Citation Nr: 21021932 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-35 297A DATE: April 14, 2021 ORDER A rating in excess of 10 percent for degenerative arthritis of the cervical spine is denied. A rating in excess of 10 percent for right shoulder impingement syndrome with traumatic arthritis is denied. A rating in excess of 10 percent for left shoulder impingement syndrome with traumatic arthritis is denied. A rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. A rating in excess of 10 percent for degenerative arthritis of the lumbar spine is denied. A rating in excess of 10 percent for osteoarthritis of the right ankle is denied. A rating in excess of 10 percent for osteoarthritis of the left ankle is denied. A rating in excess of 10 percent for left knee degenerative joint disease (DJD) is denied. Service connection for polymyositis is denied. Service connection for a right foot disorder is denied. Service connection for a left foot disorder is denied. Service connection for right hand arthritis is denied. Service connection for left hand arthritis is denied. FINDINGS OF FACT 1. The Veteran served on active duty from August 1980 to August 1983 and from March 1985 to April 1998. 2. A cervical spine disorder is manifested by subjective complaints of pain and stiffness; objective findings include forward flexion to 40 degrees at worst, a combined range of motion measured at 280 degrees at worst, and no muscle spasms, guarding or intervertebral disc syndrome (IVDS). 3. Right and left shoulder disorders are manifested by pain and at worst, range of motion limited to shoulder level. 4. GERD is manifested by symptoms of reflux, nausea, and regurgitation; there is no evidence of considerable impairment of health. 5. A lumbar spine disorder is manifested by pain with lifting and standing/sitting for long periods of time; objective findings include forward flexion to 70 degrees at worst, a combined range of motion of 170 degrees at worst, and no muscle spasms, guarding, or incapacitating episodes of IVDS. 6. Right and left ankle disorders are manifested by pain and moderate limitation of motion; there is no evidence of marked limitation of motion. 7. A left knee disorder is manifested by pain, full extension, flexion 130 degrees, and no ankylosis. 8. Polymyositis has not been shown. 9. A right foot disorder, diagnosed as plantar fasciitis, was not shown in service and it is not causally or etiologically related to any incident of service, nor is it secondary to a service-connected disability. 10. A left foot disorder, diagnosed as plantar fasciitis and arthritis, was not shown in service and is not causally or etiologically related to service nor is it secondary to a service-connected disability; left foot arthritis was not shown within one year of service and symptoms have not been continuous since service. 11. Right and left hand arthritis was not shown in service or within one year of service; symptoms were not continuous since service; the current right and left hand arthritis is not causally or etiologically related to any incident of service, nor is it secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative arthritis of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code (DC) 5237 (2020). 2. The criteria for a rating in excess of 10 percent for right shoulder impingement syndrome with traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5010-5201 (2020). 3. The criteria for a rating in excess of 10 percent for left shoulder impingement syndrome with traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5010-5201 (2020). 4. The criteria for a rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.59, 4.114, DCs 7399-7346 (2020). 5. The criteria for a rating in excess of 10 percent for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DC 5242 (2020). 6. The criteria for a rating in excess of 10 percent for osteoarthritis of the right ankle have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5271 (2020). 7. The criteria for a rating in excess of 10 percent for osteoarthritis of the left ankle have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5271 (2020). 8. The criteria for a rating in excess of 10 percent for left knee DJD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5260 (2020). 9. Polymyositis was not incurred in service. 38 U.S.C. §§ 1110, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2020). 10. A right foot disorder was not incurred in service. 38 U.S.C. §§ 1110, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2020). 11. A left foot disorder was not incurred in service nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2020). 12. Right hand arthritis was not incurred in service nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2020). 13. Left hand arthritis was not incurred in service nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The case was remanded by the Board in October 2018 for additional development. It is now back for adjudication. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Degenerative Arthritis of the Cervical Spine The Veteran has been assigned a 10 percent rating for a cervical spine disability under DC 5237. To warrant an increased rating, the evidence must show: • forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees (20 percent under DC 5237); • a combined range of motion of the cervical spine not greater than 170 degrees (20 percent under DC 5237); • muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent under DC 5237); or • IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks in the 12 months prior to examination (20 percent under DC 5243). Turning to the medical evidence, a May 2014 VA examiner noted that the Veteran denied experiencing flare-ups of neck pain. Range of motion testing revealed flexion of the cervical spine to 45 degrees without objective evidence of pain. Extension was to 45 degrees without objective evidence of pain. Right and left lateral flexion was to 45 degrees each. Right and left lateral rotation was to 70 degrees each. After repetitive use testing, there was no additional loss of motion. There was no functional loss/impairment of the cervical spine. There was also no localized tenderness or pain to soft tissue of the cervical spine, no muscle spasm of the cervical spine, and no guarding of the cervical