The examiner noted that the Veteran did not have ankylosis. At a March 2017 VA cervical spine examination, the Veteran again reported neck pain. He reported that his neck pain caused muscle tightness on the right side of his face. The Veteran reported that the right upper back pain radiated down to the middle back and also up to the neck. Further, that he had tingling and numbness, and pain radiating from the right upper back to the right arm down to his pinky and left leg down to his little toe. He reported flare-ups in the cold with a pain level of seven out of ten. He reported that after the flare-up, his pain level goes back down to three out of ten. Notably, the Veteran reported that his neck pain had improved after a surgery in 2014 but became constant again beginning in September 2016. Upon physical examination, ROM testing revealed forward flexion to 30 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 15 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. There was evidence of pain on testing. Pain was noted on examination but did not result in functional loss. There was pain with weight-bearing, and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repeated use over time and the examination was not performed during a flare-up. The examiner was unable to say whether pain, weakness, fatigability, or incoordination significantly limit functional ability after repeated use over time or during flare-ups without resorting to mere speculation. The Veteran did not have guarding, or muscle spasm of the cervical spine. The Veteran's reflex examination was normal, but he had decreased sensation to light touch in his right shoulder, right inner/outer forearm, and right hand/fingers. The Veteran had mild radiculopathy in his right-upper extremity. There were no other neurologic abnormalities. There was no ankylosis or Intervertebral Disc Syndrome (IVDS) of the cervical spine. The examiner found that the Veteran's cervical spine impacted his ability to work. In that regard, the examiner noted that the Veteran missed class once per month due to his upper back pain. Further, that he can stand, sit, or walk for 10 to 15 minutes, and that he can lift between 5 and 10 pounds without much problem. He avoided cold weather, prolonged walking, standing, sitting, lifting, and driving to prevent his neck and right upper back pain. There was evidence of pain on passive range of motion testing, and evidence of pain when the joint was used in non-weight bearing. The Veteran was afforded another VA examination in August 2020. The Veteran again reported pain with tingling. However, he noted that his condition had improved. The Veteran did report flare-ups when it gets cold and with physical activity. In that regard, the Veteran reported numbness and tingling, shooting pain down his arms and legs. His flare-ups were mild to moderate and lasted two to three hours. Upon physical examination, the Veteran's ROM were all normal. Testing revealed forward flexion to 45 degrees; extension to 45 degrees; right and left lateral flexion to 45 degrees; right and left lateral rotation to 80 degrees. However, pain was noted on right and left lateral flexion, and there was functional loss. The Veteran was able to perform repetitive-use testing with at least three repetitions. There was no loss of range of motion after three repetitions. There was no guarding or muscle spasms. The examination was not conducted during flare-ups or after repeated use over time but was medically consistent with the Veteran's statements describing functional loss during flare-ups and after repeated use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups or after repeated use over time. The Veteran had mild intermittent pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity. There was no ankylosis, or any other neurological abnormalities related to a cervical spine. The examiner noted that the Veteran's condition impacted his ability to work. Specifically, that the Veteran was retired, missed less than a week from work, but had difficulty turning his head side-to-side. There was no evidence of pain when the spine was non-weight bearing. Passive ROM of the spine was not performed as it was not feasible to do in a safe manner. A review of the record shows that the Veteran received treatment at the VA Medical Center and from private providers for various disabilities. While the record reflects that the Veteran consistently complained of chronic neck pain, and that he had surgery on his cervical spine in December 2014. The treatment notes of record do not show that the Veteran had ankylosis, or that the Veteran had forward flexion of the cervical spine to 15 degrees or less. Based on the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran is entitled to a 20 percent rating beginning on September 1, 2016. In this regard, it appears that the increased pain in the Veteran's neck began in September 2016, shortly before his March 2017 VA examination. Accordingly, in affording the Veteran the benefit of the doubt, a 20 percent rating for his cervical spine disorder is warranted from September 1, 2016. With regard to whether a rating in excess of 20 percent is warranted for the period from September 1, 2016, the Board finds that it is not. The criteria for a disability rating in excess of 20 percent for a cervical spine disorder requires evidence of flexion limited to 15 degrees or less or ankylosis. This has not been shown. In fact, the Veteran's cervical flexion was limited to, at worst, 30 degrees. Therefore, the Board finds that a rating in excess of 20 percent for the Veteran's back disability is not warranted at this time. 38 C.F.R. § 4.71a, DC 5242. Consideration has been given to assigning separate ratings for neurological abnormalities or chronic neurologic manifestations. The record reflects that the Veteran is already service-connected for radiculopathy of the right upper extremities. No other neurological abnormalities have been demonstrated. 