Citation Nr: 21023685 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-35 437A DATE: April 21, 2021 ORDER A rating of 20 percent, but no higher, for residuals of a right ankle sprain is granted. For the rating period prior to October 29, 2019, a 20 percent rating, but no higher, for residuals of a left ankle sprain is granted. For the rating period beginning October 29, 2019, a rating in excess of 20 percent for residuals of a left ankle sprain is denied. For the rating period prior to November 1, 2014, a rating in excess of 30 percent for arthritis of the cervical spine is denied. For the rating period from November 1, 2014 to October 28, 2019, a rating of 30 percent, but no higher for arthritis of the cervical spine is granted. For the rating period beginning October 29, 2019, a rating in excess of 30 percent for arthritis of the cervical spine is denied. A rating in excess of 10 percent for right knee chondromalacia is denied. A rating in excess of 10 percent for left knee chondromalacia is denied. A separate 10 percent rating, but no higher, for right knee instability is granted. A separate 10 percent rating, but no higher, for left knee instability is granted. A 20 percent rating, but no higher, for residuals of a right heel calcaneal spur excision is granted. A rating of 10 percent, but no higher, for a right heel scar is granted. A rating in excess of 10 percent for right elbow arthritis is denied. REMANDED Entitlement to service connection for fibromyalgia (also claimed as chronic pain syndrome) is remanded. Entitlement to a separate rating for cervical spine radiculopathy is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s right and left ankle disabilities, characterized by reduced range of motion, altered gait, and instability (to include during periods of flare-ups) more nearly approximate marked limitation of motion throughout the entire rating period on appeal. 2. For the entire rating period on appeal, and in consideration of the Veteran’s pain and functional impairment during flare-ups, the Veteran’s cervical spine disability more nearly approximated forward flexion of the cervical spine to 15 degrees. 3. For the entire rating period on appeal, the Veteran’s cervical spine disability is not manifested by unfavorable ankylosis of the entire cervical spine and/or incapacitating episodes that required bed rest prescribed by a physician and treatment by a physician having a total duration of at least four weeks during the past twelve months. 4. The Veteran’s right and left knee disabilities have been manifested by painful motion and slight, subjective lateral instability, but not moderate recurrent subluxation or lateral instability, ankylosis, limitation of flexion to 45 degrees, limitation of extension to 10 degrees, dislocated or removed semilunar cartilage, or impairment of the tibia or fibula. 5. The Veteran’s residuals of a right heel calcaneal spur excision more nearly approximate a “moderately severe” foot injury. 6. The Veteran’s right heel surgical scar is neither painful nor unstable. 7. The Veteran’s right elbow arthritis is manifested by pain and limitation of motion; there are no findings of ankylosis; flexion functionally limited to 90 degrees or less; extension functionally limited to 75 degrees or more; an elbow flail joint; impairment of the ulna; impairment of the radius; or significant limitation of supination or pronation. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating, but no higher, for residuals of a right ankle sprain disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2020); 85 Fed. Reg. 76464 (Feb 7, 2021). 2. For the rating period prior to October 29, 2019, the criteria for a 20 percent rating, but no higher, for residuals of a left ankle sprain disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2020); 85 Fed. Reg. 76464 (Feb 7, 2021). 3. For the rating period beginning October 29, 2019, the criteria for a rating in excess of 20 percent for residuals of a left ankle sprain disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2020); 85 Fed. Reg. 76464 (Feb 7, 2021). 4. For the rating period prior to November 1, 2014, the criteria for a rating in excess of 30 percent for arthritis of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5242 (2020). 5. For the rating period from November 1, 2014 to October 28, 2019, the criteria for a rating of 30 percent, but no higher, for arthritis of the cervical spine are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5242 (2020). 6. For the rating period beginning October 29, 2019, the criteria for a rating in excess of 30 percent for arthritis of the cervical spine are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5242 (2020); 85 Fed. Reg. 76462 (Feb 7, 2021). 7. The criteria for a rating in excess of 10 percent for right knee chondromalacia are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 8. The criteria for a rating in excess of 10 percent for left knee chondromalacia are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 9. The criteria for a separate 10 percent rating, but no higher, for right knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020); 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). 10. The criteria for a separate 10 percent rating, but no higher, for left knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020); 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). 