Citation Nr: A21019784 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 190812-25231 DATE: December 13, 2021 ORDER New and relevant evidence having been received, readjudication of the claim of entitlement to service connection for gastroenteritis is granted. Entitlement to service connection for an acquired psychiatric disorder, to include as due to a service-connected disability, is denied. Entitlement to a compensable rating for service-connected bilateral hearing loss is denied. Entitlement to a compensable rating for service-connected allergic rhinitis is denied. Entitlement to a rating in excess of 10 percent for service-connected dermatophytosis with tinea pedis is denied. Entitlement to a rating in excess of 10 percent for a service-connected painful scar of the left forehead and eye is denied. Entitlement to a rating in excess of 20 percent for service-connected lumbar degenerative joint disease (DJD) is denied. REMANDED Entitlement to service connection for gastroenteritis is remanded. Entitlement to a disability rating in excess of 10 percent for a service-connected left knee disability is remanded. Entitlement to a disability rating in excess of 10 percent for a service-connected right knee disability is remanded. Entitlement to a rating in excess of 10 percent for a service-connected right ankle sprain is remanded. FINDINGS OF FACT 1. New evidence that is relevant to the claim of entitlement to service connection for gastroenteritis has been received. 2. The preponderance of the evidence of record is against finding that the Veteran has an acquired psychiatric disorder that is related to his military service or a service-connected disability. 3. During the appeal period, the Veteran's bilateral hearing loss was manifested by hearing acuity of no worse than Level I in the right ear and Level II in the left ear. 4. During the appeal period, the Veteran's rhinitis was not manifested by greater than 50 percent obstruction of the nasal passages on both sides, complete obstruction on one side, or polyps. 5. During the appeal period, the Veteran's dermatophytosis with tinea pedis did not affect 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, nor did the disorder require systemic therapy. 6. During the appeal period, the Veteran's single painful scar of the left forehead/ eye is not manifested by four or five characteristics of disfigurement, is not at least 77 sq. cm, and does not rise to the any requisite level of functional impairment. 7. During the period on appeal, the Veteran's lumbar DJD did not result in favorable ankylosis or flexion reduced to 30 percent or less. CONCLUSIONS OF LAW 1. The criteria for readjudication of the claim for service connection for gastroenteritis have been satisfied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(d). 2. The criteria for service connection for an acquired psychiatric disorder have not been satisfied. 38 U.S.C. §§ 1110,1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for a compensable rating for service-connected bilateral hearing loss have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for a compensable rating for service-connected allergic rhinitis have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6522. 5. The criteria for rating in excess of 10 percent for service-connected dermatophytosis with tinea pedis have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7813-7806. 6. The criteria for rating in excess of 10 percent for service-connected painful scar of the left forehead and eye have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7800 to 7805. 7. The criteria for rating in excess of 20 percent for service-connected lumbar DJD have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1979 to November 1997. This matter was appealed to the Board of Veterans' Appeals (Board) from a rating decision issued in March 2019 by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Veteran opted into the modernized review system as detailed in the Veterans Appeals Improvement and Modernization Act of 2017, Pub. L. No. 115-55 (2017) (also known as the "Appeals Modernization Act" (AMA)). 38 C.F.R. § 19.2(d). At that time, he selected the Higher-Level Review lane. Accordingly, the March 2019 AMA rating decision considered the evidence of record as of the date VA received the opt-in form. In August 2019, the Veteran appealed this rating decision to the Board and requested direct review of the evidence considered by the RO. 38 C.F.R. § 20.202. The Board notes that evidence was added to the claims file during a period of time when new evidence was not allowed. The Board may not consider this evidence in the claims that it is denying below. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, as the Board is remanding the claims of entitlement to service connection for gastroenteritis and increased ratings for bilateral knee and right ankle disabilities for further development, this additional evidence will be considered by the RO in the adjudication of those claims. The Board also acknowledges the argument presented by the Veteran's representative in an October 2021 Appellate Brief that the Veteran's claims herein have never been fully and finally adjudicated by RO. In that regard, the March 2019 rating decision on appeal that denied the above claims was accompanied by a notification letter which informed the Veteran of what was decided. The letter included information on the Veteran's rights to seek further review of that rating decision, which the Veteran did in his subsequent direct review appeal and the matters were then certified to the Board. As the Veteran's representative points out, however, after explaining to the Veteran what was decided, which