Citation Nr: 21022472 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 16-00 256A DATE: April 15, 2021 ORDER Entitlement to service connection for a left hand disorder is denied. Entitlement to a rating in excess of 10 percent for osteoarthritis of the right knee with patellofemoral pain syndrome with residual surgical scar is denied. Entitlement to a rating in excess of 10 percent for status post metal fragment wound of the left lower leg with residual scar is denied. Entitlement to a rating in excess of 20 percent for osteoarthritis of the lumbar spine with degenerative joint disease is denied. Entitlement to an increased rating for hypertensive heart disease, rated as 60 percent disabling prior to January 10, 2019, is denied. REMANDED Entitlement to service connection for a right leg disorder, to include as secondary to service-connected hypertensive heart disease, is remanded. Entitlement to service connection for a respiratory disorder, to include as secondary to service-connected hypertensive heart disease or depressive disorder, is remanded. FINDINGS OF FACT 1. A left hand disorder did not manifest in service or for many years thereafter and is not related to service. 2. The Veteran’s right knee osteoarthritis with patellofemoral pain syndrome and residual surgical scar has been manifested by painful motion; flexion limited to 30 degrees or less, extension limited to 10 degrees or greater and/or instability has not been demonstrated. 3. The Veteran’s status post metal fragment wound of the left lower leg with residual scar has been manifested by painful motion; flexion limited to 30 degrees or less, extension limited to 10 degrees or greater and/or instability has not been demonstrated. 4. The Veteran's osteoarthritis of the lumbar spine with degenerative joint disease has not been manifested by forward flexion limited to 30 degrees or less, unfavorable ankylosis of the entire thoracolumbar spine, neurologic impairment outside of right and left lower extremity radiculopathy, and/or incapacitating episodes as defined by VA of a duration of at least 6 weeks during a 12-month period. 5. Prior to January 10, 2019, the Veteran's hypertensive heart disease did not result in chronic congestive heart failure; a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. A left hand disorder was not incurred in or aggravated by service and a malignant tumor may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 2. The criteria for a rating in excess of 10 percent for osteoarthritis of the right knee with patellofemoral pain syndrome with residual scar have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 3. The criteria for a rating in excess of 10 percent for status post metal fragment wound of the left lower leg with residual scar have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 4. The criteria for a rating in excess of 20 percent for osteoarthritis of the lumbar spine with degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243 (2020). 5. The criteria for a rating in excess of 60 percent for hypertensive heart disease, prior to January 10, 2019, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7007 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1976 to January 1996. In September 2018 and May 2019, the Board remanded the matters on appeal to the agency of original jurisdiction (AOJ) for additional development. The case has since returned to the Board for the purpose of appellate disposition. Following the Board’s most recent remand, the AOJ issued a rating decision in April 2020 granting service connection for strain status post right hand third finger cyst removal (claimed as right hand condition) and for conjunctival edema of the right eye (claimed as a right eye condition). As this decision represents a full grant of the matters previously on appeal, they are no longer before the Board. In addition, the AOJ issued a rating decision in September 2020 granted a 100 percent rating for atrial fibrillation status post defibrillation installation with hypertensive heart disease (previously hypertensive heart disease) effective January 10, 2019. The Board has accordingly limited the scope of the appeal as to this issue to the period prior to January 10, 2019. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). However, the Court has established that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Left hand disorder Although the Veteran’s service treatment records include various complaints and treatment related to the right hand, there is no similar documentation of a left hand injury or complaints. An August 1995 retirement examination indicated that his upper extremities were normal. In May 2017, the Veteran was treated for a left long finger mass, likely an epidermal inclusion cyst. The Veteran subsequently underwent EMG, which revealed median neuropathy of the wrists. He underwent a left finger excisional mass biopsy and left carpal tunnel release in June 2017. On VA examination in January 2020, the Veteran reported that he was diagnosed with carpal tunnel syndrome in 2019 and underwent surgical release that same year. He indicated that the surgery helped with the left side and he had no symptoms. After