Citation Nr: 21015258 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 10-23 151 DATE: March 17, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for degenerative arthritis of the left shoulder, for the period prior to February 10, 2010, is denied. Entitlement to a disability rating in excess of 30 percent for degenerative arthritis of the left shoulder, for the period beginning February 10, 2010, is denied. Entitlement to a 20 rating percent disability rating, but no higher, for left heel spurs is granted. Entitlement to a 20 percent disability rating, but no higher, for right heel spurs is granted. REMANDED Entitlement to service connection for a sleep disorder, diagnosed as obstructive sleep apnea, to include as secondary to service-connected disabilities, is remanded. Entitlement to a total disability evaluation based on individual unemployability (TDIU) prior to February 21, 2007, is remanded. FINDINGS OF FACT 1. Prior to February 10, 2010, the Veteran's left shoulder disability is shown to have been productive of a disability picture involving arm limitation of motion at shoulder level, or at most, midway between the side and shoulder level. 2. From February 10, 2010, the Veteran's left shoulder disability is shown to have been productive of painful limitation of motion, with abduction to 25 degrees or less with repeated use and with flare-ups; it has not been manifested by unfavorable ankylosis, or other impairment of the humerus, clavicle, or scapula. 3. Throughout the appeal period, the Veteran's right heel spur disability has approximated moderately severe foot impairment. 4. Throughout the appeal period, the Veteran's left heel spur disability has approximated moderately severe foot impairment. CONCLUSIONS OF LAW 1. For the period prior to February 10, 2010, the criteria for a rating in excess of 20 percent for degenerative arthritis of the left shoulder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201 (2020). 2. For the period beginning February 10, 2010, the criteria for a rating in excess of 30 percent for degenerative arthritis of the left shoulder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201 (2020). 3. The criteria for a 20 percent rating for right heel spur have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2020). 4. The criteria for a 20 percent rating for left heel spur have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1989 to October 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2007 and June 2008 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Wilmington, Delaware. This case was previously before the Board in May 2015 and July 2017. Increased Ratings – Generally Disability evaluations (ratings) are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.10. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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.”). 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.” 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. Entitlement to an evaluation in excess of 20 percent prior to February 10, 2010, and in excess of 30 percent thereafter for degenerative arthritis of the left shoulder. The Veteran asserts that he is entitled to higher ratings for his service-connected left shoulder disability. His claim for an increased rating was received in December 2007. The pertinent medical evidence of record consists of VA examinations conducted in 2008, 2010, 2015, 2019, and 2020, and VA treatment records, as outlined below. Factual Background The Veteran underwent a VA examination in April 2008. The Veteran reported that it was difficult to use his left shoulder because of restricted range of motion and raising the arm over his head. Objective examination of the left shoulder revealed forward flexion, abduction, and internal rotation from 0 to 90 degrees; external rotation was from 0 to 60 degrees. X-rays revealed postoperative and mild degenerative changes. A February 10, 2010, VA physical therapy treatment record noted that left shoulder range of motion was 0 to 20 degrees with guarding and pain. He reported worsening left shoulder pain. At present, he was limited reaching using left upper extremity in all planes including on elevation, lateral elevation, behind back, behind head and across midline. Extreme difficulty using left upper extremity for any for any ADLs (including dressing and bathing) secondary to increased symptoms level with active motion. A February 17, 2010, VA treatment record noted left shoulder range of motion was extremely limited in all planes; guarding was also noted. Physical therapy for 6 to 8 weeks was recommended. The Veteran underwent a VA examination in April 2010. Objectively, there was some tenderness over the acromioclavicular joint and maximal tenderness is over the anterior glenohumeral joint. Current pain level was a 6 out of 10. The Veteran endorsed stiffness and use of NSAIDs for treatment. Left shoulder forward flexion/abduction was from 0 to 10 degrees. Internal and external rotation was from 0 to 5 degrees. There was no change due to pain, fatigue, weakness, or lack of endurance. Range of motion was conducted three times and measured with goniometer. A contemporaneous April 2010 VA orthopedics consultation report notes that the Veteran reported a gradual, progressive loss of motion in the shoulder and that has been unable to lift his arm for about 4 years. He stated that he has pain at rest, as well as worsening pain with any attempted motion, and reported that his shoulder frequently "locks up" following which he is unable to