included the denial of the above claims, the letter states the following: We completed your request for higher-level review on the following issues. We discovered additional development actions are necessary for us to fulfill our duty to assist in gathering evidence in support of your claim. We will take action to finish our development and notify you once a decision is made on your claim. After review of record, however, the Board finds that the RO's statement that development has yet to be completed was erroneous. Notably, after the above paragraph that additional development was necessary on the "following issues," the letter again lists the above claims on appeal as those needing additional development. Routinely, had certain issues claimed by the Veteran required additional development, they would have been deferred pending this development. Instead, each issue was decided, and the accompanying rating decision discussed the evidence addressed and the reasons for each denial. Had any issue been pending additional development, such analysis would not have been included, and the issue would have instead been noted as deferred. Importantly, the Board notes that the record does reflect an actual deferred rating decision dated in February 2019, one month prior to the rating decision at issue, which includes the issues both currently on appeal and listed as requiring "additional development" in the accompanying notification letter. It notes as a duty to assist error that the above issues were not included in a previous RAMP appeal withdrawal letter. This would appear to be the very duty to assist error indicated in the March 2019 notification letter. This error was corrected in a new appeal withdrawal letter later in February 2019, and the March 2019 rating decision currently on appeal was then issued. The Board surmises that that the inclusion of the above paragraph in the March 2019 notification letter pertaining to issues requiring additional development was erroneous. As such, the Board finds that the issues on appeal were indeed fully adjudicated by the RO in March 2019 are properly before the Board. New and Relevant Evidence Gastroenteritis VA will readjudicate a previously denied claim if new and relevant evidence is presented or secured. 38 U.S.C. § 5108(a); 38 C.F.R. § 3.156(d). New evidence is evidence not previously part of the actual record before agency adjudicators. Relevant evidence is information that tends to prove or disprove a matter at issue in a claim and includes evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(1). In determining whether new and relevant evidence is presented or secured, VA will consider any VA treatment records reasonably identified by the claimant and any evidence received by VA after VA issued notice of a decision on the claim and while the evidentiary record was closed. 38 C.F.R. § 3.2501. When a supplemental claim has been submitted, the evidentiary record includes evidence received by VA before the issuance of notice of a decision on the supplemental claim. 38 C.F.R. § 3.2501(b). The RO denied the Veteran's original claim of service connection for a stomach condition in a January 1999 rating decision, finding that the evidence was against a finding that the Veteran had a current disability for service connection purposes. See 38 C.F.R. § 3.303. The claim was again denied for the same reasons in July 2014 and May 2016, now claimed as gastroenteritis. In his December 2018 RAMP opt-in, the Veteran submitted a request for a higher-level review (HLR), and an HLR decision continuing the denial was issued in the March 2019 rating decision presently on appeal where the RO determined that new and relevant evidence had not been received and the claim could not be readjudicated. Review of the record reveals that evidence received is both new and relevant to the claim. See 38 C.F.R. § 3.2501(a)(1). For example, VA treatment records dated earlier than those of record at the time of the rating decision on appeal were associated with the record in September 2020 that reflect a history of gastritis/gastroenteritis, as well as history of over-the-counter medications such as Prilosec. While the Board notes this evidence was received outside of the relevant evidentiary window, the Veteran noted on VA Forms 21-526EZ in September and November 2013 that he received treatment at Martin Army Community Hospital from December 1997 to September 2013, and at the Tuskegee, Alabama VA Medical Center (VAMC) since November 2013. Review of the record does not indicate that efforts were made to obtain all of these records at the time. Thus, as the Veteran made VA aware of the existence of these medical records, they have been in VA's "constructive possession" despite their physical existence being absent from the claims file until September 2020. See Turner v. Shulkin, 29 Vet. App. 207, 218-19 (2018). Accordingly, new and relevant evidence has been received, and readjudication of the Veteran's claim for service connection for gastroenteritis is warranted. Service Connection for an Acquired Psychiatric Disorder 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, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran contends that he suffers from anxiety as a result of his service in Korea. He asserts that, while on patrol near the demilitarized zone (DMZ), there were many night patrols in which the Veteran was fearful for his life. He also asserted that, while there, he had "knowledge of two soldiers being killed." See VA Form 21-0781 (Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD)). In order to qualify as a disability for VA compensation purposes, acquired psychiatric disorders specifically must be formally diagnosed pursuant to the diagnostic criteria set forth in DSM-5. 