Citation Nr: 21010154 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 08-02 297 DATE: February 24, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for service-connected bilateral pes planus is denied. Entitlement to an initial rating in excess of 10 percent for intervertebral disc syndrome (IVDS) is denied. Entitlement to an initial rating in excess of 10 percent for service-connected left knee osteoarthritis is denied. Entitlement to a separate 10 percent disability rating for service-connected instability of the left knee from September 21, 2005 is granted. Entitlement to an initial rating in excess of 10 percent for service-connected right knee patellofemoral syndrome is denied. Entitlement to a separate 10 percent disability rating for service-connected instability of the right knee from September 21, 2005 is granted. REMANDED Service connection for inguinal, umbilical, and ventral hernia is remanded. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran’s bilateral pes planus is not manifested by extreme tenderness of plantar surfaces of the feet or marked inward displacement and severe spasm of the tendo Achillis on manipulation. 2. The preponderance of the evidences reveals that the Veteran’s IVDS did not more nearly approximate forward flexion limited to 60 degrees or less, combined range of motion of the thoracolumbar spine limited to 120 degrees or less; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; and there were no incapacitating episodes requiring physician-prescribed bed rest, throughout the entire appeal period. 3. The preponderance of the evidence shows that the flexion of the left knee was not limited to 30 degrees or less with consideration of reduced function on repetitive motion or during flare-ups at any time during the appeal period; or, extension limited to 10 degrees or more even with consideration of reduced function on repetitive motion or during flare-ups with no evidence of ankylosis, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 4. The evidence is evenly balanced as to whether the Veteran’s osteoarthritis of the left knee is manifested by slight instability. 5. The preponderance of the evidence shows that the flexion of the right knee was not limited to 30 degrees or less with consideration of reduced function on repetitive motion or during flare-ups at any time during the appeal period; or, extension limited to 10 degrees or more even with consideration of reduced function on repetitive motion or during flare-ups with no evidence of ankylosis, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 6. The evidence is evenly balanced as to whether the Veteran’s right knee patellofemoral syndrome is manifested by slight instability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for service-connected bilateral pes planus are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5276 (2020 and 2021). 2. The criteria for an initial rating in excess of 10 percent for service-connected IVDS with degenerative arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242, 5243 (2020) and (2021). 3. The criteria for an initial rating in excess of 10 percent for service-connected left knee osteoarthritis, on the basis of painful limited motion, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2020 and 2021). 4. The criteria for a separate 10 percent disability rating for service-connected left knee instability from September 21, 2005 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5257 (2020 and 2021). 5. The criteria for an initial rating in excess of 10 percent for service-connected right knee patellofemoral syndrome, on the basis of painful limited motion, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260 (2020 and 2021). 6. The criteria for a separate 10 percent disability rating for service-connected right knee instability from September 21, 2005 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5257 (2020 and 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to September 1970. This case is before the Board of Veterans’ Appeals (Board) on appeal from Regional Office (RO) rating decisions dated in June 2006 and February 2009. In the June 2006 rating decision, the RO denied a disability rating in excess of 30 percent for service-connected bilateral pes planus and granted service connection for IVDS with a 10 percent disability rating, effective from September 21, 2005, service connected for patellofemoral syndrome of the right knee with a noncompensable disability rating, effective from September 21, 2005, and service connection for osteoarthritis of the left knee with a noncompensable rating, effective from September 21, 2005. The Veteran’s notice of disagreement (NOD) was received in August 2006. The RO issued a statement of the case (SOC) in December 2007. The Veteran’s VA Form 9, substantive appeal to the Board, was received in February 2008. In the February 2009 rating decision, the RO denied service connection for ventral and umbilical hernias, claimed as secondary to IVDS. The Veteran’s notice of disagreement (NOD) was received in July 2009. The RO issued a statement of the case (SOC) in February 2012. The Veteran’s VA Form 9, substantive appeal to the Board, was received in March 2012. In December 2013 and November 2018, the Board remanded the case to the RO for further development and adjudicative action. In a September 2018 rating decision, the RO granted a 10 percent disability rating for left knee osteoarthritis, effective September 21, 2005 and a 10 percent disability rating for patellofemoral syndrome of the right knee, effective September 21, 2005 Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 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.   Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran.  38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b).  In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  However, when the current appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999).  Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The appeal period for the Veteran’s claim for increased disability rating for bilateral pes planus is July 18, 2005, the date the RO received the Veteran’s claim for an increased rating for his bilateral pes planus. The appeal period for the Veteran’s initial increased rating claims for IVDS and bilateral knee disabilities begins September 21, 2005, the date the RO received the Veteran’s service connection claims for a back and bilateral knee disability. 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; 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). 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.” Correia v. McDonald, 28 Vet. App. 158 (2016). Furthermore, 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 regulations of the musculoskeletal system were recently amended, effective February 7, 2021. Where a law or regulation changes during the pendency of a claim for increased rating, the amendments cannot be construed to have retroactive effect unless the language requires such a result. See Kuzma v. Principi, 341 F.3d 1327, 1328 (2003) (citing Landgraf v. USI Film Prods., 511 U.S. 244 (1994)). There is no such language in the amendments to the regulations at issue in this case. Consequently, the Board has considered whether an increased evaluation may be warranted under either the old or new version of the schedule for rating disabilities of the spine; but application of the newer regulations can be no earlier than the effective date of the change. 1. Entitlement to a disability rating in excess of 30 percent for service-connected bilateral pes planus. The Veteran contends that he is entitled to a higher rating for his bilateral pes planus. The Veteran’s bilateral pes planus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). As noted above, regulations for rating musculoskeletal system under 38 C.F.R. § 4.71a, were amended, effective February 7, 2021. However, Diagnostic Code 5276, which evaluates acquired flatfoot (i.e., pes planus) was not changed. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for bilateral pes planus. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain stiffness, swelling, and fatigue at rest and pain, weakness, stiffness, swelling, and fatigue while standing or walking. The Veteran noted that pain with standing and pressure to walking resulting in rest breaks. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that at rest he has pain, stiffness, swelling, and fatigue and while standing or walking he has pain, weakness, stiffness, swelling, and fatigue would not result in symptoms more nearly approximating pronounced bilateral acquired flatfoot. Specifically, a September 2005 VA examination documents that the Veteran reported that his flat feet result in functional impairment in that he cannot do heel to foot, side to side movement, or standing on one foot. Examination revealed painful motion in both feet. Pes planus was present. There was a moderate degree of valgus present, which could be corrected by manipulations in both feet. There was no tenderness to palpation of the right foot plantar surface. The right Achilles tendon revealed good alignment. There was forefoot/midfoot malalignment of a moderate degree, which could be corrected by manipulation in the left foot. There was deformity of inward rotation of the superior portion of the os calcis and deformity of the medial tilting of the upper border of the talus. Palpation of the left foot plantar surface revealed slight tenderness. Manipulation of the left Achilles tendon produced pain. He did not have any limitation with standing or walking. He required arch support. The symptoms and pain were not relieved by the corrective shoe wear. A June 2012 VA examination of the bilateral feet shows that the Veteran reported pain in the dorsal foot mainly with prolonged walking. He takes Motrin, which helps some. The Veteran had pain on use of the bilateral feet and the pain is accentuated on use. There was no pain on manipulation of the feet. There was no indication of swelling on use. The Veteran did not have characteristic calluses, or any calluses caused by his bilateral flat feet. His symptoms were relieved by arch support (or built up shoes or orthotic). There was also no evidence of extreme tenderness of plantar surface, bilaterally. The Veteran did not have decreased longitudinale arch height on weight-bearing; however, there was evidence of marked deformity and marked pronation that is improved by orthopedic shoes or appliances of the bilateral foot. Weight-bearing line fell over or was medial to the great toe, bilaterally. The Veteran had inward bowing of the Achilles’ tendon in both feet. He did not have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation. The Veteran regularly uses braces, canes, orthotics, and ankle braces. An October 2016 VA treatment record documents that he has tried arch support in shoes and has tried prosthetic braces which did not give him much relief. He was evaluated for surgery due to his pes planus. An October 2016 VA treatment record noted that the purpose of the Arthrodesis was stop motion at painful joints in the middle