Citation Nr: 21075849 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 18-37 897 DATE: December 21, 2021 ORDER Prior to February 20, 2018, entitlement to an initial rating in excess of 10 percent disabling for lumbar spine disability is denied. Effective February 20, 2018, entitlement to a 20 percent rating for lumbar spine disability, but no higher, is granted subject to controlling regulations applicable to the payment of monetary benefits. Prior to February 20, 2018, entitlement to an initial rating in excess of 10 percent disabling for right lower extremity (RLE) radiculopathy is denied. Effective February 20, 2018, entitlement to a 20 percent rating for RLE radiculopathy, but no higher, is granted subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to service connection for left lower extremity (LLE) radiculopathy is denied. REMANDED Entitlement to service connection for bilateral foot condition, to include pes planus and hallux valgus, is remanded. Entitlement to an initial rating in excess of 10 percent disabling for right knee disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 20, 2018, the Veteran's lumbar spine disability was manifested by localized tenderness not resulting in an abnormal gait or abnormal spinal contour. The lumbar spine disability was not manifested forward flexion limited to less than 60 degrees, muscle spasm or guarding resulting in an abnormal gait or spinal contour, intervertebral disc syndrome (IVDS), ankylosis, or a neurological disability other than RLE radiculopathy. 2. Effective February 20, 2018, the Veteran's lumbar spine disability was manifested by muscle spasm resulting in an abnormal gait or abnormal spinal contour and forward flexion limited to less than 60 degrees. The lumbar spine disability was not manifested by forward flexion limited to 30 degrees or less, IVDS, ankylosis, or a neurological disability other than RLE radiculopathy. 3. Prior to February 20, 2018, the Veteran's RLE radiculopathy was manifested by symptoms more nearly approximating mild incomplete paralysis of the sciatic nerve. 4. Effective February 20, 2018, the Veteran's RLE radiculopathy was manifested by symptoms more nearly approximating moderate incomplete paralysis of the sciatic nerve. 5. The Veteran does not have a LLE radiculopathy condition. CONCLUSIONS OF LAW 1. Prior to February 20, 2018, entitlement to an initial rating in excess of 10 percent disabling for lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5237. 2. Effective February 20, 2018, entitlement to an increased 20 percent rating, but no higher, for lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DC 5237. 3. Prior to February 20, 2018, entitlement to an initial rating in excess of 10 percent disabling for RLE radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.124a, DC 8520. 4. Effective February 20, 2018, entitlement to an increased 20 percent rating, but no higher, for RLE radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.124a, DC 8520. 5. The criteria for service connection for LLE radiculopathy have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to August 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision by a Department of Veterans Affairs Regional Office (RO). In July 2021, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The Board held the record open for 30 days for the Veteran to submit additional relevant evidence. 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 ratings 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. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). Lumbar Spine and RLE Radiculopathy Factual Background The Veteran filed a service connection claim for lumbar spine disability in June 2015. An October 2016 rating decision granted service connection for lumbar spine disability and RLE radiculopathy, and assigned initial 10 percent ratings effective June 2014. He has appealed those ratings. The evidence of record includes a June 2016 VA examination noting diagnoses for lumbosacral strain and muscle spasm. The Veteran complained of back pain and right foot numbness. He denied any pain running down his leg. Back pain was also worse with increased activity. Flare-ups and functional loss resulted in increased pain and decreased range of motion (ROM). ROM testing revealed forward flexion to 90 degrees and extension to 15 degrees with pain causing functional loss. The examiner noted that the Veteran was being examined immediately after repeated use over time. Flare-ups were found to reduce ROM to 70 degrees forward flexion and 5 degrees extension. The condition was not manifested by muscle spasm or guarding, but was manifested by localized tenderness not resulting in an abnormal gait or abnormal spinal contour. Muscle strength and reflex testing were normal. The lumbar spine was not manifested by ankylosis, IVDS or other neurologic abnormalities. Decreased sensation was found for the right lower leg/ankle, and foot/toes. He was diagnosed with RLE radiculopathy manifested by mild paresthesias and/or dysesthesias and numbness. The RLE radiculopathy involved the sciatic nerve root and was mild in severity. In June 2017, a private medical record shows reports of worsening chronic lower back pain, and RLE numbness and tingling. A July 2017 medical record noted forward bending to 70 percent of range (i.e., 63 degrees). See