Citation Nr: 21013851 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 15-25 625 DATE: March 10, 2021 ORDER Entitlement to service connection for cervical spine disability, to include as secondary to service-connected degenerative disc disease of the lumbar spine, is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected low back disability and posttraumatic stress disorder (“PTSD”) is denied. Entitlement to service connection for folliculitis, to include as secondary to service-connected low back disability is denied. REMANDED Entitlement to service connection for a right hip disability, to include as secondary to service-connected low back disability is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected low back disability is remanded. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected low back disability is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to medications used for service-connected disabilities is remanded. Entitlement to an initial rating in excess of 20 percent for service-connected low back disability is remanded. Entitlement to an initial compensable rating for service-connected bilateral ingrown toenail is remanded. FINDINGS OF FACT 1. The Veteran’s cervical spine disability did not manifest during service, or within one year of separation, and is not shown to be causally or etiologically related to an in-service event, injury or disease. 2. The Veteran’s hypertension did not manifest during service, or within one year of separation, and is not shown to be causally or etiologically related to an in-service event, injury or disease. 3. The Veteran’s folliculitis did not manifest during service and is not shown to be causally or etiologically related to an in-service event, injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for service connection for folliculitis have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from May 1982 to August 1984. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2008 and March 2011 (cervical spine, right hip, right knee, right ankle, hypertension, erectile dysfunction, folliculitis, and ingrown toenail) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a March 2017 correspondence, the Veteran withdrew his request for a Board hearing. See March 2017 VA 21-0820 Report of General Information. As such, the Board finds that the Veteran’s request for a Board hearing is deemed withdrawn. By way of background, in November 2007, the Board granted the Veteran’s claim for entitlement to service connection for a low back disability. In March 2008, the RO issued a rating decision assigning a 20 percent disabling rating for a low back disability effective November 22, 1994. In September 2008, the Veteran submitted a statement stating “CUE (1) Evidence is on record that my back condition is more than 20 percent and I have new evidence to show my condition is worsen …” The Board finds that this statement constitutes as a valid notice of disagreement. In September 2018 and August 2020, the Board remanded the issues on appeal for further evidentiary development. That development having been completed the issues are once again before the Board. Service Connection Generally, to establish service connection a Veteran 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted 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. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain diseases, to include arthritis may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. Entitlement to service connection for cervical spine disability, to include as secondary to service-connected low back disability is denied. After a review of the record, the Board finds that although the Veteran has a current diagnosis of a cervical spine disability, he does not meet the criteria for service connection as the preponderance of the evidence supports a finding that the Veteran’s cervical spine disability is not casually or etiologically related to an in-service event, injury or disease. Regarding the first element of service connection (a current disability), the medical evidence reflects a diagnosis of cervical strain, degenerative disc disease of the cervical spine, cervical spondylosis, and cervical facet arthropathy. Specifically, in the July 2019 VA examination, the examiner diagnosed the Veteran with cervical strain and degenerative disc disease of the cervical spine. In a November 2016 VA treatment record, the Veteran was diagnosed with cervical spondylosis. See August 2020 CAPRI. In a September 2016 VA treatment record, the Veteran was diagnosed with cervical facet arthropathy. See August 2020 CAPRI. As such, the first element of service connection is met. Concerning the second element of service connection, a review of the service treatment records shows that the Veteran had normal neck with no report of swollen or painful joints or arthritis in the March 1982 enlistment examination and July 1984 separation examination. See December 2014 STR – Medical. The Board notes that in February 1984, the Veteran fell down a hill with his PR77 radio on his back. See September 1996 Medical Treatment Record – Government Facility. The