Citation Nr: 21012632 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 15-28 951 DATE: March 4, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stress related disorder, is denied. Entitlement to service connection for a bilateral wrist disability is granted. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of left first (big) toe with hallux rigidus is denied. REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. FINDINGS OF FACT 1. The competent and credible evidence demonstrates that the Veteran’s hypertension did not have its onset during active duty service, did not manifest within one year of separation from service, and was not caused or aggravated by his service-connected other specified trauma and stress related disorder. 2. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed bilateral wrist osteoarthritis is etiologically related to his active duty service. 3. Throughout the appeal period, the Veteran’s degenerative changes of the left first (big) toe with hallux rigidus is more appropriately characterized by severe symptoms of hallux rigidus. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stress related disorder, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for a bilateral wrist disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for entitlement to an initial evaluation in excess of 10 percent for degenerative changes of left first (big) toe with hallux rigidus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5281-5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from June 1978 to December 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in May 2014 and January 2015 by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a June 2017 Central Office hearing. A transcript of this hearing is of record. The case was initially brought before the Board in August 2018, at which time the Board denied service connection for a low back disability and a bilateral knee disability; denied a higher evaluation for plantar fasciitis with degenerative arthritis of both feet; and remanded the claims for service connection for a right ankle disability, an eye disability, hypertension, and a bilateral wrist disability and for a higher initial evaluation for degenerative changes of left first (big) toe. The Veteran appealed the August 2018 decision to the U.S. Court of Appeals for Veterans Claims (Court). In a May 2020 memorandum decision, the Court affirmed the Board’s August 2018 decision denying a higher evaluation for plantar fasciitis with degenerative arthritis of both feet, set aside the portion of the August 2018 Board decision denying service connection for a low back disability and a bilateral knee disability and remanded the matters for further proceedings. The case has been returned to the Board. Furthermore, during the pendency of the appeal, the actions specified in the August 2018 remand have been substantially completed. Thus, the matters of entitlement to service connection for a right ankle disability, an eye disability, hypertension, and a bilateral wrist disability; and entitlement to a higher initial evaluation for degenerative changes of left first (big) toe were properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). In a December 2020 rating decision, the Veteran was granted service connection for a right ankle disability and iritis, issues that had been on appeal. As these issues have been resolved by a full grant of benefits, and the Veteran has not submitted any documents indicating that he is not satisfied with the decision, the Board finds that the issues are no longer part of the current appeal. See 38 C.F.R. § 19.26(d). In addition, in the December 2020 rating decision, the RO granted service connection for left hallux rigidus and incorporated the evaluation of the disability into the 10 percent evaluation established for degenerative changes of left first (big) toe, effective January 6, 2020. The Veteran continued to appeal for a higher initial evaluation for the now service-connected degenerative changes of left first (big) toe with hallux rigidus. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as hypertension and arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 1. Entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stress related disorder The Veteran contends that he warrants service connection for hypertension. In particular, the Veteran asserts that his service treatment records (STRs) reflect evidence of elevated blood pressure readings during service. Alternatively, the Veteran asserts that his hypertension was caused or aggravated by his service-connected other specified trauma and stress related disorder. See June 2013 and June 2014 statements and June 2017 Board hearing transcript. The question before the Board is whether the Veteran’s hypertension is etiologically related to his active duty service or a service-connected disability. Based on a careful review of all the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for hypertension is warranted. The evidence shows that the Veteran has a current diagnosis for hypertension. See December 2019 VA examination. The Veteran’s STRs do document that he had elevated blood pressure readings (124/70 at June 1982 Physical; 124/74 at April 1988 reenlistment examination; 126/64 at July 1998 five-year physical examination; and 132/80 at October 1999 separation examination). The STRs do not reflect any treatment or diagnosis for hypertension. As a preliminary matter, the Board notes that hypertension is a chronic disease under 38 C.F.R. § 3.309(a). The Board has considered whether the Veteran is entitled to presumptive service connection under 38 C.F.R. § 3.307(a)(3). However, available treatment records indicate that the earliest diagnosis for hypertension was in 2006, approximately seven years after the Veteran’s separation from service. See August 2006 private treatment record. As noted above, the Veteran’s STRs do not document any findings related to any treatment or diagnosis for hypertension, despite the documented elevated blood pressure readings. There is no clinical evidence that the Veteran's hypertension existed prior to 2006. Thus, the Board finds that the evidence does