Private Medical Records Received March 2018. He last underwent a VA lumbar spine examination in February 20, 2018, during which he reported slowly progressive pain and stiffness, and right sided radiculopathy. He also reported right foot cramps of uncertain etiology. Flare-ups were reported with episodes lasting days to a few weeks and symptomatic of increased pain and stiffness. He also reported functional loss due to limitations in mobility, walking, bending and lifting. ROM testing revealed forward flexion to 65 degrees and extension to 10 degrees, with pain exhibited during testing. Abnormal ROM contributed to functional loss including difficulty bending and lifting. Flare-ups were also determined to cause pain and lack of endurance resulting in further loss of flexion to 55 degrees and extension to 5 degrees. The lumbar spine was currently manifested by a muscle spasm resulting in an abnormal gait or abnormal spinal contour. Repeated use over time was also found to limit functional ability due to pain, but the examiner stated he was unable to describe such in terms of ROM as it "limited duration or number of repetitions." Muscle strength testing was normal except for active movement against some resistance for right great toe extension. The lumbar spine was not manifested by ankylosis or other neurological abnormalities such as a bowel or bladder condition, or IVDS. A reflex examination was absent for bilateral knee and right ankle, and hypoactive for the left ankle. Sensory testing was normal except for decreased right foot/toes. He was diagnosed with RLE radiculopathy, which was not symptomatic of constant pain, but was symptomatic of moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. The RLE radiculopathy involved the sciatic nerve root and was moderate in severity. In June 2019, the Veteran reported neuropathic pain in his bilateral feet, left greater than right. See VA Medical Records Received December 2019. During the July 2021 Board hearing, the representative stated that the February 2018 VA examination included findings warranting 20 percent ratings for the lumbar spine and RLE radiculopathy. The Veteran also testified that he had not been given a diagnosis for radiculopathy affecting his left lower extremity (LLE), and that he did not have any LLE neuropathy, only symptoms of foot cramping. Lumbar Spine After a review of the evidence of record, the Board finds that prior to February 20, 2018, a rating in excess of 10 percent is not warranted. Effective February 20, 2018, the Board finds that an increased 20 percent rating, but no higher, is warranted. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Under the General Rating Formula for Diseases or Injuries of the Spine, the diagnostic code criteria pertinent to lumbar spine disabilities provides that a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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 forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding 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 warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral extension are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion for the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (2). Round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine, Note (4). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). Under the revised rating criteria, DC 5242 applies to degenerative arthritis and degenerative disc disease other than intervertebral disc syndrome (IVDS). DC 5243 applies to IVDS and directs the rater to assign that diagnostic code only when there is disc herniation with compression of the adjacent nerve root, and to assign DC 5242 for all other disc diagnoses. As the Veteran's lumbar spine disability has not been manifested by IVDS at any point during the period on appeal, the rating criteria pertaining to his lumbar spine disability has not changed substantially as a result of the February 7, 2021 amendments. Turning to the period on appeal prior to February 20, 2018, after a review of the evidence of record, the Board finds that a rating in excess of 10 percent disabling is not warranted. In this regard, throughout the period on appeal, ROM was manifested by forward flexion to, at worst, 63 degrees. Accordingly, throughout the period on appeal, the highest rating available based on limitation of motion is 10 percent. A higher 20 percent rating is not warranted during this period on appeal as the lumbar spine disability was not manifested by forward flexion limited to 60 degrees or less, or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. Turning to the period on appeal effective February 20, 2018, after a review of the evidence of record, the Board finds that an increased 20 percent rating, but no higher, is warranted. In this regard, during the February 2018 VA examination, the lumbar spine was estimated to be manifested by forward flexion to 55 degrees during flare-ups. In addition, it was also manifested by muscle spasms resulting in an abnormal gait or abnormal spinal contour. However, during this period on appeal, the lumbar spine was not manifested by forward flexion to 30 degrees or less, or ankylosis. Therefore, effective February 20, 2018, a rating in excess of 20 percent is not warranted. The Board has considered higher ratings throughout each period on