Citation Nr: 21010729 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 16-05 135 DATE: February 25, 2021 ORDER Entitlement to a rating higher than 50 percent for bilateral pes planus is denied. The claim of entitlement to service connection for left Achilles tendinitis is dismissed. New and material evidence has been submitted to reopen the claim for service connection for a left knee disability. New and material evidence has been submitted to reopen the claim for service connection for erectile dysfunction. Service connection for tinnitus is denied. Service connection for loss of teeth secondary to periodontal disease is denied for compensation purposes. Service connection for erectile dysfunction is denied. REMANDED Entitlement to a rating higher than 10 percent for residuals of left ankle fracture with osteoarthritis of the ankle is remanded. Entitlement to service connection for left hand cold injury residuals is remanded. Entitlement to service connection for right hand cold injury residuals is remanded. Entitlement to service connection for left knee condition is remanded. Entitlement to service connection for left ankle instability recurrent sprain is remanded. Entitlement to service connection for left hamstring weakness is remanded. Entitlement to service connection for hematosis acid reflux indigestion is remanded. Entitlement to service connection for a dental disability for treatment purposes is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran is evaluated at the highest available schedular rating for bilateral pes planus. 2. The Veteran’s 50 percent rating for bilateral pes planus specifically compensates the Veteran for disability of the left Achilles tendon. 3. The July 2009 rating decision denied service connection for a left knee disability and erectile dysfunction. 4. A November 2014 rating decision declining to reopen the Veteran’s claims for service connection for a left knee disability and erectile dysfunction is final. 5. New and material evidence has been submitted to reopen the claims of entitlement to service connection for a left knee disability and erectile dysfunction. 6. The Veteran does not have a current tinnitus disability for service connection purposes. 7. The evidence shows the Veteran suffers from periodontal disease. 8. Erectile dysfunction was first manifested many years after service and is not otherwise etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 50 percent for bilateral pes planus have not been met. 38 U.S.C. § 11550; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5276. 2. Service connection for left Achilles tendonitis is dismissed. 38 U.S.C. §§ 1110, 1117, 1131, 5107, 7105; 38 C.F.R. §§ 4.14, 4.172a, DC 5276. 3. The July 2009 rating decision denying service connection for a left knee disability and erectile dysfunction is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 4. The November 2014 rating decision denying the claims to reopen service connection for a left knee disability and erectile dysfunction is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 5. The criteria to reopen the issue of entitlement to service connection for a left knee disability have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(b). 6. The criteria to reopen the issue of entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(b). 7. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 8. The claimed loss of teeth and bone are not conditions which are eligible for compensation. 38 U.S.C. §§ 1131, 1712, 5107(b); 38 C.F.R. §§ 3.303, 3.381(b). 9. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1973 to August 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2014 and November 2018 rating decisions of the Department of Veterans’ Affairs (VA) Regional Office (RO) in Waco, Texas (the Agency of Original Jurisdiction (AOJ)). In December 2018, the Veteran submitted a Rapid Appeals Modernization Program (RAMP) form requesting to opt-in to the Appeals Modernization Act review system. His appeal was found to be RAMP eligible. In November 2020, he was sent a clarification letter to determine whether he wished to proceed in RAMP or remain in legacy appeal. To date, neither the Veteran nor his representative has responded to the clarification request. As such, the Board will proceed with adjudication of the merits pursuant to the legacy appeal process. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2018). Moreover, joint testing is to be conducted on both active and passive motion, 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, 170 (2016). Bilateral Pes Planus The Veteran’s bilateral pes planus is rated 50 percent disabling under 38 C.F.R. § 4.71a, DC 5276. Disabilities of the foot are rated under Diagnostic Codes 5276 through 5284. As an initial matter, neither of the Veteran’s feet has been shown to be characterized by weak foot, claw foot, metatarsalgia, hallux rigidus, hammer toes, hallux valgus, or malunion or nonunion of the tarsal or metatarsal bones such that rating the Veteran under the corresponding Diagnostic Codes would provide the Veteran with a higher rating. Accordingly, the Diagnostic Codes pertaining to those disabilities are not for application in the instant case. See 38 C.F.R. § 4.71a, DCs 5277, 5278, 5279, 5280, 5281, 5282, 5283. Under DC 5276, a noncompensable rating is assigned for mild flatfoot with symptoms relieved by built-up shoe or arch support. 