11. The criteria for a 20 percent rating, but no higher, for residuals of a right heel calcaneal spur excision are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.118, Diagnostic Code 5284 (2020). 12. The criteria for a rating of 10 percent, but no higher, for a right heel surgical scar have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2020). 13. The criteria for a disability rating in excess of 10 percent for right elbow arthritis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1979 to June 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2013 and August 2014 rating decisions. The issues on appeal were previously remanded by the Board in December 2018 and October 2020 for further development. As it pertains to the cervical spine disability, the August 2013 rating decision continued an assigned 30 percent rating for the Veteran’s cervical spine arthritis. The Veteran filed a timely notice of disagreement (NOD) to this rating decision in June 2014. Thereafter, an August 2014 rating decision decreased the rating for cervical spine arthritis to 20 percent effective November 1, 2014. The Veteran filed a timely NOD to this rating decision in March 2015. Effectively, the Veteran initiated an appeal for both the denial of a higher rating and the propriety of the reduction. However, the Agency of Original Jurisdiction (AOJ) issued a September 2015 statement of the case (SOC) which only addressed whether a rating higher than 20 percent was warranted for cervical spine arthritis. It did not address the propriety of the reduction from 30 percent to 20 percent. Therefore, the Board remanded the claim in December 2018 in order to provide the Veteran with the required SOC for the reduction issue. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). In October 2020 the Board again remanded the reduction issue as the RO had issued a supplemental SOC instead of a SOC. Following the Board’s remand, the RO issued a SOC in November 2020. The Veteran has not filed a substantive appeal as it pertains to the propriety of the reduction from 30 percent to 20 percent for the cervical spine. As such, this issue is not before the Board. Nonetheless, the Board is granting a 30 percent evaluation for the entire rating period on appeal. As such, the propriety of the reduction is essentially moot. Disability Ratings Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509- 10 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran’s service-connected disability. 38 C.F.R. § 4.14 (2020). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Right and Left Ankle Disabilities The Veteran is currently in receipt of a 10 percent rating for his right ankle disability under Diagnostic Code 5271. The Veteran is in receipt of a 10 percent rating for his left ankle disability prior to October 29, 2019, and is in receipt of a 20 percent rating thereafter. DC 5271 assess limitation of motion of the ankle as either moderate, warranting a 10 percent rating, or marked, warranting a 20 percent rating. Higher ratings for the ankle are warranted only when the ankle is ankylosed. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. The words “moderate” and “marked,” as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Effective February 7, 2021, VA’s Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38 C.F.R. § 4.71a). As it pertains to the ankle, the amended regulations clarify that “Marked” limitation of motion of the ankle requires less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. “Moderate” limitation of motion in the ankle requires less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. See 85 Fed. Reg. 76464 (Feb 7, 2021). The medical evidence of record shows decreased range of motion in both ankles throughout the entire rating period on appeal. As it pertains to the right ankle, motion has been shown to be limited to, at worst, 10 degrees in dorsiflexion and 11 degrees in plantar flexion, to include during flare-ups. See October 2019 VA ankle examination report. Previous VA examination reports show greater range of motion in the right ankle, but consideration of loss of motion during flare-ups was not provided at those times. See e. g., January 2013 VA examination (finding dorsiflexion limited to 10 degrees following repetitive use and limited to 45 degrees in plantar flexion.); see also September 2015 VA examination (right ankle dorsiflexion limited to 15 degrees and plantar flexion limited to 35 degrees). Regarding the left ankle, motion was found to be limited to, at worst, 12 degrees in dorsiflexion and 5 degrees in plantar flexion, to include during flare-ups. See October 2019 VA ankle examination report. Earlier VA examination reports show some limitation of motion in the left ankle, but again, consideration of loss of motion during flare-ups was not provided. See e. g., January 2013 VA examination (finding dorsiflexion limited to 20 degrees following repetitive use and limited to 45 degrees in plantar flexion.); see also September 2015 VA examination (left ankle dorsiflexion limited to 15 degrees and plantar flexion limited to 40 degrees). Private treatment records from the Brooks Clinic in 2012 show numerous complaints of bilateral ankle pain. In a July 2012 record, the Veteran