Veteran sustained a back injury with no complaints of neck pain. Based on the foregoing, the Board finds that there is no in-service event, injury, or illness. As such, the second element of service connection has not been met. About four years after service, in 1988, the Veteran injured his neck, back, and groin at work. See October 1988 Medical Treatment Record – Non-Government Facility. It was determined that the Veteran sustained a soft tissue injury in his neck. An x-ray scan of the cervical spine revealed no evidence of fracture, dislocation or demineralization; the intervertebral disc spaces were normally maintained; and the neural foramens were patent and no cervical rib. A physician determined that there was no orthopedic explanation for his continued complaints. The next complaint of neck pain was in a November 1997 VA treatment record. However, upon examination the Veteran exhibited normal findings. See May 1998 Medical Treatment Record – Government Facility. The Veteran continued to complain of neck pain in 1998 and 1999. See February 1999 Medical Treatment Record – Government Facility and January 1999 Medical Treatment Record – Government Facility. As noted in a January 2001 private treatment record, the Veteran was involved in a motor vehicle accident. Specifically, a car smashed the Veteran between two cars causing his body to twist. The Veteran had immediate pain in his right leg, right knee, right ankle, lumbar spine, head, and cervical spine area. The Veteran was diagnosed with cervical sprain. See February 2001 Medical Treatment Record – Non-Government Facility. In an August 2002 VA treatment record, the Veteran stated that he has intermittent episodes of neck pain and stiffness since the January 2001 motor vehicle accident. See September 2010 Medical Treatment Record – Government Facility. The Veteran did not claim that his neck pain stemmed from service. In a May 2012 VA treatment record, the Veteran again complained of neck pain. See December 2014 CAPRI. The Veteran consistently continued to complain of neck pain since. In July 2019, the Veteran was afforded a VA examination wherein the Veteran stated that his neck pain started in service when he fell with a radio on his back rolling down a hill hurting his neck and back. The examiner diagnosed the Veteran with cervical strain and degenerative disc disease of the cervical spine and opined that the Veteran’s cervical spine disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that the Veteran’s cervical spine disability is less likely than not proximately due to or the result of Veteran’s service-connected low back disability. The examiner explained that there is no medical evidence to suggest that that the Veteran’s cervical spine disability is proximately due to any of the Veteran’s service-connected disability or aggravated beyond its natural progression by service-connected low back disability. The examiner stated that arthritis in one joint do not cause arthritis in another joint. As such, the Veteran’s neck arthritis is more likely related to age. The Board affords great probative value to the July 2019 VA examiner’s assessment as it is well supported by, and is consistent with, the most probative evidence of record. The most probative evidence of record reflects that the Veteran did not injure his neck in service especially in the February 1984 fall. The Veteran did not complain of neck pain when he was treated for a low back pain as a result of the February 1984 fall. Moreover, in the July 1984 separation examination the Veteran again did not complain of any neck pain. See December 2014 STR – Medical. Further, the records show that the Veteran injured his neck at work in 1988 and again in a motor vehicle accident in 2001. See October 1988 Medical Treatment Record – Non-Government Facility. See February 2001 Medical Treatment Record – Non-Government Facility. In fact, in an August 2002 VA treatment record, the Veteran stated that he has had intermittent episodes of neck pain and stiffness since the January 2001 motor vehicle accident. See September 2010 Medical Treatment Record – Government Facility. The Veteran did not claim that he had neck pain since service. The Board recognizes the Veteran’s lay statements linking his current cervical spine disability to service. The Veteran is competent to report purported symptoms such as experiencing chronic pain during and after service. