Citation Nr: 21006317 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-09 649 DATE: February 3, 2021 ORDER Entitlement to service connection for a right leg nerve damage (also claimed as leg injury), to include as secondary to the Veteran's service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) is denied. Entitlement to service connection for a left leg nerve damage (also claimed as leg injury), to include as secondary to the Veteran’s service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is dismissed. Entitlement to a disability rating in excess of 10 percent for a torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) is denied. Entitlement to a disability rating in excess of 10 percent for unilateral scotoma of the right eye (claimed as vision disability) is denied. REMANDED Entitlement to a disability rating in excess of 20 percent for a left shoulder arthralgia (non-dominant) (claimed as left shoulder injury) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that right leg nerve damage (also claimed as leg injury) began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence of record is against finding that the Veteran has had left leg nerve damage at any time during or approximate to the pendency of the claim. 3. The Veteran’s bilateral leg nerve damage (also claimed as leg injury) are not secondary to service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia), and are not otherwise related to an in-service injury or disease. 4. During the period on appeal, the Veteran’s claim for entitlement to service connection for OSA has been approved by the RO and there no longer remains allegations of errors of fact or law for appellate consideration. 5. The Veteran’s torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) is manifested by no more than moderate limited motion of the ankle. 6. The Veteran’s corrected distance visual acuity is 20/40 in the right eye and 20/20 or better in the left eye. 7. The Veteran is diagnosed with unilateral scotoma of the right eye. CONCLUSIONS OF LAW 1. The criteria for service connection for right leg nerve damage (also claimed as leg injury) due to service or due to his service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for left leg nerve damage (also claimed as leg injury) due to service or due to his service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for dismissal of the issue of entitlement to service connection for OSA is met. 38 U.S.C. § 7105. 4. The criteria for a rating in excess of 10 percent for a torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 5. The criteria for a disability rating in excess of 10 percent for unilateral scotoma of the right eye (claimed as vision disability) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.76A, 4.79, Diagnostic Code 6081, Diagnostic Code 6066. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 2009 until his honorable discharge in March 2013. These matters come before the Board of Veterans’ Appeals (Board) on appeal from the June 2013 rating decision by the Seattle, Washington Regional Office (RO) of the United States Department of Veterans Affairs (VA); also the February 2014 and September 2014 rating decisions by the Montgomery, Alabama RO of the VA. In September 2018, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain all updated records of VA and adequately identify private treatment the Veteran has received for the disabilities remaining on appeal; schedule the Veteran for a VA examination to determine the nature and cause of any lower extremity neurological disabilities; schedule the Veteran for a VA examination to determine the nature and cause of his OSA; schedule a VA examination with an orthopedist to determine the current severity of his right ankle and left shoulder disabilities; and schedule a VA examination with an ophthalmologist to determine the current severity of his vision disability. In response, in March 2020, the RO obtained updated VA treatment records from the Birmingham, Alabama VA Medical Center (VAMC); in July 2020, the RO obtained VA examinations to evaluate the Veteran’s left shoulder and right ankle, vision, and OSA disabilities; and in September 2020, the RO obtained VA examinations for the Veteran’s bilateral leg disabilities. The Board finds that there has been substantial compliance with the Board’s previous remand directives regarding the issue(s) on appeal. Stegall v. West, 11 Vet. App. 268, 271 (1998). As will be addressed below, the Board notes that during the period on appeal, the Veteran’s claim for entitlement to service connection for OSA was granted by the RO. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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 disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of the disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). 