spine. There was no ankylosis, muscle atrophy, or radicular pain/signs of radiculopathy. The examiner indicated that the Veteran did not have IVDS of the cervical spine. Imaging studies were performed; there was no evidence of DJD/arthritis. An October 2019 VA examiner noted that the Veteran was diagnosed with cervical strain. He reported difficulty turning his neck. He denied flare-ups and functional loss/limitation. Range of motion testing revealed forward flexion to 40 degrees, extension to 40 degrees, right and left lateral flexion to 40 degrees, each, and right and left lateral rotation to 60 degrees each. There was pain on right and left lateral rotation only. The pain did not cause functional loss. There was no objective evidence of tenderness or pain on palpation of the associated soft tissue of the cervical spine. Repetitive use testing was accomplished and there was no additional loss of function or range of motion after three repetitions. On examination, there was no guarding or muscle spasm. There was no atrophy or ankylosis. Sensory examination was normal. There were no signs or symptoms of radiculopathy. The examiner indicated that the Veteran did not have IVDS. There was evidence of pain on passive range of motion. There was no evidence of pain when the joint was used in non-weight bearing. A September 2020 VA examiner diagnosed degenerative arthritis of the cervical spine. The Veteran reported difficulty moving his neck. He had stiffness and difficulty when driving. He denied flare-ups but reported functional loss or impairment in terms of pain and stiffness when turning his neck. Range of motion testing revealed normal range of motion (forward flexion to 45 degrees, extension to 45 degrees, right and left lateral flexion to 45 degrees each, and right and left lateral rotation to 80 degrees each). Pain was not noted on examination. There was mild tenderness/pain to palpation of the soft tissue at the mid cervical spine posteriorly. There was no evidence of pain with weightbearing. Repetitive use testing was accomplished, and it did not result in additional loss of function or range of motion. The examiner opined that pain significantly limits functional ability with repeated use over time (in terms of moderate pain with head turning). No additional factors contribute to the disability. There was no muscle atrophy or ankylosis of the spine. There were no neurologic abnormalities or radiculopathy signs/symptoms. There was no IVDS. There was no objective evidence of pain on non-weight bearing. Passive range of motion could not be performed. The diagnosis listed above was noted to be a correction of a prior diagnosis, as December 2012 and May 2014 cervical spine X-rays revealed osteophytes, and a July 2016 X-ray referred to degenerative changes in the cervical spine. The remaining medical evidence does not show more severe cervical spine symptoms. Based on the above, the medical evidence does not support a rating in excess of 10 percent. In this regard, the October 2019 VA examination measured the forward flexion of his cervical spine at 40 degrees at worst, and found the combined range of motion of his cervical spine to be 270 degrees at worst. Additionally, the Veteran consistently did not have muscle spasms or guarding. Finally, the examinations revealed no IVDS. Accordingly, the medical evidence does not support a rating in excess of 10 percent. Right and Left Shoulder Impingement Syndrome with Traumatic Arthritis The right and left shoulder impingement syndrome with traumatic arthritis are each rated at 10 percent under DC 5010-5201. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5010 states that arthritis due to trauma, substantiated by X-rays, is to be rated as degenerative arthritis, which will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. Pursuant to 5201, limitation of motion of the arm, a 20 percent rating is warranted for both the major and minor arm with limitation of motion at shoulder level. The Veteran is right hand dominant. Pertaining to limitation of motion, for the major and minor arm, a disability of the shoulder may be rated under DCs 5200-5203. Higher ratings require: • intermediate ankylosis between favorable and unfavorable (30 percent for minor arm and 40 percent for major arm under DC 5200); • limitation of motion midway between side and shoulder level (30 percent for major arm under DC 5201) • limitation of motion to no more than 25 degrees from the side (30 percent for minor arm and 40 percent for major arm under DC 5201); • impairment of the humerus with malunion and marked deformity (30 percent for major arm under DC 5202); or • fibrous union of the humerus (40 percent for minor arm and 50 percent for major arm under DC 5202). Turning to the medical evidence, in a May 2014 examination, the Veteran reported flare-ups of shoulder pain, right worse than left. Right shoulder flexion was to 150 degrees with pain at 150 degrees, right shoulder abduction was to 140 degrees with pain at 140 degrees, left shoulder flexion was to 170 degrees with pain at 170 degrees, and left shoulder abduction was to 160 degrees with pain at 160 degrees. After repetitive use testing, right shoulder flexion was to 150 degrees, but pain at 140 degrees, and left shoulder flexion was to 170 degrees, but pain at 160 degrees. The examiner opined that the Veteran had functional loss/functional impairment of the shoulders due to pain on movement. There was no localized tenderness or pain to soft tissue of the shoulders, no muscle spasm, and no guarding of the shoulders. Muscle strength testing was full. There was no ankylosis of either shoulder. All tests for rotator cuff conditions were negative. There was no history of mechanical symptoms (clicking, catching, etc.) or recurrent dislocations, and there was no evidence of AC joint condition/tenderness to the AC joint. Although it was noted that the Veteran underwent arthroscopic surgery in 1997 for his left shoulder disorder, there was no residual signs or symptoms due to arthroscopic shoulder surgery. Imaging studies revealed bilateral degenerative or traumatic arthritis of the shoulders. There was no ankylosis or muscle atrophy. An October 2019 VA examiner diagnosed bilateral shoulder strain. The Veteran denied flare-ups of shoulder pain or functional loss or impairment of the