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, the Board finds the Veteran to be an inaccurate historian. Specifically, as noted above, there are no service treatment record documenting treatment, let alone continual treatment, for a neck condition. Instead, during each of his in-service examinations, the Veteran specifically denied having any recurrent neck pain. It stands to reason that if the Veteran had been treated continuously due to recurrent back pain, such would have been noted during one of his in-service examinations. The Veteran’s lay statements are further contradicted by the August 2002 VA medical record showing he had intermittent episodes of neck pain and stiffness since the January 2001 motor vehicle accident and not since service. See September 2010 Medical Treatment Record – Government Facility. Accordingly, the Board finds the Veteran to be an inaccurate historian and provides his lay statements little probative value. The preponderance of the evidence does not support a finding that any cervical spine disability manifested to a compensable level in the first post-service year. 38 C.F.R. § 3.309(a). Based on the records, the Veteran was diagnosed with a cervical sprain in 1988, about four years after service. Further, a June 1988 x-ray scan of the cervical spine revealed unremarkable findings. Specifically, the x-ray scan of the cervical spine revealed no evidence of fracture, dislocation or demineralization; the intervertebral disc spaces were normally maintained; and the neural foramens were patent and no cervical rib. As there is no evidence of manifestation within the first post-service year, service connection for a cervical disability based on the presumption in favor of chronic disease would not be warranted in this case. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. In conclusion, the preponderance of the evidence establishes that his cervical spine disability was not manifested during service or for many years thereafter and is not otherwise related to his active service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Thus, the claim is denied. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected low back disability and PTSD is denied. After a review of the record, the Board finds that although the Veteran has a current diagnosis of hypertension, he does not meet the criteria for service connection as the preponderance of the evidence supports a finding that the Veteran’s hypertension is not casually or etiologically related to an in-service event, injury or disease. Regarding the first element of service connection (a current disability), in the October 2010 VA examination the Veteran was diagnosed with hypertension. Concerning the second element of service connection, a review of the service treatment records shows that the Veteran had normal vascular system and normal blood pressure readings in the March 1982 enlistment examination and July 1984 separation examination. See December 2014 STR – Medical. Based on the foregoing, the Board finds that there is no in-service event, injury, or illness. As such, the second element of service connection has not been met. As for the third element, the Veteran was afforded a VA examination in October 2010 and a disability benefits questionnaire (DBQ) in July 2019. In the October 2010 VA examination, the examiner opined that it would be mere speculation to opine whether or not the Veteran’s hypertension is due to or aggravated by the Veteran’s PTSD or low back disability. The examiner explained that although both pain and stress may temporarily elevate blood pressure, the current medical literature does not support a cause and effect relationship between either pain or PTSD and hypertension. There is no current objective evidence that the Veteran’s service-connected PTSD and low back disability could have caused or aggravated to any degree his current hypertension. In the July 2019 DBQ, the Veteran again claimed that he developed high blood pressure due to his PTSD and increased pain. The Veteran conceded that he did not have high blood pressure in service. The examiner opined that the Veteran’s hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there is no evidence of hypertension in service and as such there is no medical nexus for the development of hypertension due to a low back disability. The examiner also opined that the Veteran’s hypertension is less likely than not proximately due to or the result of the Veteran’s service-connected disabilities. The examiner explained that there is no medical evidence to suggest that hypertension is proximately due to any of the Veteran’s service-connected disability or aggravated beyond its natural progression by a service-connected disability. The examiner explained that hypertension develops with the aging process in most individuals, and it is found to be more common in certain at-risk populations such as African Americans and those with family history of hypertension. The Board gives great probative value to the VA examiners’ medical opinions as it is uncontradicted and based on the examiners’ medical knowledges, training, and experience. The Veteran conceded that his hypertension manifested after service. Although the Veteran claims that his hypertension manifested as a result of his PTSD and low back-pain he failed to submit any medical evidence in support of his claim. The October 2010 examiner stated that current medical literature does not support a cause and effect relationship between either pain or PTSD and hypertension. The July 2019 examiner stated that hypertension is related to age. As there are no contradicting medical evidence, the Board affords great probative value to the VA examiners’ medical opinions and finds that the Veteran’s hypertension was not proximately caused by or aggravated by his service-connected low back disability and/or PTSD. As for presumptive service connection based on chronic disease, the Board finds the preponderance of the evidence does not support a finding that the Veteran’s hypertension manifested to a compensable level in the first post-service year. 38 C.F.R. § 3.309(a). Based on the records, the Veteran’s hypertension manifested in 2010, about 25 years after service. See September 2010 Medical Treatment Record – Government Facility. As such, there is no evidence of hypertension within the first post-service year. Accordingly, service connection for hypertension based on the presumption in favor of chronic disease is not warranted in this case. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. In sum, the criteria for service connection for hypertension have not been met. The evidence does not show that the Veteran’s hypertension is directly related to his military service. Further, there is insufficient evidence to support the Veteran’s allegation that his hypertension was proximately caused by or aggravated by his service-connected low back disability and PTSD. Accordingly, service connection for hypertension must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Entitlement to service connection for folliculitis, to include as secondary to service-connected low back disability is denied. After a review of the record, the Board finds that although the Veteran has a current diagnosis of a folliculitis, he does not meet the criteria for service connection as the preponderance of the evidence supports a finding that the Veteran’s folliculitis is not casually or etiologically related to an in-service event, injury or disease. At the outset, the Board finds that in May 2011 VA treatment record the Veteran was diagnosed with folliculitis. See December 2011 Medical Treatment Record – Government Facility. As such, the first element of service connection has been met. Concerning the second element of service connection, a review of the service treatment records shows that the Veteran had normal skin and neck with no reports of skin disease in the March 1982 enlistment examination and July 1984 separation examination. See December 2014 STR – Medical. Despite the lack of medical evidence, the Veteran claimed that his folliculitis manifested in service and that he had a shaving profile while in active duty. See August 2020 CAPRI. The Board finds the Veteran’s statement about the onset of his folliculitis has low probative value. The post service treatment records show that the Veteran was diagnosed with folliculitis in 2011, 2015, 2016, and 2018. Specifically, in the May 2011 VA treatment record the Veteran was diagnosed with folliculitis. See December 2011 Medical Treatment Record – Government Facility. In April 2015, the Veteran was treated for pseudofolliculitis barbae. See May 2015 CAPRI. In February 2016 VA treatment record, the Veteran was noted to have few erythematous folliculo centric papules. See August 2020 CAPRI. Prior to 2011, and despite the substantial amount of medical treatment records, there is no complaint, endorsement, or treatment for folliculitis. Moreover, the Board finds it probative that the Veteran’s first complaint of folliculitis occurred in 2011 the same year that he filed a claim for folliculitis. Based on the foregoing, the Board finds that the second element of service connection has not been met. As for the third element, the Veteran was afforded a VA examination in July 2019 wherein the examiner opined that the Veteran’s folliculitis is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner also opined that the Veteran’s folliculitis is less likely than not proximately due to or the result of the Veteran’s service-connected disabilities. The examiner explained that although the Veteran has a diagnosis of folliculitis after service in 2013, 2014, and 2015, there is no evidence of chronic or ongoing complaints, diagnosis, evaluations and or treatments for folliculitis in the Veteran’s service treatment records. Moreover, the Veteran does not have specific service-connected disabilities that would have led to the development of folliculitis. As such, a nexus is not established at this time. The Board affords great probative value to the July 2019 VA examiner’s assessment as it is well supported by, and is consistent with, the most probative evidence of record. The most probative evidence of record reflects that although the Veteran has recurrent folliculitis since 2011, the Veteran did not have folliculitis in service. Despite the substantial amount of medical evidence associated with the file the Veteran did not endorse having any folliculitis-related issues until 2011 around the same time he filed a claim for folliculitis. As stated above, the Board does not find the Veteran’s statement regarding the onset of folliculitis to be credible. As such, the Board finds that the Veteran did not have folliculitis in service and that his current folliculitis is not etiologically related to service. In conclusion, the preponderance of the evidence establishes that his folliculitis was not manifested during service or for many years thereafter and is not otherwise related to his active service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Thus, the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right hip disability, to include as secondary to service-connected low back disability is remanded. 