38 C.F.R. §§ 4.125, 4.130; Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020). However, it is unclear as to whether the Veteran has been diagnosed with any acquired psychiatric disorder. During a VA mental disorders examination in May 2014, the VA examiner noted that the Veteran had symptoms of mild memory loss and diagnosed the Veteran with an unspecified neurocognitive disorder according to the DSM-5. However, an additional examination was afforded to the Veteran in March 2016. After interview and examination, the examiner opined that the Veteran did not, in fact, have a mental disorder that conforms with the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-5). While the Veteran described feelings of paranoia regarding his work quality and some sleep impairment, he did not endorse any symptoms consistent with a mental disorder relating to his military service, and the examiner noted that his score on the Beck Depression Inventory was negative for significant depressive symptoms. The Board does note, however, that the examiner also indicated that the Veteran demonstrated some difficulty upon mental status examination, as he was unable to "perform serial 7s and recalled two of three words following a brief time delay." Regardless, and assuming that the Veteran has had a diagnosis of a neurocognitive disorder during the appeal period, the evidence is against a finding that such is related to his military service. The Veteran's STRs are negative for any suggestion of any neurocognitive impairment, and the Veteran has denied any history of mental health treatment or medications. Importantly, outside of filing his service connection claims and asserting in-service stressors, in no statement in support of his claim has the Veteran asserted that he suffers from psychiatric symptoms other than memory problems. Other than the VA examinations afforded to him during his claim, the Veteran's medical records are negative for further treatment or examination beyond periodic psychological screenings during unrelated VA medical treatment, which are absent any reports of PTSD, depression, or symptoms indicative of any other acquired psychiatric disorder. Depression and PTSD screenings have all been negative. The Board points out that that the Veteran is already service-connected for an in-service traumatic brain injury (TBI), and a VA TBI examination in April 2017 notes mild memory loss and difficulty concentrating. That examination, however, did not find that the Veteran's TBI resulted in any mental disorder for the purpose of secondary service connection under 38 C.F.R. § 3.310. Moreover, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition, i.e., the avoidance of "pyramiding." 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Brady v. Brown, 4 Vet. App. 203, 206 (1993). Here, the Veteran is already in receipt of a 10 percent disability rating for his TBI, and this rating already contemplates not only a mild cognitive impairment, but also residual headaches. See May 2017 Rating Decision; 38 C.F.R. §§ 4.124a, Diagnostic Codes 8045. As there is no probative evidence of a separate mental disorder distinct from his TBI residuals, to compensate the Veteran twice by awarding service connection for a neurocognitive impairment would "overcompensate the claimant for the actual impairment of his earning capacity." Brady, 4 Vet. App. at 206. As such, service connection for an acquired psychiatric disorder is denied. The Board has considered the Veteran's statements, to include his assertions that he has an acquired psychiatric disorder that is related to service or his service-connected TBI. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, his lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings 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. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. 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."). 1. A compensable rating for bilateral hearing loss. The Veteran is in receipt of a noncompensable (zero percent) rating for bilateral hearing loss. He filed a claim for an increased rating in January 2016. After review of the evidence, a compensable rating is not warranted. Ratings of defective hearing are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85. Under 38 C.F.R. § 4.85, Table VI, Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination, is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination and the pure tone threshold average. The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by 4. Table VII, Percentage Evaluation for Hearing Impairment, is used to determine the rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The disability rating is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000 and 4000 Hertz is 55 decibels or more, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be determined from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Table VIA can also be used when the examiner certifies that use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc. 38 C.F.R. § 4.85(c). Turning to the evidence, the Veteran was afforded a VA audiological examination for his increased rating claim in March 2016. He reported to the examiner that his hearing loss causes difficulty hearing conversation. The results of the physical examination, as measured by a puretone audiometry test, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 65 105 105 73 LEFT 10 15 55 55 34 In addition, speech recognition was 92 percent in the right ear and 100 percent in the left ear, as measured by the Maryland CNC test. Applying these values to Table VI, his right and left ears are each assigned a Level II and Level I Roman numeral designation, respectively. Pursuant to Table VII, this corresponds with the currently assigned noncompensable rating. The Board finds that the current rating contemplates the Veteran's above-discussed reports of functional impact of his hearing loss on daily life. Indeed, the assignment of disability ratings for hearing impairment is derived from a mechanical formula based on levels of pure tone threshold average and speech discrimination. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In this case, the results are against assignment of a compensable rating at any point during the period on appeal. Thus, as the evidence is against a finding that the Veteran's hearing loss more nearly approximates the criteria for a higher rating, entitlement to a compensable rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.85 2. A compensable rating for allergic rhinitis. The Veteran is in receipt of a noncompensable (zero percent) rating for allergic rhinitis, status post septorhinoplasty. He filed a claim for an increased rating in January 2016. After review of the evidence, a compensable rating is not warranted. The Veteran's allergic rhinitis is rated under 38 C.F.R. § 4.97, Diagnostic code 6522. Pursuant to Diagnostic code 6522 for allergic rhinitis, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A 30 percent rating is warranted for allergic or vasomotor rhinitis with polyps. A VA examination was afforded to the Veteran for the purpose of his increased rating claim in April 2016. The Veteran reported a cough, runny nose, and watery eyes in spite of taking allergy medication. Although physical examination confirmed rhinitis and a permanent hypertrophy of the nasal turbinates, the examiner did not find that the Veteran had an obstruction greater than 50 percent on either side of the nasal passage. The examiner also noted no nasal polyp or any granulomatous condition. While the Board acknowledges that the Veteran is service-connected for sinusitis (the rating for which is not on appeal), no additional disability was noted to be present during this examination, including sinusitis, any larynx or pharynx conditions, a deviated septum, or tumors or neoplasm. The Veteran's treatment records are consistent with the above findings upon examination. Although a history of rhinitis was noted during the appeal, his treatment records were silent for any evidence of an increase in symptomology that would suggest that a higher rating may be warranted under the applicable criteria. After careful review, the Board finds the preponderance of the evidence is against a finding that the Veteran has had greater than 50 percent obstruction of both nasal passages, or complete obstruction of either nasal passage, the criteria for a higher rating under Diagnostic Code 6522. 38 C.F.R. § 4.97. The clinical evidence also does not establish the presence of nasal polyps during the appeal period. In sum, as the preponderance of the evidence is against a finding that the Veteran's rhinitis more nearly approximates the criteria for a higher rating, a compensable rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.97. 3. A rating in excess of 10 percent for dermatophytosis with tinea pedis. The Veteran is in receipt of a 10 percent rating for dermatophytosis with tinea pedis. He filed a claim for an increased rating in January 2016. After review of the evidence, a compensable rating is not warranted. The Veteran's dermatophytosis with tinea pedis is current evaluated under 38 C.F.R. § 4.118, Diagnostic Code 7813-7806. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case therefore indicates that dermatophytosis (which includes tinea pedis) under Diagnostic Code 7813 is the service-connected disorder and that the disorder is rated under Diagnostic Code 7806 for dermatitis or eczema as the prominent disability. Diagnostic Code 7813 contemplates disability due to dermatophytosis and directs that disabilities such as onychomycosis, or tinea pedis of the feet, be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801-7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813. In this case, the manifestations of the Veteran's tinea pedis more closely approximate dermatitis under Diagnostic Code 7806. The Board notes that, during the pendency of the appeal, the rating criteria for evaluating a skin disorder under 38 C.F.R. § 4.118 were amended effective August 13, 2018. 83 Fed. Reg. 32583 (July 13, 2018). These amendments revised Diagnostic Codes 7806 and 7813, to state that disabilities evaluated under these diagnostic codes should be evaluated under the General Rating Formula for the Skin. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to August 13, 2018 and both the old and new rating criteria from August 13, 2018, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change effective August 13, 2018, under Diagnostic Code 7806, a 10 percent disability rating is warranted where at least 5 percent, but less than 20 percent of the entire body or at least 5 percent, but less than 20 percent of exposed areas are affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; where systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted where more than 40 percent of the entire body or more than 40 percent of the exposed areas are affected; or where there was constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. As of August 13, 2018, under the amended criteria, the General Rating Formula for the Skin provides that a noncompensable rating is warranted where there is no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating will be warranted where there is at least one of the following: Characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is warranted where there is at least one of the following: Characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. Systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. 