presented with bilateral ankle pain and described the pain as “sharp” and “constant.” Upon examination, the Veteran had pain to palpation with decreased range of motion in all planes, although specific degrees were not indicated. During a November 2012 treatment session, the Veteran indicated that he “feels ankles will give out.” In a December 2012 treatment note, it was indicated that the Veteran’s gait was slowed, and he could not walk “on tip toes or heels due to ankle pain.” The Veteran required the use of a cane to assist with ambulation. The Veteran also displayed pain upon rising from a seated position and while transitioning through the first few steps. The Veteran has also described his ankle flare-ups as very painful and resulting in stiffness in the joint. See e. g., September 2015 VA examination. The Veteran has indicated that his ankle pain was aggravated by walking. He also reported experiencing stabbing pain at random. See October 2019 VA examination. He has consistently reported difficulty walking and an inability to run. See January 2013 VA examination. Upon review of the evidence of record, the Board finds that 20 percent ratings, but no higher, for the right and left ankle disabilities are warranted throughout the entire rating period on appeal. Although range of motion testing prior to the October 2019 VA examination showed higher degrees of motion, the 2013 and 2015 VA examiners did not properly consider the Veteran’s symptoms and functional limitations during flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017) (addressing what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups). In addition to limitation of motion of the ankle, the Board has specifically considered the Veteran’s altered gait, use of a cane, and reports of instability of the ankle joints. Additionally, the Veteran continuously reported having difficulty walking and an inability to run. As such, 20 percent rating are warranted for the right and left ankle disabilities throughout the entire rating period on appeal. The Board further finds that ratings in excess of 20 percent are not warranted for the rating period on appeal. A 20 percent rating is the highest rating available under DC 5271. Further, there is neither lay reports nor medical evidence of ankylosis of the ankle. As such, higher ratings are not available under DC 5270. Cervical Spine Disability The Veteran is currently in receipt of a 30 percent rating for his cervical spine disability for the rating period prior to November 1, 2014. From November 1, 2014 to October 28, 2019, the Veteran’s cervical spine rating was assigned a 20 percent evaluation. His rating was increased to 30 percent effective October 29, 2019. The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) encompasses such disabling symptoms as pain, ankylosis, limitation of motion, muscle spasm, and tenderness. Diagnostic codes 5235-5243 are included under the General Rating Formula. Under the General Rating Formula, the following ratings are either currently assigned or available: 100 percent for unfavorable ankylosis of the entire spine; 40 percent for unfavorable ankylosis of the entire cervical spine; 30 percent for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS) provides a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Effective February 7, 2021, VA’s Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38 C.F.R. § 4.71a). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3-2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021.  Hence, VA has made clear that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied.  For applications filed on or after the effective date, only the new criteria will be applied.  As the Veteran’s claim was pending prior to February 7, 2021, the Board will consider entitlement under the prior regulations as well as the updated regulations from February 7, 2021 forward, applying the most favorable criteria for the Veteran. The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5242 and 5243 were not to the rating schedule itself but added instruction to classify disabilities associated with IVDS under DC 5243 and all other intervertebral disc disabilities under 5242. As such, DC 5242 now reflects “Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)”; DC 5243 now reflects “Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve route; assign diagnostic code 5242 for all other disc diagnoses.” As such, the changes do not impact the general rating formula and evaluation of the disability under the pre-and post-February 7, 2021 regulations is not required. Upon review of the record, the Board further finds that the evidence is in equipoise as to whether the Veteran’s cervical spine disability more nearly approximates a 30 percent rating, but no higher, for the entire appeal period. Throughout the rating period on appeal, the Veteran’s cervical spine flexion has been limited between 11 degree and 25 degrees. See January 2013 VA spine examination (flexion limited to 20 degrees, with pain starting at 20 degrees and following repetitive use testing); see also April 2014 VA spine examination (flexion of the cervical spine was limited to 25 degrees, to include after repetitive use testing); see October 2019 VA cervical spine examination (flexion was limited to 11 degrees, to include during flare-ups). The Veteran has not been diagnosed with IVDS of the cervical spine. Notably, the October 2019 VA examination was the only evaluation which considered the Veteran’s additional functional loss (in degrees) during flare-ups. The Veteran has also described his neck pain as “severe,” especially during weather changes. See e. g, April 2015 VA examination. Private treatment records dated in July 2012 show that the Veteran had aching and constant neck pain that was described as “incapacitating.” The Veteran has also been awarded Social Security Administration disability benefits, in part, due to his cervical spine disability. