Citation Nr: 21013684 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-28 865 DATE: March 10, 2021 ORDER Entitlement to service connection for hammer toes, to include as secondary to service-connected plantar fasciitis, is granted. Entitlement to service connection for sacrum disability, to include coccyx pain and coccygeus-sacral muscle spasm, claimed as torqued sacrum, is granted. Entitlement to a disability rating of 20 percent from January 20, 2010 to January 8, 2014, and 40 percent thereafter for service-connected osteoarthritis of lumbar spine is granted. REMANDED Entitlement to service connection for familial hypertriglyceridemia is remanded. Entitlement to service connection for chronic pancreatitis, to include as secondary for familial hypertriglyceridemia, is remanded. Entitlement to service connection for diabetes mellitus, to include as secondary for familial hypertriglyceridemia, is remanded. FINDINGS OF FACT 1. The probative evidence of record is in equipoise as to whether the Veteran’s bilateral hammer toe disability is proximately due to his service-connected bilateral plantar fasciitis. 2. The evidence is at least in equipoise as to whether the Veteran’s sacrum disability, to include coccyx pain and coccygeus-sacral muscle spasm, began during active service. 3. From January 20, 2010 to January 8, 2014, the Veteran’s osteoarthritis of lumbar spine was manifest by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 4. After January 8, 2014, the Veteran’s osteoarthritis of lumbar spine is manifest by forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hammer toes as secondary to service-connected bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for sacrum disability, to include coccyx pain and coccygeus-sacral muscle spasm have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Prior to January 8, 2014, the criteria for a rating of 20 percent and no higher for osteoarthritis of lumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 4. After January 8, 2014, the criteria for a rating in excess of 40 percent and no higher for osteoarthritis of lumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active service from May 1992 to December 1994. This case is before the Board of Veterans’ Appeals (Board) from March 2010, June 2010 and October 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned Veterans’ Law Judge at a January 2016 hearing. In July 2018, the Board remanded these matters to the RO for additional development. Except as discussed in the remand section of this decision, the Board finds there has been substantial compliance with the Board’s remand directives in accordance with Stegall v. West, 11 Vet. App. 268, 271 (1998), and may proceed with appellate review. 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). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection may be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In addition, where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Hammertoes. Per the Veteran’s hearing testimony, his hammertoe disorder was either caused or aggravated by his active service (1/15/2016 Hearing Testimony, pg. 5). The Veteran has also asserted that his hammer toes are related to his service-connected plantar fasciitis (5/22/2013 Form 9; 8/25/2020 Rating Decision - Codesheet). The Veteran’s diagnosis with bilateral hammer toes is confirmed by the medical evidence of record (1/04/2019 CAPRI, pg. 268). The Veteran is service connected for bilateral plantar fasciitis (8/25/2020 Rating Decision – Codesheet). Service treatment records reveal complaints of foot pain during service, attributed to plantar fasciitis. The Veteran was also treated for bilateral blisters on his heels. 1/19/1995 STR – Medical, pgs. 3, 23, 37, and 40). During service, the Veteran was not assessed with pes planus or pes cavus. The question for the Board is whether the Veteran’s currently diagnosed hammer toes began during service or is at least as likely as not related to an in-service injury, event, or disease, to include his bilateral plantar fasciitis. On this issue, there are medical opinions for and against a nexus to service. The Veteran was afforded a May 2019 VA examination for foot conditions. Diagnoses of hammer toes and acquired pes cavus were confirmed, in addition to status post second digit fracture on the right foot, and bilateral heel spurs. After review of the Veteran’s record and an in-person examination, the May 2019 examiner opined the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service-connected condition (5/17/2019 C&P Exam). The examiner explained that it is more plausible for hammer toes to be secondary to pes planus or pes cavus than plantar fasciitis. The examiner also opined the Veteran’s hammer toes were not at least as likely as not aggravated beyond natural progression by service-connected plantar fasciitis. The examiner cited to medical literature in concluded there is no objective evidence to support Veteran's