part of the foot. A VA surgeon noted in October 2016 that the Veteran had stage 3 posterior tibial tendon dysfunction (i.e. acquired flat foot). He had failed orthotics and bracing. He was currently limited in his ability to ambulate. It was recommended that the Veteran have left triple Arthrodesis with allograft and possible tendo-achilles lengthening. The Veteran underwent triple Arthrodesis for flatfoot deformity with allograft tendo-achilles lengthening of the left foot in October 2016. A July 2018 VA examination documents that the Veteran reported daily bilateral foot pain. He has a history of arthrodesis in 2016 due to ongoing foot pain. The examiner noted that the Veteran did not have extreme tenderness of plantar surfaces of both feet. He had decreased longitudinal arch height in both feet on weight-bearing. There was no objective evidence of marked deformity or marked pronation of both feet. Weight-bearing line did not fall over or was medial to the great toe, bilaterally. The Veteran did not have inward bowing of the Achilles’ tendon in both feet. He also did not have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation. He examiner noted that the Veteran had mild left foot arthrodesis. The condition did not chronically compromise weight bearing and it did not require arch supports, custom orthotic inserts, or shoe modifications. The examiner noted that the Veteran did not use any assistive devices as a normal mode of locomotion. In light of the foregoing, the preponderance of the medical and lay evidence reflects that the Veteran’s bilateral pes planus does not result extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achillis on manipulation. Thus, entitlement to 50 percent disability rating for bilateral pes planus is not warranted at any time during the appeal. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court’s holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court’s holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran’s disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. In conclusion, the Board finds that the preponderance of the evidence is a rating in excess of 30 percent for bilateral pes planus. 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. 2. Entitlement to an initial rating in excess of 10 percent for IVDS. The Veteran contends that he is entitled to a higher rating for his service connected IVDS, currently rated as 10 percent disabling, because he has chronic aching pain in the lower back and pain with movement to include flexion. The Veteran’s IVDS is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243 that evaluated IVDS. The regulations for evaluating musculoskeletal disabilities were amended, effective from February 7, 2021. Prior to February 7, 2021, Diagnostic Code 5243 directs IVDS to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. Effective February 7, 2021, Diagnostic Code 5243 directs to assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root and assign diagnostic code 5242, which evaluated degenerative arthritis and degenerative disc disease other than IVDS, for all other disc diagnoses. However, the rest of Diagnostic Code 5243 was not amended and still directs IVDS to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. The criteria used under the General Rating Formula for Diseases and Injuries of the Spine and under the Formula for IVDS Based on Incapacitating Episodes were not amended. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. The preponderance of the evidence in this case is against the assignment of a rating in excess of 10 percent for arthritis of the thoracolumbar spine. In the April 2006 VA examination, the Veteran stated that his symptoms from his lumbar spine disability include constant pain, stiffness, and poor bending. The pain travels to his legs. The pain is described as follows: crushing in nature, burning in nature, aching in nature, sharp in nature, sticking in nature, and cramping in nature. The pain level is at a 10. The Veteran reported that his back disability does not cause incapacitation. The Veteran reported in the June 2012 VA examination that his main complaint was chronic aching in the lower back and pain with flexion. Motrin helps with his pain. The Veteran stated in the July 2018 VA examination that he still experiences daily pain. He experiences pain with sitting and bending forward to the floor. Nonetheless, even considering the Veteran’s lay statements of symptoms, the degree of any additional limitation reflected by such statements would not result in limitation of more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Specifically, the April 2006 VA examination reveals that the Veteran had forward flexion to 70 degrees with pain beginning at 70 degrees. A combined range of motion of the thoracolumbar spine was to 125 degrees. The examiner noted that joint functio of the spine was additionally limited pain after repetitive use. It was not additionally limited by fatigue, weakness, lack of endurance, and incoordination. The above factors additionally limited the joint function by zero degrees. Muscle spasm was absent. The June 2012 VA examination shows that flexion of the thoracolumbar spine was to 90 degrees with pain beginning at 70 degrees. A combined range of motion of the thoracolumbar spine was to 240 degrees. Range of motion did not change after repetitive-use testing. The Veteran has function loss and/or functional impairment of the thoracolumbar spine due to pain on movement. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. A July 2018 VA examination reveals that the thoracolumbar spine had forward flexion from zero to 70 degrees. A combined range of motion of the thoracolumbar spine was to 220 degrees. There was no additional loss of function or range of motion after three repetitions. The examiner determined that forward flexion of the thoracolumbar spine was limited to 65 degrees due to pain and incoordination with repeated use over a period of time. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. While the Veteran is diagnosed with IVDS, the evidence of record shows that the Veteran was not prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Regarding neurological impairment, the Veteran stated in the April 2006 VA examination that his back pain travels to his legs. The medical evidence shows that the Veteran has not been diagnosed with a neurological disorder of the right lower extremity associated with his service-connected IVDS. While the Veteran is competent to report symptomatology that he experiences, he has not shown that he has the medical experience or training to relate his symptoms to his service-connected IVDS, which is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Thus, the Veteran’s statement his back pain travels to his right leg is not competent evidence indication he has a neurological disorder of the right lower extremity that is related to his service-connected IVDS. Regarding the left lower extremity, the Veteran was diagnosed with nerve involvement of the superficial peroneal nerve in the April 2006 VA examination. Specifically, the Veteran reported that his low back pain travels to his legs in an April 2006 VA examination. The examiner documented that there were signed of IVDS and the findings were as follows: L5 sensory deficit of the left dorsal foot and left lateral foot and sensory deficit of the left later foot. The examiner stated that nerve involved is most likely the peripheral superficial peroneal nerve. Paralysis of the superficial peroneal nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8522. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8622 and 8722. Under these criteria, mild incomplete paralysis is rated as 0 percent disabling (noncompensable). Moderate incomplete paralysis is rated as 10 percent disabling. Severe incomplete paralysis is rated as 20 disabling. Complete paralysis of the superficial nerve; eversion of foot weakened is rated as 30 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The evidence of record demonstrates that the Veteran’s impairment of the superficial peroneal nerve of the left lower extremity is characterized by mild impairment. While the veteran had reported radiating pain in the left lower extremity, the April 2006 VA examiner stated that involvement of the superficial peroneal resulted in no complication. The examiner also indicated that the deficit of the left dorsal foot, left lateral foot were wholly sensory in nature. However, the VA examinations in June 2012 and July 2018 reflect that the Veteran’s sensory evaluation was normal in the left lower extremity. Muscle strength and reflexes were normal in the June 2012 and July 2018 VA examinations. Straight leg raises raising tests were normal in the April 2006, June 2012, and July 2018 VA examination. The June 2012 and July 2018 VA examiners determined that the Veteran did not have radicular pain or any other signs or symptoms of radicular pain. Accordingly, the Board finds that the Veteran is not entitled to a separate disability rating for impairment of the superficial peroneal nerve of the left lower extremity as a noncompensable rating more closely approximates the Veteran’s disability picture throughout the appeal period. In addition, the evidence reflects that the Veteran does not have any bowel or bladder problems related to his IVDS. See VA examinations dated in April 2006, June 2012, and July 2018. Furthermore, there is no medical evidence of any neurological disability other than the impairment of the superficial peroneal nerve of the left lower extremity related to the Veteran’s service-connected back disability. Thus, the Veteran is not entitled to a separate disability rating for bowel impairment, bladder impairment or any neurological disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for IVDS. Accordingly, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial rating in excess of 10 percent for service-connected left knee osteoarthritis. The Veteran contends that he is entitled to a higher rating because he experiences swelling, constant, pain, fatigue, weakness, lack of endurance, and incoordination. The Veteran also asserts that sometimes he has instability problems. See February 2008 VA Form 9. The Veteran’s service-connected left knee osteoarthritis is rated under Diagnostic Code 5003-5260. 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 for the left knee reflects that degenerative arthritis under Diagnostic Code 5003 is the service-connected disorder and that limitation of flexion rated under Diagnostic Code 5260 is the residual condition. The assigned Diagnostic Code 5260 suggests that left knee osteoarthritis is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the left knee disability has manifested as osteoarthritis and been rated based on painful noncompensable limitation of motion, and that left knee osteoarthritis has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period. Therefore, the Diagnostic Code assigned should have been Diagnostic Code 5010, to show that the left knee osteoarthritis is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board is changing the Diagnostic Code for the left knee disability back to 5010 to reflect the actual rating previously assigned. 