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s cervical spine disability more nearly approximates a 30 percent rating for the entire increased rating period on appeal. As there is no medical evidence of ankylosis of the cervical spine, a rating in excess of 30 percent is not warranted. See e. g. January 2013, April 2015, and October 2019 VA examination reports (noting that the Veteran did not have ankylosis of the cervical spine). The Board may also consider whether higher ratings based upon the Formula for Rating IVDS Based on Incapacitating Episodes are warranted. The record does not reflect that the Veteran has IVDS or that he has been prescribed periods of bed rest for cervical spine IVDS during the appeal period which would meet the criteria for a higher rating in excess of 30 percent. Thus, the Board finds that this alternative rating method likewise provides no basis for any higher rating. Accordingly, the Board finds that, for the rating period prior to November 1, 2014, a rating in excess of 30 percent for arthritis of the cervical spine is not warranted. For the rating period from November 1, 2014 to October 28, 2019, a rating of 30 percent, but no higher for arthritis of the cervical spine is granted. For the rating period beginning October 29, 2019, a rating in excess of 30 percent for arthritis of the cervical spine is not warranted. The issue regarding whether separate ratings for cervical spine radiculopathy are warranted is being addressed in the remand section below. Right and Left Knee Disabilities The Veteran seeks higher ratings in excess of 10 percent for his service-connected right and left knee disabilities, diagnosed as chondromalacia. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to Diagnostic Code 5003, 5010, and 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, Diagnostic Code 5010, instructed the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under the revised criteria, Diagnostic Code 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under both the earlier and revised rating criteria, degenerative arthritis is rated under Diagnostic Code 5003. Under this code, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA’s General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As it pertains to recurrent subluxation or instability of the knee, and as noted above, revisions to Diagnostic Code 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76457 (Feb 7, 2021). Because these changes took effect during the pendency of the Veteran’s appeal, both the former and revised criteria will be considered in evaluating the Veteran’s service-connected right knee disability. However, application of the new criteria prior to the effective date of the amended regulation is not allowed. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Green v. Brown, 10 Vet. App. 111, 116-119 (1997); see also 38 U.S.C. § 5110 (g). Prior to February 7, 2021, instability of the knee was rated under Diagnostic Code 5257, which provided ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee, which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As it pertains to patellar instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See DC 5257 (Effective February 7, 2021). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. The Veteran’s currently assigned 10 percent ratings have been awarded based on painful motion of the knee joints. Because the Veteran’s range of knee motion in flexion, to include during repetitive use testing, has been no worse than 100 degrees (right knee) and to 90 degrees (left knee), ratings in excess of 10 percent are not warranted under DC 5260. See January 2013 VA examination report (noting flexion limited to 100 degrees bilaterally and normal extension); see September 2015 VA examination (flexion in the right knee limited to 100 degrees and limited to 90 degrees in the left following repetitive use testing); see also October 2019 VA examination report (indicating that flexion was limited to 100 degrees bilaterally during flare-ups and following repetitive use testing, bilaterally). Further, as noted in the 2013, 2015, and 2019 VA knee examination reports, the Veteran has been able to fully extend both knees; as such, higher or separate compensable ratings under Diagnostic Code 5261 are not warranted. The Board recognizes the Veteran’s reports of continued bilateral knee pain and stiffness, as discussed in the VA examination reports dated in 2013, 2015, and 2019. The Board considered this knee pain, as well as any additional limitations of motion due to pain (including difficulty with prolonged sitting, walking, running, kneeling, and bending). However, even considering