foot conditions, including bilateral hammer toes, were aggravated beyond normal progression by service-connected plantar fasciitis (5/17/2019 C&P Exam). The Veteran also underwent an October 2019 VA examination. Although the October 2019 examiner provided a negative nexus opinion with regard to direct service connection, the examiner opined that the Veteran’s diagnosis of hammertoes is at least as likely as not (probability 50 percent or greater) due to the Veteran’s service-connected plantar fasciitis. The examiner explained that hammer toes result from muscle imbalances that occur both from a pronated or flat foot and from a supinated or high arched foot. The mechanism of deformity is different, but the result can appear similar. Supporting the opinion, the examiner cited to medical literature and the Veteran’s medical records, and physical examination (10/23/2019 C&P Exam). An August 2020 addendum opinion was subsequently obtained for clarification (8/25/2020 CAPRI). After conducting a records review, the August 2020 provided negative nexus opinions for both direct and secondary service connection. The examiner also found it less likely as not that the Veteran's bilateral hammertoes were aggravated beyond natural progression by his service-connected bilateral plantar fasciitis, citing to the same medical literature. The examiner cited to medical literature that explained hammer toes, claw toes, and lesser toe deformities are relatively common and arise from soft tissue injury, inflammatory arthritis, neuromuscular disorders, or trauma, although genetic predisposition may play a role. The examiner explained the mechanism underlying hammertoe deformities, noting the mechanism for these injuries is complex. After considering the various medical opinions, the Board finds the medical evidence of record weighs against a finding for entitlement to service connection for hammertoes on a direct basis. Indeed, all of the medical opinions of record come to the same conclusion in that regard. As to the question whether the Veteran’s currently diagnosed hammer toe disability is proximately due to his service-connected bilateral pes planus, the Board finds the probative evidence of record to be at least in equipoise. Although the May 2019 VA examiner and the August 2020 addendum provided negative nexus opinions with respect to secondary service connection, the Board finds the October 2019 opinion, which accompanied an in-person examination, to be thorough, and based on an accurate medical history. The rationale for the opinion is sufficiently detailed and incorporates an understanding of the medical facts of record and contains clear conclusions with supporting data. For these reasons, the Board finds the medical evidence to be in equipoise and, after resolving doubt in favor of the Veteran, the Board finds that the Veteran’s hammertoe disability is proximately due to or the result of service-connected plantar fasciitis, and thus service connection for hammer toes is warranted. 38 C.F.R. § 3.310 (a). 2. Sacrum disability, to include coccyx pain and coccygeus-sacral muscle spasm, claimed as torqued sacrum. The Veteran seeks service connection for a torqued sacrum, also described in the record as a tailbone injury, that was sustained on active duty. He has described riding in the back of a truck while on active duty. He has consistently described sitting on a tire in the bed of the truck. When the truck hit a hole, he was jarred and the rim of the tire impacted his coccyx (1/20/2010 VA 21-4138 Statement In Support of Claim; 8/30/2010 VA 21-4138 Statement In Support of Claim; 1/04/2019 CAPRI, pg. 642). The Veteran’s active problem list includes pain of the left and right hip joint. Hip pain was also noted in conjunction with the Veteran’s lower back pain in August 2013 (12/04/2019 CAPRI, pg. 26; 01/04/2019 CAPRI, pg. 79) A January 2014 back examination noted a separate diagnosis of fracture of the coccyx, with spasm (10/23/2015 CAPRI, pgs. 112 and 117). The forgoing establishes a present disability. The Board next turns to whether there was an in-service incurrence or aggravation of a disease or injury. On this point, the evidence of record supports the occurrence of an in-service injury. In addition to the Veteran’s credible statements regarding the injury, his service treatment record and separation physical provide contemporaneous support that an in-service tailbone injury occurred in 1994 (2/09/1995 STR, pg. 2; 1/20/2016 Medical Treatment Record - Non-Government Facility; 1/18/2011 VA Examination, pg. 13; 4/20/2014 STR – Medical, pg. 10). Shortly after service, in March 1995, the Veteran’s symptoms, to include complaints regarding his coccyx, were assessed and he was diagnosed with osteoarthritis of the lumbar spine and coccygeus sacral muscle spasm (3/02/1995 VA Examination, pg. 3). Additional post service treatment records reflect hip pain complaints associated with and in addition to his back complaints. February 2002 