appeal; however, the evidence of record establishes that the Veteran's lumbar spine disability has not been manifested by, or nearly approximated, ankylosis or IVDS. The Board has also considered assigning higher disability ratings pursuant to 38 C.F.R. § 4.40 and 4.45. In this regard, the Board acknowledges the Veteran's reported complaints of pain and painful motion. However, his lumbar spine disability has been rated based on limitation of motion (i.e., functional loss) caused by pain. As such, the Board finds that the currently assigned disability ratings take into account functional limitations based on painful motion and there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Board has additionally considered separate ratings based on other neurological disorders, such as radiculopathy or bowel or bladder condition. In this regard, he is already service connected for RLE radiculopathy which is addressed below. As discussed more fully below, despite a June 2019 VA medical record noting neuropathic pain in the bilateral feet, the Veteran has not been diagnosed with LLE radiculopathy. He is also service connected for a left knee and left hip condition. Importantly, during his recent July 2021 Board hearing, he specifically denied experiencing LLE neuropathic pain or a diagnosis for LLE radiculopathy, and instead attributed his symptoms to foot cramping. Accordingly, as LLE radiculopathy is not shown by the record, a separate rating is not warranted. Lastly, during the entire period on appeal, the lumbar spine has not been manifested by a bowel or bladder condition. Accordingly, a separate rating based on another neurological disorder is not warranted at any time during the appeal period. In summary, the preponderance of the evidence of record is against assigning a disability rating greater than 10 percent prior to February 20, 2018, for the service-connected lumbar spine disability. Effective February 20, 2018, a higher 20 percent rating, but no higher, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.124a; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). RLE Radiculopathy After a review of the evidence of record, the Board finds that prior to February 20, 2018, a rating in excess of 10 percent is not warranted. Effective February 20, 2018, the Board finds that an increased 20 percent rating, but no higher, is warranted. RLE radiculopathy is rated pursuant to 38 C.F.R. § 4.124a, DC 8520, which governs the sciatic nerve. Under DC 8520, disability ratings of 10, 20, 40, and 60 percent are warranted, respectively, for mild, moderate, moderately severe, and severe incomplete paralysis of the sciatic nerve. Id. A 60 percent rating also requires marked muscular atrophy. A disability rating of 80 percent is warranted for complete paralysis of the sciatic nerve: the foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or lost. Id. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Other nerves of the lower extremities include the external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial), posterior tibial, internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves. Paralysis, neuritis, and neuralgia thereof is addressed by DCs 8521 through 8530, 8621 through 8630, and 8721 through 8730. As set forth below, the evidence shows that the Veteran's sciatic nerves are affected. Accordingly, use of DC 8520 for sciatic nerve is most appropriate. Turning to the period on appeal prior to February 20, 2018, after a review of the evidence of record, the Board finds that an initial rating in excess of 10 percent disabling is not warranted. In this regard, the Board notes that the only significant evidence of record during this period on appeal is the June 2016 VA examination report which found the RLE radiculopathy manifested by sciatic nerve root involvement, with symptoms mild in severity, which is supported by diagnostic testing revealing only mild paresthesias and/or dysesthesias and numbness. Accordingly, based on the rating criteria, a higher 20 percent rating is not warranted pursuant to DC 8520 prior to February 20, 2018. Turning to the period on appeal effective February 20, 2018, the Board finds that an increased 20 percent rating, but no higher, is warranted. In this regard, a review of the February 2018 VA examination shows that the severity of the RLE radiculopathy was moderate which is supported by diagnostic testing revealing moderate symptoms. As the Veteran's symptoms have not been found moderately severe, or severe in nature, a higher 30 percent disability rating is not warranted. In summary, the preponderance of the evidence of record is against assigning a disability rating greater than 10 percent prior to February 20, 2018, for the service-connected RLE radiculopathy. Effective February 20, 2018, a higher 20 percent rating, but no higher, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.124a; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). LLE Radiculopathy The Veteran seeks entitlement to service connection for LLE radiculopathy, claimed as severe leg and foot cramping. This claim is separate from the service connection claim for bilateral foot condition addressed in the Remand section below. The Board further notes the Veteran is service connected for left knee and hip disabilities. In addition to the evidence listed in the Factual Background