additional limitation of motion or function of the knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), the evidence still does not show that the bilateral knee disability more nearly approximates the criteria for a higher ratings. Repetitive-use testing during the VA examinations discussed above showed no significant decreased range of motion in either knee. Moreover, there is no evidence of any knee ankylosis, dislocated semilunar cartilage, or malunion of the tibia and fibula to support higher or separate ratings under DCs 5256, 5258, or 5262. The Board next finds that, based on the evidence of record, the Veteran’s right and left knee disabilities, based on instability, warrant separate 10 percent ratings throughout the period on appeal. Stability testing during the period on appeal has consistently found no instability; however, the Veteran has reported that his knees are unstable. See e. g., September 2015 VA examination report (Veteran reported that he was unable to walk or stand for long periods and that his knee was “very unstable when walking or standing.”); see also October 2019 VA examination report (Veteran reported occasionally wearing knee braces). Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347 (2018). Because the Veteran has competently and credibly reported bilateral knee instability symptoms, the Board finds that separate 10 percent ratings are warranted for slight lateral instability for the rating period on appeal. The Veteran’s knee instability is not more accurately described as moderate. The medical records do not specifically describe instability of the knee joints and VA examiners and private treatment records have consistently found that the knee joints are normal on all stability tests. The Board finds that knee instability that causes functional impairment but is undetectable on all forms of examination is best characterized as slight in nature. The Board has also considered whether higher ratings are warranted beginning February 7, 2021, and pursuant to the revised criteria for DC 5257. In this case, the Veteran has been shown to have chondromalacia and has not been diagnosed with a sprain, incomplete ligament tear, or repaired complete ligament tear. Further, the Veteran’s bilaterally knee instability does not more nearly approximate “recurrent instability.” As noted above, VA and private examiners have consistently found that the knee joints are normal on all stability tests. The Veteran’s chondromalacia associated with his knees has also not required surgical repair. Accordingly, higher ratings for instability of the knee joints is not warranted under both the earlier and revised rating criteria. For these reasons, the Board finds that separate 10 percent ratings are warranted for slight lateral instability of the right and left knee for the rating period on appeal. The Board further finds that the weight of the evidence is against a grant of ratings in excess of 10 percent for painful motion associated with chondromalacia of the right or left knee. 38 U.S.C.§ 5107 (b); 38 C.F.R. §§ 4.3, 4.7. Residuals of Right Heel Calcaneal Spur Excision and Scar The Veteran’s right heel disability is currently rated as 10 percent disabling under DC 5284 for the entire rating period on appeal. His right heel scar has been assigned a noncompensable rating. Under DC 5284, a 10 percent rating is assigned for moderate foot injury. A 20 percent rating is assigned for moderately severe foot injury. A severe foot injury warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5284. A Note to DC 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. The words “moderately severe” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “slight” and “moderate” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Upon review of the evidence of record, the Board finds that the Veteran’s right heel disability symptomatology more nearly approximates that contemplated by a 20 percent initial rating under DC 5284 for a moderately severe foot injury. 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5284. In this regard, the Veteran has continuously reported symptoms of sharp and aching heel and foot pain. See e. g., January 2013, September 2015, and October 2019 VA foot examination reports. The Veteran has further indicated that his heel pain impacts his ability to walk and stand. During a September 2015 VA examination, the examiner specifically indicated that the Veteran’s heel disability compromised weight bearing and resulted in pain on movement and disturbance of locomotion. The Veteran has used a cane to assist with ambulation as a result of his ankle and heel pain. During the October 2019 VA examination, it was further indicated that the Veteran’s pain was located in the heel and outside of the ankle with “sharp electrical like jolt to outside of right foot and across the top of foot.” This electric-like jolt was noted to also radiate to the lateral calf. The Veteran was limited in climbing stars and ladders, and had pain with prolonged standing and walking. The Board also notes that the Veteran underwent excision of a right Haglund deformity (i. e., an enlargement of the bony section of the heel) in June 2017. Treatment records from Dr. Traczyk surrounding this time indicate continued complaints of pain in the right heel, which was noted to