interview and physical examination, the examiner determined that there was no diagnosis of a left hand disorder. With respect to the Veteran’s carpal tunnel syndrome, this was a neurological condition involving the wrist, onset post service and unrelated to service. In conclusion, the examiner opined that the claimed condition was less likely as not related to service. He found that the disability was not diagnosed until 2017, and there was no evidence to support that it was related to service. The examiner noted that the risk factors for developing carpal tunnel included anatomy of the wrist, certain occupations and certain medical conditions such as diabetes mellitus. In sum, none of the probative evidence supports a finding of a relationship between the Veteran's claimed left hand disorder and service. There is no indication in the record of left hand injury and/or onset in service or for many years thereafter. The only pertinent medical opinions of record is that of the January 2020 VA examiner, who had a thorough review of all pertinent evidence and stated there is no relationship among the Veteran's current left hand disorder, diagnosed as carpal tunnel syndrome, and his service. Thus, the only credible, probative opinions of record weighs against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim. The Veteran has also not provided any lay evidence in support of his claim other than by filing the claim for service connection. To the extent that the Veteran advances his own theory that his left hand disorder is related to service, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because he was a layperson, conflicts with Jandreau, 492 F3d. at 1372). In any event, the probative value of these general assertions in this regard is outweighed by the evidence outlined above documenting the onset of left hand disorder many years after service with no suggestion that such disability has been caused and/or aggravated by an in-service event or injury. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a left hand disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. 2. Right knee osteoarthritis with patellofemoral pain syndrome and residual scar The Veteran’s service-connected right knee osteoarthritis with patellofemoral pain syndrome and residual scar is rated as 10 percent disabling pursuant to Diagnostic Code 7805-5620. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The hyphenated diagnostic code in this case indicates that the service-connected disability is considered to be a scar of the right knee (Diagnostic Code 7805) rated on the basis of limitation of flexion of the knee (Diagnostic Code 5260). The normal flexion of the knee is 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion to 60 degrees warrants a 0 percent rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The normal range of extension of the knee is 0 degrees. Limitation of extension to 5 degrees warrants a 0 percent rating. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Symptoms associated with the removal of semilunar cartilage warrant a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Impairment in the form of recurrent subluxation or lateral instability warrants a 10 percent rating if slight, 20 percent if moderate, and 30 percent if severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the majority of these diagnostic codes were not changed. The only relevant change is to Diagnostic Code 5257, which provides that a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability, or for sprain/ligament tear causing persistent instability without prescription for an assistive device, while a 20 percent rating is warranted for: a) sprain, incomplete ligament tear, or repaired complete ligament tear causing permanent instability, and a medical provider prescribed brace or assistive device for ambulation, or; b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribed assistive device or bracing for ambulation, or for a diagnosed condition involving the patellofemoral complex with recurrent instability requiring prescription for a brace and a cane or walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective February 7, 2021). On VA examination in December 2012, the Veteran reported numbness and tingling in the leg. The Veteran described flare-ups during which he could not put on his shoes. Range of motion testing revealed flexion to 140 degrees or greater and extension to 0 degrees, with no objective evidence of painful motion. The Veteran was able to perform 3 repetitions with no additional change in range of motion. Crepitus was present. There was no tenderness or pain to palpation for the joint line or soft tissue. Muscle strength testing was normal. There was no history of patellar subluxation or dislocation. Joint stability testing yielded normal findings. There was a history of right meniscotomy in 2007 but no symptoms or residuals. The Veteran reported that he occasionally used a brace. Right knee x-ray revealed mild degenerative arthritis changes. The examiner diagnosed osteoarthritis of the right knee and patellofemoral pain syndrome. VA treatment records throughout the appeal period document complaint of knee pain. On