shoulder joints. Right shoulder flexion was 150 degrees, abduction was to 140 degrees, external rotation was to 80 degrees, and internal rotation was to 80 degrees. Pain was noted on examination but it did not contribute to functional loss. Left shoulder flexion was to 170 degrees, abduction was to 170 degrees, external rotation was to 90 degrees, and internal rotation was to 90 degrees. No pain was noted on examination. Bilaterally, there was no pain with weightbearing, no objective evidence of localized tenderness or pain on palpation of the joint, and no objective evidence of crepitus. There was pain on passive range of motion. There was no pain on non-weightbearing. The Veteran was able to perform repetitive use testing and range of motion did not change after three repetitions. Muscle strength testing was full, there was no atrophy, and there was no ankylosis of either shoulder. Right shoulder rotator cuff test (Hawkin’s test) was positive. There was no indication/evidence of shoulder instability, dislocation, or labral pathology. No clavicle, scapula, AC joint, or sternoclavicular joint condition was suspected. There was no loss of head (flail shoulder), nonunion (false flail joint), or fibrous union of the humerus. There was no malunion of the humerus with moderate or marked deformity. It was noted that the Veteran underwent arthroscopic surgery on the left in 1997 and on the right in 2018. No assistive device was used. A January 2020 private treatment record noted that range of motion testing of the right shoulder revealed flexion to 114 degrees, extension to 48 degrees, external rotation at 90 degrees of abduction was 72 degrees and internal rotation at 60 degrees of abduction was 60 degrees. Flexion was the most painful, rated 4/10. The Veteran reported pain on flexion, external rotation, and abduction. There was no guarding on the right and he was able to use his right extremity. There was a breakdown of lifting mechanics on the right. The remaining medical treatment records do not show more severe shoulder symptoms. As the medical evidence does not reflect ankylosis, limitation of motion on the right midway between side and shoulder level, intermediate ankylosis between favorable and unfavorable, limitation of motion to no more than 25 degrees from the side, impairment of the humerus with malunion and marked deformity on the right, or fibrous union of the humerus, the medical evidence does not support a higher rating. GERD GERD is rated at 10 percent under DC 7399-7346 for hiatal hernia. The Board will consider all relevant diagnostic codes. Under the relevant regulations, a higher rating will be warranted when the objective medical evidence shows the following: • persistently recurrent epigastric distress that is productive of considerable impairment of health, with symptoms to include: dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. (30 percent under DC 7346) A May 2014 VA examination report revealed that the Veteran took medication for GERD. Symptoms included reflux, regurgitation, and nausea. The nausea was noted to occur twice a year and last less than a day. He had no esophageal stricture, spasm or acquired diverticulum of the esophagus. A September 2020 VA examiner diagnosed GERD, present since 1996 and unchanged. The Veteran reported reflux symptoms and remained on medication. He did not have any current symptoms due to medication compliance; however, he reported reflux symptoms if he was late or forgot to the medication. The only symptom noted was reflux. He did not have esophageal stricture, spasm, or acquired diverticulum. The examiner specifically indicated that there is no change in the Veteran’s condition. Based on the above, a rating in excess of 10 percent is not warranted. In this regard, the May 2014 VA examination revealed that the Veteran experienced reflux, regurgitation, and nausea as a result of GERD; however, the September 2020 VA examination report indicated that the disability had not worsened and the symptoms (reflux) had improved with treatment, rather than resulting in a considerable impairment of health. Accordingly, the medical evidence does not support a rating in excess of 10 percent. Lumbar Spine Degenerative Arthritis The lumbar spine degenerative arthritis has been rated at 10 percent under DC 5242 as degenerative arthritis. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following: • forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent); • combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent); • muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); • incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); Turning to the medical evidence, a May 2014 VA examiner noted that the Veteran had DJD of the thoracolumbar spine. He reported flare-ups which consisted of pain with lifting. Range of motion testing revealed flexion to 70 degrees with pain at 70 degrees, extension to 20 degrees with pain at 20 degrees, right and left lateral flexion each to 20 degrees with pain at 20 degrees, and right and left lateral rotation to 20 degrees with pain at 20 degrees. Repetitive use testing was accomplished. After three repetitions, all ranges of motion were the same except for left lateral rotation, which was limited to 15 degrees. There was functional loss/impairment of the thoracolumbar spine after repetitive use but the only contributing factor was pain on movement. There was no localized tenderness or pain to soft tissue, no muscle spasm, and no guarding of the thoracolumbar spine. There was a diagnosis of IVDS but there were no incapacitating episodes of IVDS in the past 12 month period. There was no ankylosis, muscle atrophy, or radicular pain/signs of radiculopathy. An October 2019 VA examiner diagnosed degenerative arthritis of the thoracolumbar spine. The Veteran complained that the pain was worse. He denied flare-ups and functional loss/impairment of the thoracolumbar spine. On examination, forward flexion of the thoracolumbar spine to 70 degrees, extension to 20 degrees, right and left lateral flexion each to 20 degrees, and right and left lateral rotation each to 20 degrees. Pain was noted on examination (during forward flexion only) and it caused functional loss. There was no evidence of pain with weight bearing. There was also no tenderness or pain to palpation of