Citation Nr: 21021172 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 15-29 116 DATE: April 12, 2021 ORDER Entitlement to a 10 percent disability rating, but no higher, for left ulnar neuropathy is granted throughout the period on appeal. Entitlement to a compensable rating for dermatitis prior to March 21, 2014 is denied. Entitlement to a 10 percent rating, but no higher, for dermatitis is granted from March 21, 2014. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a right knee disability, to include as secondary to service-connected foot disabilities, is remanded. Entitlement to a disability rating in excess of 10 percent for bilateral heel spurs is remanded. Entitlement to a disability rating in excess of 10 percent for left foot bunion is remanded. Entitlement to a compensable disability rating for right foot bunion is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s left ulnar neuropathy manifested in no more than mild incomplete paralysis of the median nerve. 2. Prior to March 21, 2014, the Veteran’s dermatitis affected less than 5 percent of the total body area and exposed area and was treated with non-systemic topical corticosteroids. 3. From March 21, 2014, the Veteran’s dermatitis has affected less than 5 percent of the total body area and exposed area and has been treated with intermittent systemic therapy for less than 6 weeks per year. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 10 percent disability rating, but no higher, for left ulnar neuropathy have been met throughout the period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. 2. The criteria for entitlement to a compensable rating for dermatitis prior to March 21, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806. 3. The criteria for entitlement to a 10 percent rating, but no higher, for dermatitis have been met from March 21, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1979 to August 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from April 2012 and November 2018 rating decisions by a Department of Veterans Affairs (VA) regional office. In February 2017, the Veteran testified before the undersigned Veterans Law Judge with respect to the increased rating issues currently on appeal. In August 2018, the Board remanded the issues of entitlement to increased ratings for left ulnar neuropathy and dermatitis, and denied increased ratings for bilateral heel spurs and bunions. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In April 2020, the Court issued a Memorandum Decision vacating the Board’s decision as to these issues and remanding the matters. Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The evidentiary record does not reasonably raise the prospect that the Veteran’s disabilities are not and cannot be adequately rated under the Rating Schedule. 1. Entitlement to a compensable rating for left ulnar neuropathy prior to October 18, 2016, and to a rating in excess of 10 percent from December 1, 2016. The Veteran is currently assigned a noncompensable disability rating for left ulnar neuropathy prior to October 18, 2016, and a 10 percent disability rating from December 1, 2016, pursuant to 38 C.F.R. § 4.124a Diagnostic Code 8515, for paralysis of the median nerve. The Veteran is in receipt of a temporary total rating for the period from October 18, 2016, through November 30, 2016. This claim stems from a November 2011 claim. The Veteran contends that he is entitled to higher ratings because his left ulnar neuropathy results in pain, numbness, and cramping. Paralysis of the median nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8515. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8615 and 8715). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent disabling for the major extremity and 20 percent disabling for the minor extremity. Severe incomplete paralysis is rated as 50 percent disabling for the major extremity and 40 percent disabling for the minor extremity. Complete paralysis of the median nerve is described by the following characteristics: the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand; incomplete and defective pronation, absence of flexion of the index finger and feeble flexion of the middle finger, the inability to make a fist, and the index and middle finger remaining extended; the inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at right angles to the palm; weakened flexion of the wrist; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Complete paralysis is rated as 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. The Board notes that “Mild,” as relevant to a physical condition, is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed January 25, 2021). “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. The term “severe” is used throughout the rating schedule, including in Diagnostic Code 8515, to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific diagnostic code. Within the context of Diagnostic Code 8515, which establishes a successive, tiered rating structure, it represents the highest or most extreme level of incomplete paralysis. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Preliminarily, the Board notes that the record reflects that the Veteran is right-hand dominant. Accordingly, the left extremity is considered the minor extremity for purposes of rating this disability. In July 2014, the Veteran underwent an electromyogram (EMG) to evaluate the impairment of the nerve. He complained of numbness and muscle cramps following a left ulnar nerve transposition in 1988, with symptoms having improved but remaining present since that time. Testing revealed findings that were possibly compatible with the presence of distal left ulnar sensory neuropathy, but there was no definite electrophysiologic evidence of a left ulnar neuropathy at the elbow detected by this study. The Veteran first underwent VA examination in connection with this claim in April 2015. The examiner diagnosed left ulnar nerve transposition without residuals. The Veteran reported that, in spite of his prior surgery, he still had pain. He also indicated that the last two fingers of his left hand would “cramp up” during cold weather. The examiner opined that there were no symptoms