38 C.F.R. § 4.71a, DC 5276. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo-Achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Id. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 30 percent disabling for bilateral disability. Id. A maximum 50 percent rating is awarded where bilateral flatfeet are manifested by pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo-Achillis on manipulation, that is not improved by orthopedic shoes or appliances. Id. Turning to the facts of the case, the Veteran filed a service connection claim for pes planus in September 2018. At the October 2018 VA examination, the Veteran reported experiencing pain and a burning sensation on the bottom of his feet. To alleviate his symptoms, he used orthotics, a cane, and a walker. During flare ups, the Veteran was unable to walk very far due to his symptoms. Upon examination, the examiner noted both pain and swelling upon use of the feet along with extreme tenderness on the plantar surfaces bilaterally; however, there was no evidence of pain on manipulation of either foot. While there was decreased longitudinal arch height of both feet upon weight-bearing, there was no objective evidence of marked deformity or marked pronation of both feet. The Veteran also endorsed marked inward displacement and severe spasm of the bilateral achilles tendons. The Board notes VA treatment records during the period under consideration which document treatment for the Veteran’s pain associated with the bilateral pes planus. Upon review of the record, the Board finds that a rating higher than 50 percent is not warranted for the Veteran’s service-connected bilateral pes planus. As it currently stands, the assigned 50 percent rating is the highest evaluation allowed under the law for this condition. The Board can find no basis for a higher schedular evaluation, nor has the Veteran offered specific argument in this regard. In evaluating the Veteran’s level of disability, functional loss was considered. 38 C.F.R. §§ 4.40, 4.45. During the period under consideration, the Veteran complained of pain and swelling in her feet causing limitation in ambulation, which he is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The medical evidence, in particular the VA examination report, have associated these symptoms to the Veteran's bilateral pes planus. Further, these symptoms are included in the basis for the 30 percent and 50 percent ratings. Therefore, these factors, and their resulting functional limitation, are fully contemplated by the current assigned ratings. The Board finds the current ratings encapsulate the Veteran’s current symptoms. 38 C.F.R. §§ 4.40, 4.45, 4.59. To that end, the Board has also considered whether an extraschedular rating may be warranted. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. See Thun v. Peake, 22 Vet. App. 111 (2008). This is not a mechanical test, but rather takes into consideration the underlying disability and the applicable diagnostic criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369 (2016). In Doucette, the criteria for evaluating hearing loss were solely based on audiometric tests and the Court made a common sense observation that symptoms related to decreased hearing acuity were contemplated by the schedular criteria. The Court later explained that Thun’s first step is satisfied only when a claimant presents symptoms that a “truly unusual or exceptional.” Long v. Wilkie, 2020 U.S. Vet. Claims LEXIS 2371 (Dec. 30, 2020). Here, the Veteran has been provided the maximum schedular rating for bilateral pes planus under DC 5276 which contemplates pain, swelling, tenderness, and marked inward displacement and severe spasm of the bilateral achilles tendons. The Board recognizes that the Veteran alleges additional impairment which affects his left hamstring, left ankle instability and left knee. Such disability is capable of being evaluated separately under different diagnostic codes, and the service connection claims are being developed in the REMAND below. As these additional symptoms are capable of evaluation by conventional rating means, the Veteran does not present with an “exceptional” disability for extraschedular purposes. New and Material Evidence The Veteran seeks to reopen his service connection claims for a left knee disability and erectile dysfunction. Unappealed rating decisions are final with the exception that a claim may be reopened by the submission of new and material evidence. When an appellant seeks to reopen a claim based on new evidence, VA must first determine whether the additional evidence is “new and material.” Second, if VA determines that new and material evidence has been added to the record, the claim is reopened and VA must evaluate the merits of the appellant’s claim considering all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140 (1991); Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996). “New” evidence means evidence not previously submitted to VA decision makers. “Material” evidence means evidence that relates to an unestablished fact necessary to substantiate the claim. Cumulative or redundant evidence is not new and material. 