the joints or associated soft tissue of the thoracolumbar spine. Repetitive use testing was accomplished and there was no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability after repeated use over time. There was no guarding or muscle spasm of the thoracolumbar spine. Sensory examination as normal and there were no signs or symptoms of radiculopathy. There was no ankylosis of the spine. There was evidence of pain on passive range of motion. There was no evidence of pain when the joint was used in non-weight bearing. A September 2020 VA examiner diagnosed degenerative arthritis of the thoracolumbar spine and lumbar spine degenerative disc disease. The Veteran reported that sitting or standing for long periods of time resulted in back pain. Due to the pain, he must adjust his position or rest. Range of motion testing revealed forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees each, and right and left lateral rotation to 30 degrees each. The examiner noted no pain on examination. There was tenderness or pain on palpation of the soft tissue of the thoracolumbar spine (mid lumbar spine, moderate pain). After repetitive use testing, range of motion/functional ability did not change. The examiner opined that pain significantly limited functional ability with repeated use over time. After repetitive use over time, the examiner opined that flexion would be to 70 degrees, but the remaining excursions of motion remained the same. The Veteran denied flare-ups. There was no guarding or muscle spasm of the thoracolumbar spine. Muscle strength testing was normal. There was no ankylosis. Tests for radiculopathy were negative. There was no IVDS. There was no pain on non-weight bearing. Passive range of motion testing could not be accomplished. Based on the above, a rating in excess of 10 percent is not warranted. In this regard, the VA examinations measured the forward flexion of the Veteran’s lumbar spine at 70 degrees at worst and found the combined range of motion of his lumbar spine to be 170 degrees at worst. The examiners further found that he did not have muscle spasms or guarding of the lumbar spine or any incapacitating episodes of IVDS. Accordingly, the medical evidence does not support a rating in excess of 10 percent. Right and Left Ankle Osteoarthritis The right and left ankle disabilities are each rated at 10 percent pursuant to DC 5271. A higher rating is warranted when the objective evidence shows the following: • marked limitation of motion in the ankle; • ankylosis of the subastragalar or tarsal joint in poor weight bearing position; • malunion of the os calcis or astragalus with marked deformity; or • ankylosis of the ankle in plantar flexion. Turning to the medical evidence, a November 2014 VA examiner noted that the Veteran reported progressive bilateral ankle pain 8/10 and was on medication. He was a mail carrier and his ankles were worse with all the walking. He denied flare-ups. He reported functional loss in terms of having to stop and rest his ankles as he worked. This slowed him down but he was given an accomodation and was able to complete his route. Right and left ankle dorsiflexion was to 10 degrees, and plantar flexion for both ankles was to 45 degrees. There was pain bilaterally on dorsiflexion only and there was pain with bilateral ankle weightbearing. On examination, there was pain over the soles of both feet. Repetitive use testing did not change range of motion testing after three repetitions. The examiner noted that progressive pain, but not any loss of motion, limited functional ability bilaterally with repeated use over time. Muscle strength testing was full and there was no atrophy or ankylosis. There was no ankle instability or dislocation bilaterally. Bilateral ankle osteoarthritis was documented. The Veteran did not use any assistive device such as a brace. An October 2016 private treatment record indicated that examination of the ankles revealed normal range of motion and normal sensation without tenderness, swelling, discoloration, crepitus, weakness, or deformity. An October 2019 VA examiner noted that the Veteran took ibuprofen for ankle pain. Recently he had an injury while jogging and ruptured his left Achilles tendon. He underwent surgical repair of the tendon in April 2019. He denied flare-ups of the ankles. He also denied functional loss/impairment of the ankles. Range of motion testing revealed dorsiflexion of the right ankle was to 20 degrees and plantar flexion was to 40 degrees. No pain was noted on examination. Left ankle range of motion testing revealed dorsiflexion to 10 degrees and plantar flexion to 40 degrees. There was pain on dorsiflexion only. There was no evidence of pain with weight bearing and no crepitus, bilaterally. Repetitive use testing was accomplished, and range of motion/functional ability did not change. The examiner opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability after repeated use over time. Muscle strength testing was full. There was no atrophy or ankylosis. There was no ankle instability or dislocation. The Veteran did not use any assistive device. There was evidence of pain on passive range of motion. There was no pain when the joint was used in non-weight bearing. An October 2019 VA opinion noted that the Veteran recently had an injury while jogging (rupture of Achilles tendon, left). He was status/post repair of the tendon in April 2019. The examiner opined that this was an acute injury and less likely than not a progression of the progression of the service-connected left ankle osteoarthritis. An April 2020 VA opinion similarly indicated that the rupture of the left Achilles tendon injury was not aggravated by the service-connected left ankle osteoarthritis. Instead, it was an acute injury likely secondary to overexertion of the tendon during exercise causing the rupture. Based on the above, the medical evidence does not support rating in excess of 10 percent. While the evidence shows decreased range of motion for both plantar flexion and dorsiflexion, the Veteran denied flare-ups and functional loss and the severity of the limitation of motion did not rise to the level of marked. In this regard, at worst, the Veteran’s dorsiflexion was only to 10 degrees (half of full dorsiflexion) and plantar degrees was to 40 degrees (5 degrees less than full