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected low back disability is remanded. 3. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected low back disability is remanded. At the outset, the Board notes that the Veteran has a current diagnosis of degenerative joint disease of the hip; bursitis of the hip region; right hip strain, right knee arthrosis; right knee medial meniscus tear; and degenerative joint disease of the right ankle. Specifically, in a February 2015 VA treatment record, the Veteran was diagnosed with degenerative joint disease of the hip and bursitis of the hip region. See September 2020 CAPRI. In a November 2018 VA treatment record, the Veteran was diagnosed with right knee arthrosis and right knee medial meniscus tear. See August 2020 CAPRI. In an August 2019 VA treatment record, the Veteran was diagnosed with degenerative joint disease of the right ankle. See August 2020 CAPRI. A review of the service treatment records shows that in the July 1984 separation examination the Veteran was noted to have normal lower extremities with no reports of swollen or painful joints, cramps in legs, arthritis, bursitis, or trick or locked knee. See December 2014 STR – Medical. However, due to the Veteran’s service-connected low back disability, the Board notes that the Veteran has an antalgic gait. Specifically, in an April 2001 private treatment record the Veteran was noted to have slightly antalgic gait that favors the right lower extremity. See June 2001 Medical Treatment Record – Non-Government Facility. In an October 2003 disability treatment record, it was noted that the Veteran ambulates only with a walker and that the Veteran was limping. See August 2003 Medical Treatment Record – Non-Government Facility. In a March 2019 VA treatment record, the Veteran was noted to have abnormal and antalgic gait. See August 2020 CAPRI. However, the Board notes that at other times the records show that the Veteran had normal gait and ambulates independently. For instance, in a December 2019 VA treatment record, the Veteran was noted to have normal gait and that the Veteran ambulated independently without the use of an assistive device. See August 2020 CAPRI. The Veteran was afforded a VA examination in October 2010 and a disability benefits questionnaire (DBQ) in July 2019. Regarding the Veteran’s right hip disability, in the October 2010 VA examination, the examiner diagnosed the Veteran with a right hip strain but also noted that a more precise diagnosis was not rendered as there was no objective data to support a more definitive diagnosis. The examiner opined that it would be only mere speculation to opine whether or not the Veteran’s right hip strain is due to or aggravated to any degree by the Veteran’s service-connected low back disability. The examiner explained that the documented gait abnormalities of current record are not of sufficient severity and chronicity to cause or aggravate disease in other joints and the current medical literature does not support such a cause and effect relationship between spine and other joint disease. There is no current objective evidence that the Veteran’s low back disability could have caused or aggravated to any degree his current claimed right hip strain, right knee strain, or right ankle disability. Unlike the October 2010 VA examiner, the July 2019 examiner determined that the Veteran did not have a current diagnosis of a right hip disability. Instead the examiner determined that the Veteran’s right hip symptoms are related to the Veteran’s back condition. As such, the examiner opined that the Veteran’s right hip disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner also opined that the Veteran’s right hip disability is less likely than not proximately due to or the result of Veteran’s service connected low back disability as the hip pain is due to the Veteran’s low back disability and that the Veteran does not have a separate hip disability. As for the Veteran’s right knee disability, in the October 2010 VA examination, the examiner diagnosed the Veteran with a right knee strain but also noted that a more precise diagnosis was not rendered as there was no objective data to support a more definitive diagnosis. The examiner opined that it would be mere speculation to opine whether or not the Veteran’s right knee strain is due to or aggravated to any degree by the Veteran’s service-connected low back disability. The examiner explained that the documented gait abnormalities of current record are not of sufficient severity and chronicity to cause or aggravate disease in other joints and that the current medical literature does not support such a cause and effect relationship between spine and other joint disease. There is no current objective evidence that the Veteran’s low back disability could have caused or aggravated to any degree his current claimed