38 C.F.R. § 4.71a, General Rating Formula, Note 1. The Board has also carefully considered the VA examinations of record and whether they complied with Correia and Sharp, and Board finds that the most recent August 2020 VA examination complied with these requirements. To the extent previous examination findings of record relative to the cervical spine are not completely in compliance with Correia and/or Sharp, the Board finds that remand for additional examination would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). In that regard, the Board emphasizes that current examination findings would not be useful in adjudicating the rating assigned for the periods prior to August 2020 and any retrospective opinion would merely impose an additional burden on VA with no benefit flowing to the Veteran, as VA would be asking an examiner to speculate as to the pre- August 2020 ranges of motion. REASONS FOR REMAND 1. Entitlement to service connection for erectile dysfunction. The Board finds that additional development is warranted before the remaining claim on appeal is decided. The Veteran has indicated that his erectile dysfunction is related to his service-connected PTSD. In response to the Veteran's claim, he was most recently afforded a VA examination for his erectile dysfunction in August 2020, and a VA opinion was provided. However, a review of the opinion shows that it is inadequate for adjudication purposes. In this regard, the opinion is internally inconsistent, as the examiner makes both a finding that the Veteran's current erectile dysfunction was less likely as not proximately due to the Veteran's service-connected condition, and a finding that it is possible that PTSD has aggravated the Veteran's erectile dysfunction. Moreover, the Board notes that the opinion is too speculative to support a grant of service connection. See, e.g., McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding a doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus). Accordingly, remand is warranted for a new VA medical opinion consistent with the directives herein. 2. Entitlement to service connection for hypertension. The Veteran was afforded an August 2020 VA examination for his claimed hypertension. The Board finds the August 2020 VA examination inadequate for adjudication purposes. The only rationale provided for the negative nexus was that there was a long silence for the claimed condition, and there was no chronicity of care. Nevertheless, the examiner did not otherwise consider/discuss the favorable STRs suggesting that the Veteran may have had a hypertension diagnosis during service. Accordingly, remand is warranted for a new VA examination consistent with the directives herein. 3. Entitlement to service connection for right and left leg shin splints. The Board notes that the Veteran has consistently asserted that he had shin splints while in service. Indeed, the Veteran's service treatment records show that the Veteran received treatment for shins splints while in service. The Veteran's VA treatment records reflect that the Veteran's shin splints resolved while in service. However, the Veteran has consistently stated that he still suffers from shin splints whenever he increases his activity. Specifically, he stated that walking for 30 minutes will cause his shins to become symptomatic. The Veteran reported that he avoids walking and standing to prevent his shins splints from recurring. There are multiple VA examinations of record that mention the Veteran's claimed shin splints, however, a VA opinion has not been obtained that fully address the Veteran's lay statements indicating that he still does have shin splints if he increases his activity. On remand, an opinion should be obtained to address the Veteran's claimed shin splint disability. 4. Entitlement to a higher initial rating for a left knee disability is remanded. The Board emphasizes that development of the claims for service connection for right and left shin splints will yield evidence pertinent to the service-connected left knee disability. As such, the Board concludes that the increased rating claim for the left knee disability is inextricably intertwined with his service connection claims remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, remand of the inextricably intertwined increased rating claim is therefore required. 