be worse with ambulation and increased activity. Despite previous treatment, to include the excision of the right heel spur in 1994, his symptoms persisted. In July 2017 and August 2017 post-operative follow up notes, Dr. Traczyk indicated that the Veteran was “still” having numbness on the lateral aspect of the right heel. He also reported “significant” pain with range of motion of the ankle and “burning” pain along the peroneal nerve and lateral achilles from the calf to the heel. The Board finds that the Veteran’s symptoms, to include an additional surgery in 2017, are suggestive of functional impairment more nearly approximating moderately severe foot injury for the service-connected right foot disability. For these reasons, a 20 percent rating is warranted for the Veteran’s service-connected right heel disability. Neither the Veteran nor his representative has challenged the use of Diagnostic Code 5284 to rate his service-connected right heel disability. The Board has considered whether any other diagnostic code applicable to the foot could warrant a higher rating, or separate compensable ratings. The Veteran’s service-connected disability does not include flat foot; weak foot; claw foot; metatarsalgia, anterior (Morton’s disease); hallux valgus; or hammertoe. Thus, alternative Diagnostic Codes 5276, 5277, 5278, 5279, 5280, and 5282 are not for application. The Board finds that despite the Veteran’s complaints of heel pain with prolonged walking or prolonged standing, the clinical record reflects that he has remained ambulatory. The Veteran’s use of a cane has not been found to be solely due to his heel disability, but instead, was noted to be used to support his knees and back. Moreover, neither the Veteran nor any examiner has established that the Veteran’s pain results in functional loss that would equate to a severe level of disability during the entirety of the appellate period. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinsky, 1 Vet. App. 49 (1990). Right Heel Scar The Veteran is in receipt of a noncompensable evaluation for his right heel scar. The Veteran is currently rated pursuant to Diagnostic Code 7805. During the pendency of this appeal, VA recently published a final rule amending its regulations on skin disabilities effective August 13, 2018. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted VA to do otherwise and VA did so. See VAOGCPREC 7-2003. The Board will therefore evaluate the Veteran’s scars under both the old and new criteria, keeping in mind that the revised criteria may not be applied to any time period before the effective date of the change. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114 ; VAOPGCPREC 3-2000 (Apr. 10, 2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Board will discuss both periods of regulations in order to determine if a compensable rating is warranted under the applicable scar criteria during that time period. Under the scar regulations in effect prior to August 13, 2018, scars that, as here, do not impact the head, face, or neck are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805. Under Diagnostic Code 7801, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is deep and nonlinear, and covers an area of at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7802, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is superficial and nonlinear, and covers an area of at least 144 square inches (929 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable of painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7805, any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect from October 23, 2008 to August 13, 2018). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are associated with underlying soft tissue damage. Scars that are associated with underlying soft tissue damage in an area or areas exceeding 6 square inches (39 square centimeters) are rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 square centimeters) are rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 square centimeters) are rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 square centimeters) are rated as 40 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect since August 13, 2018). Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are not associated with underlying soft tissue damage. A scar that is not associated with underlying soft tissue damage in an area or areas of 144 square inches (929 square centimeters) or greater is rated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect since August 13, 2018). Diagnostic Code 7804 provides ratings for scars that are unstable or painful. One or two scars that are unstable or painful are rated as 10 percent disabling. Three or more scars that are unstable or painful are rated as 20 percent disabling. Five or more scars that are unstable or painful are rated as 30 percent disabling. Note (1) to DC 7804 provides that an unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804 (in effect since August 13, 2018). Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect since August 13, 2018). The only VA examination report that specifically addresses the Veteran’s right heel scar is the October 2019 VA scar examination. At that time, the examiner indicated that the Veteran had undergone surgery to the right heel in 1994 and “had another surgery for bone spur,” presumably referring to the 2017 procedure. The examiner indicated that the right heel scar measure 3.5cm by 0.2 cm. There was no limitation of function noted as a result of the scar. At the time of the examination, the Veteran reported pain over the scar. The Veteran’s treatment records do not document any residual complaints or treatment for his heel scar. For these reasons, the Board finds that a 10 percent rating, but no higher, for the right heel scar is warranted. The Board has also considered whether the Veteran is entitled to a compensable rating under a different diagnostic code. However, the objective findings noted in the VA examinations do not warrant compensable ratings under Diagnostic Codes 7801, 7802, or 7804 either prior to or since August 13, 2018, as the scar does not cover an area of at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.) (Diagnostic Code 7801); cover an area of at least 144 square inches (929 sq. cm.) (Diagnostic Code 7802); or, are described as painful or unstable (Diagnostic Code 7804). Accordingly, a 10 percent rating for pain associated with the right heel scar is warranted. However, as the preponderance of the evidence is against a finding of a rating in excess of 10 percent, the benefit-of-the-doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. 55. Right Elbow Arthritis The Veteran’s right elbow disability (dominant extremity) has been assigned a 10 percent rating throughout the entire period on appeal for arthritis with limitation of motion (limitation of motion in flexion from November 2009 to October 28, 2019, and limitation of supination beginning October 29, 2019). The Board will consider whether a rating in excess of 10 percent is warranted for the service-connected right elbow disability under any of the potentially applicable criteria for evaluating the elbow and forearm, which are found at 38 C.F.R. § 4.71a, DCs 5205 through 5213. DC 5205 provides that ankylosis of the major elbow is to be rated as follows: for favorable ankylosis of the elbow at an angle between 90 degrees and 70 degrees, a 40 percent rating is warranted; for intermediate ankylosis of the elbow, at an angle of more than 90 degrees, or between 70 degrees and 50 degrees, a 50 percent rating is warranted; for unfavorable ankylosis of the elbow, at an angle of less than 50 degrees or with complete loss of supination or pronation, a 60 percent rating is warranted. Under DC 5206, a 10 percent rating contemplates flexion of either forearm limited to 100 degrees. A 20 percent rating contemplates flexion of either forearm limited to 90 degrees or flexion of the minor forearm limited to 70 degrees. A 30 percent rating contemplates flexion of the major forearm limited to 70 degrees. A 40 percent rating contemplates flexion of the major forearm limited to 55 degrees. A maximum 50 percent rating contemplates flexion of the major forearm limited to 45 degrees or less. DC 5207 provides that extension of the major forearm limited to 45 degrees is rated as 10 percent disabling; limited to 60 degrees is rated as 10 percent; 75 degrees is rated as 20 percent; limited to 90 degrees is rated 30 percent; limited to 100 degrees is rated 40 percent; and limited to 110 degrees is rated 50 percent disabling. DC 5208 provides that major forearm flexion limited to 100 degrees with forearm extension limited to 45 degrees is rated 20 percent. 38 C.F.R. § 4.71a. DC 5209 provides ratings for other impairment of the elbow. Joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, is rated 20 percent disabling for the major side. Flail joint of the elbow is rated 60 percent disabling for the major side. 38 C.F.R. § 4.71a DC 5210 provides that nonunion of the radius and ulna, with flail false joint, is rated 50 percent disabling for the major side. DC 5211 provides for ratings based on impairment of the ulna. Malunion of the ulna with bad alignment is rated 10 percent for the major side; nonunion of the ulna in the lower half is rated 20 percent for the major side; nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity is rated 30 percent for the major side; nonunion of the ulna in the upper half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent for the major side. DC 5212 provides for ratings based on impairment of the radius. Malunion of the radius with bad alignment is rated 10 percent disabling for the major side; nonunion of the radius in the upper half is rated 20 percent disabling for the major side; nonunion of the radius in the lower half, with false movement, without loss of bone substance or deformity is rated 30 percent disabling for the major side; nonunion of the radius in the lower half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent disabling for the major side. DC 5213 provides ratings based on impairment of supination and pronation of the forearm. Under this Code, supination of the forearm limited to 30 degrees or less is rated 10 percent disabling for the major side. Limitation of pronation with motion lost beyond the last quarter of arc, so the hand does not approach full pronation, is rated 20 percent disabling for the major side; limitation of pronation with motion lost beyond the middle of arc is rated 30 percent disabling for the major side. Loss of supination or pronation due to bone fusion, with the hand fixed near the middle of the arc or moderate pronation, is rated 20 percent disabling for the major side; loss of supination or pronation due to bone fusion, with the hand fixed in full pronation, is rated 30 percent disabling for the major side; and loss of supination or pronation due to bone fusion, with the hand fixed in supination or hyperpronation, is rated 40 percent disabling for the major side. The normal range of motion of the elbow is from 0 degrees of extension to 145 degrees of flexion. 