right hip strain, right knee strain, or right ankle disability. The July 2019 examiner diagnosed the Veteran with knee strain and opined that the Veteran’s knee disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that the Veteran’s onset was in the mid to late 1990s as such his right knee pain occurred post service. The examiner also opined that the Veteran’s right knee disability is less likely than not proximately due to or the result of the Veteran’s service-connected low back disability. The examiner explained that there is no medical evidence to suggest that the Veteran’s right knee disability is proximately due to any of the Veteran’s service-connected disability or aggravated beyond its natural progression by service-connected low back disability. The examiner also stated that there is no evidence that the Veteran’s back pain caused a change in his gait that was so severe that it would aggravate normal aging process of degenerative arthritis. The examiner noted that it would be difficult to exclude the impact that lower leg injury might have had on the joint from the 2000 motor vehicle accident. Regarding the Veteran’s right ankle disability, in the October 2010 VA examination, the examiner diagnosed the Veteran with a right ankle minimal degenerative joint disease but also noted that a more precise diagnosis was not rendered as there was no objective data to support a more definitive diagnosis. The examiner opined that it would be mere speculation to opine whether or not the Veteran’s right ankle disability is due to or aggravated to any degree by the Veteran’s service-connected low back disability. The examiner explained that the documented gait abnormalities of current record are not of sufficient severity and chronicity to cause or aggravate disease in other joints and that the current medical literature does not support such a cause and effect relationship between spine and other joint disease. There is no current objective evidence that the Veteran’s low back disability could have caused or aggravated to any degree his current claimed right hip strain, right knee strain, or right ankle disability. The July 2019 examiner determined that the Veteran does not have a current diagnosis of a right ankle disability. The examiner opined that the Veteran’s right ankle disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner also opined that the Veteran’s right ankle disability is less likely than not proximately due to or the result of the Veteran’s service-connected low back disability as the ankle pain is related to lumbar radiculopathy and not a separate ankle disability. The Board finds that an addendum opinion is warranted. First, the Board finds that despite the current diagnosis of degenerative joint disease of the hip, bursitis of the hip region, right hip strain, and degenerative joint disease of the right ankle, the July 2019 examiner determined that there is no separate diagnosis of the right hip and ankle. Second, although the October 2010 and July 2019 examiners noted that the Veteran’s antalgic gait was not so severe that it would aggravate normal aging process of degenerative arthritis, the examiners did not address the impact that an antalgic gait would have over 20 years. The Board finds that the examiners should address not only the severity of the gait but as well as the chronicity and longitudinal effect of having about 20 years of antalgic gait on the Veteran’s right hip, knee, and ankle. 4. Entitlement to service connection for erectile dysfunction, to include as secondary for medications for service-connected disabilities is remanded. The Veteran has a current diagnosis of erectile dysfunction. Specifically, in the October 2010 VA examination the Veteran was diagnosed with erectile dysfunction. The Veteran was afforded a VA examination in October 2010 and a disability benefits questionnaire (DBQ) in July 2019. In the October 2010 VA examination, the examiner diagnosed the Veteran with incomplete erectile dysfunction and noted that a more precise diagnosis cannot be rendered as there was no objective data to support a more definitive diagnosis. The examiner stated that it would be mere speculation to opine whether or not the Veteran’s current erectile dysfunction is due to or aggravated to any degree by his low back disability. The examiner explained that there is no current objective evidence that the Veteran’s erectile dysfunction is caused or aggravated to any degree by his service-connected low back disability. There is no objective evidence of the level and location of neurologic dysfunction required for this to be a spinal complication. Additionally, there is no current objective evidence that the Veteran’s low back disability could have caused or aggravated to any degree his erectile dysfunction. The July 2019 examiner opined that the Veteran’s erectile dysfunction is less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that there is no medical evidence to suggest that erectile dysfunction is related to an in-service injury, even to disease. At this time, etiology of erectile dysfunction is unknown. The examiner opined that the Veteran’s erectile dysfunction is less likely than not proximately due to or the result of the Veteran’s service-connected condition as etiology of erectile dysfunction is unknown. A review of the records shows that in an August 2001 VA treatment record, the Veteran reported of erectile dysfunction after taking to Paxil. See March 2003 Medical Treatment Record – Government Facility. As erectile dysfunction is a common side effect of antidepressants, the Board finds that a remand is warranted to obtain an addendum opinion on whether the Veteran’s medications for PTSD, such as Paxil, can cause the Veteran’s erectile dysfunction. 