38 C.F.R. § 4.71a. Diagnostic Code 5010 provides that arthritis due to trauma, when established by x-ray findings, should be rated as degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purpose of rating a disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. A veteran who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee osteoarthritis. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due functional loss due to stiffness, weakness, swelling, giving way with standing, poor stability, lack of endurance, locking after long activity, fatigability, and constant pain. His condition does not cause incapacitation. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating flexion limited to 45 degrees or less or extension limited to 10 degrees or more. In this regard, an April 2006 VA examination reveals that flexion was to 140 degrees and extension was to zero degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use or during flare-ups. The anterior and posterior cruciate ligaments stability test of the left knee was within normal limits. The medial and lateral collateral ligaments stability test of the left knee was within normal limits. The medial and lateral meniscus stability test of the left knee was within normal limits. [Include discussion of relevant facts in relation to the criteria. A June 2012 VA examination shows that left knee flexion was to 140 degrees and extension was to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions with no additional loss in range of motion for flexion or extension of the left knee. The examiner determined that the Veteran did not have additional limitation in range of motion of the knee or lower leg following repetitive-use testing and he did not have any functional loss and/or functional impairment of the left knee. A July 2018 VA examination reveals flexion was to 135 degrees and extension was to zero degrees. The examiner noted that there was pain on flexion. There was no additional loss of function or range of motion after three repetitions. The examiner determined that pain and incoordination significantly limit functional ability with repeated use over a period of time. Flexion was limited to 130 degrees with repeated use over a period of time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups, because the Veteran denied flare-ups. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). To this end, the Veteran reported in the April 2006 VA examination that his left knee disability resulted in poor stability, weakness, locking, and giving way. The Veteran reported that he sometimes has instability problems in the February 2008 VA Form 9. 38 C.F.R. § 4.71a, Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee. Prior to February 7, 2021, under this diagnostic code, slight recurrent subluxation or lateral instability warrants a 10 percent disability rating. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warrants a 30 percent disability rating. The United States Court of Appeals for Veterans Claims has held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie,30 Vet. App. 347, 349 (2018). In this case, there is no objective evidence of instability of the left knee at any time during the appeal period. Specifically, the April 2006 VA examination documented that there were no signs of fatigue, weakness, or incoordination of the left knee. Anterior and posterior cruciate ligaments stability tests of the left knee were within normal limited Medical and lateral collateral ligaments stability test of the left knee were within normal limits. The medial and lateral meniscus stability tests of the left knee were within normal limits. June 2012 and July 2018 VA examinations show that there was no evidence or history of recurrent patellar subluxation or dislocation. Anterior, posterior, and medial, and lateral instability tests were normal. The July 2018 VA examiner noted that the Veteran did not have a history or recurrent effusion. Nonetheless, the Veteran reported experiencing weakness, giving way, and instability of the left knee. There is nothing in the claims to indicate that the lay statements regarding the symptoms he experiences are not credible. Thus, the credible lay evidence supports a finding that, in addition to painful motion, the Veteran also experienced left knee symptoms more nearly approximating slight instability in the left knee throughout the appeal period, warranting a separate compensable rating under Diagnostic Code 5257 from September 21, 2005. Resolving reasonable doubt in favor of the Veteran, entitlement to a separate 10 percent rating for slight lateral instability of the left knee under DC 5257 is warranted. However, the preponderance of the evidence does not support a separate rating higher than 10 percent. As discussed above, there is no objective evidence of joint instability. The grant of 10 percent rating is based on the Veteran’s probative reports of right knee weakness, giving way, and dislocation. The description of his right knee weakness, giving way and dislocation is not consistent with moderate impairment as he did not describe symptoms occurring on any consistent basis nor did he report a history of falls due to instability. Finally, there is no objective evidence to support a finding of moderate instability. Diagnostic Code 5257 was amended, effective February 7, 2021. Under the amended criteria, Diagnostic Code 5257 evaluates other impairment of the knee of recurrent subluxation or instability or