VA examination in January 2020, the Veteran reported a history of cyst inside the right knee cap with right knee arthroscopic surgery in 2007. He had no visible scar now and did not have any complaints related to the right knee. He denied flare-ups of the knee. Range of motion testing revealed right knee flexion to 110 degrees and extension to 0 degrees. No pain was noted on exam, and there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform 3 repetitions of range of motion, with no additional loss of function or range of motion. There was no evidence of pain on non-weight bearing and passive range of motion was the same as active range of motion. There was no additional estimated loss of function or range of motion on flare-ups or on repeated use over time. Muscle strength testing was normal with no indication of atrophy. With respect to stability, there was no history of recurrent subluxation or lateral instability. Joint stability testing was normal. The Veteran did not have a meniscal condition. He did have a history of surgery, undergoing right knee arthroscopic surgery for cyst removal, but with no symptoms. The examiner diagnosed right knee osteoarthritis and patellofemoral pain syndrome. The examiner further indicated that the right knee scar was no longer visible. With respect to the currently assigned 10 percent rating for right knee patellofemoral pain syndrome with residual surgical scar under Diagnostic Code 5260, the 10 evaluation contemplates pain on motion. It is also consistent with flexion limited to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of extension limited to 30 degrees. 38 C.F.R. § 4.7; DeLuca. A separate rating may also be assigned for limitation of flexion. In this case, the medical evidence establishes at worse, flexion limited to 110 degrees and full extension of the knee. As flexion is not limited to 30 degrees or less, and extension is not limited to 10 degrees or more an evaluation in excess of 10 percent is not warranted (and a separate evaluation for limited extension is not warranted). In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, while the Veteran has reported increased limitation on flare-up, neither the medical nor lay evidence suggests that he is limited to 30 degrees flexion or compensable limitation of extension. As a result, the 10 percent rating for his osteoarthritis with patellofemoral pain syndrome with residual surgical scar adequately compensates him for his symptoms. With regard to other impairment of the right knee, while the Veteran occasionally wore a brace, he has not indicated instability of the knee. Furthermore, instability testing on examination has been normal with no indication of history of recurrent subluxation or lateral instability. The Board has also considered the revised criteria, but again, there is no indication of recurrent instability, or ligament tear or sprain. As such, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's right knee disability was manifested by recurrent subluxation or lateral instability, and a higher rating is not warranted on this basis. Furthermore, there is no credible evidence of ankylosis, symptoms related to dislocation or removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. Moreover, extension has been normal (to zero degrees) throughout the appeal period with no additional loss of range of motion on repetitive use or during flare-ups. As a final note, the Board has considered whether a separate rating is warranted for scar of the right knee, however, the scar is not visible or productive of any impairment. Accordingly, a compensable rating for scarring is not warranted. In conclusion, the Board finds that a preponderance of the evidence is against a rating in excess of 10 percent for right knee osteoarthritis with patellofemoral pain syndrome with residual scar. In denying an increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Status post metal fragment wound, left lower leg with residual scar The Veteran’s service-connected status post metal fragment wound of the left lower leg with residual scar is also rated as 10 percent disabling under Diagnostic Code 7805-5620. Thus, the rating criteria for the right knee discussed above also apply to the left lower leg disability. On VA examination in December 2012, the Veteran reported pain, numbness and tingling in the leg. The Veteran described flare-ups during which he could not put on his shoes. Range of motion testing revealed flexion to 140 degrees or greater and extension to 0 degrees, with no objective evidence of painful motion. The Veteran was able to perform 3 repetitions with no additional change in range of motion. Crepitus was present. There was no tenderness or pain to palpation for the joint line or soft tissue. Muscle strength testing was normal. There was no history of patellar subluxation or dislocation. Joint stability testing yielded normal findings. There were no symptoms or residuals related to a meniscus condition. The Veteran reported that he occasionally used a brace. The examiner diagnosed patellofemoral pain syndrome and status post metal fragment wound of the left lower leg. An April 2015 VA telehealth report indicates