move his arm at all. Objectively, there was some tenderness over the acromioclavicular joint, but maximal tenderness is over the anterior glenohumeral joint. The examiner stated, “The patient is unwilling to allow more than about 10 degrees of forward elevation and probably only five degrees of abduction. With flexion through the lumbar spine the patient allows forward elevation to approximately 120 degrees, but is able to perform only very slight circumduction through the glenohumeral joint.” The diagnostic assessment was as follows: “Near complete loss of shoulder motion (glenohumeral and scapulothoracic) now thirty years status post Bristow procedure. This is quite likely largely related to glenohumeral arthritis. Cannot exclude a loose body. Also, the patient's markedly restricted motion renders exam of the rotator cuff virtually impossible.” The Veteran underwent a VA examination in September 2015. He complained of increasing left shoulder pain, aching, sharp, and constant with a severity of 7 out of 10. It was worse with repeated use and better after use of heat and ibuprofen. Flexion, abduction, and internal rotation ranges of motion were from 0 to 40 degrees; external rotation was from 0 to 60 degrees. The Veteran used his right arm/shoulder to do overhead movement. There was pain with all ranges of motion. There was pain with weight bearing. There was lateral tenderness. He was able to perform repetitive use testing with no additional loss of range of motion. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. Pain significantly limited functional ability with repeated use over a period of time and with flare-ups. Left shoulder muscle strength testing was 4/5. There was no ankylosis. Functional impact was described as increased pain with repeated use of upper extremities. The Veteran underwent a VA examination in September 2019. The Veteran described constant left shoulder pain with worsening range of motion and episodes of locking. He stated that he had been to urgent care for left shoulder flare-ups with last time being in 2018 and was given oxycodone and a sling. He described flareups as follows: “Left shoulder will have a sharp pain and almost feel like it is dislocated. States pain increases with movement or weight bearing. States the left shoulder will lock up, rates pain then as 10/10 and describes as excruciating and will have to take an oxycodone to relieve the pain. Occurs 2-3times a year. Lasts 1 week.” Functional limitations were described as limited ability to bathe self, take off shirt, soak feet/nail care, being intimate with his wife, and do household chores. Objectively, left shoulder flexion was from 0 to 90 degrees; abduction from 0 to 85 degrees; external rotation from 0 to 20 degrees; and internal rotation from 0 to 10 degrees. Pain was noted in all planes of motion and resulted in a functional loss. The Veteran reported moderate pain on palpation to top of shoulder and deltoid area and severe pain on palpation to anterior shoulder. There was crepitus and pain with weight bearing. He was able to perform repetitive use testing with three repetitions and there was no additional loss of range of motion. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner stated that pain significantly limited functional ability with repeated use over a period of time and with flare-ups but was unable to describe this in terms of range of motion. The examiner explained, “States repeated use of left shoulder will trigger a flare-up and increase the pain to where he is very restricted on ROM of his left shoulder. Veteran's significantly limited functional ability with repeated use over a period of time is subjective. Veteran is not being examined after repeated use over a period of time on today's exam, therefore I am unable determine ROM after repeated use over a period of time without resorting to mere speculation.” With respect to flare-ups, the examiner explained, “States during a flare-up he has very limited ROM to his left shoulder in all planes of ROM. Veteran's significantly limited functional ability during a flare-up is subjective. Veteran is not being examined during a flare-up on today's exam, therefore I am unable determine ROM during a flare-up without resorting to mere speculation.” The Veteran stated that he wore a left shoulder sling at times due to pain. Muscle strength testing for forward flexion was 3/5 while abduction was 4/5. There was no atrophy and no ankylosis. There was no history of dislocation but there was instability, dislocation, or suspected labral pathology. The Veteran’s left shoulder was very stiff which made it hard for him to perform some of the tests. The Veteran was a former CDL instructor and reported that his left shoulder condition made it difficult to drive for his job. With respect to Correia, the September 2019 examiner stated that there was objective evidence of pain with passive range of motion testing and when being used in non-weight bearing. The Veteran underwent a VA examination in October 2020. The Veteran described left shoulder pain as sharp, stabbing pain and stiffness ("It feels like it locks") and limited ability to raise arm. He described functional impact of flare-ups as follows: "It's a burning sensation. It gets stuck and excruciating pain. Soaking in Epsom salts or heating pad helps with the pain but not the range of motion." He described these episodes as occurring once every few months, 10/10, lasting 2 to 3 days. Functional impact was described as follows: "I can't shave or wash my face all that good. Everything