plantar flexion). Importantly, the Veteran denied functional impairment and flare-ups. There is no additional medical evidence which reflected more severe limitation of motion. Finally, the evidence of record does not show ankylosis, or malunion of the os calcis or astragalus with marked deformity. Therefore, the medical evidence does not support a rating higher than 10 percent. Left Knee DJD The Veteran is rated under DCs 5010-5260 for limitation of extension of the leg and 38 C.F.R. § 4.59 regarding painful motion. The Board will also consider all potentially relevant diagnostic codes. In order to warrant a higher rating, the evidence must show: • ankylosis of the knee with a favorable angle in full extension or in slight flexion between 0 and 10 degrees (30 percent under DC 5256); • moderate recurrent subluxation or lateral instability (20 percent under DC 5257); • dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint (20 percent under DC 5258); • flexion of the knee limited to 30 degrees (20 percent under DC 5260); • extension of the knee limited to 15 degrees (20 percent under DC 5261); or • impairment of the tibia or fibula with a moderate knee disability (20 percent under DC 5262). Turning to the medical evidence, a January 2015 VA examiner diagnosed left knee strain and degenerative arthritis of the left knee. The Veteran reported experiencing flare-ups and functional loss/impairment of the left knee which consist of more pain on prolonged walking and getting out of his vehicle. Range of motion testing revealed flexion of the left knee to 130 degrees and extension to zero with pain on left knee flexion but no pain with weightbearing on the left. There was tenderness of the patella. Flexion of the right knee was to 140 degrees and extension was to zero degrees with no pain on examination or with weightbearing on the right. The examiner noted that pain significantly limited functional ability with repeated use over time on the left but not the right. A description of limited functional ability could not be described in terms of range of motion. The Veteran described flare-ups of both knees. He indicated that they were mild to moderate, occurred frequently, and lasted an hour. Muscle strength was full. There were no other factors contributing to disability. There was no atrophy or ankylosis. There was no history of recurrent subluxation or effusion. All joint stability tests were normal for both knees. There was no evidence of a meniscal/semilunar cartilage condition. There was crepitus on the left. An October 2019 VA examiner diagnosed left knee osteoarthritis. The Veteran denied flare-ups and functional loss/impairment of the left knee. Right knee flexion was to 140 degrees and extension was to zero degrees; there was no pain or crepitus and no pain with weight bearing. Left knee flexion was to 130 degrees with pain and extension was to zero without pain. There was no pain with weightbearing. There was no objective evidence of pain or localized tenderness on palpation of the left knee. There was objective evidence of crepitus. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use of either knee over time. Muscle strength testing was normal bilaterally. There was no atrophy or ankylosis of either knee. There was no history of recurrent subluxation or effusions and the left knee joint was stable. There was no evidence of a meniscal/semilunar cartilage condition. There was no use of any assistive device. Turning to the evidence, the Veteran has been diagnosed with left knee osteoarthritis; however, the medical evidence does not show that the left knee disability caused incapacitating exacerbations. Similarly, a review of the remaining private and VA medical records failed to demonstrate any such incapacitating exacerbations due to arthritis. Therefore, the evidence does not support a higher rating based on arthritis. Next, the Veteran has not claimed nor does the medical evidence show that he has ankylosis in the left knee. Importantly, the VA examiners found that his left knee was not ankylosed. Similarly, neither the remaining private nor VA medical records note that he had ankylosis in the left knee. As such, a higher rating due to ankylosis is not warranted. Next, the Veteran has not claimed, and the medical evidence does not show, that he has a history of recurrent subluxation. The VA examiners recorded that he did not have a history of recurrent subluxation or lateral instability of the left knee. Stability tests were normal. Similarly, a review of the private and VA medical records do not note any recurrent subluxation or lateral instability. Therefore, a higher rating for recurrent subluxation or lateral instability is not warranted for the left knee. With respect to the semilunar cartilage, the Veteran does not have a meniscal injury. The VA examiners noted that the Veteran had no semilunar cartilage/meniscal condition. As such, there is no basis to afford a higher rating in this regard. Next, the evidence does not support higher ratings based on limitation of flexion or extension. To that end, the Veteran is currently assigned a 10 percent rating for limitation of flexion for pain rather than measured limitation of flexion, in the left knee. Extension has consistently been full. At no point during the appeal period was his range of motion for the left knee measured at less than 30 degrees for flexion, or 10 degrees for extension. An increased rating is warranted when there is a permanent increase in severity of symptoms but not for temporary decreases in functionality. As such, the medical evidence does not support higher ratings under DCs 5260-5261 for limitation of motion. Next, the Veteran has not claimed, and the evidence does not show, impairment of the tibia or fibula. VA examiners did not find any impairment of the tibia or fibula in the left leg. Further, private and VA medical records did not show a left or right tibia or fibula impairment. Therefore, a higher rating is not warranted under these criteria. As to all increased rating claims, the Board has considered the Veteran’s lay statements that his disabilities are worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which the disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeal are denied. Service Connection Claims Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. In