that the Veteran endorsed left knee pain, which he rated 5 out of 10, 4 times per month. On VA examination in January 2019, the Veteran reported that he underwent removal of a metal fragment in 1988, with surgical scar at the anterior left leg measuring 2 x 1.4 centimeters. The left knee now felt stiff at the posterior knee. He denied flare-up of the knee. Range of motion testing revealed left knee flexion to 110 degrees and extension to 0 degrees. No pain was noted on exam, and there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform 3 repetitions of range of motion, with no additional loss of function or range of motion. There was no additional estimated loss of function or range of motion on flare-ups or on repeated use over time. There was no evidence of pain on non-weight bearing and passive range of motion was the same as active range of motion. Muscle strength testing was normal with no indication of atrophy. With respect to stability, there was no history of recurrent subluxation or lateral instability. Joint stability testing was normal. The Veteran did not have a meniscal condition. He did have a history of surgery, undergoing left leg status-post metal fragment removal. The scar associated with the fragment removal was well-healed and stable with no pain or deep tissue damage. With respect to the currently assigned 10 percent rating for status post metal fragment of the left lower leg with residual scar, under Diagnostic Code 5260, the 10 evaluation contemplates pain on motion. It is also consistent with flexion limited to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of extension limited to 30 degrees. 38 C.F.R. § 4.7; DeLuca. A separate rating may also be assigned for limitation of flexion. In this case, the medical evidence establishes at worse, flexion limited to 110 degrees and full extension of the knee. As flexion is not limited to 30 degrees or less, and extension is not limited to 10 degrees or more an evaluation in excess of 10 percent is not warranted (and a separate evaluation for limited extension is not warranted). In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, while the Veteran has reported increased limitation on flare-up, neither the medical nor lay evidence suggests that he is limited to 30 degrees flexion or compensable limitation of extension. As a result, the 10 percent rating for his adequately compensates him for his symptoms. With regard to other impairment of the left knee, while the Veteran occasionally wore a brace, he has not indicated instability of the knee. Furthermore, instability testing on examination has been normal with no indication of history of recurrent subluxation or lateral instability. The Board has also considered the revised criteria, but again, there is no indication of recurrent instability or ligament sprain or tear. As such, the Board concludes that the preponderance of the evidence is against a finding that the Veteran’s left knee disability was manifested by recurrent subluxation or lateral instability, and a higher rating is not warranted on this basis. Furthermore, there is no credible evidence of ankylosis, symptoms related to dislocation or removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. As a final note, the Board has considered whether a separate rating is warranted for scar of the left knee, however, the scar is not productive of any additional impairment, does not measure an area at least 144 square inches, and is not unstable, painful or resulting in underlying tissue damage. Accordingly, a separate compensable rating for scarring is not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-05. In conclusion, the Board finds that a preponderance of the evidence is against a rating in excess of 10 percent for status post metal fragment of the left lower leg with residual scar. In denying an increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Osteoarthritis of the Lumbar Spine with Degenerative Joint Disease The Veteran contends that he is entitled to an increased rating for his lumbar spine disorder. His lumbar spine disability, osteoarthritis of the lumbar spine with degenerative joint disease, is rated as 20 percent disabling under the criteria of 38 C.F.R. § 4.71A, Diagnostic Code 5003-5243, which provides that intervertebral disc syndrome (IVDS) is to be evaluated unde the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS based on Incapacitating Episodes. At the outset, the Board notes that while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the rating criteria for the spine and IVDS were not changed. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. IVDS (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. A 10 percent disability rating is assigned for incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, with higher evaluations for incapacitating episodes of increased duration. Note 1 states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. A December 2012 VA examination report reflects the Veteran complaint of pain when he laid down for 3 hours, after which he needed to get up or sit up to relieve his symptoms. He endorsed flare-ups to the point where he back pain prevented him from walking. Range of motion testing revealed flexion to 90 degrees or greater with pain at 80 degrees. Extension was to 30 degrees or greater with pain at 20 degrees. Right and left lateral flexion were to 20 degrees, with pain at 20 and 10 degrees, respectively. Right and left lateral rotation were to 30 degrees or greater with pain at 10 and 20 degrees, respectively. The Veteran was able to perform 3 repetitions with no change in range of motion. Additional functional loss included pain on movement. The Veteran had localized tenderness or pain to palpation for the joints and/or soft tissues of the thoracolumbar spine. He did not have guarding or muscle spasm. He used a brace on occasion. Neurologically, there was decreased sensation in the right and left lower extremities. No other neurologic abnormalities were indicated. The examiner noted that IVDS was present and resulted in a total duration of incapacitating episodes lasting less than 1 week during the past 12 months. The examiner diagnosed osteoarthritis of the lumbar spine with degenerative disc disease. He found that the disability would impact the Veteran’s ability to work in that there was partial impairment of physical activities of employment such as heavy lifting, pushing, and pulling due to osteoarthritis of the lumbar spine. On VA examination in January 2020, the Veteran reported low back pain, particularly when laying on the back, which caused him to need to reposition. He took Tramadol as needed. During flare-ups, he reported it hurt when he walked and laid down. With respect to functional loss, the Veteran indicated that his back disability limited physical activity. Range of motion testing revealed flexion to 90 degrees, extension to 15 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 30 degrees. Pain was noted on examination, but it did not cause functional loss, though it was noted on all segments of range of motion. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. Passive range of motion was the same as active range of motion. The Veteran was able to perform repetitive use testing with at least 3 repetitions, and there was no loss of function or range of motion after 3 repetitions. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time or flare-up, and that the examination was consistent with the Veteran’s statements describing functional loss with repetitive use over time or flare-up, with pain, fatigue, and lack of endurance contributing to functional loss. The examiner estimated range of motion after repetitive use or on flare-up as flexion to 70 degrees, extension and right and left lateral flexion to 15 degrees, and right and left rotation to 30 degrees. The Veteran did not have guarding or muscle spasm of the back. The examiner found no signs or symptoms of radiculopathy in either extremity. There was no ankylosis or other neurologic abnormalities. The examiner further noted that the Veteran did not have IVDS of the spine, and ankylosis was also denied. The examiner diagnosed osteoarthritis of the lumbar spine with degenerative joint disease, and indicated that the disability did not impact his ability to work. After review of the competent medical evidence, the Board finds that the weight of the evidence is against a disability rating in excess of 20 percent for the lumbar spine disability. This is also consistent with the medical evidence of record, which fails to show that the Veteran's forward flexion of the thoracolumbar spine was less than 30 degrees. Moreover, the evidence fails to show that the Veteran had favorable ankylosis of the entire thoracolumbar spine. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Moreover, the Board has considered range of motion findings in passive and non-weight bearing situations, consistent with Correia, as well as the 2019 examiner’s estimated range of motion on flare-up. In this case, the estimated range of motion was to 70 degrees forward flexion. There is nothing otherwise to suggest forward flexion of the spine limited to less than 30 degrees or ankylosis of the thoracolumbar spine. With regard to separate ratings for neurological abnormalities or chronic neurologic manifestations, the record reflects that the Veteran is already service connected for radiculopathy of the right and left lower extremities associated with his low back disability. This matter is not before the Board at this time. No other neurological abnormalities have been demonstrated. The Board has considered a rating on the basis of IVDS. In order to warrant a higher rating on this basis, incapacitating episodes having a total duration of at least 4 weeks during a 12-month period must be shown. The 2019 VA examiner indicated that the Veteran’s disability picture is not manifested by IVDS episodes. While the 2012 VA examiner found the disability to be productive of incapacitating episodes, these episodes were of a duration of less than 1 week during a 12-month period. In light of the foregoing, the Board finds that a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted. The Veteran has not provided any specific contentions as to why he believes a higher rating is warranted. Neither the medical evidence nor the lay evidence of record suggests