5. Entitlement to a higher initial rating for headaches is remanded. In January 2012, the Veteran was afforded a VA headaches examination. At that time, the Veteran reported the location of his headaches vary. He reported that sometimes they are at the top of his head, and other times they are behind his eyes. He reported that flashing lights, nausea, vomiting, photophobia, and phonophobia will periodically accompany the headaches. The examiner noted that the Veteran had lost no work from headache pain, in the last 12 months, and that the Veteran had no prostrating headaches in the last 12 months. The Veteran used medication for his headaches. The examiner noted that the Veteran's headaches have not affected his occupation or activities of daily living. The Veteran reported that he suffered from prostrating headaches approximately once per month. He reported that he was taking medication to control his headaches. In March 2017, the Veteran was afforded a VA headaches examination. At that time, the Veteran reported that he has had migraine headaches since 2006 but that he was given nasal spray which helped his symptoms. The Veteran reported that his headaches became more frequent in 2010, occurring once or twice per month. The Veteran reported that his headaches resolved after taking medication. He reported that his headache frequency and severity has been the same since 2010 until the present. His headaches caused nausea, vomiting, and light and noise sensitivity. The examiner found that the Veteran did not have characteristic prostrating attacks of migraine headache pain. However, he noted that the Veteran takes medication twice per week. The examiner noted that the Veteran's headache condition does impact his ability to work. In that regard, the Veteran missed work due to headaches from 2010 until 2013. In August 2020, the Veteran was afforded another VA headaches examination. At that time, the Veteran reported pain and pressure in the middle of his head and behind his right eye but reported that the condition had improved. Indeed, the Veteran continued to take medication which improved his headache condition. The Veteran's symptoms only consisted of pain on both sides of the head, and nausea. The headaches typically lasted for less than one day. Again, the examiner found that the Veteran did not have characteristic prostrating attacks of migraines. The examiner noted that the Veteran's headache condition did not impact his ability to work. The Board notes that there is no information as to the frequency or severity of the reported symptoms without consideration of the ameliorative effects of medication. Accordingly, the Veteran's claim for a higher initial rating for service-connected migraines must be remanded for a VA examination that fully addresses the relevant rating criteria. The matters are REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Following the record development above, obtain a VA addendum opinion by an appropriate examiner to determine the nature and etiology of any current erectile dysfunction. The examiner should review the claims file and indicate that review in the report. Any indicated studies should be performed. The examiner should opine as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's erectile dysfunction was caused or aggravated by service-connected PTSD. The examiner is advised that aggravation is defined as any increase in disability. The examiner should address the August 2020 opinion that states both that the Veteran's current erectile dysfunction was less likely as not proximately due to the Veteran's service-connected condition, and a finding that it is possible that PTSD has aggravated the Veteran's erectile dysfunction. A rationale for all requested opinions shall be provided. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Following the record development above, obtain a VA addendum opinion from an appropriate examiner to determine the nature and etiology of the Veteran's hypertension. The examiner should review the claims file and indicate that review in the report. Any indicated studies should be performed. The examiner should be sure to discuss the significance of the finding that there was no chronicity of care. Based upon the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any hypertension is etiologically related to service. In rendering this opinion, the examiner must consider and discuss the Veteran's STRs that hypertension on his problems list. A rationale for all requested opinions shall be provided. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. Following the record development above, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran's bilateral shin splints. The examiner should review the claims file and indicate that review in the report. Any indicated studies should be performed. The examiner should be sure to address the Veteran's lay statements that he does have shin splints, but that he has limited his activity to avoid shin pain. a) Based upon the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any shin disability is etiologically related to service. b) The examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) that any shin disability is caused or aggravated by the Veteran's service-connected disabilities, to include his left knee disability and bilateral plantar fasciitis. The examiner is advised that aggravation is defined as any increase in disability. A rationale for all requested opinions shall be provided. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 5. Following the record development above, schedule the Veteran for a VA examination with an appropriate examiner to determine the current nature and severity of the Veteran's service-connected headaches. The claims file must be made available to and reviewed by the examiner. All indicated tests and studies must be performed. The examiner should report all signs and symptoms necessary for evaluating the Veteran's service-connected headaches under the rating criteria, to include, if possible, determining the severity of the Veteran's condition in an unmedicated state. All findings should be reported in detail. PAUL E. METZNER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Cannaday, 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.