addition to the laws and regulations outlined above, service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). “In the absence of proof of a present disability there can be no valid claim.” See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Polymyositis The Veteran filed a claim for service connection for polymyositis in December 2013. The record contains conflicting medical evidence regarding whether the Veteran has a diagnosis of polymyositis. Essentially, private medical records noted a diagnosis of polymyositis and VA treatment records did not. A January 2012 private medical record noted a diagnosis of polymyositis (this appears to be the earliest diagnosis). VA treatment records included a May 2012 note that stated “[n]o evidence of polymyositis” and a November 2014 note from a doctor that there were “no signs of polymyositis.” Also of record is a June 2013 letter from Dr. F.C., which stated that the Veteran “was in the military and possibly could of been [] exposed to certain fuels, oils, or lubricants that could possibly have caused his polymyositis.” A November 2014 VA treatment record noted that EMGs/nerve conduction studies were normal and inflammatory markers were previously felt to not have any inflammatory muscle diagnosis. An April 2015 Family and Medical Leave Act (FMLA) form completed by Dr. F.C. referenced polymyositis. A VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance) dated in September 2017 completed by a private doctor noted a diagnosis of polymyositis in the legs. A September 2020 VA muscle injures examiner noted that the Veteran had back and neck pain, that Dr. C. told him his CPK was "elevated," and that Dr. C. told him that he had polymyositis. However, the examiner opined that the Veteran did not have polymyositis, as he has had no muscle biopsy to confirm this diagnosis and no electrodiagnostic findings consistent with polymyositis. Importantly, an April 2012 EMG was normal. Additionally, an "electrodiagnostic report" dated January 2008 made mention of impaired conduction over the sural nerve, right and left; however, the examiner pointed out that no latencies were noted and that the sural nerve was a sensory branch, not a motor branch. As such, the examiner concluded that the reported finding on this "electrodiagnostic report" had no clinical correlation to polymyositis, because this finding was not relevant to the claim of polymyositis. Finally, the examiner indicated that there was no evidence of abnormal myositis specific antibodies either. A September 2020 VA clinician found that the Veteran failed to meet the necessary diagnostic criteria for polymyositis and as such, no diagnosis of polymyositis could be rendered. It was noted that although the Veteran saw a Dr. F who stated that he may have polymyositis based on the non-specific finding of an elevated CPK, the Veteran has a normal EMG in April 2012. Further, it was noted that EMG/NCV studies were normal, there was no evidence of myositis specific antibodies, no clinical findings of loss of strength, and no documentation of rhabdomyolysis or any other muscle injury. Further, the Veteran had a CPK of 539 in April 2012 and notes from Rheumatology dated in November 2015 noted that the CPK was "appropriate for his well-developed musculature." As such, since the Veteran does not have documentation of the diagnostic criteria for polymyositis (normal EMG, no muscle biopsy findings of polymyositis, no myositis specific antibodies, and only episodes of elevated CPK that is not specific for polymyositis and could be elevated due to multiple reasons), no diagnosis of polymyositis could be rendered. The Board finds that the VA examination and opinion were adequate. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiner was not fully aware of the Veteran’s past medical history or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the diagnosis of polymyositis and had sufficient facts and data on which to base the conclusion. Importantly, the examiner based the opinion on the medical/diagnostic testing and clinical findings, and provided sound medical reasoning for the stated opinion. Therefore, the examiner’s opinion to be of great probative value. Based on the medical evidence of record, polymyositis has not been shown. While there are diagnoses of such in the record, they are not based on any specific clinical findings or diagnostic studies/tests. Notably, the September 2020 opinion stated that the private diagnoses lack medical foundation with no documentation of the necessary diagnostic criteria. Therefore, the diagnoses of polymyositis of record are given less probative value and the medical evidence does not support the claim. Right and Left Foot Disorders The Veteran filed a claim in September 2014 for entitlement to service connection and listed a disability of “Bilateral Feet.” A September 2017 VA Form 21-2680 noted a diagnosis of neuropathy of the left and right feet. A November 2017 private medical record reflected a chief complaint of bilateral foot pain. The Veteran “stated that he injured his neck and back in the military.” The impression was “G60.9,” which internet research indicated is an ICD-10-CM (the International Classification of Diseases, Tenth Revision, Clinical Modification) code for hereditary and idiopathic neuropathy, unspecified. The November 2017 medical record also indicated that the Veteran “was informed that neck and back injuries can cause neuropathic symptoms in his lower extremities.” As to an in-service incurrence, the Veteran sought treatment in January 1983 for a left foot sprain, in May 1985 for a left big toe injury and possible sprain (X-rays were negative), in August 1987 for a contusion left foot, in September 1987 a two week complaints of left foot pain and a diagnosis of foot strain (an X-ray report noted that “[t]he foot itself is normal in appearance”). Therefore, left foot complaints were noted in service. Post-service medical evidence reflects a diagnosis of plantar fasciitis first diagnosed in 2016 noted at an October 2019 VA examination. The Veteran was treated with orthotics. He denied flare-ups and functional loss/impairment of the feet. On examination, he had pain on use of the feet. An October 2019 VA opinion report noted that the Veteran had a current diagnosis of plantar