1. Entitlement to service connection for right leg nerve damage (also claimed as leg injury), to include as secondary to the Veteran's service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) 2. Entitlement to service connection for a left leg nerve damage (also claimed as leg injury), to include as secondary to the Veteran’s service-connected torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that bilateral nerve damage began during service and has existed since that time and/or it is related to an in-service right ankle injury. First, affording the Veteran the benefit of the doubt, the Board finds that there is evidence of a current disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran is diagnosed with neuropathic pain. See September 2020 and October 2020 VA examinations. Second, the Board finds that there is evidence of a service-connected disability. See Wallin, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran is service connected for torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia). Third, the Board finds that there is not medical nexus evidence establishing a connection between the Veteran’s service-connected disability and the current disability. The Veteran was afforded multiple VA examinations. The Board notes that the Veteran submitted private provider medical treatment records from January 2014 that reflected normal NCS of the right peroneal motor, posterior tibial motor, sural sensory, superficial peroneal sensory, and distal sural sensory nerves. The January 2014 private provider noted that the results are normal and that there is no evidence of large fiber polyneuropathy of the right lower extremity and that a normal nerve conduction study cannot exclude radiculopathy or small fiber neuropathy and suggested that if radiculopathy is suspected, needle EMG may be of more benefit. The Veteran was afforded a VA examination in January 2014. The January 2014 did not provide a nexus opinion, but noted that the Veteran did not show up for his appointment and released the limited report. The Veteran was afforded a second VA examination in October 2019. The October 2019 VA examiner opined that the Veteran’s bilateral nerve damage was related to his active service because it was at least as likely as not (50 percent probability or greater) incurred while serving in the Army at Fort Hood, Texas in 2011 and at least as likely as not (50 percent probability or greater) proximately due to or the result of the Veteran’s service-connected right ankle disability because the claimed condition is at least as likely as not secondary to the Veteran’s service-connected right ankle sprain in 2011 at Fort Hood, Texas. Unfortunately, the October 2019 VA examiner did not provide a rationale for the conclusory opinions that were provided. The October 2019 VA examiner opined that the Veteran’s bilateral nerve damage was less likely than not (less than 50 percent probability) aggravated beyond its natural progression by the Veteran’s right ankle disability because the complaint is predominantly subjective pain and unusual diminished sensation in the right lateral or leg region, making it difficult to determine a baseline severity. The Board finds that the October 2019 VA examination to be inadequate because the examiner does not provide a detailed rationale for the opinions provided. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Veteran was afforded a third VA examination in September 2020. Right Lower Extremity The September 2020 VA examiner opined that the Veteran’s right lower extremity nerve damage was less likely than not (less than 50 percent probability) aggravated beyond its natural progression by his right ankle disability and is less likely than not (less than 50 percent probability) proximately due to or the result of his right ankle disability because the Veteran had normal nerve conduction studies of the right peroneal, posterior tibial motor, sural sensory, superficial peroneal sensory, and distal rural sensory nerves on January 17, 2014, interpreted on January 27, 2014. The September 2020 VA examiner opined that the Veteran’s right leg nerve damage is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness because based on the October 2019 VA examination, the October 2019 VA examiner diagnosed neuropathic pain in the right distal lower extremity and no evidence of nerve injury in the left lower leg, no evidence compatible with small fiber neuropathy and no convincing evidence of radiculopathy in either lower extremity. The September 2020 VA examiner also noted that the finding of decreased strength in both ankle plantar and dorsal flexion would require injury to both the tibial and peroneal nerves or the L5 and S1 nerve roots, which is highly unlikely and moreover, the Veteran’s right lower extremity nerve conduction studies in January 2014 were normal with no evidence of nerve injury and that the Veteran’s ankle pain and ankle weakness with subjective numbness is more likely due to traumatic right ankle arthropathy and not neuropathy. Left Lower Extremity The September 2020 VA examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s left lower extremity nerve damage is aggravated beyond its natural progression by his right ankle disability and that it is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s right ankle disability because there is no evidence of a lower left extremity nerve injury. Furthermore, the September 2020 VA examiner opined that his left lower extremity nerve injury is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness because there is no evidence of left leg nerve injury. The Board finds that the September 2020 VA examination to be adequate because the examiner provided a detailed rationale for the opinions provided. Accordingly, entitlement to service connection on both a secondary basis and direct basis for bilateral nerve damage of the lower extremities is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for OSA The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. In the present case, the issue of entitlement to service connection for OSA was remanded by the Board in September 2018. Subsequent to the remand, the RO granted the Veteran’s claim for entitlement to service connection for OSA with an evaluation of 50 percent disabling. The Veteran has not appealed the decision and hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 4. Entitlement to a disability rating in excess of 10 percent for a torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) The Veteran asserts that he is entitled to a higher disability rating. The Veteran’s torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia) is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. According to MERRIAM WEBSTER, “moderate” means “tending toward the mean or average amount or dimension”. See www.merriam-webster.com/dictionary/moderate. “Marked” means “having a distinctive or emphasized character”. See www.merriam-webster.com/dictionary/marked. 