is pretty much one handed. I can't lift anything and can't reach for things that need 2 hands. Some days I can't tie my shoes. I can't put a tie on. I can't reach for anything with my left hand. I can't play a guitar or go fishing.” Objectively, left shoulder flexion was from 0 to 60 degrees; abduction from 0 to 30 degrees; external rotation from 0 to 30 degrees; and internal rotation from 0 to 30 degrees. Pain was noted in all planes of motion and resulted in a functional loss. There was crepitus and objective evidence of pain with weight bearing. He was able to perform repetitive use testing. After three repetitions, range of motion was as follows: shoulder flexion was from 0 to 55 degrees; abduction from 0 to 25 degrees; external rotation from 0 to 25 degrees; and internal rotation from 0 to 25 degrees. Pain, fatigue, weakness, and lack of endurance caused this functional loss. Such factors also significantly limited functional ability with repeated use over a period of time. In terms of range of motion, loss was described as follows: shoulder flexion was from 0 to 55 degrees; abduction from 0 to 25 degrees; external rotation from 0 to 25 degrees; and internal rotation from 0 to 25 degrees. Pain, fatigue, weakness, and lack of endurance also significantly limited functional ability with flare-ups. In terms of range of motion, loss was described as follows: shoulder flexion was from 0 to 40 degrees; abduction from 0 to 20 degrees; external rotation from 0 to 20 degrees; and internal rotation from 0 to 20 degrees. Muscle strength was 3/5 throughout. There was no atrophy or ankylosis. No rotator cuff condition was suspected. Functional impact was described as follows: “Unable to lift objects that require the use of the left arm. Difficult to tie shoes and dress himself independently. Unable to drive.” The examiner stated that degenerative arthritis of the left shoulder limited the Veteran's ability to reach for objects above waist, raise arm above head and perform a significant number of ADLs for prolonged periods of time. The Veteran stated that these of ADLs, such as dressing, shaving, showering, are significantly impaired by the impaired range of motion and accompanying pain. With respect to Correia, there was pain on passive range of motion and in non-weight bearing. Analysis – Prior to February 10, 2010 In this case, the Veteran’s left shoulder disability is rated as 20 percent disabling for the period prior to February 10, 2010, under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. The evidence of record shows that the Veteran is right-handed and, therefore, his left arm is the minor extremity. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder also warrants a 20 percent rating for the minor extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left shoulder degenerative arthritis prior to February 10, 2010. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements on VA examination in 2008 (i.e., that he was unable to raise his arm above his head due to pain) would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity. As noted, despite the Veteran’s complaints of pain, he demonstrated forward flexion, abduction, and internal rotation to 90 degrees and external rotation to 60 degrees. Such findings simply do not approximate the next-higher 30 percent rating criteria under DC 5201. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher (or separate) rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. Indeed, none of the medical evidence for this period demonstrates ankylosis (or range of motion findings approximating ankylosis) of scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula so as to warrant higher or separate ratings under DCs 5200, 5202, or 5203, respectively. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 20 percent for degenerative arthritis of the left shoulder for the period prior to February 10, 2010. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Analysis - From February 10, 2010 For the period beginning February 10, 2010, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for degenerative arthritis of the left shoulder. As noted, the Veteran’s left shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of arm. Under Diagnostic Code 5201, limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. As the Veteran is in receipt of the highest schedular rating for limitation of motion of the arm of the minor extremity, there is no basis to award a higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher or separate disability rating. As the evidence does not show impairment of the clavicle or scapula, Diagnostic Code 5203 is not applicable. See 2010, 2015, 2019, and 2020 VA Shoulder/Arm Examination Reports. Furthermore, with respect to ankylosis, the Board acknowledges that an April 2010 VA treatment note cited to near complete loss of motion of the left shoulder; however, the Veteran still demonstrated 10 degrees of forward elevation and five degrees of abduction on objective examination. Such findings do not approximate ankylosis, which is the immobilization and consolidation of a joint due to disease, injury, or surgical procedure. See Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Moreover, no VA examiner has ever diagnosed the Veteran with ankylosis of the left shoulder or scapulohumeral articulation. See, e.g., 2015, 2019, and 2020 VA Shoulder/Arm Examination Reports (expressly noting that ankylosis is not present). Accordingly, a higher or separate rating under DC 5200 is not warranted. Additionally, while