38 C.F.R. § 3.156(a). To reopen, the new and material evidence must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). This is a low threshold that is meant to enable, rather than preclude, reopening. Shade v. Shinseki, 24 Vet. App. 110 (2010). The focus is not on whether the evidence remedies the principle reason for the previous denial, but whether the evidence, taken together, would at least trigger the duty to assist by providing a medical opinion. Id. at 117. Left Knee Disability The Veteran was initially denied service connection for a left knee disability in July 2009 on the basis that the Veteran’s left knee bipartite patella was a congenital defect and was not compensable for VA purposes. The evidence at that time included the Veteran’s service treatment records, lay statements, and medical treatment records. The Veteran did not appeal or submit new and material evidence within one year of that decision; thus, the July 2009 rating decision is final. 38 U.S.C. § 7105(c) (2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2009). The Veteran requested to reopen his claim in July 2014; that request was denied in a November 2014 rating decision. The evidence at that time included updated medical treatment records. The AOJ denied the Veteran’s claim to reopen, reasoning that sufficient new and material evidence had not been submitted. The Veteran did not appeal that decision or submit new and material evidence within one year; thus, the November 2014 rating decision is final. 38 U.S.C. § 7105(c) (2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2014). Since that time, evidence added to the claims file include the October 2018 VA examination and updated medical treatment records, which diagnose chronic left knee conditions, which are compensable for VA purposes. Since this evidence was not previously considered and it raises a possibility of substantiating the Veteran’s claim, it constitutes new and material evidence sufficient to reopen the claim. Erectile Dysfunction Similarly, the Board finds that new and material evidence has been submitted to reopen the claim for service connection for erectile dysfunction. The Veteran’s claim was initially denied in July 2009 on the basis that there was no evidence that the Veteran’s diagnosed erectile dysfunction was incurred in or caused by service. The evidence at that time included the Veteran’s service treatment records and medical treatment records. By letter dated August 7, 2009, the Veteran was notified of this decision and his appellate rights. The Veteran did not appeal and did not submit new and material evidence withing one year of that decision; thus, the July 2009 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran sought to reopen the claim in July 2014; that request was denied in November 2014 on the basis that new and material evidence had not been submitted. By letter dated December 8, 2014, the Veteran was notified of this decision and his appellate rights. The Veteran did not appeal and did not submit new and material evidence within one year of that decision. Therefore, the November 2014 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Since that time, new and material evidence in the form of the October 2018 VA examination and opinion has been submitted. Since this evidence was not previously considered and it raises a possibility of substantiating the Veteran’s claim, it constitutes new and material evidence sufficient to reopen the claim. As the AOJ has reviewed the claim on the merits, there is no prejudice to the Veteran with the Board adjudicating the claim on the merits also. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, may be service connected on an aggravation basis. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Achilles tendonitis The Veteran seeks to establish his entitlement to service connection for left Achilles tendonitis. The Board notes that VA regulations prohibit compensating a claimant twice for the same symptomatology. 38 C.F.R. § 4.14. As explained by the Court, compensating a claimant twice for the same symptomatology “would overcompensate the claimant for the actual impairment of his earning capacity.” Brady v. Brown, 4 Vet. App. 203, 206 (1993) (compensation for somatic aspects of psychiatric disorder precluded by 38 C.F.R. § 4.14 and previous version of 38 C.F.R. § 4.132 where the psychiatric disorder was the predominant disorder to be rated). The Veteran is in receipt of the maximum 50 percent rating under DC 5276 which specifically contemplates severe spasm of the tendo-Achillis on manipulation. The lesser criteria specifically contemplate inward bowing of the tendo-Achillis. As symptoms and disability of the left Achilles is compensated as a symptom of service-connected bilateral pes planus, there is no “controversy” or “justiciable” service connection issue before the Board and this aspect of the claim is dismissed. 