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 factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia). The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, lack of endurance, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that weekly flair-ups would not result in symptoms more nearly approximating marked limited motion or limitation so distinctive or emphasized that it would approximate marked limited motion. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 10 percent for torn anterior talofibular ligament with mild peroneus longus tendinopathy and associated mild tendinosis of the right ankle (claimed as right ankle arthralgia). In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to a disability rating in excess of 10 percent for unilateral scotoma of the right eye (claimed as vision disability) The Veteran asserts that he is entitled to a higher disability rating. Unless otherwise directed, evaluate diseases of the eye under the General Rating Formula for Diseases of the Eye. 38 C.F.R. § 4.79, Diagnostic Codes 6000 through 6009. Impairment of Visual Acuity is rated under Diagnostic Codes 6061 through 6066. Impairment of Visual Fields is rated under Diagnostic Codes 6080 through 6081. The Veteran is rated under Diagnostic Code 6066. However, the Board finds that the appropriate Diagnostic code is 6081-6066. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 6081 provides for a 10 percent disability rating for unilateral scotoma with scotoma affecting at least one-quarter of the visual field (quadrantanopsia) or with centrally located scotoma of any size. 38 C.F.R. § 4.80, Diagnostic Code 6081. Diagnostic Code 6066 provides disability ratings where vision in one eye (the poorer eye) is 10/200 or better. Where visual acuity in one eye (the poorer eye) is 10/200, a 30 percent disability rating is warranted where vision in the other eye is 20/40. A 40 percent disability rating is warranted where vision in the other eye is 20/50. A 50 percent disability rating is warranted where vision in the other eye is 20/70. A 60 percent disability rating is warranted where vision in the other eye is 20/100. A 70 percent disability rating is warranted where vision in the other eye is 20/200. An 80 percent disability rating is warranted where vision in the other eye is 15/200. A 90 percent disability rating is warranted where vision in the other eye is 10/200. Id. Where visual acuity in one eye (the poorer eye) is 15/200, a 20 percent disability rating is warranted where vision in the other eye is 20/40. A 30 percent disability rating is warranted where vision in the other eye is 20/50. A 40 percent disability rating is warranted where vision in the other eye is 20/70. A 60 percent disability rating is warranted where vision in the other eye is 20/100. A 70 percent disability rating is warranted where vision in the other eye is 20/200. An 80 percent disability rating is warranted where vision in the other eye is 15/200. Id. Where visual acuity in one eye (the poorer eye) is 20/200, a 20 percent disability rating is warranted where vision in the other eye is 20/40. A 30 percent disability rating is warranted where vision in the other eye is 20/50. A 40 percent disability rating is warranted where vision in the other eye is 20/70. A 60 percent disability rating is warranted where vision in the other eye is 20/100. A 70 percent disability rating is warranted where vision in the other eye is 20/200. Id. Where visual acuity in one eye (the poorer eye) is 20/100, a 10 percent disability rating is warranted where vision in the other eye is 20/40. A 20 percent disability rating is warranted where vision in the other eye is 20/50. A 30 percent disability rating is warranted where vision in the other eye is 20/70. A 50 percent disability rating is warranted where vision in the other eye is 20/100. Id. Where visual acuity in one eye (the poorer eye) is 20/70, a 10 percent disability rating is warranted where vision in the other eye is 20/40. A 20 percent disability rating is warranted where vision in the other eye is 20/50. A 30 percent disability rating is warranted where vision in the other eye is 20/70. Id. Where visual acuity in one eye (the poorer eye) is 20/50, a 10 percent disability rating is warranted where vision in the other eye is 20/40. A 10 percent disability rating is warranted where vision in the other eye is 20/50. Where visual acuity in one eye (the poorer eye) is 20/40, a noncompensable disability rating is warranted where vision in the other eye is 20/40 or better. Id. Evaluations of defective vision from noncompensable to 100 percent based on organic impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. §§ 4.76(a), 4.79. The examination for visual impairment must be conducted by a licensed optometrist or by a licensed ophthalmologist and the examiner must identify the disease, injury, or any other pathologic found. 