not show that the Veteran's hypertension manifested within one year of separation from service; nor does it show that he had continuous symptoms of hypertension following service. Accordingly, the Board finds that the Veteran's hypertension, as a chronic disease, is not entitled to service connection on a presumptive basis. However, the Board must still consider whether the Veteran’s hypertension is directly related to his active duty service. On that basis, the Board finds that a December 2019 VA opinion provides the most probative evidence regarding the etiology of the Veteran’s hypertension. Following an objective evaluation, an interview of the Veteran, and a review of relevant medical records, the December 2019 VA examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by service. In making that determination, the December 2019 VA examiner found that a review of the Veteran’s STRs revealed numerous blood pressure readings, including some in the normal range, some slightly elevated, and one or two in the abnormal range. The blood pressure readings in the abnormal range and most slightly elevated were taken when the Veteran reported pain. Finding that those same records did not include any three-day blood pressure checks, the December 2019 VA examiner explained that such checks are the gold standard for diagnosing hypertension. Because blood pressure varies throughout the day and night, rises with pain, stress, excitement, chemical stimulants, etc., and the blood pressure returns to baseline after the responsible factor decreases or goes away, the December 2019 VA examiner noted that it is important to take several measurements and to do so in the absence of temporary increases. Overall, the December 2019 VA examiner determined that the Veteran’s blood pressure readings during service did not meet the criteria for hypertension. Accordingly, the Board finds that service connection for hypertension on a direct basis is not warranted. Finally, the Board has considered whether the Veteran is entitled to service connection on a secondary basis. The December 2019 VA examiner opined that the Veteran’s hypertension was less likely than not proximately due to, the result of, or aggravated by his service-connected other specified trauma and stress related disorder. Similarly to the direct service connection opinion, the December 2019 VA examiner relied on the finding that blood pressure readings can vary due to temporary factors and return to baseline after those factors decrease or go away. Noting a review of the bulk of the peer-reviewed literature, the December 2019 VA examiner found that chronic stress does cause blood pressure elevations, but blood pressure returned to baseline levels once the individual is calm. Moreover, the December 2019 VA examiner noted that stressors increase blood pressure only in the short-term. Those short-term levels do not need to be treated and do not respond to blood pressure treatment. Overall, the Board finds that service connection for hypertension on a secondary basis is not warranted. The only evidence in support of the Veteran’s contentions is his own lay assertions. Lay evidence may be competent to establish a medical etiology or nexus. However, given that the Veteran has not demonstrated that he has the requisite specialized knowledge or training, the Board finds that he is not competent to provide a medical opinion as to the etiology of his hypertension. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, his lay assertions have little probative value. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s claim for service connection for hypertension on a direct, secondary, and presumptive basis. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a bilateral wrist disability The Veteran contends that he warrants service connection for a bilateral wrist disability. In particular, the Veteran asserts that during active duty service, he worked as a Yeoman with administrative duties consisting of typewriter and computer keyboard work and records handling, which caused him wrist problems. In addition, his assignment as a Yeoman was physically demanding with moving and relocating office equipment and supplies, lifting and maneuvering cleaning equipment during cleanliness inspections, and carrying boxes of Xerox paper up and down numerous ladders throughout the ship for replenishment. The Veteran contends that because of the overuse of his wrists with the up and down motion from typing and the constant strain of lifting supplies, he developed his current bilateral wrist problems. See June and September 2014 statements and June 2017 Board hearing transcript. The question before the Board is whether the Veteran’s bilateral wrist disability is etiologically related to active duty service. Based on a careful review of all the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for a bilateral wrist disability is warranted. The evidence shows that the Veteran has a current diagnosis for bilateral wrist osteoarthritis. See January 2020 VA examination. According to the Veteran’s DD Form 214, his military occupational specialty was as a Yeoman throughout his service in the U.S. Navy. Based on the circumstances of the Veteran’s service, his competent and credible testimony attesting to the nature of his duties during service, and the lack of evidence to the contrary, the Board finds that the evidence supports that the Veteran sustained bilateral wrist problems during service. Now, the Board recognizes that the record includes conflicting medical opinions concerning whether the Veteran’s current bilateral wrist osteoarthritis is etiologically related to his active duty service. With regard to the medical opinions obtained, as with all types of evidence, it is the Board’s responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). In January 2020, the VA examiner opined that the Veteran’s bilateral wrist disability was less likely than not incurred in or caused by his duties as an administrative clerk during service. In that regard, the January 2020 VA examiner relied on the findings that the Veteran’s service treatment records did not document complaints or treatment for wrist pain and his