38 U.S.C. § 7105(d). See Schoen v. Brown, 6 Vet. App. 456, 457 (1994); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Tinnitus The Veteran seeks service connection for tinnitus. Upon review of the record, the Board finds that service connection for tinnitus is not warranted, as there is no evidence of a current diagnosis of tinnitus. In this case, the Veteran claimed entitlement to service connection for tinnitus in his September 2018 application. However, since that time he has denied having tinnitus. During the appeal period, the Veteran sought treatment for various disabilities. Periodically, the Veteran’s treating physicians asked if the Veteran experienced tinnitus, which he denied. See VA Treatment Records dated March 13, 2014, July 19, 2017, April 19, 2019, and July 26, 2019. At the October 2018 VA examination, the examiner inquired as to the circumstances surrounding the onset and severity of the Veteran’s tinnitus. The Veteran was unsure of the onset date. In regard to his symptomatology, the Veteran described his tinnitus as “hearing someone calling him, but he does not see them.” The examiner provided a negative nexus, reasoning that the Veteran’s symptoms were not consistent with noise-induced tinnitus nor was it consistent with that of tinnitus that is secondary to hearing. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. §§ 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). “In the absence of proof of a present disability there can be no valid claim.” See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that a current disability may include a diagnosis at the time the claim was filed or during its pendency). In the present case, there is no medical diagnosis of tinnitus. Tinnitus is defined as “a noise in the ears such as ringing, buzzing, roaring, or clicking.” Smith v. Principi, 17 Vet. App. 168, 170 (2003). The Board acknowledges that tinnitus is a unique disability in that it can subjectively identified by a veteran, but in this instance the Veteran specifically denied having any ringing of the ears or head noises throughout the appeal period. The medical opinion of record indicates that the symptoms reported by the Veteran – hearing someone call him – is not a medical symptom of tinnitus. The Veteran is not competent himself to attribute the symptom of hearing voices as a manifestation of tinnitus. Given the combination of these factors, the Board finds that there is no current disability, and therefore entitlement to service connection must be denied. In making this determination the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable and entitlement to service connection is denied. Loss of Teeth Secondary to Periodontal Disease The Veteran appeals the denial of service connection for a dental disorder. Under current VA regulations, compensation is only available for certain types of dental and oral conditions, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150. Compensation is available for loss of teeth if such is due to loss of substance of body of maxilla or mandible, only if such bone loss is due to trauma or a disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, as such loss is not considered disabling. Id. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities and will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. The evidence shows that the Veteran’s missing teeth and bone loss are due to periodontal disease and not due to trauma or other diseases. The November 2018 VA examination revealed periodontal disease as the only dental disability. The examiner did not identify any conditions of the mandible, maxilla, or teeth due to anatomical loss or bony injury of the mandible or maxilla. Moreover, service treatment records are silent for trauma to the teeth, mouth, or head. The Veteran has also not identified any trauma or other disease that could qualify for service-connected compensation. The current disabilities of missing teeth and periodontal disease, absent any evidence of trauma or other disease, are not compensable. See 38 C.F.R. §§ 3.381(b), 4.150. The law is against service-connected compensation for the Veteran’s dental conditions. See 38 C.F.R. §§ 3.303, 3.381. Therefore, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 3.102. Erectile Dysfunction The Veteran is also seeking service connection for erectile dysfunction. For the following reasons, the Board finds that service connection for erectile dysfunction is not warranted. The Veteran’s service treatment records are silent for any complaints, manifestations, or treatments related to erectile dysfunction. Upon discharge, the Veteran’s relative systems were clinically normal. See Report of Medical History dated July 31, 1974; Report of Medical Examination dated August 1, 1974. Post-service, the Veteran was first diagnosed with erectile dysfunction in 2005. At that time, the Veteran reported having trouble achieving erections since 2004. Upon examination, the Veteran’s treating