fasciitis. The examiner indicated that there was no documented flat foot in service. The examiner opined that the current diagnosis was likely an ongoing process of wear and tear. A September 2020 VA examiner indicated that the Veteran was diagnosed with degenerative arthritis of the left foot. He reported pain in both feet with prolonged standing and walking. The examiner opined that the in-service left foot sprain resolved. On examination, the Veteran did not complain of any pain and there was normal evaluation of the feet. However, he indicated that the pain arose from prolonged standing and walking, which he had not done prior to the examination. He took ibuprofen for the pain. He denied flare-ups but reported functional loss/impairment. A September 2020 VA examiner noted that there were no findings of neuropathy of the feet either on examination or supported by the history or the information in the claims file. The examiner specifically found that the Veteran had a normal EMG/NCV in 2012, no sensory loss, no motor loss, no abnormal reflexes, and no findings of peripheral nerve entrapment on the right or left foot. The examiner, a neurosurgeon, interviewed the Veteran and the Veteran reported pain in both feet. At the time of the examination, he had no pain on either the left or the right foot. The examiner indicated that incidental findings of left foot MTP and IP arthritis were noted in the evaluation because it was standard practice to note all relevant medical information available; however, the examiner pointed out that the Veteran did not have tenderness, limitation of range of motion, deformity, alteration of gait, ankylosis, loss of strength or sensation or treatment for a right or left foot condition. The examiner found that despite the Veteran's report of pain, no additional physical examination findings or additional radiographic findings were available to support additional diagnoses at the time of the VA examination. The examiner opined that it is less likely than not that left foot arthritis was caused by or related to service or caused/aggravated by service-connected disability. The examiner stated that there was no evidence of left foot arthritis in service, as the record was silent for radiographic findings of left foot arthritis until 2016. There was also no evidence of a fracture in service that would cause arthritis years later. The examiner further opined that there was no medical foundation on which to support any kind of connection between a cervical spine disability or lumbar spine disorder and left foot arthritis. In sum, the competent and credible medical evidence does not support a diagnosis of right or left foot neuropathy. Despite there being private medical evidence showing such a diagnosis, the September 2020 VA examiner undermined those findings by pointing out that there is no evidence in the record to support such diagnoses. Specifically, the April 2012 EMG study was normal and there was consistently no evidence of sensory loss, motor strength loss or physical examination findings or history findings that would intimate at the possibility of a peripheral neuropathy of the feet. As such, the first element of service connection is not met with respect to the diagnosis of neuropathy of the feet. Although the Veteran has current diagnoses of left foot arthritis and bilateral plantar fasciitis, the evidence does not show that either disorder was present in service, that left foot arthritis was present within one year of service, that left foot arthritis symptoms have been continuous since service, or that either disorder was related to service, to include the foot injuries in service. Importantly, the VA examiners opined that the bilateral plantar fasciitis was not related to service and instead was related to wear and tear over the years. Another VA examiner opined that left foot arthritis was not related to service or service-connected disability. The examiner reasoned that there was no fracture in service that could lead to arthritis later in life, and X-rays did not reveal left foot arthritis in service. Finally, the examiner noted that there is no medical correlation between a cervical spine disability or lumbar spine disorder and left foot arthritis. As to presumptive service connection, no chronic disease or injury was shown in service. While the Veteran was treated for left foot sprain, a left big toe injury (possible sprain but negative X-ray report), left foot contusion, and foot strain in service, no chronic symptoms were shown as a result of any left foot injury. Also significant is the lack of right or left foot symptoms at the time of service separation. In fact, the January 1998 retirement examination noted normal evaluation of the feet and the Veteran denied foot trouble on the Report of Medical History. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the Veteran’s in-service injuries occurred in the 1980s (last noted injury in 1987) and he was discharged from service in January 1998 with a notion of normal feet. Moreover, he did not seek treatment for his foot symptoms until 2014. While the 2014 treatment records indicate bilateral midfoot pain for years, private treatment records from 2006 noted pain in other joints but no foot pain. This weighs against later statements regarding ongoing foot pain since service. Additionally, an August 2013 private treatment record noting complaints of back pain and pain in the legs, indicated that the Veteran reported that he was on his feet all day at work (he had been a mail carrier for 14 years), but did not reflect any complaints of foot pain. Finally, an October 2017 private treatment record noted that the Veteran reported pain on the bottom of both feet which had been present for three to four years, dating the onset to 2013-2014, many years after discharge. Even assuming the onset of symptoms after 2006, as the Veteran was discharged in 1998 and symptoms were not identified until after 2006 at the earliest, after years of being a mail carrier, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1998 but did not note symptoms until after 2006 at the earliest, with treatment beginning in 2014 and X-rays of left foot arthritis in 2016. This evidence does not support presumptive service connection on a “manifest within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. Right