DC code 5202 allows for ratings in excess of 30 percent, the Veteran has not been shown to have fibrous union, nonunion, or loss of head of the left humerus. See, e.g., 2019 and 2020 VA Shoulder/Arm Examination Reports (expressly checking “no” as to having loss of head, nonunion, or fibrous union of the humerus). Moreover, no malunion of the humerus has been demonstrated. As such, a higher or separate rating under DC 5202 is not warranted. To the extent that the Veteran has endorsed episodes of recurrent shoulder dislocation and/or guarding, VA cannot combine the Veteran's current DC 5201 rating and a separate DC 5202 rating by analogy as they both contemplate limitation of motion (described as guarding of arm movement in DC 5202), and separate ratings would violate the anti-pyramiding provisions of 38 C.F.R. § 4.14. Furthermore, the Veteran's rating under DC 5201 encompasses his entire left shoulder disability, including the evidence of pain, weakness, stiffness, guarding, and instability. As such, separate ratings under DC 5201 and 5202 would improperly constitute ratings for duplicative or overlapping symptomatology. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for a rating in excess of 30 percent for degenerative arthritis of the left shoulder for the period beginning February 10, 2010. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Entitlement to an evaluation in excess of 10 percent for right heel spurs. Entitlement to an evaluation in excess of 10 percent for left heel spurs. The Veteran asserts that he is entitled to higher ratings for his service-connected bilateral heel spurs. The pertinent medical evidence of record consists of VA examinations conducted in 1997, 1998, 2010, 2015, 2019, and 2020, and VA treatment records, as outlined below. Factual Background Historically, service connection for bilateral heel spurs was granted with a 10 percent evaluation, effective from October 1, 1996. In an October 2007 rating decision, the RO determined that a separate evaluation under DC 5284 for each foot should have been assigned. The RO therefore assigned separate 10 percent ratings for each foot, effective from October 1, 1996. The Veteran underwent a VA examination in July 1997. At that time, he complained of constantly, daily pain in his heels. His gait was normal but he was unable to heel or toe walk because of pain in his heels. The Veteran underwent a VA examination in December 1998. There was painful motion, bilaterally, and 22 degrees of inversion and 0 degrees of eversion. There was poor muscle power present. There was moderate pronation. He was unable to stand on his toes or do any heel-toe supination or pronation gait due to severe pain. X-rays showed bilateral large calcaneal spur. The Veteran underwent a general VA examination in April 2010. He was wearing shoe inserts. There were no callosities, breakdown, or unusual shoe wear pattern. There were no ulcers. The diagnosis was bilateral heel spurs. Severity was noted as mild. Functional assessment noted limitations in walking more than 100 feet; standing on feet for more than 15 minutes; using a cane for ambulation; walking slowly; and an antalgic gait (abnormal heel, toe, and tandem gait). The Veteran underwent another VA foot examination in September 2015. X-rays showed plantar calcaneal spurs. The examiner diagnosed bilateral plantar fasciitis. The Veteran described burning pain, flare-ups after excessive walking, and functional impact of not being able to run. The Veteran had pain on use and manipulation of the feet. There were no callouses or swelling. He used arch supports. The weight-bearing line fell over or medial to the great toes, bilaterally. The examiner described the disability as moderate in severity. There was pain on examination of both feet with disturbance of locomotion. He described the pain as a 4 out of 10. He used orthotic insoles. The Veteran underwent a VA foot examination in September 2019. The diagnosis was bilateral heel spurs. No associated conditions were noted. The Veteran stated that he had a period, from 1999 to 2005, where the pain improved. After 1999, the pain worsened. Currently, the pain is worse in the morning and can decrease with movement. He stated that he had orthotics made. He stated the pain continues to worsen over time. Current pain level was 8 out of 10 and described as sharp pain that increases when pressure is applied to heels. Treatment included orthotics, hot water soaks as needed, massages, cream as needed, and Ibuprofen and Tylenol. He reported flareups that he described as so painful that he has to stay in bed or sit in a chair all day. This occurs 2 to 3 days per week, lasting about 1 day. Pain is a 10/10 at those times and is so excruciating it brings him to tears. Functional impairment was described as impairs walking; unable to place pressure on heels during flare-ups; wife bathes him when he cannot stand in shower; impair ability to stand, shower, or cook for himself; limits ability to drive; and has to sit down every 25 feet when walking. There was pain on physical examination of both feet; contributing factors included pain on movement, pain on weight-bearing, pain on non-weight bearing, disturbance of locomotion, and interference with standing. The Veteran stated that with repeated use and flare-ups, he was unable to walk or place pressure on his feet. He required a cane or human assistance to walk. The examiner further noted that the Veteran was ambulating with a cane and a moderate limp. The Veteran reported moderate pain on palpation of