recurrent patellar instability. With respect to recurrent subluxation or instability, a 20 percent disability rating is warranted for the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and a medical provider prescribes a brace and/or assistive decide (e.g., cane(s), crutch(es), walker) for ambulation or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent disability rating is warranted for Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Regarding recurrent patellar instability, a 20 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. The medical evidence shows that the Veteran’s left knee disability was not manifested by a sprain, incomplete or complete ligament tear, repaired complete ligament tear, unrepaired complete ligament tear, or failed repair of complete ligament tear. The medical and lay evidence also reflects that the Veteran’s instability of the left knee is not persistent as the Veteran asserts that he sometimes has instability problems. The Veteran denied having instability and locking in the June 2012 VA examinations that the Veteran reported pain as his current symptom of his left knee disability with no mention of any symptoms of left knee instability. Moreover, the evidence shows that the Veteran does not have diagnosed condition involving the patellofemoral complex and he did not have patellar instability or surgical repair. Accordingly, the Veteran is not entitled to a disability rating in excess of 10 percent for instability of the left knee is not warranted as of February 7, 2012 under the amended criteria. Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. However, the medical and lay evidence shows that the Veteran’s left knee disability is not manifested by ankylosis, dislocation of the semi-lunar cartilage, symptomatic removal of semilunar cartilage, or any impairment of the tibia and fibula, or genu recurvatum throughout the entire appeal period. Thus, Diagnostic Codes 5256, 5258, 5259, 5262 and 5263 are not applicable in this case under the prior criteria or as of February 7, 2012 under the amended criteria. In conclusion, the evidence is evenly balanced with respect to a separate 10 percent disability rating for slight instability of the left knee under Diagnostic Code 5257, effective September 21, 2005. However, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for the service-connected left knee osteoarthritis throughout the entire appeal period. In denying such a rating, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38C.F.R. §§4.3, 4.7. 4. Entitlement to an initial rating in excess of 10 percent for service-connected right knee patellofemoral syndrome. The Veteran contends that he is entitled to a higher rating because he experiences swelling, constant, pain, fatigue, weakness, lack of endurance, and incoordination. The Veteran also asserts that sometimes he has instability problems. See February 2008 VA Form 9. The assigned Diagnostic Code 5257 suggests that the right knee right knee patellofemoral syndrome is rated based on slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. However, a review of the evidence and the September 2018 rating decision reflects that right knee patellofemoral syndrome was rated based on painful noncompensable limitation of motion under 38 C.F.R. § 4.59, and that patellofemoral syndrome of the right knee has not had compensable limitation of motion at any time during the relevant rating period. Therefore, the Diagnostic Code assigned should have been Diagnostic Code 5299-5260, to show that the patellofemoral syndrome is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board is changing the Diagnostic Code for right knee patellofemoral syndrome to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. A veteran who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). The Board finds that the preponderance of the evidence is against separate compensable rating or a rating in excess of 10 percent for patellofemoral syndrome under Diagnostic Codes 5260 and 5261. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to stiffness, weakness, swelling, giving way with standing, poor stability, lack of endurance, locking after long activity, fatigability, and constant pain. His condition did not cause incapacitation. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating flexion limited to 45 degrees or less or extension limited to 10 degrees or more. Specifically, an April 2006 VA examination reveals that flexion of the right knee was to 140 degrees and extension was to zero degrees. The joint function of the right knee was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use or during flare-ups. The anterior and posterior cruciate ligaments stability test of the right knee was within normal limits. The medial and lateral collateral ligaments stability test of the right knee was within normal limits. The medial and lateral meniscus stability test of the right knee was within normal limits. A June 2012 VA examination shows that right knee flexion was to 140 degrees and extension was to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions with no additional loss in range of motion for flexion or extension of the left knee. The examiner determined that the Veteran did not have additional limitation in range of motion of the knee or lower leg following repetitive-use testing and he did not have any functional loss and/or functional impairment of the left knee. A July 2018 VA examination reveals right knee flexion was to 135 degrees and extension was to zero degrees. The examiner noted that there was pain on flexion. There was no additional loss of function or range of motion after three repetitions. The examiner determined that pain and incoordination significantly limit functional ability with repeated use over a period of time. Right knee flexion was limited to 130 degrees with repeated use over a period of time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups, because the Veteran denied flare-ups. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). To this end, the Veteran reported in the April 2006 VA examination that his right knee disability resulted in poor stability, weakness, locking, and giving way. The Veteran reported that he sometimes has instability problems in the right knee in the February 2008 VA Form 9. 38 C.F.R. § 4.71a, Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee. Prior to February 7, 2021, under this diagnostic code, slight recurrent subluxation or lateral instability warrants a 10 percent disability rating. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warrants a 30 percent disability rating. The United States Court of Appeals for Veterans Claims has held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie,30 Vet. App. 347, 349 (2018). In this case, there is no objective evidence of instability of the right knee at any time during the appeal period. Specifically, the April 2006 VA examination documented that there were no signs of fatigue, weakness, or incoordination of the right knee. Anterior and posterior cruciate ligaments stability tests of the right knee were within normal limited Medical and lateral collateral ligaments stability test of the right knee were within normal limits. The medial and lateral meniscus stability tests of the right knee were within normal limits. June 2012 and July 2018 VA examinations show that there was no evidence or history of recurrent patellar subluxation or dislocation. Anterior, posterior, and medial, and lateral instability tests were normal. The July 2018 VA examiner noted that the Veteran did not have a history or recurrent effusion. Nonetheless, the Veteran reported experiencing weakness, giving way, and instability of the right knee. There is nothing in the claims to indicate that the lay statements regarding the symptoms he experiences are not credible. Thus, the credible lay evidence supports a finding that, in addition to painful motion, the Veteran also experienced symptoms more nearly approximating slight instability in the right knee throughout the appeal period, warranting a separate compensable rating under Diagnostic Code 5257 from September 21, 2005. Resolving reasonable doubt in favor of the Veteran, entitlement to a separate 10 percent rating for slight lateral instability of the right knee under Diagnostic Code 5257 is warranted. However, the preponderance of the evidence does not support a separate rating higher than 10 percent. As discussed above, there is no objective evidence of joint instability. The grant of 10 percent rating is based on the Veteran’s probative reports of right knee weakness, giving way, and dislocation. The description of his right knee weakness, giving way, and instability is not consistent with moderate impairment as he did not describe symptoms occurring on any consistent basis nor did he report a history of falls due to instability. Finally, there is no objective evidence to support a finding of moderate instability. As noted above, Diagnostic Code 5257 was amended, effective February 7, 2021. In this case, the medical evidence shows that the Veteran’s right knee disability was not manifested by a sprain, incomplete or complete ligament tear, repaired complete ligament tear, unrepaired complete ligament tear, or failed repair of complete ligament tear at any time during the appeal period. The medical and lay evidence also reflects that the Veteran’s instability of the left knee is not persistent as the Veteran asserts that he sometimes has instability problems. The Veteran denied having instability and locking in the June 2012 VA examination. In the July 2018 VA examination, the Veteran reported pain as his current symptom of his left knee disability with no mention of any symptoms of left knee instability. Although the Veteran has a diagnosed condition involving the patellofemoral complex of the right knee, the medical evidence shows that he has not had surgical repair of the patellofemoral complex. Thus, the Veteran is not entitled to a disability rating in excess of 10 percent for instability of the right knee is not warranted as of February 7, 2012 under the amended criteria. Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. However, the medical and lay evidence shows that the Veteran’s right knee disability is not manifested by ankylosis, dislocation of the semi-lunar cartilage, symptomatic removal of semilunar cartilage, any impairment of the tibia and fibula, or genu recurvatum throughout the entire appeal period. Thus, Diagnostic Codes 5256, 5258, 5259, 5262 and 5263 are not applicable in this case under the prior criteria or as of February 7, 2012 under the amended criteria. In conclusion, the evidence is evenly balanced with respect to a separate 10 percent disability rating for slight instability of the right knee under Diagnostic Code 5257, effective September 21, 2005. However, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for the service-connected right knee patellofemoral syndrome the entire appeal period. In denying such a rating, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38C.F.R. §§4.3, 4.7. REASONS FOR REMAND Service connection for inguinal, umbilical, and