physicals throughout service, including upon retirement, did not mention wrist pain. Overall, the January 2020 VA examiner concluded that 2014 MRI reports documenting the Veteran’s bilateral wrist osteoarthritis could have developed after his retirement. In December 2020, the VA examiner opined that the Veteran’s bilateral wrist disability was at least likely as not due to his administrative duties during service. In that regard, the December 2020 VA examiner noted that the Veteran had a 21-year history of working as an administrator during service. Furthermore, the Veteran had a diagnosis for bilateral wrist osteoarthritis, which was confirmed by an August 2014 MRI. In this case, the Board finds that the January 2020 VA examiner’s opinion and December 2020 VA examiner’s opinion are both based on objective findings, consideration of the Veteran’s in-service duties, and a review of relevant medical records. Under these circumstances, the Board cannot find a basis for finding that one competing opinion is more probative than the other. Accordingly, the Board finds that the evidence is at least in equipoise that the Veteran’s bilateral wrist osteoarthritis is etiologically related to his duties during active service. In summary, resolving all reasonable doubt in favor of the Veteran, his service connection claim for a bilateral wrist disability must be granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Higher Evaluation 3. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of left first (big) toe with hallux rigidus The Veteran asserts that his degenerative changes of left first toe with hallux rigidus is worse than his current evaluation reflects. At his June 2017 Board hearing, the Veteran testified that he experienced excruciating pain. He said that he was scheduled for surgery on his left big toe, but he reportedly postponed the surgery, because he was unable to take the time off from work. Even though the Veteran had administrative duties at work, he said that he had other collateral duties, which required him to go to the stockroom and pick up items in a different department. He explained that he was not just sitting at his desk and typing at all times. He was still walking constantly. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 125; 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. VA is required to evaluate the Veteran’s disability under the most appropriate rating criteria that will provide the most benefit to the Veteran. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran’s degenerative changes of the left first (big) toe with hallux rigidus has been currently evaluated as 10 percent disabling, effective June 20, 2014, under 38 C.F.R. § 4.71a, Diagnostic Codes 5281-5284. The Veteran is in receipt of the maximum available schedular evaluation under Diagnostic Code 5281, which is rated under Diagnostic Code 5280 for hallux valgus. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The Board notes that VA has amended the rating criteria for musculoskeletal system disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Diagnostic Code 5281 was not changed by the February 7, 2021 amendments. Under Diagnostic Code 5281, unilateral, severe hallux rigidus is to be rated as severe hallux valgus. A Note provides that this rating is not to be combined with claw foot ratings. Diagnostic Code 5280 was not changed by the February 7, 2021 amendments. Under Diagnostic Code 5280, a single, maximum 10 percent rating is warranted for either severe unilateral hallux valgus, if equivalent to amputation of the great toe, or operated unilateral hallux valgus with resection of metatarsal head. Diagnostic Code 5284 was not changed by the February 7, 2021 amendments. Diagnostic Code 5284 provides the rating criteria for other foot injuries. A 10 percent rating is assigned for a moderate symptoms. A 20 percent rating is assigned for moderately severe symptoms. A maximum 30 percent is assigned for severe symptoms. 38 C.F.R. § 4.71a. The rating schedule does not define the terms "moderate," "moderately severe," and "severe" as used in this diagnostic code. Adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." 38 C.F.R. § 4.6. VA General Counsel has determined that Diagnostic Code 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion. VAOPGCPREC 09-1998. Based on a careful review of all the subjective and clinical evidence, the Board finds that throughout the appeal period, the Veteran’s degenerative changes of left first (big) toe with hallux rigidus does not warrant a higher 20 percent initial evaluation under Diagnostic Code 5284. As noted above, the Veteran is already in receipt of the maximum schedular evaluation under Diagnostic Code 5280. Additionally, the Board notes that the Veteran is also service-connected for plantar fasciitis with degenerative arthritis of both feet. The Veteran is compensated for plantar fasciitis with degenerative arthritis of both feet under Diagnostic Code 5276 for his symptoms of accentuated pain on manipulation and use. See July 2016 rating decision. Throughout the appeal period, the Veteran underwent several VA examinations, which documented the symptoms associated with his service-connected left toe disability. Given the Veteran’s service-connected plantar fasciitis, the Board has limited its discussion of the findings at those VA examinations to those symptoms specifically associated with his service-connected left toe disability. Clinical findings at a September 2014 VA examination show that the Veteran had foot pain over the great toe metatarsophalangeal (MTP) joint. The September 2014 VA examiner found that the Veteran’s symptoms of bilateral MTP joint degenerative joint disease (DJD) was of moderate severity. At a December 2014 VA examination, the Veteran reported having chronic dorsal left first great toe pain. Upon objective evaluation, the December 2014 VA examiner found that the Veteran had mild to moderate symptoms on the left due to hallux rigidus. The December 2014 VA examiner also found that the Veteran experienced pain, weakness, and fatigability that significantly limited functional ability during flare-ups or when the foot is used repeatedly over a period