the left heel and severe pain on palpation of the right heel. He reported increased pain to heels on manipulation of both feet secondary to the bilateral heel spurs. The Veteran underwent a VA foot examination in October 2020. The Veteran described burning sensation in the feet. The examiner found no functional loss. Pain, fatigability, weakness, or incoordination significantly limited functional ability during flare-ups or when the feet were used repeatedly over a period of time to the extent that he has to rest after 10 minutes of standing. The examiner noted that the Veteran had documented diabetic peripheral neuropathy of the feet. VA treatment records dated throughout the appeal period note treatment for bilateral foot pain diabetic-related foot care and conditions including neuropathy. Analysis The Veteran's right and left heel spurs have each been rated as 10 percent disabling under DC 5284, effective from October 1, 1996. See 38 C.F.R. § 4.71a, DC 5284. DC 5284, which pertains to other foot injuries, provides for a 10 percent rating for a moderate foot disability, a 20 percent rating for moderately severe foot disability, and the maximum 30 percent rating for severe foot disability. A 40 percent rating is assigned for actual loss of use of the foot. See 38 C.F.R. § 4.71a, DC 5284, Note. Heel spurs are not specifically listed in the rating schedule, DC 5284 is applicable. See also Copeland v. McDonald, 27 Vet. App. at 337 (DC 5284 only applies to foot disabilities for which there is not already a specific DC). Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Based on the above evidence, to specifically include the 2015 and 2019 VA foot examinations and the Veteran's own description of his bilateral foot/heel pain with resulting limitation in functioning, the Board finds that a 20 percent rating, indicative of "moderately severe" disability under Diagnostic Code 5284, is warranted. Indeed, overall, the evidence indicates that the Veteran’s right and left heel spurs have been manifested by burning bilateral heel pain; pain on palpation of both heels; use of orthotics; an inability to heel to toe walk; limitations with walking, standing, driving, bathing, and other ADLs; pain on movement and with weight-bearing and on non-weight bearing; disturbance of locomotion; and an inability to walk or put pressure on his heels during frequent flare-ups and with repeated use. The Board recognizes that the VA examiners have variously described the Veteran’s condition as mild to moderate in nature; however, given the Veteran’s descriptions of severe pain on examination and the documented functional impairment caused by flare-ups and with repeated use, the Board finds that, overall, the right and left heel spurs approximate a “moderately severe” foot disability/injury under DC 5284. The Board finds that a rating greater than 20 percent is not warranted, based on lack of evidence showing severe impairment of the feet. No VA examiner has ever described the Veteran’s heel spurs as severe in nature. While the Veteran has variously described his own foot/heel pain as severe in nature, the Board finds such symptoms and functional impairment are contemplated by the 20 percent ratings assigned herein. Moreover, the evidence fails to suggest that the Veteran's right and left heel spurs are analogous to actual loss of use of the foot, as the Veteran's feet are functional and he can walk and stand. See 38 C.F.R. § 4.71a, Diagnostic Code 5284, Note. Thus, the Board finds that the symptoms have not more nearly approximated a rating greater than 20 under Diagnostic Code 5284. In considering the applicability of other foot DCs, the Board finds that DCs 5277 (weak foot), 5278 (claw foot), 5279 (metatarsalgia), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), and 5283 (malunion or nonunion of the tarsal or metatarsal bones) do not apply, as the Veteran is service-connected for right and left heel spurs and the symptoms attributable to it do not overlap with these foot disorders. Additionally, although the 2015 VA examiner diagnosed plantar fasciitis, this was based on an in-service diagnosis (in 1996); this condition has since resolved and has not been shown on any prior or subsequent VA examination. To the extent that the Veteran was noted to have symptoms such as pain on use/manipulation and weight-bearing line over or medial to the great toe, such symptoms are listed under DC 5276, which contemplates flatfoot. A single 30 percent rating under DC 5276 could arguably be assigned, by analogy, for the bilateral foot symptoms. However, an evaluation under DC 5284 is more favorable, as separate 20 percent ratings may be assigned for each foot, rather than a single 30 percent rating under DC 5276. In conclusion, affording the Veteran the benefit of the doubt, the preponderance of the evidence supports the assignment of an initial 20 percent rating for service-connected right and left heel spurs; to this extent, the appeal is granted. REASONS FOR REMAND Entitlement to service connection for a sleep disorder, diagnosed as obstructive sleep apnea, to include as secondary to service-connected disabilities, is remanded. The Veteran contends that his sleep apnea is related to active duty service or, alternatively, it is proximately due to, or aggravated by service-connected disabilities. The Board obtained a VA opinion in October 2015 that addressed the issue of secondary causation with respect to service-connected GERD with hiatal hernia. See October 2015 VA Opinion (finding that sleep apnea was unlikely due