38 U.S.C. § 4.118 (a). Here, the preponderance of the evidence shows that a disability rating in excess of 10 percent for the Veteran's skin condition is not warranted at any time under either version of the regulations. In this regard, a VA examination afforded during the appeal in April 2016, reflects that the Veteran's dermatophytosis with tinea pedis of the feet affects between 5 to 20 percent of the total body area and no exposed areas. He was noted to use only over-the-counter topical medication, with a total duration of 6 weeks or more, but not constant, over the previous 12 months. The Veteran's medical treatment records during the appeal are not in significant conflict with the findings upon VA examination. The Board acknowledges the Veteran's reported use of topical treatment during the appeal, and that the use of systemic treatment can warrant higher ratings under Diagnostic Code 7806 regardless of the total area affected by his condition. However, Diagnostic Code 7806 draws a clear distinction between "systemic therapy" and "topical therapy" as the operative terms of the diagnostic code. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Systemic therapy means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Id. at 1355. Regardless of whether the Veteran applied topical treatment for durations that would warrant a higher disability rating, the evidence is against a finding that that he was treating his body as a whole. Rather, the Veteran used topical medication to treat only the area of the feet affected by his condition. Thus, at no time during the period on appeal has the Veteran's topical treatment constituted "systemic therapy" for the purposes of Diagnostic Code 7806. The Board has considered whether any other diagnostic codes pertaining to the skin are applicable in this case under both the amended VA regulations and the VA regulations in effect prior to August 13, 2018 (other than the ratings for scars, which are addressed in the Veteran's left forehead scar claim, below), but the Veteran has not been diagnosed with any of the disabilities contemplated by Diagnostic Codes 7815-7833. Accordingly, a rating under those diagnostic codes would not be appropriate. In sum, as the preponderance of the evidence is against a finding that the Veteran's dermatophytosis with tinea pedis more nearly approximates the criteria for a higher rating, an increased rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.118. 4. A rating in excess of 10 percent for a painful scar of the left forehead and eye. The Veteran seeks a rating in excess of 10 percent for a painful scar of the left forehead and eye. After review of the evidence, the Board finds that an increased rating is not warranted. Diagnostic Codes 7800 to 7805 pertain to scars. 38 C.F.R. § 4.118. As previously noted, the Schedule of ratings for the skin were amended effective August 13, 2018. See 83 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the old version of the diagnostic codes only (old code); however, for the period beginning August 13, 2018 the Board will consider both the old and amended version (amended code) of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Relevant specifically to this claim, Diagnostic Code 7800, which remained unchanged by the amended code, provides for a 10 percent evaluation when there is one characteristic of disfigurement. A 30 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with two or three characteristics of disfigurement. A 50 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or with four or five characteristics of disfigurement. A maximum, 80 evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. The eight characteristics of disfigurement are as follows: (1) Scar 5 or more inches (13 or more cm.) in length; (2) Scar at least one-quarter inch (0.6 cm.) wide at its widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo- or hyperpigmented in an area exceeding 6 square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 square inches (39 sq. cm.); (7) Underlying soft tissue missing in an area exceeding 6 square inches (39 sq. cm.); and (8) Skin indurated and inflexible in an area exceeding 6 square inches (39 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. Diagnostic Code 7801 provides for a 10 percent disability evaluation for a scar that is not of the head, face, or neck, that is deep and nonlinear (old code) or associated with underlying soft tissue damage (amended code), and that has an area of at least 6 square inches (39 sq. cm.). Higher ratings are available if larger areas are affected. Under the old code, a "deep scar" is defined as one associated with underlying soft tissue damage. The old and amended codes also differ regarding instructions for totalling the area affected when there is more than one qualifying scar. Diagnostic Code 7802 provides for a 10 percent disability evaluation for a scar not of the head, face, or neck, that is superficial and nonlinear (old code) or not associated with underlying soft tissue damage (amended code) and which covers an area of at least 144 square inches (929 sq. cm.) or more. No higher ratings are available under either version of this code. Under the old code, a "superficial scar" is defined as one not associated with underlying soft tissue damage. The old and amended codes also differ regarding instructions for totalling the area affected when there is more than one qualifying scar. Diagnostic Code 7804 provides for a 10 percent disability evaluation for one or two scars that