that an evaluation in excess of 20 percent is warranted at this time. Accordingly, the Board concludes that a rating in excess of 20 percent for osteoarthritis of the lumbar spine with degenerative joint disease is not warranted. In denying an increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Hypertensive heart disease The Veteran likewise contends that he is entitled to an increased rating for his hypertensive heart disease. As indicated above, the AOJ recharacterized the disability as atrial fibrillation status post defibrillation installation with hypertensive heart disease and assigned a 100 percent rating for the disorder pursuant to Diagnostic Code 7007-7011, effective January 10, 2019. Prior to January 10, 2019, the disability was rated as 60 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7007. Under Diagnostic Code 7007, a 60 percent evaluation is assigned when there is more than one episode of acute congestive heart failure in the past year; or when a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent evaluation is warranted for chronic congestive heart failure; or when there is a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope; or when there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7007. Most of the diagnostic codes used to evaluate diseases of the heart have nearly identical rating criteria. See 38 C.F.R. §§ 4.100, 4.104, Diagnostic Codes 7000-7006, 7015-7020. When evaluating cardiovascular disorders under Diagnostic Codes 7000-7007, 7011, and 7015-7020, it must be ascertained in all cases whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or x-ray) is present and whether or not there is a need for continuous medication. 38 C.F.R. § 4.100(a). METs testing is also required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction has been measured and is 50 percent or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; (4) when a 100 percent evaluation can be assigned on another basis. 38 C.F.R. § 4.100(b). If left ventricular ejection fraction (LVEF) testing is not of record, the cardiovascular disability must be based on the alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. 38 C.F.R. § 4.100(c). One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, so contraindicated, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. See 38 C.F.R. § 4.104, Note (2). On VA examination in December 2012, the Veteran reported that he did not experience angina, shortness of breath, fatigue, dizziness, or syncope attacks. He had not had myocardial infarction, congestive heart failure, arrhythmia, a heart valve condition, or an infectious heart condition. On physical examination, auscultation of the heart revealed a 2/6 systolic ejection murmur. Peripheral pulses were normal. Diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. EKG showed hypertrophy, possible left ventricular hypertrophy. Echocardiogram revealed trace mitral regurgitation and left atrial enlargement. LVEF was 35 percent. Interview-based METs testing revealed fatigue at greater than 5-7 METs. The examiner indicated that METs limitation was due solely to the heart condition. The examiner diagnosed cardiomyopathy, concentric left ventricular hypertrophy, diastolic dysfunction, valvulopathy secondary to cardiomyopathy, and left atrial enlargement secondary to mitral regurgitation back into the left atrium. A June 2015 VA anesthesiology consult indicated that a June 2013 transthoracic echocardiogram revealed normal right and left ventricular systolic function with LVEF of 50-55 percent. A July 2018 cardiology note reflects LVEF of 25-30 percent. On VA examination in January 2020, the examiner indicated that atrial fibrillation was diagnosed in 2018. Due to this, a defibrillator was installed in January 2019. The Veteran denied chest pain, but reported shortness of breath with asthma, using an inhaler for breathing as needed. The Veteran did not have congestive heart failure, but cardiac arrhythmia was present (atrial fibrillation). Cardiac hypertrophy was indicated on echocardiogram. Echocardiogram revealed LVEF of 40 percent. Mild concentric left ventricular hypertrophy was present. An interview-based METs test revealed dyspnea at greater than 7-10 METs. The examiner diagnosed hypertensive heart disease and atrial fibrillation status-post defibrillator installation. The examiner noted that, given the report of asthma, LVEF would be a better indicator of his heart condition. The record reflects that the Veteran was assigned a 100 percent rating pursuant to Diagnostic Code 7011 based upon placement of a the defibrillator in January 2019. Accordingly, a higher 100 percent rating is not warranted prior to this date. Prior to that date, a preponderance of the evidence here is against finding a workload of 3 METs or less which results in dyspnea, fatigue, angina, dizziness, or syncope or left ventricular dysfunction with an ejection fraction of less than 30 percent, either of which would support a 100 percent rating under Diagnostic Code 7007. Interview-based METs test revealed, at worst, workload of greater than 5 but less than 7 resulted in symptoms such as dyspnea or fatigue. In addition, while LVEF was 25-30 percent in