Citation Nr: 21013265 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 10-47 910 DATE: March 9, 2021 ORDER Entitlement to service connection for neurological symptoms of the hands, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for neurological symptoms of the fingers, to include as due to an undiagnosed illness, is denied. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the right hip is denied. Entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of flexion is denied. Entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of abduction is denied. REMANDED Entitlement to service connection for a low back disability, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for neurological symptoms of the feet, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for neurological symptoms of the toes, to include as due to an undiagnosed illness, is remanded. FINDINGS OF FACT 1. Neurological symptoms of the hands were not shown in service, an organic disease of the nervous system was not manifest within one year of active service; and, the preponderance of the evidence fails to establish that any chronic neurological symptoms of the hands is etiologically related to service or to an undiagnosed illness. 2. Neurological symptoms of the fingers were not shown in service, an organic disease of the nervous system was not manifest within one year of active service; and, the preponderance of the evidence fails to establish that any chronic neurological symptoms of the fingers is etiologically related to service or to an undiagnosed illness. 3. The evidence demonstrates that the Veteran’s service-connected osteoarthritis of the right hip, manifested by limitation of extension, is manifested by no more than X-ray evidence of arthritis and painful motion on extension not limited to 5 degrees. 4. The evidence demonstrates that the Veteran’s service-connected osteoarthritis of the right hip, manifested by limitation of flexion, is manifested by flexion greater than 45 degrees. 5. The evidence demonstrates that the Veteran’s service-connected osteoarthritis of the right hip, manifested by limitation of abduction, is manifested by abduction with motion beyond 10 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for neurological symptoms of the hands, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307,3.309, 3.317. 2. The criteria for entitlement to service connection for neurological symptoms of the fingers, to include as due to an undiagnosed illness, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307,3.309, 3.317. 3. The criteria for entitlement to an initial rating in excess of 10 percent for osteoarthritis of the right hip have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5251. 4. The criteria for entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of flexion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5252. 5. The criteria for entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of abduction have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5253. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from August 1988 to August 1992. He served in Southwest Asia from August 1990 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2010 rating decision by the Roanoke, Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA). In November 2015, the Veteran testified at a personal hearing before a Veterans Law Judge who is unavailable to participate in a decision. A copy of the transcript of that hearing is of record. Correspondence dated in January 2018, in essence, noted the Veteran had withdrawn his request for an additional Board hearing. The issues on appeal were remanded for additional development in March 2016 and April 2018. The Board notes that an October 2016 rating decision found the osteoarthritis of the right hip issue on appeal rated as 10 percent disabling under Diagnostic Codes 5255-5010 (femur impairment and traumatic arthritis) was more appropriate rated as 10 percent disabling under Diagnostic Codes 5003-5251 (degenerative arthritis and limitation of extension. Separate noncompensable ratings were established for right hip limitation of flexion (Diagnostic Code 5252) and right hip limitation of abduction (Diagnostic Code 5253). The increased rating matters for appellate review have been revised accordingly. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The term “disability” for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). Certain chronic diseases, including organic diseases of the nervous system, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). VA regulations also provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability became manifest either during active service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstrations of laboratory abnormalities. Chronic multisymptom illness of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Signs or symptoms involving skin, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurologic signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the respiratory system (upper or lower), (9) Sleep disturbances, (10) Gastrointestinal signs or symptoms, (11) Cardiovascular signs or symptoms, (12) Abnormal weight loss, and (13) Menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 (Aug. 3, 1998). “The very essence of an undiagnosed illness is that there is no diagnosis.” Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006); see also Gutierrez v. Principi, 19 Vet. App. 1, 10 (2004) (a Persian Gulf War veteran’s symptoms “cannot be related to any known clinical diagnosis for compensation to be awarded under section 1117”). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Organic diseases of the nervous system are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). A medical opinion based upon an inaccurate factual premise may be discounted entirely. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. 