attributable to any peripheral nerve conditions. Testing revealed normal muscle strength, deep tendon reflexes, and sensory responses. Microfilament testing was negative in the bilateral upper extremities, and there were no trophic changes. The examiner opined that all nerve groups were normal. In March 2019, the Veteran reported to the neurology clinic of the Naval Hospital in Pensacola with a several-year history of numbness, tingling, and burning pain in the left medial forearm and hand. He stated that his symptoms were worse with standing and certain arm positions. He underwent a repeat nerve conduction study in January 2019 which demonstrated mild improvement. While he had moderate to severe median neuropathies at the bilateral wrists related to the separate process of carpal tunnel syndrome, he denied having symptoms suggestive of median neuropathy outside of some mild left-hand weakness. Bulk, tone, and strength were normal upon motor examination. On sensory examination, he reported diminished sensation to pain and temperature along the medial aspect of the left forearm and hand. He had normal and symmetric reflexes. The Veteran most recently underwent VA examination in March 2020. The Veteran stated that the underside of his left hand would cramp and that the fourth and fifth fingers of his hand would sometimes go numb. He further reported that these fingers were sensitive to the touch and often tingled, and stated that he thought they were weaker than his other fingers. The examiner noted symptoms of mild paresthesias and/or dysesthesias in the left upper extremity related to this condition. The Veteran indicated that the symptoms were intermittent and based on pressure on the elbow. Testing again revealed normal muscle strength, deep tendon reflexes, and sensory responses. There was no evidence of trophic changes. Special testing conducted on the median nerve was negative. Ultimately, the examiner opined that there was mild incomplete paralysis of the median nerve with only sensory impairment. There was mild hyperesthesia resulting in minimal functional impairment. During his February 2017 hearing, the Veteran reported that his prior surgeries, in 1988 and October 2016, relieved some of his pain but that he still suffered from numbness in the forearm. He stated that he wore occasionally wore an elbow protector. The Veteran’s wife, who has medical training as a nursing assistant, testified that she helped the Veteran by putting cream on his elbow and rubbing his muscles, but that the Veteran’s pain went to his hands and that his fingers would retract and cramp or spasm. Regarding impairment of motor functions, no medical provider, including the Veteran’s treating clinicians or VA examiners, have found evidence of impairment of motor function in the left arm or hand other than the Veteran’s reports of slight weakness in the hand. The Veteran has reported that the fourth and fifth fingers of his left-hand cramp, spasm, or draw up toward the arm, but these symptoms have not been shown upon examination. The Board finds the medical evidence of record to be more probative because the providers are able to conduct testing designed specifically to measure manifestations of nerve impairment. The Veteran is competent to report what he experiences, but the Board finds more probative the objective findings of the medical providers. Regarding sensory disturbance, the evidence suggests that the Veteran has had diminished sensation to pain and temperature. Furthermore, the Veteran has reported transient numbness and tingling. Regarding pain, the Veteran has reported pain which has improved, but not relented, with surgeries. Regarding trophic changes, loss of reflexes, muscle atrophy, or complete paralysis the evidence does not suggest, nor does the Veteran allege, that these symptoms are present. Based on the above, the Board finds that the disability is primarily manifested by sensory disturbance and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifested by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to mild incomplete paralysis. In that regard, as the Veteran’s symptoms have been largely consistent throughout the period on appeal, the Board finds that a 10 percent rating, for mild incomplete paralysis of the minor extremity, is warranted throughout the period on appeal. In the absence of other, or more severe, manifestations of the disability, however, the Board cannot find that there is moderate or severe incomplete paralysis of the nerve. As such, a rating in excess of 10 percent cannot be granted. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence weighs in favor of a finding of mild incomplete paralysis throughout the period on appeal. Accordingly, entitlement to a 10 percent rating is warranted throughout and, to that extent, the claim is granted. 2. Entitlement to a compensable initial disability rating for dermatitis. The Veteran’s dermatitis is rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7806, for dermatitis or eczema. This matter stems from the Veteran’s November 2011 service connection claim; while he initially claimed entitlement to service connection for lichen planus, service connection was ultimately awarded for dermatitis. The Schedule of ratings for the skin were amended effective August 13, 2018. See 83 Fed. Reg. 32,592 (July 13, 2018). Prior to August 13, 2018, the Board will consider the old version of the diagnostic codes only (old code); however, for the period beginning August 13, 2018 the Board will consider both the old and amended version (amended code) of the diagnostic codes and rate based on whichever is most favorable to the Veteran. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is dermatitis, as this is the disability for which service connection has been awarded. The Veteran first underwent VA examination in connection with this claim in December 2012. The examiner diagnosed minimal dermatitis at the neck, most likely related to his military service. The examiner noted that the Veteran had used various steroid creams including hydrocortisone, clotrimazole, and fluocinonide to treat the area. Topical corticosteroids had been used constantly or near-constantly for the past 12 months. The Veteran reported a history of rashes on other areas as well, including his armpits, groin, and knees. The examiner opined that there were no systemic manifestations and no condition causing scarring or disfigurement of the head, face, or neck. The examiner further indicated that the condition affected less than 5 percent of the total body area. The same month, however, the Veteran asked for another VA examination because he stated that the examiner only examined areas of his body exposed by clothing. The Veteran next underwent VA examination in July 2013. Physical examination revealed mild lichenification of the skin without evidence of recent excoriation at the base of the bilateral lateral neck, and no acute inflammation was noted. The Veteran reported recurrent flare-ups which required the use of topical steroids. In that regard, he had used topical corticosteroids constantly or near-constantly for the past 12 months. The examiner indicated that there were no systemic manifestations and that the condition did not result in scarring or disfigurement of the head, face, or neck. There had been no debilitating or non-debilitating episodes or urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in the past 12 months. The examiner reported that the condition affected less than 5 percent of the Veteran’s total body area. In January 2014, the Veteran stated that he felt his dermatitis was severe as it affected multiple areas of his body and caused a great amount of discomfort because it was ongoing and did not heal. The record reflects that the Veteran saw a private dermatologist, Dr. N.S. around this time. In March 2014, Dr. N.S. began to treat the sites where the dermatitis appeared with Kenalog injections, after which the Veteran reported improvement. The Veteran next underwent VA examination in April 2015, but it appears that the examiner mistakenly believed that service connection was in effect for lichen planus, rather than dermatitis. As such, the examiner found that the condition had not been treated with oral or topical medications in the past 12 months, and found that the veteran reported symptomatology inconsistent with his service-connected diagnosis. The examiner did note that the Veteran had dermatitis covering less than 5 percent of the total body area and none of the exposed area. As the examination was conducted under the misapprehension that the Veteran was service connected for lichen planus, the Board will afford this examination little probative value except as to reports specifically addressing dermatitis. In February 2017, the Veteran testified that he had previously used a steroid cream that caused his skin to thin and, as a result, he could no longer wear clothing with a lot of color without breaking out. He further indicated that the condition worsened with sweating in the summer months, particularly considering the fact that the Veteran worked outside with heavy equipment in Florida. He reported using topical creams as well as Kenalog injections. The Veteran’s wife testified that the pigmentation of the Veteran’s skin had changed in places. The Veteran most recently underwent VA examination in March 2020. The Veteran reported that he had breakouts under his arms, on his neck, and behind his knees. He used a steroid cream as needed and consistently used hydrocortisone cream. The examiner reported the constant or near-constant use of topical corticosteroids or other immunosuppressive medications for the past 12 months. The rash covered less than 5 percent of the Veteran’s total body area and of the total exposed area. There was a confluent macular rash to the back of the Veteran’s neck measuring 20 centimeters by 6 centimeters with no papules or excoriation. There was no scarring or disfigurement, and the examiner opined that there was minimal functional impairment. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations at any point prior to March 21, 2014, because the Veteran’s dermatitis did not more nearly approximate at least 5 percent of the entire body or of exposed areas, nor was intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required. As noted above, since this claim was filed prior to August 13, 2018, the Board must determine whether the Veteran’s topical corticosteroid affects the body as a whole in treating a veteran’s skin condition. Burton, 30 Vet. App. 286. Upon review, there is no indication in the record that this treatment was indeed systemic. In that regard, the corticosteroid was applied topically only to the areas where the dermatitis occurred, less than 5 percent of the Veteran’s total body area. The evidence does not demonstrate, nor does the Veteran suggest, that the effect of this topical medication, intended or otherwise, is systemic. From March 21, 2014, however, under either the pre- or post-August 13, 2018 regulations as applicable, the Board finds a 10 percent rating, but no higher, is warranted. In that regard, the record reflects that the Veteran began treating his dermatitis using Kenalog injections. The Board finds the intended effect of these injections to be systemic. See, e.g., Mayo Clinic (https://www.mayoclinic.org/ drugs-supplements/triamcinolone-injection-route/description/drg-20074674, accessed March 30, 2021) (“[Kenalog] injection is used to treat inflammation”). While it is unclear whether the Veteran has continued to use Kenalog injections through the present, he did testify that he used the injections at his February 2017 hearing. Accordingly, the Board will resolve the benefit of the doubt in the Veteran’s favor and find that a 10 percent rating is warranted from March 21, 2014. The Board does not find, however, that a rating in excess of 10 percent is warranted under either the old or new criteria. The evidence does not reflect that 20 percent or more of the entire body or exposed areas was involved. Furthermore, while the Board has found that the Veteran began to use systemic therapy in March 2014, the Board is unable to establish from the evidence that it was used in sufficient frequency or duration to find that it was in use more than 6 weeks per year. In that regard, the injections are only noted in treatment records from 2014 and in the February 2017 hearing transcript. As noted above, the Board has already resolved the benefit of the doubt in the Veteran’s favor in order to find that a 10 percent rating is warranted. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms, to include a painful or itchy rash. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, while the Veteran has asserted that the rash covers more of his body than the examiners have reported, the Board finds the examiners are in the best position to calculate the amount of total skin involved. As such, the evidence does not show that the Veteran’s disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence weighs in favor of a finding that a 10 percent rating, but no higher, is warranted from March 21, 2014, but no earlier. To that extent, the claim is granted. REASONS FOR REMAND While further delay is regrettable, remand of the below claims is necessary before a decision may be rendered as to these matters. 1. Service connection for bilateral hearing loss. The Veteran underwent VA examination in connection with his claim for entitlement to service connection for bilateral hearing loss in October 2018. The examiner opined that the Veteran’s hearing loss was less likely than not related to his active duty service as his separation audiogram showed normal hearing and no significant threshold shift from the entrance examination. However, the examiner did not explain the clinical significance of this finding and a lack of hearing loss in service does not, itself, preclude service connection. See Hensley v. Brown, 5 Vet. App. 155 (1993). As this opinion is insufficient for purposes of determining service connection, remand is necessary so that a new opinion may be obtained. 2. Service connection for a right knee disability. The Veteran also underwent VA examination in connection with his claim for entitlement to service connection for a right knee disability in October 2018. The examiner diagnosed right knee tendonitis/tendinosis and osteoarthritis and opined that it was less likely than not proximately due to or the result of the Veteran’s service-connected foot disabilities because there was no compromised gait on the right. The Board finds this opinion insufficient for purposes of determining service connection. In that regard, the examiner did not provide a rationale for the opinion stated. Furthermore, the examiner did not provide an opinion as to whether the right knee disability is directly related to service, although the Veteran contends that it may be related to climbing in and out of armored vehicles thousands of time and running in boots during service. The Veteran’s representative has also advanced the theory that the Veteran’s knee disability is related to multiple right ankle sprains in service, and that pain management for the Veteran’s service-connected foot disabilities may have helped to mask knee symptoms over the years. Accordingly, the Board finds remand is warranted so that a new opinion may be obtained which properly addresses these theories. 3. Ratings for bilateral heel spurs and left and right foot bunions. As noted above, the Veteran’s claims for increased ratings for his service-connected foot disabilities were remanded by the Court. In the April 2020 Memorandum Decision, the Court directed the Board to remand the claims for a new examination specifically addressing which diagnosed foot problems are manifestations of the Veteran’s service-connected disabilities. The Court also found that a new examination needs to be conducted in order to satisfy testing requirements set forth in Correia v. McDonald, 28 Vet. App. 158 (2016). Accordingly, remand is warranted so that a new VA examination may be conducted. Obtained VA treatment records, as well as any relevant private treatment records identified by the Veteran, should be obtained and associated with the record. The matters are REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his bilateral hearing loss, right knee disability, bilateral heel spurs, and bilateral bunions claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current bilateral hearing loss had onset during service or is otherwise related to an in-service injury, event, or disease, to include in-service noise exposure as a transportation specialist. In offering the opinion, the examiner is reminded that a lack of demonstrated hearing loss in service alone is not a sufficient ground upon which to rest a negative opinion. The examiner is asked to address the significance of facts relied upon in offering the opinion. For example, if no significant threshold shift in hearing during service is noted as a reason for a negative opinion, why is this fact important? The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current right knee disability had onset during service or is otherwise related to an in-service injury, event, or disease, to include in-service ankle sprains. The examiner should also address whether any current disability of the right knee is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected foot disabilities, to include as a result of pain or altered gait. In offering the opinion, the examiner is asked to consider whether right knee symptoms may have been masked by treatment for the Veteran’s foot disabilities. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, schedule the Veteran for a VA ¬¬¬foot examination to determine the current symptoms, level of severity, and functional impairment associated with his bilateral heel spurs and bunions. The claims file should be reviewed by the examiner. The examiner must address all current foot problems and distinguish which are manifestations of his service-connected disabilities and which are unrelated. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups and after repetitive use over time. The joints involved should be tested for pain on both active and passive motion, and in weight-bearing and nonweight-bearing. (Continued on the next page.) If any of the above cannot be accomplished without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and explain why that is the case. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. D. Bruce, 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.