of time. In that regard, the December 2014 VA examiner determined that the Veteran would have more left great toe pain with proportionate increase in activity. Furthermore, due to his left great toe limitations, the Veteran was unable to endure 20 minutes of persistent standing, walking, or marching of 20 minutes or longer. At a January 2020 VA examination, the VA examiner noted that surgery had been recently recommended due to the Veteran’s hallux rigidus, but the Veteran had currently declined that option. He continued to experience left great toe pain with walking and pushing off using his left foot. Upon objective evaluation, the January 2020 VA examiner found that the Veteran’s mild or moderate symptoms of hallux rigidus on the left side was a progression of his initial DJD. Excess fatigability was noted, but no symptoms were found that significantly limited functional ability during flare-ups or repeated use over a period of time. The Board notes that in a U.S. Court of Appeals for the Federal Circuit (Federal Circuit) decision, Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019), the Federal Circuit held that when rating foot conditions not listed in the Rating Schedule, VA must consider analogous ratings under Diagnostic Code 5284, for other foot injuries, even when other listed, service-connected foot disabilities are present. Here, the Board finds that the primary symptomatology associated with the Veteran's service-connected left toe disability is hallux rigidus, which is already compensated under Diagnostic Code 5280 for severe symptoms. The symptoms of arthritis and left great toe pain are also already contemplated by the Veteran’s evaluation for hallux rigidus. There are no manifestations of the Veteran’s service-connected degenerative changes of the left first (big) toe with hallux rigidus that are not contemplated by Diagnostic Code 5280. Thus, the Board finds that there is no basis upon which to award a higher 20 percent initial evaluation under Diagnostic Code 5284. Accordingly, the Board finds that throughout the appeal period, the Veteran’s degenerative changes of the left first (big) toe with hallux rigidus is no more than 10 percent disabling. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 10 percent initial evaluation claim for degenerative changes of left first (big) toe with hallux rigidus. Therefore, the benefit-of-the-doubt rule does not apply, and the higher evaluation claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for a bilateral knee disability is remanded. As discussed above, in its May 2020 memorandum decision, the Court set aside the portion of the August 2018 Board decision denying service connection for a low back disability and a bilateral knee disability and remanded the matters for further proceedings. The Court found that in its August 2018 decision, the Board had rejected the Veteran’s account of suffering low back and bilateral knee pain since service, in part, because his records did not reflect medical complaints or reports of those conditions. However, the Court noted that at his June 2017 Board hearing, the Veteran testified that he did not seek medical treatment or complain of conditions unless they were “really somewhat extreme.” He explained that he had experienced multiple conditions that he did not report or have documented, because he felt he just had to deal with them. The Court found that the Board provided inadequate reasons and bases for its decision when it failed to address this hearing testimony. Additionally, the Court determined that the Board had relied on VA examinations that did not consider the Veteran’s account of in-service symptoms. On that basis, the Court pointed to a recent decision in Miller v. Wilkie, 32 Vet. App. 249, 256, 259 (2020), in which the Court held that the duty to assist required an examiner to “address the veteran's lay statements to provide the Board with an adequate medical opinion,” in part because “medical opinions can inform credibility findings.” On remand, the Court directed the Board to consider the application of the Miller decision to the present case. The record includes VA opinions addressing the etiology of the Veteran’s current low back disability and bilateral knee disability from March 2015 and July 2015, which predate the Veteran’s June 2017 Board hearing testimony. Given the Court’s direction to consider the holding under Miller, which provides that an adequate medical opinion must address the Veteran’s lay statements, the Board finds that the currently available evidence is insufficient to adjudicate the service connection claims. Accordingly, a remand is required to obtain supplemental VA opinions to address the Veteran’s account of his in-service symptoms as well as his statements concerning medical treatment, or lack thereof, for those conditions. The matters are REMANDED for the following actions: 1. Obtain all the outstanding treatment records for the Veteran’s low back disability and bilateral knee disability that are not currently of record. 2. Obtain an addendum opinion by an appropriately qualified clinician to determine the nature and etiology of the Veteran’s low back and bilateral knee disabilities. The examiner should provide an opinion addressing whether it is at least as likely as not that the Veteran’s low back disability and bilateral knee disability are related to his active duty service. In providing the above opinion, the examiner should address the Veteran’s contentions that his low back and bilateral knee disabilities developed due to the physical demands of his duties during service as a Yeoman in the U.S. Navy. The examiner should also address the Veteran’s lay statements, including his June 2017 Board hearing testimony, which described his in-service symptoms, the history and continuity of those symptoms, and the extent to which he sought medical treatment for conditions during service. (Continued on the next page)   A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 3. Readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, send the Veteran a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Journet Shaw, 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.