treatment notes mention decrease range of motion in the Veteran's hip due to pain in the buttock area (10/24/2013 CAPRI, pg. 19) September 2002 treatment note describes bilateral lower extremity burning over the entire legs that started in 1995 after he injured his back in service. The diagnosis at that time according to the Veteran was coccydynia with lower muscular back spasms (10/24/2013 CAPRI, pg. 7) May 2010 X-rays of the sacrum and coccyx showed calcific density on the right side of one of the lower sacral segments that may represent old fracture at that site. The Veteran was diagnosed at that time with lumbar osteoarthritis with left sacroiliac dysfunction. The May 2010 examiner’s positive nexus opinion relating to the Veteran’s lumbar spine noted that, based upon the patients historical account of his military injury, he portrays a classic type mechanism of injury that would have "torqued" his pelvis and led to a sacroiliac dysfunction which would involve muscle tightness and spasm of the coccygeus-sacral area muscles. This process has nothing to do with osteoarthritis of the lumbar spine and is a separate injury and/or condition (7/07/2010 Medical Treatment Record - Government Facility, pgs. 8 and 9) A private physical therapist described the Veteran as being diagnosed with osteoarthritis of the lumbar spine and also identified significant coccygodynia with apparent sacral torsion as a separate condition (8/30/2010 Third Party Correspondence). A private physician letter of December 2012 describes the Veteran’s ongoing sacrum and coccyx pain. The doctor opined that, based on subjective and objective observation along with the Veteran’s description of the original injury and the subsequent history of ongoing pain, it is reasonable to assume that his current pelvic and back pathology is related to the service related coccygeal fracture that he sustained in the early 1990s. The physician provided an opinion that the Veteran’s degenerative disc disease is likely related to that injury as well. (12/07/2012 Medical Treatment Record - Non-Government Facility). The examiner The Veteran was afforded a July 2019 VA examination with an orthopedic surgeon, who opined that the Veteran’s sacral fracture is a separate and distinct disability, as it affects how the Veteran is able to sit. The examiner explained while degenerative changes of the lumbar spine may affect posture while sitting, the Veteran has pinpoint tenderness adjacent to the fracture site while sitting. The examiner opined that this disability while sitting would not be present with isolated arthrosis of the lumbar spine (7/22/2019 C&P Exam, pg. 16). In considering the totality of the medical evidence of record, the Board finds it weighs in favor of the Veteran’s claim of service connection for a sacrum disability, as separate from his service-connected lumbar spine disability. The private medical opinions from the physical therapist and the December 2012 physician, taken in conjunction with the statement by the July 2019 VA examiner opining the sacral fracture suggest that the Veteran has a sacrum disability, to include coccyx pain, in addition to his service-connected lumbar spine disability The Board also notes the Veteran complained of back and hip pain during service, prior to the injury to his coccyx (2/09/1995 STR, pgs. 1-2). The Board finds this too supports that the Veteran’s back and sacral/coccyx injuries are separate. In light of the foregoing, the Board finds the evidence to at least be in equipoise on the issue of service connection for a sacrum disability, to include coccyx pain and coccygeus-sacral muscle spasm. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a sacrum disability to include coccyx pain and coccygeus-sacral muscle spasm is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Disability rating in excess of 20 percent from January 20, 2010 to July 6, 2019, and in excess of 40 percent thereafter for service-connected osteoarthritis of lumbar spine By this decision, the Veteran is awarded a separate disability rating for his sacrum disability. Accordingly, the Veteran’s disability has been recharacterized as osteoarthritis of the lumbar spine. On January 15, 2010, the Veteran claimed entitlement to an increased rating, contending his service-connected lumbar spine had increased in severity (1/20/2010 VA 21-4138 Statement In Support of Claim). The Veteran’s disability rating of 20 percent was assigned pursuant to diagnostic codes 5003-5295. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Since his appeal, the Veteran’s disability rating for osteoarthritis of lumbar spine was increased to 40 percent, effective July 6, 2019 pursuant to Diagnostic Code 5242, representing a partial grant of the benefit sought. Additionally, he was assigned disability ratings for radiculopathy of the lower extremities, at a 10 percent rating from August 3, 2015 to November 5, 2015 pursuant to Diagnostic Dode 8521, increased to 40 percent thereafter, pursuant to Diagnostic Code 8520 (8/25/2020 Rating Decision – Codesheet). The question before the Board remains whether the Veteran is entitled to a disability rating in excess of 20 percent from January 20, 2010 to July 6, 2019, and in excess of 40 percent thereafter, for his lumbar spine disability. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242 under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Additionally, it is noted that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. 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. After February 7, 2021, Diagnostic Code 5242 was changed to address degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010). Diagnostic Code 5003, concerning degenerative arthritis, other than post-traumatic: 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 (DC 5200 etc.). When however, 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, rate as below: A 20 percent disability rating will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbation; A 10 percent disability rating will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1): The 20 and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Diagnostic Code 5010 provides post-traumatic arthritis should be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25, the combined ratings table. The regulatory changes to the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a as amended effective February 7, 2021, 85 Fed. Reg. 230 (Nov 30, 2020), do not impact the rating of the Veteran’s disability under the general rating formula. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Review of the medical evidence of record reveals a May 2010 VA examination in which thoracolumbar spine range of motion was measured as follows: flexion to 75 degrees, left lateral flexion to 30 degrees, left lateral rotation to 20 degrees, right lateral flexion to 30 degrees, right lateral rotation to 30 degrees with objective evidence of pain on active range of motion. A measurement for extension was not noted. However, even without an extension measurement, the Veteran’s combined range of motion exceeded 120 degrees. Spasm was noted, as well as abnormal gait, described as antalgic (7/07/2010 Medical Treatment Record - Government Facility, pgs. 4 and 6). January 2011 VA examination showed flexion to 70 degrees, extension to 15 degrees, left lateral flexion to 15 degrees, left lateral rotation to 15 degrees, right lateral flexion to 30 degrees; right lateral rotation to 30 degrees with objective evidence of pain on active range of motion. The combined range of motion exceeded 120 degrees. Spasm was noted and gait was described as normal. However, abnormal spine curvatures were noted. (1/18/2011 VA Examination, pg. 17). A January 2014 VA examination recorded range of motion measurements of forward flexion at 45 degrees, with painful motion beginning at 30 degrees, extension to 20 degrees, with painful motion beginning at 15 degrees, right and left lateral flexion at 20 degrees, and left and right lateral rotation as 20 degrees. He was assessed with functional loss, that includes less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, interference with sitting, standing and/or weight-bearing, and lack of endurance (1/08/2014 VA Examination, pgs. 2-3). A July 2019 VA examination assessed the Veteran's range of motion as forward flexion 30 degrees, extension as 10 degrees, right and left lateral flexion as 20 degrees, and right and left lateral rotation as 30 degrees. functional loss noted, to include factors of pain, fatigue, weakness, lack of endurance, with no additional range of motion loss noted. during flare ups, the Veteran's range of motion limitations were measured as forward flexion 20 degrees, extension 10 degrees, right and left lateral flexion 15 degrees, and right and left lateral rotation 20 degrees with no ankylosis or IVDS (7/22/2019 C&P Exam) The Board has considered that medical evidence from as early as December 2009 confirms the Veteran’s osteoarthritis, and describes difficulty with the simplest of tasks, like bed mobility and ambulation (8/30/2010 Third Party Correspondence). Other medical evidence of record reveals that the Veteran’s back manifested with abnormal gait, spasm, and abnormal contour, it did not suggest pain resulted in functional impairment reducing his forward flexion to 30 degrees or less until January 8, 2014 (1/08/2014 VA Examination, pg. 2) The preponderance medical evidence prior to January 8, 2014 does not reveal limitation of forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The Veteran’s symptoms as described in the record do not suggest that they approximated favorable ankylosis. Flare ups of the Veteran’s symptoms do not approximate favorable ankylosis of the thoracolumbar spine. Findings of favorable or unfavorable ankylosis are not of record, nor is limitation of forward flexion of the thoracolumbar spine to 30 degrees or less. As such, an award higher than 20 percent is not warranted, prior to January 8, 2014. From January 8, 2014, the Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to include pain, weakened movement, excess fatigability, and incoordination. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that does not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Accordingly, a rating in excess of 40 percent is not warranted. Regarding neurological impairment, the Veteran has already been granted service connection for radiculopathy of the lower extremities (8/25/2020 Rating Decision - Codesheet) and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability to include bowel or bladder impairment. Based on the forgoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for osteoarthritis of the lumbar spine prior to January 8, 2014. A rating of 40 percent for osteoarthritis of the lumbar spine thereafter is granted, in consideration of the totality of symptoms, including functional effects not captured by range of motion testing but which, on the whole, more nearly approximate the next-higher 40 percent rating. REASONS FOR REMAND 4. Service connection for familial hypertriglyceridemia. 5. Service connection for chronic pancreatitis, to include as secondary for familial hypertriglyceridemia. 6. Service connection for diabetes mellitus, to include as secondary for familial hypertriglyceridemia. In its July 2018 remand, the Board directed that the Veteran be afforded an examination by an endocrinologist to obtain opinions as to the nature and etiology of the Veteran’s hypertriglyceridemia, pancreatitis, and diabetes mellitus. The examiner was to address the Veteran’s contention that his hypertriglyceridemia, pancreatitis, and/or diabetes mellitus have been aggravated (worsened beyond the normal course of the condition) by any service-connected disability, to specifically include major depressive disorder. Although the Veteran was afforded an August 2019 VA examination, the examiner did not address the Veteran’s contentions that his service-connected disabilities, to include major depressive disorder, prevents him from complying with treatment plans, causing or aggravating his hypertriglyceridemia, pancreatitis, and diabetes mellitus. The Board finds that as a result of this omission, there has not been substantial compliance with the Board’s remand directives in accordance with Stegall v. West, 11 Vet. App. 268, 271 (1998), and remand is required. The matters are REMANDED for the following action: Forward the claims file to the August 2019 examiner if available (if not available, to a comparably qualified and appropriate clinician) for an addendum opinion consistent with this remand. If the following cannot be addressed without an examination, an examination should be scheduled. The examiner should determine the nature and etiology of any hypertriglyceridemia, pancreatitis, and diabetes mellitus. The examiner must offer an opinion as to whether it is at least as likely as not related (probability 50 percent or greater) to the Veteran’s military service, to include elevated laboratory readings of blood glucose and triglycerides in service. The examiner should offer an explanation as to whether the claimed familial hypertriglyceridemia is a diagnosed medical condition. The examiner should also indicate whether familial hypertriglyceridemia is more appropriately described as a disease, which might be worsened beyond its normal course, or as a defect, which follows a known course unaffected by supervening events. The examiner should review the Veteran’s statements of record and the articles submitted and address the significance of the points raised. The examiner should also address whether the Veteran’s hypertriglyceridemia, or pancreatitis, or diabetes mellitus are shown to be caused or aggravated (worsened beyond the normal course of the condition) by any service-connected disability, to specifically include major depressive disorder. The examiner is reminded to consider the Veteran’s lay reports, and a reason must be provided if the Veteran’s lay reports are rejected. Lay statements cannot be rejected solely due to a lack of medical documentation. If there is a medical reason to accept or not accept the Veteran’s contentions, the examiner should provide them. If the absence of medical documentation is relevant, the relevance must be explained because the absence of evidence is not positive evidence of the existence or non-existence of an event. If the examiner is able to gather additional understanding or information regarding the circumstances surrounding any inservice injury or event, the examiner should include that information in his remarks. The examiner should reconcile any conflicting medical evidence of record to the extent possible. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and explain why this is so, (e.g., whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. A. Myers 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.