July 2018, findings from 2012, 2013, and 2019 all reveal LVEF of 40 or greater. Therefore, the criteria for a 100 percent rating are not more nearly approximated. There is further no evidence of chronic congestive heart failure, which is another of the criteria for a 100 percent rating under Diagnostic Code 7007. Congestive heart failure is not indicated by the Veteran's medical records, and VA examinations in 2012 and 2019 note no history of congestive heart failure. Thus, based on the forgoing, the Board finds that a preponderance of the evidence is against a rating in excess of 60 percent for the Veteran's hypertensive heart disease. In denying an increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Although the Board regrets the delay, upon review of the claims file, the Board believes that additional development on the remaining claims is warranted. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Moreover, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In addition, the Court of Appeals for Veterans Claims (Court) has held “that a remand by this Court or the Board confers on the veteran or other claimant, as a matter of law, a right to compliance with the remand orders.” Stegall v. West, 11 Vet. App. 268, 271 (1998). As such, compliance with the terms of the remand is necessary prior to further appellate review, and if not, “the Board itself errs in failing to ensure compliance.” Id. 1. Service connection for a right leg disorder As indicated in the Board’s previous remand, service treatment records include a complaint of right leg pain following a three-mile run in September 1979. An August 1995 retirement examination indicated that his lower extremities were clinically normal. However, in the associated report of medical history, he reported cramps in his legs. The physician noted that he experienced leg cramps during exercise and that the symptoms had continued or 20 years. In May 1997, the Veteran underwent a VA general examination. He reported varicose veins in the bilateral legs, above and below the knee, since 1995. Physical examination revealed single superficial varicosities above and below the knee bilaterally. There were a few sacculations over the medial right thigh. The December 2012 VA knee and lower leg examination revealed diagnosis of osteoarthritis of the right knee, bilateral patellofemoral pain syndrome, and patella tendinitis of the right knee. The Veteran reported that he experienced sharp pain in his legs since 1995. The examiner stated that there was no pathology to render a diagnosis of a right leg disorder. October 2017 VA treatment records note a history of edema and indicated that the right leg was three times larger than the left leg. A venous duplex of the lower extremity was positive for venous reflux in the right great saphenous vein. In November 2017, the Veteran underwent ablation of varicose vein using adhesive. Follow-up records indicated a successful vena seal closure of the right great saphenous vein with improvement in appearance but not in swelling. In June 2018, the Veteran continued to report right lower extremity edema. A July 2018 venous duplex revealed severe reflux involving the superficial veins of the bilateral lower extremities. He continued to experience right lower extremity edema, which VA providers found was less likely due to congestive heart failure and lymphedema. The matter was remanded in May 2019 for an opinion as to whether the claimed disorder was related to service or to service-connected hypertensive heart disease. The record reflects that the Veteran was afforded a VA knee and lower leg examination in February 2020, at which time the examiner indicated there was no evidence to support additional diagnosis beyond the right knee disorder for which he is already service-connected. However, there is no indication that the examiner elicited a symptom history from the Veteran. The prior history of venous reflux in the right great saphenous and ablation was not noted, nor were the Veteran’s reports of consistent extremity swelling in and since service noted. Moreover, the Board observes that disabilities involving the veins are not orthopedic disorders, and therefore a knee and lower leg examination may not be sufficient to confirm the presence of a current disability. See 38 C.F.R. § 4.104 (including diseases of the arteries and veins as part of the schedule of ratings for cardiovascular disorders). Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran’s documented medical history and assertion, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. Stegall, 11 Vet. App. at 271. 