38 C.F.R. § 4.76(b). Examination of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Id. Unless medically contraindicated, the fundus must be examined with the Veteran’s pupils dilated. Id. The evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. 38 C.F.R. § 4.75(d). Combine the evaluation for visual impairment of one eye with evaluation for other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under diagnostic code 7800). Id. When the Veteran has anatomical loss of one eye and is unable to wear a prosthesis, increase the evaluation for visual acuity under diagnostic code 6063 by 10 percent, but the maximum evaluation for visual impairment of both eyes must not exceed 100 percent. A 10-percent increase under the paragraph precludes an evaluation under diagnostic code 7800 based on gross distortion or asymmetry of the eye but not an evaluation under diagnostic code 7800 based on other characteristics of disfigurement. Examinations of visual acuity must include the central uncorrected and corrected visual acuity for distance and near vision using Snellen’s test type or its equivalent. 38 C.F.R. § 4.76(a). Evaluation of central visual acuity on the basis of corrected distance vision with central fixation, even if a central scotoma is present. 38 C.F.R. § 4.76(b). However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, evaluate the visual acuity of the poorer eye using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. Id. For evaluations of restrictions in visual field(s), the examiner must use either Goldmann kinetic perimetry or automated perimetry using Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability. 38 C.F.R. § 4.77. Determination of the average concentric contraction of the visual field of each eye by measuring the remaining visual field (in degrees) at each of the eight principal meridians 45 degrees apart, adding them, and dividing the sum by eight. 38 C.F.R. § 4.77(b). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, separately evaluate the visual acuity and visual field defect (expressed as a level of visual acuity), and combine them under the provisions of 38 C.F.R. § 4.25. An October 2019 VA examination reveals that the Veteran had the following visual impairment(s): 10.15.2019 Uncorrected Distance Corrected Distance Uncorrected Near Corrected Near RIGHT 20/50 20/40 20/40 20/40 LEFT 20/40 20/20 or better 20/40 20/20 or better The October 2019 VA examination also revealed that the Veteran has a documented visual field defect of a centrally located scotoma. As noted above, regulations provide that for evaluations of restrictions in visual field(s), the examiner must use either Goldmann kinetic perimetry or automated perimetry using Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability. 38 C.F.R. § 4.77. The Board notes that the October 2019 VA examination utilized confrontation visual field testing and confirmed the Veteran’s diagnosis of a centrally located scotoma of the right eye, which has a fixed disability rating of 10 percent under Diagnostic Code 6081. Because the diagnosis results in the fixed disability rating of 10 percent disabling for a centrally located scotoma, and the Veteran is already rated at that disability rating, the Board will not remand the case for further examination. Based on the evidence above, a disability rating in excess of 10 percent for the Veteran’s loss of visual acuity and centrally located scotoma is not warranted. The Veteran’s visual acuity of 20/40 corrected distance visual acuity in the right eye and 20/20 or better corrected distance visual acuity in the left eye warrants a non-compensable disability rating. Additionally, the Veteran’s centrally located scotoma of the right eye warrants a 10 percent disability rating. Combining the Veteran’s results for visual acuity at a non-compensable disability rating and his centrally located scotoma of the right eye disability rating of 10 percent results in a combined disability rating of 10 percent disabling. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a disability rating in excess of 10 percent for a loss of visual acuity and impairment of visual field. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 6. Entitlement to a disability rating in excess of 20 percent for a left shoulder arthralgia (non-dominant) (claimed as left shoulder injury) is remanded. While the record contains a contemporaneous VA examination regarding the Veteran’s left shoulder arthralgia (non-dominant) (claimed as left shoulder injury), the examination does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The Board notes that the VA examiner noted that flare-ups of the left shoulder occur once weekly with severe flare-ups and that the left shoulder flare ups last 2-3 days and are precipitated by over activity and are alleviated by rest, ice, and heat. The examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups or to determine if the Veteran’s flare-ups produce limitation of motion to 25 degrees from the side. Therefore, remand is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left shoulder arthralgia (non-dominant) (claimed as left shoulder injury). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, 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. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement 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). The examiner should specifically opine if the Veteran’s flare-ups produce limitation of motion to 25 degrees from the side. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, Associate 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.