section above, the Board notes that the service treatment records (STRs) are silent for any complaints or treatment related to any LLE radiculopathy. His June 1970 separation examination shows he reported both "yes" and "no" with regard to foot trouble and he denied any swollen or painful joints. In August 2015, the Veteran reported nocturnal leg cramping and occasional tingling and numbness in his right foot. Leg cramping was found likely secondary to hydrochlorothiazide medication. See VA Medical Records Dated December 2019. The threshold requirement that must be met with respect to any service connection claim is competent evidence of a current disability during the pendency for which service connection is being sought; in this case, a diagnosed LLE radiculopathy condition. See 38 U.S.C. § 1110. The record does not include any such evidence. As noted above, the Veteran underwent VA lumbar spine examinations in June 2016 and February 2018. A review of those examination reports shows he has been diagnosed with RLE radiculopathy, but has not been diagnosed with LLE radiculopathy. Importantly, during his Board hearing, he specifically denied having been diagnosed with LLE radiculopathy and stated that he did not have any LLE neuropathy. His only reported symptoms concerned foot cramping. In this regard, a separate claim for bilateral foot condition is currently on appeal. As such, as there is no evidence of a current LLE radiculopathy condition, he has not presented a valid claim. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). REASONS FOR REMAND Bilateral Foot Condition The Veteran seeks entitlement to service connection for bilateral foot condition. Specifically, he asserts that he was treated for a bilateral foot condition during service caused by parachute jumping, marches and running. See November 2017 Letter. He underwent a VA foot examination in June 2016, and was diagnosed with bilateral pes planus and bilateral hallux valgus. The examiner also noted that the service treatment records (STRs) and VA medical records were silent for any foot disorder. The Veteran reported trauma to his feet due to jumping out of airplanes, and that he was treated during service by a podiatrist during which he received accommodative shoes. However, the examiner found no STRs in support of this claim and stated that a nexus opinion could not be rendered without further evidence. In this regard, it was noted that the Veteran was going to submit private treatment records and that he felt STRs were missing. In a September 2016 VA addendum report, a different examiner opined that it was "less likely as not" that the bilateral foot condition was etiologically related to service. In support of this opinion, the examiner noted that pes planus tended not to develop or progress years after injury. Therefore, as the condition was not noted during service, the examiner found it less likely related to service. During his July 2021 Board hearing, the Veteran testified that the September 2016 VA examination report was biased. In this regard, he testified that when he reported for his examination, the examiner refused to examine his feet. However, a review of the September 2016 VA examination report shows that an in-person examination was not requested. Instead, the examiner was asked to base a nexus opinion on the evidence contained in the claims file. Moreover, while the examiner did provide a negative nexus opinion with regard to bilateral pes planus, he did provide favorable nexus opinions for lumbar spine and bilateral knee disabilities. Therefore, the Board finds no bias in the September 2016 VA examination report. Instead, the Veteran appears to be referring to VA examinations that occurred in February 2018 that were conducted by the same examiner. However, these examinations were conducted in relation to claims for left hip condition and a TDIU necessitating examinations of the service-connected lumbar spine, RLE radiculopathy and bilateral knee disabilities. Therefore, as he was not service connected for any foot condition at that time, a VA foot examination was not requested. See February 2018 VA Form 21-2507a, Request for Physical Examination. In any event, the Board finds the September 2016 VA addendum report inadequate to adjudicate this issue on appeal. Specifically, the examination report only provides a nexus opinion concerning bilateral pes planus. As noted above, the Veteran has also been diagnosed with bilateral hallux valgus. While the Veteran has asserted entitlement to service connection for bilateral pes planus, he has consistently reported incurring, and being treated for, foot injuries during service, with symptoms consisting of pain. In this regard, a July 2016 private medical record shows he reported right foot pain dating back to his time in service. In this regard, he reported multiple right foot injuries during service due to parachute jumps. Symptoms had reportedly worsened since that time. He was diagnosed with right foot pain secondary to right bunion deformity and right dorsal exostosis of the first metatarsal cuneiform joint, and degenerative joint disease (DJD) with deformity at the right talonavicular cuneiform joint. See Private Medical Records Received November 2017. When a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, in order to properly adjudicate this