are unstable or painful. A 20 percent disability evaluation is assigned where there are three or four scars that are unstable or painful. A 30 percent disability evaluation is assigned where there are five or more scars that are unstable or painful. An unstable scar is one where there is frequent loss of skin covering over the scar. If one or more scars are both unstable and painful 10 percent is added to the evaluation. Under the new and amended codes, pursuant to Diagnostic Code 7805, a scar may be rated on any disabling effect(s) not considered as part of the above. At the outset, the Board notes that the Veteran is in receipt of two separate ratings under different diagnostic codes for the same left forehead and eye scar that is associated with his in-service head injury a disfiguring scar of the left forehead and eye rated as 30 percent disabling during the entire appeal period under Diagnostic Code 7800, and a painful scar of the left forehead and eye rated as 10 percent disabling during the entire appeal period under Diagnostic Code 7804, the latter of which is on appeal. Note 3 to Diagnostic Code 7804 notes that scars evaluated under Diagnostic Codes 7800, 780, 7802, or 7805 may also receive and evaluation under this code when applicable. See 38 C.F.R. § 4.118. Although the Veteran has only appealed the 10 percent rating under Diagnostic Code 7804, both ratings pertain to the same scar. As such, the Board will address the propriety of both ratings assigned to this particular scar. Turning to the evidence, the Veteran filed his claim for an increased rating in January 2016 and a VA examination was afforded the following April 2016, which the Board notes was prior to the amended ratings. His left forehead scar measured 6 cm. X 0.2 cm., and while painful, was specifically noted as not both unstable and painful. There was no elevation, depression, adherence to underlying soft tissue, missing underlying soft tissue, or abnormal pigmentation of the scar. The Veteran reported, however, that his scar rendered him unable to completely close his left eyelid, resulting in dry eye. There were no other pertinent physical findings, complications, conditions, signs, or symptoms (such as muscle or nerve damage) associated with the scar. Based on the foregoing, the Veteran was assigned a 10 percent rating for his painful scar under Diagnostic Code 7804 effective the date of his January 2016 increased rating claim, based on one or two scars that are unstable or painful. As the Veteran does not have three or four scars that are unstable or painful associated with his in-service head injury, a higher 20 percent rating is not warranted under this code. Additionally, a 30 percent rating was also assigned under Diagnostic Code 7800 effective the date of his increased rating claim. A 30 percent rating is assigned under Diagnostic Code 7800 when the scar results in visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. Thus, absent four or five characteristics of disfigurement, a higher, 50 percent rating is not warranted under this code. Based on the foregoing, the Board finds the evidence is against a finding that the Veteran's left forehead and eye scar warrants ratings higher than those already assigned. The scar does not meet the number of characteristics of disfigurement, nor does it meet the size requirements, for a higher rating under Diagnostic Codes 7800 to 7802. Moreover, as there is only a single, painful scar, a rating in excess of 10 percent cannot be awarded when considering Diagnostic Code 7804. While the Board acknowledges the Veteran's inability to completely close his left eye, resulting in dry eye and the use of lubricating drops, the General rating Formula for Diseases of the Eye assigns a higher, 40 percent rating when there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months. 38 C.F.R. § 4.79. Such is not shown in this case. Moreover, Diagnostic Code 6022, the rating specific to lagophthalmos (incomplete or defective closure of the eyelids), affords only a maximum 10 percent rating based on unilateral lagophthalmos. Id. As such, a higher rating based on limitation of function pursuant to Diagnostic Code 7805 is also not warranted. The Board has considered whether higher ratings could be warranted under any other diagnostic code but has found none. In sum, as the preponderance of the evidence is against a finding that the Veteran's painful scar of the forehead and left eye more nearly approximates the criteria for a higher rating, an increased rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.118. 5. A rating in excess of 20 percent for lumbar DJD. The Veteran sought an increased disability rating for his lumbar DJD in January 2016, and his rating was subsequently increased from 10 to 20 percent in the rating decision on appeal. He continues to seek an increased rating. After review of the evidence, a higher rating is not warranted. 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 Spinal Formula provides for a 20 percent disability 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 disability 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 disability 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, Spinal 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). 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). 