1. Entitlement to service connection for neurological symptoms of the hands, to include as due to an undiagnosed illness. 2. Entitlement to service connection for neurological symptoms of the fingers, to include as due to an undiagnosed illness. The Veteran contends that he has neurological symptoms of the hands and fingers as a result of active service, including due to service in Southwest Asia. In correspondence dated in December 2009 he reported having symptoms primarily on the right side and that the symptoms could be tracked back to 1991 while he served on the USS GUAM. He stated they had progressively gotten worsen and that in the beginning he had no more than slight tingling in the right hand. At his November 2015 hearing he testified that he experienced neurologic symptoms to the left hand during active service and that he currently experienced intermittent neurologic symptoms. Service treatment records are negative for complaint, treatment, or diagnosis of neurological symptoms of the hands and fingers. The Veteran’s June 1992 separation examination revealed a normal clinical evaluation of the neurologic system. In reports of medical history dated in January 1993 and November 1996 he denied having or having ever had neuritis. Records show he served in Southwest Asia from August 1990 to April 1991. He separated from active service in August 1992. An August 2013 VA Gulf War general medical examination found the Veteran’s neurological symptoms including to the bilateral upper extremities to have no pathology since an examination was normal. There was no formal neurological diagnosis for the complaint. The examiner found there were no signs and/or symptoms that may represent an undiagnosed illness or a diagnosed medically unexplained chronic multisymptom illness. VA examination in May 2019 included a diagnosis of left trigger finger with a date of diagnosis in April 2019. It was noted that the Veteran reported he had fallen off a truck in 1990 dislocating his right thumb and hurting his left ring finger. He stated he was not treated for the injuries in service but that he continued to have left ring finger at times without pain until 2004/2005 when he started having pain in the joints. VA medical opinion in May 2019 found it was less likely that the Veteran had neurological symptoms of the hands and fingers that were incurred in or caused by an in-service injury, event, or illness. The examiner noted that all available medical records and current peer reviewed medical literature had been reviewed. It was noted that records showed the Veteran was involved in a motor vehicle accident in September 2016 and that follow-up treatment reports noted complaints of trigger finger. The examiner reiterated that it was less likely that the claimed disorders of the hands and fingers were incurred in or caused by an in-service injury, event, or illness. VA central nervous system and neuromuscular examination in July 2019 included diagnoses of vascular diseases and thrombosis, transient ischemic attack (TIA), or cerebral infarction. The examiner noted that he was not a neurologist, but that the Veteran had been seen by a neurologist and the records of that treatment had been reviewed. It was further explained that a peripheral nerve disability benefits questionnaire (DBQ) was not completed because no peripheral nerve condition was diagnosed. The claim for neurological disturbances including to the bilateral hands and fingers was found to be associated with a diagnosis of history of transient central nervous system ischemia related to thrombocythemia. It was also noted that the Veteran had a stroke in the 2000s. The claimed disorder was found to be less likely incurred in or caused by the claimed in-service injury, event, or illness. As rationale, it was noted that the strongest evidence that the disorder was not service related was a February 1998 pathology report and a February 2003 VA treatment report noting essential thrombocytosis was diagnosed in 1996. The disorder was noted to be a disease with specific etiology and diagnosis. The examiner stated there was no factual evidence to support the likelihood of specific environmental exposure in Southwest Asia as the cause of the claimed conditions. There was no undiagnosed illness or medically unexplained chronic multisymptom illness. The cause of the essential thrombocytopenia was identified as genetic mutation. It was explained that thrombocythemia caused excess cell production and that when the Veteran’s platelet count was higher than 700,000 he had transient neurological symptoms because the blood flow likely was affected and ischemia resulted. A July 2019 addendum opinion found a left ring finger trigger finger disorder was not manifested by any neurological disturbance of the hands or fingers. Rather it was noted that trigger finger conditions were due to inflammation of the tendon sheath that results in swelling of the tendon. A neurological examination revealed the hands and fingers were completely normal. The examiner also found that based upon review of current peer-reviewed literature there were no neurological symptoms to the hands and fingers that were etiologically related to service in Southwest Asia. Based upon the evidence of record, the Board finds that neurological symptoms of the hands and fingers were not shown in service, that an organic disease of the nervous system was not manifest within one year of active service, and that the preponderance of the evidence fails to establish that any chronic neurological symptoms of the hands or fingers are etiologically related to service or to an undiagnosed illness. Service treatment records are negative for any neurological abnormalities or complaints to the hands or fingers. The overall evidence in this case, including the July 2019 VA opinions, is found to be persuasive and to have been based upon adequate rationale. The July 2019 examiner is shown to have reviewed of the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The explanation provided as to why an examination by a neurologist was not warranted is found to be adequate for substantial compliance with the prior remand directives. Although the Veteran reported, in essence, that he had neurological symptoms to the hands and fingers since 1991, the Board finds this report to be not credible due to inconsistency with the other evidence of record. In fact, post-service reports of medical history dated in January 1993 and November 1996 show the Veteran denied having or having ever had neuritis. The Board notes that neuritis is defined as an inflammatory or degenerative lesion of a nerve marked especially by pain, sensory disturbances, and impaired or lost reflexes. https://www.merriam-webster.com/dictionary/neuritis (last viewed Mar. 1, 2021). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to etiologically link any such symptoms to a current diagnosis. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that they received any special training or acquired any medical expertise in evaluating such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. Consideration has also been given to the Veteran’s personal assertions that he has neurological symptoms of the hands and fingers as a result of service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The chronic disabilities at issue are not matters that are readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In conclusion, the Board finds service connection for neurological symptoms of the hands and fingers is not warranted. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against the claims. Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran’s disability claim may require re-ratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). VA’s General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In this present case, VA must consider the claim for a higher rating pursuant to the former and revised regulations only after February 7, 2021. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran’s claim. The Board notes, however, that the criteria applicable to musculoskeletal hip disorders (Diagnostic Codes 5250, 5251, 5252, 5253, 5254, 5255) were unchanged by the revised regulations effective February 7, 2021. The revisions for post-traumatic arthritis (Diagnostic Code 5010) removed an instruction to rate such disorders as degenerative arthritis under Diagnostic Code 5003. Post-traumatic arthritis disabilities after February 7, 2021, are to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. Under the revised criteria, only degenerative arthritis disabilities under Diagnostic Code 5003 may be assigned a compensable rating for arthritis with noncompensable limitations of motion. As the changes to Diagnostic Code 5010 are not advantageous to the Veteran only the old criteria are considered for this decision. Prior to February 7, 2021, traumatic arthritis was rated pursuant to the criteria in Diagnostic Code 5010, which directed that evaluations were to be made pursuant to the criteria for degenerative arthritis found in Diagnostic Code 5003. 38 C.F.R. § 4.71a. Degenerative arthritis 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. In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note (1). Under Diagnostic Code 5250, a 90 percent rating is provided for hip ankylosis that is unfavorable, extremely unfavorable ankylosis with the foot not reaching the ground and necessitating crutches; a 70 percent is provided for intermediate ankylosis; and a 60 percent rating for favorable ankylosis with flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction. 38 C.F.R. § 4.71a, Diagnostic Code 5250. Diagnostic Code 5251 provides a 10 percent rating where thigh extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Diagnostic Code 5252 provides a 40 percent rating where thigh flexion is limited to 10 degrees; 30 percent where limited to 20 degrees; 20 percent where limited to 30 degrees; and 10 percent where limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5253 provides a 20 percent rating where an impairment of the thigh results in limitation of abduction with motion lost beyond 10 degrees; 10 percent with limitation of adduction and cannot cross legs; and 10 percent with limitation of rotation and cannot toe-out more than 15 degrees on the affected leg. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Diagnostic Code 5254 provides an 80 percent rating for flail hip joint. 38 C.F.R. § 4.71a, Diagnostic Code 5254. Under Diagnostic Code 5255, impairment of femur, an 80 percent rating is provided for fracture or shaft or anatomical neck with nonunion and loose motion (spiral or oblique fracture) and a 60 percent rating with nonunion without loose motion and with weight bearing preserved with aid of brace. A 60 percent rating is also provided for fracture of the surgical neck with false joint. For malunion the disability is to be evaluated under the diagnostic codes for the knee or the hip, whichever results in the highest evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5255. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id. Such evidence may include facial expression, such as wincing, muscle spasm, and crepitation. See 38 C.F.R. § 4.59. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. An adequate orthopedic examination should record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing, address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. See Correia v. McDonald, 28 Vet. App. 158 (2016) An examination does not need to be conducted during an actual flare-up in order to account for additional functional impairment. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Instead, examiners are asked to estimate the functional impairment experienced during a flare-up, considering all competent evidence of functional loss that is available in the record. Id. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. 3. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the right hip. 4. Entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of flexion. 5. Entitlement to an initial compensable rating for osteoarthritis of the right hip manifested by limitation of abduction. The Veteran contends, in essence, that increased ratings are warranted for his service-connected right hip disabilities. His right hip disorder claim was received by VA on November 13, 2009. At his November 2015 hearing he testified that he experienced right hip pain and that he received epidural shots two times per year. He described having fallen because of the hip and reported having good days and bad days. The pertinent evidence of record includes a November 2009 VA X-ray study noting minimal osteoarthritis in the right hip. VA examination in March 2010 included a diagnosis of osteoarthritis of the right hip. It was noted the Veteran reported symptoms of stiffness, lack of endurance, locking, and pain. He reported flare-ups as often as five times per month with each episode lasting for three days. The flare-ups were precipitated by physical activity and were described as pain and limitation of motion. He described his overall functional impairment as very limited walking, standing, sitting, lifting, and climbing stairs due to pain. The examiner noted the Veteran walked with a normal gait. Leg length measurements were not significant. An examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. No assistive devices for ambulation were required. An examination of the right hip revealed tenderness with no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, subluxation, or ankylosis. Range of motion studies were within normal limits with flexion from 0 to 125 degrees, extension from 0 to 30 degrees, adduction from 0 to 25 degrees, abduction from 0 to 45 degrees, external rotation from 0 to 60 degrees, and internal rotation from 0 to 40 degrees. There was no change in motion after repetitive motion testing. The examiner noted that X-ray studies revealed a separate bony density adjacent to the superolateral acetabulum possibly due to prior trauma. The right hip disorder was found to have no effect on the Veteran’s usual occupation and no limitations on his daily activities. VA examination in August 2013 included a diagnosis of osteoarthritis to the right acetabuli. The Veteran complained of pain and flare-ups daily with excess weight bearing. Range of motion studies revealed right hip flexion to 100 degrees with objective evidence of painful motion at 90 degrees. Extension was greater than 5 degrees with objective evidence of painful motion at greater than 5 degrees. Abduction was not lost beyond 10 degrees, adduction was not limited such that he could not cross his legs, and rotation was not limited such that he could not toe-out more than 15 degrees. Range of motion after repetitive-use testing revealed flexion to 100 degrees, extension greater than 5 degrees, abduction not lost beyond 10 degrees, adduction not limited such that he could not cross his legs, and rotation not limited such that he could not toe-out more than 15 degrees. There was functional loss of the right hip due to less movement than normal and pain on movement. Muscle strength was normal and there was no ankylosis of the joint. The examiner stated the hip condition did not impact the Veteran’s ability to work. VA examination in May 2016 included a diagnosis of right hip osteoarthritis. The Veteran reported that his hip disorder had worsened and that he had flare-ups including waking up with pain. He stated he could not sleep for a full night and could not sit for 15 or 20 minutes without readjusting. Range of motion studies revealed flexion to 90 degrees, extension to 25 degrees, abduction to 40 degrees, and adduction to 25 degrees. Adduction was not limited such that he could not cross his legs. External rotation was from 0 to 50 degrees and internal rotation was from 0 to 30 degrees. There was functional loss of the right hip due to an inability to squat and get up without assistance. There was exhibited pain with range of motion on flexion and extension. There was no evidence of pain with weight bearing, localized tenderness or pain on palpation, or objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive-use testing. The examination was found to be neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. An opinion as to whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups could not be provided without mere speculation. Muscle strength was normal without muscle atrophy and there was no ankylosis of the joint. It was noted the Veteran used crutches occasionally for locomotion due back and hip pain. The examiner stated the hip condition impacted the Veteran’s ability to work due to difficulty running, having to shift positions in 15 to 20 minutes, and difficulty climbing steps. VA examination in May 2019 included a diagnosis of right hip osteoarthritis. It was noted that the Veteran reported the disorder had gotten worse over the past 12 months with more pain, sharp and aching pain, that was constant and associated with stiffness. He stated his gait was shorted and he limped due to an inability to open up his hip joint. He reported he was unable to sit or stand for long, had to constantly readjust due to hip pain, and needed help and assistance when walking up stairs. He described having functional loss due to inability to full extend his right hip, walk for long, pain-affected sleep. Range of motion studies revealed flexion to 100 degrees, extension to 20 degrees, abduction to 25 degrees, and adduction to 25 degrees. Adduction was not limited such that he could not cross his legs. External rotation was from 0 to 45 degrees and internal rotation was from 0 to 25 degrees. There was functional loss of the right hip due to an inability to squat and get up without assistance. There was exhibited pain with range of motion