issue on appeal, an addendum VA examination report is necessary. Right Knee Disability The Veteran last underwent a VA knee examination in February 2018. He reported functional loss due to limitations in the duration of his ability to walk, and limitations in his ability to ambulate stairs and squat. Muscle strength was normal, and the right knee was not manifested by a meniscal condition, recurrent subluxation or lateral instability. He denied using any assistive device as a normal mode of locomotion. Evidence received after the February 2018 VA examination includes a December 2018 VA medical record noting reports that the right knee kept popping out of place resulting in pain. See VA Medical Records Received December 2019. During a recent July 2021 Board hearing, he testified that his right knee would regularly and unexpectedly collapse causing him to lose his balance, and that he was extremely limited in walking only short distances, and unable to stand for any length of time without pain. He further testified that right knee popped out. He denied using any assistive devices for ambulation, although he did state he would use a knee brace if he had to go someplace. Evidence of a change in the condition or allegation of worsening of the condition renders an examination inadequate for rating purposes. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007); see also Proscelle v. Derwinski, 2 Vet. App. 629 (1992). In consideration of evidence of worsening right knee symptomatology since the last VA examination, a remand is warranted for a new VA examination. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. TDIU The Veteran asserts that his combined service-connected disabilities preclude his ability to obtain gainful employment. In this regard, during his July 2021 Board hearing, he testified that he stopped working due to nerve and foot pain which interfered with his ability to sleep. He also reported that he became irritable and that he had problems focusing due to lack of sleep. Symptoms reported related to his service-connected psychiatric disorder included avoiding people. Additionally, in an August 2021 letter, he stated that he retired in August 2015 because he was no longer able to meet the physical and mental requirements. In this regard, he reported back, bilateral knee and hip pain that severely interrupted his sleep and prevented him from being able to fully function during the day. He last underwent a VA mental disorder examination in March 2018. The examiner noted a diagnosis for adjustment disorder with anxiety manifested by occupational and social impairment due to mild or transient symptoms. The Veteran reported that he enjoyed playing golf and being outdoors. The only symptoms noted were anxiety and chronic sleep impairment. According to testimony provided during the July 2021 Board hearing, the Veteran asserts worsening psychiatric symptoms, including irritability, that precludes his ability to work. Therefore, as this claim is inextricably intertwined with symptoms related to his service-connected psychiatric disorder, and in consideration of reported worsening symptomatology, the Board finds that a VA psychiatric examination is necessary to adequately adjudicate this issue on appeal. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records not already associated with the file. 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of his bilateral foot disorder, to include diagnosed bilateral hallux valgus (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed bilateral foot disorder, to include bilateral hallux valgus, is etiologically related to his period of service? The examiner should also consider the diagnoses in the July 2016 private medical record, which shows he reported right foot pain dating back to his time in service. In this regard, he reported multiple right foot injuries during service due to parachute jumps. Symptoms had reportedly worsened since that time. He was diagnosed with right foot pain secondary to right bunion deformity and right dorsal exostosis of the first metatarsal cuneiform joint, and degenerative joint disease (DJD) with deformity at the right talonavicular cuneiform joint. The examiner is asked to consider the Veteran's statements that he received treatment for his bilateral feet during service, and that the conditions were caused by wear and tear, including as due to parachute jumps, running and marching. The examiner should review pertinent documents in the claims file. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. After the development in #1 is completed, schedule the Veteran for an examination by an appropriate examiner to determine the current nature and severity of his service-connected right knee disability. 4. After the development in #1 is completed, schedule the Veteran for a VA examination to determine the current severity of his service-connected psychiatric disorder. The examiner should review the evidence associated with the record. The examiner should identify the nature, frequency, and severity of all current manifestations of the Veteran's psychiatric disorder and specify the degree of occupational or social impairment. (Continued on the next page) 5. Thereafter, the RO should readjudicate the claims on appeal, to include the claim for a TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.