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). A 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks. Higher ratings are available with incapacitating episodes of greater duration during a 12-month period. In this case, there is no competent evidence of incapacitating episodes as defined by regulation of the duration required for a higher rating. At the outset, the Board notes that the Veteran's increased 20 percent rating was based, not on limitation of motion findings, but on an April 2016 VA examiner's findings that the Veteran's disability manifested muscle spasms with an abnormal gait or spinal contour. Range of motion (ROM) testing was performed during the examination, and showed entirely normal motion, including flexion at 90 degrees. As such, absent favorable ankylosis or flexion reduced to 30 degrees or less, the next higher 40 percent rating is not warranted. Review of the Veteran's medical treatment records during the relevant period on appeal are not in significant conflict with the above ROM findings. Further, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiners, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. At the examination, the Veteran reported flare-ups consisting of increased pain with bending and with certain movements, not limited range of motion. Thus, while given the opportunity to describe functional limitation related to the disability, the Veteran's statements do not suggest the requisite limitation of motion necessary for a higher rating, i.e., flexion that would be greatly reduced from normal (90 degrees) to 30 degrees or less. Thus, the Board finds that the range of motion findings on examination depict the estimated range of motion during a flare-up and after repetitive use over time. Treatment records do not show greater limitation of motion than the examination findings. As the Veteran had no limited motion in the thoracolumbar spine, ankylosis is also not present. The Board acknowledges that the functional equivalent of ankylosis during flare-ups pursuant to 38 C.F.R. § 4.40 and 4.45 can nevertheless satisfy the criteria for a rating based on ankylosis. See Chavis v. McDonough, 34 Vet. App. 1, 20 (2021). Here, however, despite the Veteran's complaints, the evidence does not suggest that pain did resulted in the functional equivalent of ankylosis of the lumbar spine at any time during the period on appeal. In Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), ankylosis was defined as "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." It is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure"). DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 94 (32nd ed. 2012). The Veteran has not described, including during any medical examination, a limitation of motion during flare-ups of pain that essentially results in stiffening, fixation, or immobility of his lumbar spine. Given the above, a higher rating is not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Spinal Formula. Regarding relevant neurological findings, the examiner noted that, despite the Veteran's reports of lower extremity numbness and tingling in his legs 3-4 times per month, he did not have actual signs or symptoms of radiculopathy. These findings were confirmed in a contemporaneous VA peripheral nerves examination that included necessary neurological testing of muscle strength, sensation, and reflexes. There is no other evidence in significant conflict with these findings. Therefore, the Board finds there are no other symptoms which should be addressed by a separately-assigned disability rating. In sum, as the preponderance of the evidence is against a finding that the Veteran's lumbar DJD more nearly approximates the criteria for a higher rating, an increased rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.71a As to all of the increased rating claims being denied above, the Board is sympathetic to the Veteran's lay statements that his disabilities are worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND While the Board regrets further delay, the Veteran's remaining claims must be remanded. 1. Entitlement to service connection for gastroenteritis. As noted above, the Veteran noted in 2013 service connection claims that he received treatment from Martin Army Community Hospital (ACH) in Fort Benning, Georgia, dated back to December 1997. Review of the record does not reflect that all attempts were made to obtain these records, as those Martin ACH records that are in the claims file date back only to 2011. Despite the RO's finding of a lack of a current chronic disability for service connection purposes, the Martin ACH treatment reports current of record do suggest a history of gastroenteritis, gastritis, as well as a history of gastrointestinal issues such as diverticulosis. Moreover, the Veteran STRs indicate a history of indigestion and/or heartburn in service. While an initial VA examination in January 1998 did diagnose gastroenteritis at the time, no medical opinion has been obtained that addresses any relationship between any current gastrointestinal or gastroesophageal disability and his military service. Accordingly, remand is necessary to correct these pre-decisional duty-to-assist errors. 2. Ratings in excess of 10 percent for bilateral knee disabilities In light of Sharp v. Shulkin, 29 Vet. App. 26 (2017), a remand is necessary to afford the Veteran with an adequate examination regarding the severity of his service-connected knee disabilities. In Sharp, the Court held that, pursuant to VA regulations and the VA Clinician's Guide, when conducting evaluations for musculoskeletal disabilities, VA examiners are obligated to inquire whether there are periods of flare-ups and repetitive use over time and, if the answer is yes, examiners are to state their severity, frequency, and duration, name the precipitating and alleviating factors, and estimate, per the veteran, to what extent, if any, flare-ups and repetitive use over time affect functional impact. Sharp, 29 Vet. App. at 26. Further, VA examiners are expected to offer opinions on functional loss that would occur