on flexion, extension, abduction, and external rotation. There was evidence of pain with weight bearing and localized tenderness or pain on palpation without objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive-use testing. The examination was found to be medically consistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. Pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups without change in range of motion. Muscle strength was normal without muscle atrophy and there was no ankylosis of the joint. There was no evidence of malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. It was noted the Veteran used no assistive devices as a normal mode of locomotion. The examiner stated the hip condition impacted the Veteran’s ability to work due to inability to perform task that required prolonged standing, prolonged walking, any degree or running, crawling, squatting, or stooping. The examiner explained that weight-bearing and passive motion studies were performed to the extent they could be done safely without change in the reported range or motion. Based upon the evidence of record, the Board finds that the Veteran’s service-connected osteoarthritis of the right hip, manifested by limitation of extension, is manifested by no more than X-ray evidence of arthritis and painful motion on extension not limited to 5 degrees. The evidence also demonstrates that his service-connected osteoarthritis of the right hip is manifested by flexion greater than 45 degrees and abduction with motion beyond 10 degrees. The overall evidence of record demonstrates no ankylosis, malunion or nonunion of the femur, flail hip joint, or significant leg length discrepancy. As the evidence demonstrates no compensable loss of motion under an applicable diagnostic code and the regulations prior to February 7, 2021, under Diagnostic Code 5003 are applicable, only a single 10 percent rating may be assigned for the right hip joint. The Veteran’s limitation of motion is objectively confirmed by findings including satisfactory evidence of painful motion. The Board notes that an adequate discussion of functional loss includes consideration of manifest functional loss during flare-ups. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38 C.F.R. § 3.344(a) and 38 C.F.R. § 4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given to the Veteran’s reports indicating flare-ups of increased pain and functional loss. The reported flare-ups, however, are not shown to additionally limit function in a quantifiable way and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. In sum, the Board finds the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. Here, the reports of exacerbation or flare-ups are not quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38 C.F.R. § 3.344(a) regarding stabilization of ratings. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he is not competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability, however, has been provided by VA medical professionals who have examined him. VA findings in this case directly address the criteria under which the disability is evaluated, including whether a specific symptom caused a level of impairment required for a higher disability rating. The Board accords these medical findings greater weight than any subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The preponderance of the evidence in this case is against any higher or additional separate ratings. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability, to include as secondary to a service-connected disability, is remanded. 2. Entitlement to service connection for neurological symptoms of the feet, to include as due to an undiagnosed illness, is remanded. 3. Entitlement to service connection for neurological symptoms of the toes, to include as due to an undiagnosed illness, is remanded. Subsequent to the April 2018 Board remand a VA medical opinion was obtained in May 2019 which found the Veteran’s current lumbar spine disability was less likely proximately due to his service-connected right hip osteoarthritis disability. The examiner found rather that his lumbar spine arthritis was more likely related the natural aging process and his obesity. A September 2020 medical opinion also found the main cause of the Veteran’s obesity was not believed to be due to decreased activity as a result of his service-connected pes planus and right hip disabilities. However, as the September 2020 opinion did not adequately address matters as to aggravation, further development is required. Under applicable law VA must consider aggravation in addition to causation in the context of claims where a theory of secondary service connection, with obesity as an intermediate step, is explicitly raised by a veteran or reasonably raised by the record. Walsh v. Wilkie, 32 Vet. App. 300, 306-307 (2020). The Board notes that the issues as to neurological symptoms of the feet and toes are inextricably intertwined with the low back disability claim. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding (a) whether the Veteran had an incremental increase in his obesity due to a service-connected disability; (b) if so, whether the incremental increase of obesity as a result of service-connected disability was a substantial factor in causing low back arthritis; and (c) whether the low back arthritis would have occurred but for the incremental increase in obesity due to the service-connected disability. The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any “incremental increase in disability” need not be permanent. A complete rationale must be provided based upon a review of the evidence of record, including discussion as to any back injury sustained in December 1998 after lifting a heavy box. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues remaining on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Douglas 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.