ventral hernia is remanded. Another remand is necessary to obtain a new VA medical opinion regarding the Veteran’s service connection claim for residuals of inguinal, umbilical, and ventral hernias. In this regard, the Veteran contends that his hernias are caused by service and his symptoms began in service and continued to the present. Specifically, the Veteran asserts that abdominal pain and treatments reflect back to February 1972. See September 2020 correspondence. In the alternative, the Veteran contends that his hernias are secondary to his service-connected IVDS and/or medication used to treat his service-connected disabilities. The claims file contains medical opinions dated in April 2008, August 2018, and August 2020. The April 2008 VA examiner determined it is less likely as not that this Veteran’s umbilical and ventral hernias are service connected or related to his service-connected disabilities. The Veteran’s hernias are due to muscle wall weakness in the abdomen and not due to his service-connected back condition. In December 2013, the Board remanded the claim to obtain a VA medical to address whether the Veteran’s hernias were secondary to his IVDS. An August 2018 VA examiner also provided the opinion that the Veteran’s ventral hernia is less likely than not proximately due to or the result of the Veteran’s service-connected IVDS. He noted that a ventral hernia is a bulge of tissue through an opening of weakness within the abdominal wall muscle. In a November 2018 remand, the Board determined that the medical opinion was incomplete as the examiner did not address the Veteran’s history of umbilical hernia repair and focused solely on the ventral hernia. The Board also determined that the VA examiner’s rationale provided a definition for ventral hernia, but the examiner did not explain how such definition provided an explanation for the negative opinions. An August 2020 VA examiner provided the opinion that the Veteran’s inguinal, umbilical, and ventral hernias were not proximately caused by or aggravated by the Veteran’s service-connected IVDS. The examiner explained that the first complaint of a hernia condition was in 1997 with a noted inguinal hernia 27 years after he left military service. This hernia was not associated with IVDS, so aggravation cannot be established. The April 2008 examiner did not provide any explanation in support of his opinion that the hernias were not related to service and the November 2018 and August 2020 VA examiner’s opinion did not specifically address direct service connection. In addition, the Veteran’s lay statements as to the onset of his alleged symptoms of a hernia since service have not been addressed. Finally, the examiners did not provide a clear explanation why the Veteran’s current IVDS could not cause an inguinal, umbilical, and ventral hernia after the initial injury. The matters are REMANDED for the following action: Obtain a VA medical opinion with respect to the Veteran’s service connection claim for inguinal, umbilical, and ventral hernias. Only provide an examination if one is deemed necessary by the medical specialist. The contents of the entire, electronic claims file to include a complete copy of this REMAND, must be made available to the examiner, and the examination report should reflect full consideration of the Veteran’s documented medical history and lay assertions. The medical specialist is asked to provide an opinion on whether the Veteran’s inguinal, umbilical, and ventral hernias and any residuals thereof documented in the medical record at any point pertinent to the current appeal (even if now asymptomatic or resolved) is at least as likely as not (i.e., a fifty percent or greater probability) in part caused by or related to the Veteran’s active military service. The examiner should provide an explanation for all conclusions reached. As part of his or her explanation, the examiner should discuss the lay statements from the Veteran regarding symptoms stomach pain in service with continuous or recurrent symptoms since discharge from service and whether such abdominal pain is at least as likely as not related to the Veteran’s inguinal, umbilical, and/or ventral hernias. Notably, the absence of documented evidence of associated symptoms during and shortly after service should not, alone, serve as the sole basis for a negative opinion. The medical specialist also may not dismiss the Veteran’s complaints of post-service symptoms solely because they are not documented in post-service medical treatment records. In this regard, the medical specialist is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically be acknowledged and considered in formulating opinions. If lay assertions in any regard are discounted, the medical specialist should clearly so state, and explain why. If the inguinal, umbilical, and/or ventral hernias are deemed not directly related to active military service, then the examiner should opine as to whether it is as likely as not that the Veteran’s inguinal, umbilical, and/or ventral hernias (a) was caused; OR (b) is or has been aggravated (worsened beyond the natural progression) by the Veteran’s service-connected disabilities, particularly IVDS, to include any medication used to treat such disabilities. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. A complete, clearly-stated rationale for the conclusions reached-to include identification of evidence and medical authority relied upon-must be provided. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Berry, 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.