to GERD or hiatal hernia). The Board also obtained opinions in September 2019 that addressed secondary aggravation (by GERD/hiatal hernia), as well as a direct theory of entitlement. Since that time, the Veteran (via his accredited representative) has raised the issue of whether his service-connected skin condition (granuloma annulare with psoriaform dermatitis); acquired psychiatric disorder; hypertension; and/or and bilateral heel spurs have caused or aggravated his sleep apnea. See January 2020 Appellate Brief. In support of these theories, the Veteran’s representative cited to several medical articles/studies, to include a study documented in the Journal of Clinical Sleep Medicine which found a high prevalence of obstructive sleep apnea in patients with psoriasis and hidradenitis suppurativa. The Veteran's representative also essentially contended that his obesity was an intermediate step between the Veteran’s current obstructive sleep apnea and his service-connected acquired psychiatric disorder and bilateral heel spurs (by hindering aerobic exercise). In this regard, the Board notes that obesity is not a disease or disability for which service connection may be granted. See VAOPGCPREC 1-2017 (holding the "longstanding policy of [VA], that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis, is consistent with title 38, United States Code" and "[o]besity per se is not a 'disability' for purposes of 38 C.F.R. § 3.310"). However, service connection may be granted under 38 C.F.R. § 3.310 if obesity was an "intermediate step" between a service-connected disability and a current disorder. See VAOPGCPREC 1-2017. In order for secondary service connection to be granted under theory, the record must demonstrate that: (1) the service-connected disability caused the veteran to become obese or aggravated his obesity; (2) the obesity or the aggravation of obesity as a result of the service-connected disability was a substantial factor in causing the claimed disorder; and (3) the claimed disorder would not have occurred but for obesity caused or aggravated by the service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). In light of the above, the Board finds that the secondary theories raised by the Veteran and his representative should be addressed on remand. Entitlement to a TDIU prior to February 21, 2007. In a September 2016 rating decision, the RO granted a TDIU effective February 21, 2007, i.e., as the date the Veteran first met the schedular criteria. The period prior to February 21, 2007, remains on appeal. In view of the increased ratings assigned herein for each foot, and the need to remand the sleep apnea issue, the claim for TDIU prior to February 21, 2007 is inextricably intertwined with the AOJ’s implementation and development thereof. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Specifically, any additional steps necessary to determine eligibility for TDIU prior to February 21, 2007 under either a schedular basis (38 C.F.R. § 4.16(a)) or extraschedular consideration (38 C.F.R. § 4.16(b)) may be unnecessary. Therefore, the Board must remand the claim for TDIU and allow for the implementation of the further development of the Veteran's remaining increased ratings increased ratings granted herein and the outcome of the remand of the sleep apnea issue. Additionally, the RO should undertake appropriate development of the Veteran's TDIU claim itself prior to adjudication. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from a qualified examiner on the etiology of the Veteran's obstructive sleep apnea. The claims files must be made available to the examiner. The examiner is requested to review all pertinent records associated with the claims file. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If an examination is deemed necessary, one must be provided. For the Veteran's diagnosed obstructive sleep apnea, the examiner should provide an opinion as to the following: a) Whether it is at least as likely as not (a 50 percent or greater probability) that the obstructive sleep apnea disorder was caused or aggravated by his service-connected skin condition (granuloma annulare with psoriaform dermatitis); acquired psychiatric disorder; hypertension; and/or and bilateral heel spurs? b) In so doing, the examiner should also specifically opine whether it is at least as likely as not (50 percent probability or greater) that the service-connected acquired psychiatric disorder or bilateral heel spurs caused him to become obese or gain weight; or aggravated by his obesity? In providing this opinion, the examiner should address whether the Veteran's obesity was an intermediate step between his current sleep apnea and his service-connected acquired psychiatric disorder and/or bilateral heel spurs. In consideration of such circumstances, the examiner should explain whether the obesity was a substantial factor in causing the Veteran's sleep apnea; and should also provide an opinion as to whether the Veteran's sleep apnea would not have occurred or worsened but for the weight gain caused or aggravated by his service-connected disability. A detailed rationale supporting the examiner’s opinions should be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 2. After implementation of increased rating grants for the bilateral heel spurs and completion of the adjudication of the sleep apnea service connection issue, reconsider entitlement to TDIU prior to February 21, 2007. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Hoeft 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.