5. Entitlement to an initial rating in excess of 20 percent for service-connected low back disability is remanded. 6. Entitlement to an initial compensable rating for service-connected bilateral ingrown toenail is remanded. In July 2015, the Veteran filed a VA 10-5345 Request for and Authorization to Release Medical or Health Information. The Veteran stated that he received treatment from South Point Dr. North from 2005 to the present; Lake City VA in 2015; and the Florida Institute of Pain Medicine and Dr. Bernard Canlas around March 2015. See July 2015 VA 10-5345 Request for and Authorization to Release Medical or Health Information records. The Board finds that no attempts were made to obtain these records. As such, the Board finds that remand is warranted. The matters are REMANDED for the following action: 1. Obtain records from South Point Dr. North from 2005 forward; Lake City VA in 2015; and Florida Institute of Pain Medicine and Dr. Bernard Canlas around March 2015. See July 2015 VA 10-5345 Request for and Authorization to Release Medical or Health Information records. 2. Right hip, right knee, and right ankle disability - Obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran’s right hip, knee, and ankle disability. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s right hip, knee, and ankle disability had its onset in service or is otherwise etiologically related to service. The examiner should consider that the records show that the Veteran has a current diagnosis of degenerative joint disease of the hip; bursitis of the hip region; right hip strain, right knee arthrosis; right knee medial meniscus tear; and degenerative joint disease of the right ankle. Specifically, in a February 2015 VA treatment record, the Veteran was diagnosed with degenerative joint disease of the hip and bursitis of the hip region. See September 2020 CAPRI. In a November 2018 VA treatment record, the Veteran was diagnosed with right knee arthrosis and right knee medial meniscus tear. See August 2020 CAPRI. In an August 2019 VA treatment record, the Veteran was diagnosed with degenerative joint disease of the right ankle. See August 2020 CAPRI. If no diagnosis is rendered for the Veteran’s right hip, knee, and ankle disability, the examiner must determine whether the Veteran’s right hip, knee, and ankle pain causes functional impairment. If the Veteran’s right-hip, knee, and ankle pain causes functional impairment, then the examiner must determine if the Veteran’s right hip, knee, and ankle functional impairment at least as likely as not (50 percent probability or more) had its onset in service or is otherwise etiologically related to service. Additionally, the examiner must provide an opinion as to whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran’s right hip, knee, and ankle disability was (a) caused by or has been (b) aggravated (worsened beyond the natural progress of the disorder) by his service-connected low back disability. The examiner is reminded that the standard does not require that worsening be permanent worsening. The examiner must address the impact that an antalgic gait has on the Veteran’s right hip, knee, and ankle. The Board notes that the records reflect that the Veteran has a slight antalgic gait but the examiner should address if this slight antalgic gait of over 20 years has any impact on the Veteran’s right hip, knee, and ankle disability such that it would cause or aggravate the Veteran’s right hip, knee, and ankle disability. If aggravation is found, identify to the extent possible the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the service-connected disability. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Erectile dysfunction - Obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of erectile dysfunction. The examiner must provide an opinion as to whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran’s erectile dysfunction was (a) caused by or has been (b) aggravated (worsened beyond the natural progress of the disorder) by the medications used for his service-connected disabilities. The examiner is reminded that the standard does not require that worsening be permanent worsening. The examiner should consider that in an August 2001 VA treatment record the Veteran reported of erectile dysfunction after taking to Paxil. See March 2003 Medical Treatment Record – Government Facility. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Noh, Associate 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.