physicians have found that the Veteran’s erectile dysfunction was secondary to medication he was prescribed for benign prostate hyperplasia or alternatively, a complication of his diabetes mellitus See VA Treatment Records dated March 16, 2005, June 20, 2005, March 16, 2006, and October 1, 2019. At the October 2018 VA examination, the Veteran indicated that his erectile dysfunction was manifested in 1974. Upon review of the record, the examiner opined that the Veteran’s erectile dysfunction was less likely than not proximately due to or the result of service, to include his cold injury residuals and any relevant medications. In so finding, the examiner reasoned there is no medical evidence to support a relationship between cold injury and erectile dysfunction. The examiner indicated that given the limited extent of the Veteran’s cold injury, as evidenced by lack of amputations or soft tissue damage, it is unlikely that the Veteran’s in-service cold injury and/or its residuals caused erectile dysfunction. The examiner also found that the medical evidence did not reveal any medications being used specifically to treat cold injuries or their residuals which would cause erectile dysfunction. Based on the above, the Board finds that service connection for erectile dysfunction is not warranted. The most probative evidence consists of the Veteran’s treatment medical records, which attribute his erectile dysfunction to his non-service-connected disabilities and/or their medications. These findings were made by credible medical professionals upon review of the Veteran’s medical history, to include his prescriptions, and examination of the Veteran. As they consider the Veteran’s entire medical history and are rendered by competent and credible professionals, the Board finds these opinions to be highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Contrarily, the Board affords the Veteran’s lay statements little probative value. To the extent the Veteran attributes his erectile dysfunction to his period of service, to include residuals of his cold injuries, the Board finds that he is not competent to do so. Such an opinion requires advanced medical training and knowledge of pathology and the internal disease process, which is outside the purview of lay witnesses. The Veteran has not demonstrated that he has specialized training that would afford his nexus opinion probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran currently claims that his erectile dysfunction started either during service or shortly thereafter in 1974. See October 2018 VA Examination. As a lay witness, the Veteran is certainly competent to describe any symptoms within his immediate purview. However, the Board assigns his current statements regarding onset less probative value than his previous statements in 2005 and 2006 wherein he indicated that his erectile dysfunction onset in 2004. When reviewing the inconsistent and/or contradictory accounts as to symptom onset, the Board places greater probative weight to the Veteran’s report of symptomatology when seeking treatment as they were made in the context of seeking appropriate evaluation for any existing disabilities. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence may have greater probative value than history provided by the Veteran). Thus, while the Veteran is competent to report having symptomatic manifestations of erectile dysfunction since service, the Board finds that such statements are not consistent with the overall evidentiary record and his prior statements to medical providers reporting the onset many years after service. In sum, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s erectile dysfunction manifested during service or is otherwise attributable to service. The claim is denied. REASONS FOR REMAND Left Ankle Fracture The Veteran contends that his left ankle disability is more severe than the assigned rating contemplates. The Veteran’s left ankle disability is currently rated 10 percent disabling, indicative of moderate limitation of motion of the ankle. To warrant a higher rating, the ankle disability must manifest marked limitation of motion. 38 C.F.R. § 4.71a, DC 5271. Words such as “moderate” and “marked” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Board observes that recent revisions to the criteria of DC 5271, effective February 7, 2021, clarify that prior regulatory references to “marked” means less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion and that “moderate” means less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. 