during flare-ups and repetitive use over time based on estimates derived from relevant sources, including the Veteran's lay statements. Id. at 34. In other words, stating that the examination was not conducted during a flare-up or following repetitive use over time as the sole rationale for not addressing the functional impacts of such will not be sufficient. Here, while the VA examiner did note that the examination was being conducted after repetitive use over time, and therefore the range of motion results upon examination were reflective of such instances, the examination was noted as not being conducted during a flare up. Despite the VA examiner describing the Veteran's symptoms during a flare-up earlier in the examination report, the examiner failed to describe any additional functional loss during such an instance as it would resorting to speculation. The Board is aware of the difficulty in providing an opinion that in part requires some speculation, particularly when the Veteran is not experiencing a flare-up at the time of examination. Nonetheless, the failure to obtain an adequate medical examination that complies with governing legal guidelines is a pre-decisional duty to assist error. 38 C.F.R. § 3.159(c). Accordingly, a new medical examination is necessary. 3. A rating in excess of 10 percent for a right ankle sprain. The Veteran seeks a rating in excess of 10 percent for his right ankle disability., October 2016. For reasons similar to the Veteran's knee disability claims above, the appeal must be remanded to afford him with an adequate examination regarding the severity of the Veteran's disability. A VA examination was afforded during the relevant period on appeal in October 2016, where plantar dorsiflexion in the right ankle was reduced to 10 degrees and plantar flexion was reduced to 25 degrees. While the examiner noted the Veteran's statement's that flare-ups of right ankle pain results in increased difficulty walking, the examiner did not provided estimations of additional functional loss during a flare up or during repetitive use over time. As with the Veteran's knee claims, the examiner stated that doing so would be resorting to speculation as the Veteran was not being observed during flare up or after repetitive use over time. Accordingly, a new medical examination is necessary. The matters are therefore REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claim, to include VA records treatment records dating back to the Veteran's release form service in 1997, particularly from Martin Army Community Hospital in Fort Benning, Georgia. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken, to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current gastrointestinal or gastroesophageal disability onset during service or is otherwise related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the VA examination in 1998 indicating a diagnosis of gastroenteritis, as well as service treatment records indicating indigestion and heartburn. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA ¬¬¬knee examination to determine the current symptoms, level of severity, and functional impairment associated with his bilateral knee disabilities. The claims file should be reviewed by the examiner. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and after repetitive use over time. If it is not possible to specifically estimate range of motion during flare-up and after repetitive use over time without speculation, the examiner is asked to opine as to whether, during these conditions, flexion of either knee would be limited to 30 degrees or less, or extension or either knee would be limited to 15 degrees or more. In addition, the examiner is also asked to apply the above instructions in providing a retrospective opinion as to the severity of the Veteran's service-connected knee disabilities during the April 2016 VA examination. The opinion should opine as to the functional loss attributable to the Veteran's service-connected knee disabilities at the time due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use. Such impairment should be reported in terms of additional degrees of limitation of motion. If the above actions cannot be accomplished without speculation, 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) and explain why that is the case. 4. After records development is completed, schedule the Veteran for a VA examination to determine the current symptoms, level of severity, and functional impairment associated with his right ankle disabilities. The claims file should be reviewed by the examiner. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and after repetitive use over time. If it is not possible to specifically estimate range of motion during flare-up and after repetitive use over time without speculation, the examiner is asked to opine as to whether, during these conditions, the right ankle would be limited to less than 5 degrees dorsiflexion or less than 10 degrees planter flexion. In addition, the examiner is also asked to apply the above instructions in providing a retrospective opinion as to the severity of the Veteran's service-connected right knee disability during the October 2016 VA examination. The opinion should opine as to the functional loss attributable to the Veteran's service-connected right ankle disability at the time due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use. Such impairment should be reported in terms of additional degrees of limitation of motion. If the above actions cannot be accomplished without speculation, 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) and explain why that is the case. Joshua Castillo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.