and Left Hand Arthritis The medical evidence of record reflects a diagnosis of a current bilateral hand disability. In this regard, a November 2014 VA rheumatology note included an assessment of “[g]eneralized (early) osteoarthritis with Heberden nodes at most of the finger [distal interphalangeal (DIP)] joints” and a November 2015 VA rheumatology included an assessment of “[o]steoarthritis multiple joints of the hands.” Additionally, the September 2020 VA examination report noted a diagnosis of bilateral hand arthritis. As such, the requirement of a current disability has been met. As to an in-service incurrence, the STRs referenced in-service treatment related to the Veteran’s hands. With respect to the left hand, in June 1987, he complained of a one-day history of an injury to the left first DIP joint when he “traumatized it by his thumb hanging on the net.” There was decreased range of motion, the left DIP was “slightly edemic” and metacarpals tenderness. The assessment was a contused left first metacarpal versus questionable soft tissue and he was given a splint. A radiologic consultation request for the left thumb noted that the Veteran caught his thumb in a net playing basketball but there were no significant abnormalities. There was also decreased range of motion of the metacarpophalangeal (MP) joint of the left thumb with tenderness and no edema. Negative X-rays were referenced. The assessment was left thumb sprain and he was prescribed Motrin. An August 1987 a radiologic consultation request for the left hand third finger, noted that the Veteran jammed and extended the finger during football practice and referenced the proximal interphalangeal (PIP) joint. The radiologic report stated that “[t]here is a smooth ossicle ventral to the PIP joint consistent with either an accessory ossicle or an old avulsion injury. The rest of the exam is unremarkable.” With respect to the right hand, in October 1986, the Veteran was scheduled to follow-up on a right hand injury but did not report to the clinica. While it is unclear, it is apparent that he experienced some sort of right hand injury. In June 1993, he was in a car accident. A July 1993 follow-up noted indicated that he complained of limited use of right hand and reported that he had an inability at certain times to close his right hand into a fist. As such, the second element of service connection an inservice incurrence has been met. As to a medical nexus, a September 2020 clinician related that it was less likely than not that bilateral hand arthritis was related to service. The examiner pointed out that there was no evidence of hand arthritis until 2015. Although a 1998 X-ray study revealed possible avulsion fracture versus accessory ossicle in the PIP joint, the examiner opined that joint in question in the 1998 X-ray was not the one affected by arthritis as per the July 2020 left hand X-ray. There is no medical evidence in favor of the claim on a direct basis. As such, the medical evidence does not support the claim as to direct service connection. With regard to secondary service connection, the September 2020 VA examiner also opined that there was no foundation to even begin to consider how any of the Veteran’s service-connected disabilities affecting other parts of the body were in any possible way related to right or left hand arthritis. There is no medical evidence that weighs in favor of such a relationship on a secondary basis. As to presumptive service connection, no chronic disease or injury related to either hand in service. While the Veteran was treated for multiple hand/finger injuries in service, no chronic symptoms were shown as a result of any hand injury. He was treated and he did not report any further complaints. Also significant is the lack of hand/finger injury residuals at the time of service separation. Importantly, on the Report of Medical History at separation, the Veteran denied bone, joint or other deformity and arthritis rheumatism or bursitis. On examination at separation, no hand complaints or findings were noted. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connected based on continuity of symptomatology since service. Specifically, the Veteran’s in-service injuries occurred in the late 1980s and early 1990s and he was discharged from service in 1998 with no hand or finger findings. Moreover, he did not seek treatment for his hand symptoms until 2014. This suggests an onset of symptoms in approximately 2014. As he was discharged in 1998 and symptoms were not identified until 2014 at the earliest, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1998 but did not note symptoms until 2014 at the earliest, with treatment beginning in 2015 and arthritis diagnosed in 2015. This evidence does not support presumptive service connection on a “manifest within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. The Board has considered the Veteran’s lay statements that he has polymyositis, disorders of the feet, bilateral hand arthritis, which were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the disorders due to the medical complexity of the matters involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeals are denied. The RO complied with the directives of the October 2018 Board remand. It associated all up-to-date VA medical records with the claims file, made an attempt (via letter dated August 7, 2019) to get authorization from the Veteran to obtain his private treatment records (but he responded in writing on August 14, that he was currently in receipt of VA treatment only) and scheduled him for the requested VA examinations. See Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board finds that all examination and opinion reports were adequate for rating purposes. Specifically, the examiners completely addressed all the sections in the Disability Benefits Questionnaire, including reviewing the claims folder, conducting a physical examination, identifying diagnoses, obtaining a medical history from the Veteran, identifying the current symptoms and treatment, and offering a medical opinion and rationale regarding the issues on appeal. For those reasons, the Board finds that the examinations were adequate. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Redman, 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.