85 Fed. Reg. 76453 (Nov. 30, 2020). In proposing this rule, VA indicated that this standard was currently used by VA and was being codified “as a clarification of current policy and would ensure consistent application of these criteria among rating personnel.” See 82 Fed. Reg. 35719, 35723 (Aug. 1, 2017). The Veteran filed a service connection claim for his left ankle disability in September 2018. At the October 2018 VA examination, the Veteran reported having residual pain 4-5 times per week, which limited his ability to squat or stand on his toes. In terms of flare ups, he indicated that his “leg gives out,” causing him to fall. Range of motion testing revealed dorsiflexion to 10 degrees and plantar flexion to 30 degrees upon both active and passive range of motion. The examiner noted pain upon examination that caused functional loss. However, there was no evidence of localized tenderness or pain on palpation of the joint or associates soft tissue, nor was there evidence of pain on weight-bearing, crepitus, muscle atrophy or ankylosis; the examiner noted that there was pain in the left ankle with non-weight-bearing. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. However, the examiner found that pain would significantly limit functional ability with repeated use over time and during flare ups. The examiner noted that the additional limitation in function was variable depending upon the Veteran’s usage of the ankle. The Veteran demonstrated normal strength in the left ankle; however, ankle instability was suspected. Here, the examiner found that the Veteran’s motion loss was variable depending on usage of the ankle, but did not give a specific description of this variability in terms of estimated degrees of range of motion. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated as follows: “the VA Clinician’s Guide makes explicit what DeLuca clearly implied: it instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veterans themselves.” Id. at 6. Even when the claimant is not experiencing a flare-up at the time of the examination, a VA examiner must elicit relevant information as to the Veteran’s flares or ask him [or her] to describe the additional functional loss, if any, he [or she] suffered during flares and then estimate the Veteran’s functional loss due to flares based on all the evidence of record-including the veteran’s lay information-or explain why [he or] she could not do so.” The Board finds that the VA examination is inadequate as the examiner did not elicit from the Veteran a description of the variable range of his motion loss. Cold Residuals of the Hands The Veteran is seeking service connection for cold residuals of the bilateral hands. This issue was previously before the Board in August 2019, at which time, it was remanded for an adequate nexus opinion. Specifically, the examiner was to consider all of the Veteran’s symptomatology of his bilateral upper extremities when rendering a diagnosis. Here, the November 2019 examiner opined that the Veteran did not manifest cold injury residuals of the bilateral upper extremities; rather, the examiner found that the Veteran’s “neurologic pathology” was related to his carpal tunnel syndrome. As it is unclear whether the examiner considered all the Veteran’s symptoms as outlined in the previous remand, the Board finds that a clarifying addendum opinion specifically addressing all the Veteran’s symptoms is required. Orthopedic Disabilities The Veteran is seeking service connection for the following orthopedic disabilities: a left knee condition, left hamstring weakness, and left ankle instability recurrent sprain. The Veteran was afforded examinations for these disabilities in October 2018. In regard to the left knee condition, the examiner failed to provide a nexus opinion on the issues of either direct or secondary service connection. As for the left ankle instability, the examiner found that these disabilities were not caused by service or the Veteran’s left ankle arthritis but did not consider the service-connected bilateral pes planus nor the aggravation component. In addition, the examiner failed to determine whether the Veteran’s left hamstring weakness was caused or aggravated by his service-connected disabilities. As such, remand is required to obtain adequate opinions regarding the Veteran’s orthopedic disabilities. Service Connection for Hematosis Acid Reflux The Veteran is seeking service connection for chronic reflux. At the October 2018 VA examination, the examiner provided a negative nexus between the Veteran’s current reflux and his period of service. In so finding, the examiner found that the Veteran had one acute instance of reflux during service, which resolved. According to the examiner, there was no evidence of a chronic reflux condition during service. Based on the evidence of record, the Board finds that remand is required to obtain an adequate opinion. Here, the October 2018 VA examiner found that the Veteran’s current disability was not related to service since the Veteran experienced only one instance of reflux during service. However, the Veteran’s service treatment records document the Veteran’s continued stomach trouble. He often reported issues with burning stomach pain and hematemesis. Treating physicians attributed his symptoms to a possible ulcer; however, it is unclear whether appropriate diagnostic testing was conducted to confirm this assessment. Upon discharge, the Veteran reported having continued “stomach trouble.” Accordingly, as the October 2018 VA opinion is based on an inaccurate factual premise, the Board finds that remand is required to obtain another opinion regarding the nature and etiology of the Veteran’s current reflux. Dental condition for Treatment Purposes As noted above, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. §§ 3.381, 4.150. To date, the AOJ has not referred the dental claim for adjudication at the appropriate VA medical center as the record does not appear to contain a decision from the VA medical center on the issue of entitlement to dental treatment. Thus, remand is required for the appropriate referral and adjudication. TDIU Finally, because a decision on the above remanded issues could significantly impact a decision on the issue of entitlement to TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Associate updated private and VA treatment records with the claims folder. 