2. Service connection for a respiratory disorder The Veteran’s service treatment records contain multiple entries documenting complaints of and treatment for shortness of breath, wheezing, and hyperventilation. March 1978 and March 1979 reports showed that he complained of chest pain, shortness of breath, and breathing problems due to hyperventilation. A March 1987 acute medical care note indicated that his shortness of breath was due to his weight. In September 1981, June 1983, and August 1987, the Veteran was noted to have situational stress with hyperventilation. The August 1995 retirement examination indicated that his lungs were clinically normal. However, on the associated report of medical history, he noted shortness of breath. The physician noted occasional shortness of breath with walking or running. Dyspnea on exertion was also noted on post-service general medical examination in May 1997. A 2013 VA treatment record indicates that the Veteran had been prescribed an inhaler. An August 2017 post-service VA treatment records document the Veteran’s complaints of wheezing and shortness of breath. He reported a history of asthma and was advised to use inhalers. A July 2018 pulmonary function test revealed mild air trapping and mild restrictive lung disease. December 2018 records noted chronic respiratory insufficiency due to heart failure. On VA respiratory examination in January 2020, the Veteran reported that his doctor told him in 1996 that he had asthma. The examiner diagnosed asthma and noted a date of diagnosis of 2020. The examiner found the Veteran’s asthma to be less likely than not related to service. In so finding, the examiner noted that there were no complaints related to asthma in service except for a few notations of sore throat. The examiner also found a relationship between asthma and the service-connected heart disorder less likely than not, noting that there was no medical pathology to establish a relationship on a causal or aggravation basis. However, the examiner did not consider the in-service reports of shortness of breath. Moreover, the examiner did not discuss the post-service history of similar respiratory symptoms, the Veteran report of earlier diagnosis of asthma and chronic symptoms, or the VA treatment records documenting earlier use of an inhaler. Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran’s documented medical history and assertions and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. Stegall, 11 Vet. App. at 271. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of his right leg disorder, to specifically include consideration of disorders of the right leg veins. All pertinent evidence of record must be made available to and reviewed by the examiner. All necessary tests and studies should be performed. The examiner must identify all right leg disorders (other than his service-connected right knee osteoarthritis and right lower extremity radiculopathy) present during the period of the claim. Following a review of the relevant records and lay statements, the examiner must provide the following opinions with respect to each disorder present during the period of the claim. (a)Whether it is at least as likely as not (50 percent or greater probability) that the disorder manifested in or is otherwise related to active duty service, to include any symptomatology therein. (b)Whether it is at least as likely as not (50 percent or greater probability) that the disorder was caused or aggravated by his service-connected heart disorder. Separate opinions regarding causation and aggravation are required. In so opining, the examiner should consider and discuss the following: (1) the August 1995 report of medical history noting a 20-year history of leg cramps during exercise; (2) the May 1997 VA examination showing superficial varicose veins on bilateral legs and a few sacculations over the right medial thigh; (3) the post-service VA treatment records showing treatment for venous reflux in the right great saphenous vein and right lower extremity edema; and (4) the August 2018 VA treatment record indicating that his continuing edema was likely due to congestive heart failure and lymphedema. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 2. Forward the claims file to an examiner with sufficient expertise for addendum opinion as to the nature and etiology of the claimed respiratory disorder. All pertinent evidence of record must be made available to and reviewed by the examiner. If additional examination is deemed necessary, one should be provided. Following a review of the relevant records and lay statements, the examiner must provide the following opinions with respect to the diagnosed asthma: (a) Whether it is at least as likely as not (50 percent or greater probability) that the disorder manifested in or is otherwise related to active duty service, to include any symptomatology therein. (b) Whether it is at least as likely as not (50 percent or greater probability) that the disorder was caused or aggravated by his service-connected disorder, to include his heart disorder and psychiatric disorder. Separate opinions regarding causation and aggravation are required. In providing the requested opinion, the examiner should specifically consider and address the service treatment records documenting complaint of shortness of breath, the 1997 report of dyspnea on exertion, and the reports of prescribed inhaler. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. 3. The agency of original jurisdiction must review the examination reports and opinions to ensure they are adequate and comply with the Board’s specific remand directives herein. If deficient in any manner, corrective action must be taken at once. J. O’CONNELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.