2. Afford the Veteran an appropriate VA examination to determine the nature and severity of his service-connected left ankle disability. The examiner should expressly discuss whether the Veteran has left ankle instability which had been suspected by October 2018 VA examiner, and discuss whether such instability is a symptom attributable to the service-connected left ankle disability and/or bilateral pes planus with impairment of the left Achilles. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26 (2017), the examiner is asked to describe whether pain, weakness, or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares. The examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. Also, in order to comply with the Court’s decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the VA examination must include range of motion testing in the following areas: Active motion; Passive motion; Weight-bearing; and Non-weight-bearing. 3. Forward the Veteran’s claims file to an appropriate clinician for an addendum opinion determining the nature and etiology of the Veteran’s symptoms of the bilateral hands. The examiner should opine whether it is at least as likely as not that the Veteran’s symptoms are related to his period of service, including his established exposure to cold weather. The examiner is asked to specifically discuss and clarify whether the Veteran’s reported symptoms, including numbness in the palms of his hands, intermittent locking of the fingers, discomfort in the joints of his fingers, and sensitivity to touching cold items, are potentially evidence of a cold injury. The need for further examination is left to the discretion of the examiner. A rationale must be provided for the opinions offered, and if the requested opinion cannot be provided on a medical or scientific basis and without invoking processes relating to guesses or judgment based upon mere conjecture, the reviewing physician should explain why this is so. 4. Schedule the Veteran for an orthopedic VA examination to determine the nature and etiology of the Veteran’s left knee disability, left hamstring weakness, and left ankle instability. Upon review of the record and examination of the Veteran, the examiner should determine whether it is at least as likely as not the Veteran’s left knee disability, left hamstring weakness, and left ankle instability are a) caused by the effects of service-connected left ankle arthritis and bilateral pes planus OR b) whether it is at least as likely as not that the Veteran’s service-connected left ankle arthritis and bilateral pes planus causes additional functional impairment of left knee disability, left hamstring weakness, and left ankle instability (a medically discernible increase in symptoms or disability, even if temporary, above the baseline level of disability). The examiner is specifically requested to discuss whether the effects of the left ankle arthritis and bilateral pes planus are medically capable of causing additional functional impairment of left knee disability, left hamstring weakness, and left ankle instability and, if so, whether this particular Veteran has demonstrated additional functional impairment. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s hematosis acid reflux. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran’s hematosis acid reflux at least as likely as not related to service? Provide a rationale to support the opinion. In providing the requested opinion, the examiner should consider the following in-service events: a) September 14, 1973: Veteran reports a history of peptic ulcer in 1973. He was treated for acute gastritis. b) October 13, 1973: The Veteran is diagnosed with ulcer following complaints of stomach pain. c) May 7, 1974 through June 11, 1974: The Veteran reports continued stomach issues and is prescribed Maalox to alleviate his symptoms. In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? (continued on the next page) 6. Refer the claim for entitlement to service connection for a dental injury for treatment purposes to an appropriate VA Medical Center to determine whether the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161. Then, adjudicate the claim as requested by VHA, if the claim is returned to the AOJ from VHA. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Orie, 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.