38 C.F.R. § 4.71, Plate I. After a review of the evidence, the Board finds the Veteran is not entitled to a rating in excess of 10 percent for his service-connected right elbow disability. The Board notes that the Veteran has a diagnosis of arthritis of the right elbow and reports limitation of motion due to symptoms of pain. While the Board finds that this warrants the Veteran’s current 10 percent rating, a rating in excess of 10 percent is not warranted. Even when taking into account the Veteran’s complaints of pain and functional loss (to include during periods of flare-ups), the record does not reflect his right elbow disability is manifested by flexion limited to 90 degrees; extension limited to 75 degrees; flexion limited to 100 and extension to 45; loss of supination or pronation due to bone fusion with the hand fixed near the middle of the arc or moderate pronation, nor limitation of pronation with motion lost beyond the last quarter of the arc with the hand not approaching full pronation or limitation of supination to 30 degrees or less. In this regard, the Veteran’s limitation of motion in flexion has been limited to, at worst, 105 degrees following repetitive use testing and during flare-ups. See October 2019 VA examination report. Compare January 2013 VA examination (noting flexion limited to 140 degrees); see April 2014 VA examination (flexion limited to 100 degrees, to include after repetitive use testing); see also September 2015 VA examination report (noting that flexion was limited to 125 degrees). Moreover, the 2013, 2014, 2015, and 2019 VA elbow examination reports showed full range of motion of the right elbow in extension. Forearm supination and pronation were only slightly limited to, at worst, 75 degrees in supination and 70 degrees in pronation, to include during flare-ups. See October 2019 VA examination report. In view of the foregoing, the Board finds that the Veteran does not reflect the Veteran meets or nearly approximates the criteria for a rating in excess of 10 percent for his right elbow disability based upon range of motion; i.e., he is not entitled to a rating in excess of 10 percent under DCs 5206, 5207, 5208 or 5213. To the extent that the Veteran has a diagnosis of arthritis of the right elbow, the Board finds that a rating in excess of 10 percent is not warranted as only one joint (the right elbow) is involved and has a documented diagnosis of arthritis. Under DC 5003/5010, a 20 percent rating is not warranted unless there is x-ray evidence of 2 or more major joints with occasional incapacitating episodes. See 38 C.F.R. § 71.a, DC 5003. With respect to the other potentially applicable DCs, the Board notes that the Veteran has never been diagnosed with ankylosis of the right elbow. In fact, the 2015 and 2019 examinations specifically noted the Veteran did not have joint ankylosis. Therefore, DC 5205 is not applicable to the instant case. The evidence also does not show any impairment of the radius that indicates nonunion of the radius or malunion with improper alignment. Accordingly, a rating of 20 percent is not warranted under DCs 5209, 5210, 5212, and 5213. (As no impairment of the Ulna has been shown 5211 is also not applicable.) For these reasons, the Board finds that the Veteran does not meet or nearly approximate the schedular criteria for a rating in excess of 10 percent for his service-connected right elbow disability under any of the potentially applicable DCs. In making this determination, the Board considered the Veteran’s complaints of pain. However, a thorough review of the record does not indicate the Veteran met or nearly approximated the criteria for a rating in excess of 10 percent even when taking into account his complaints of pain and functional impairment. 38 U.S.C.§ 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND Fibromyalgia (also claimed as Chronic Pain Syndrome) In October 2019, the Veteran was afforded a VA fibromyalgia examination. At that time, the examiner indicated that the Veteran had been diagnosed with “subjective” chronic pain syndrome in 2012. However, in a corresponding medical opinion, the examiner stated that the Veteran did not meet the criteria for a diagnosis of fibromyalgia. Instead, the examiner noted that symptoms of fibromyalgia could be confused with those of arthritis or other inflammatory conditions. It was further noted that the only diagnosis was for “subjective” chronic pain syndrome. In a following December 2020 medical opinion, the VA examiner indicated that the Veteran’s pain was due to other conditions, to include the cervical spine and shoulder disabilities. The examination report findings did not support a diagnosis of fibromyalgia as evidence by lack of pain to multiple trigger points. Private treatment records beginning in 2012 show diagnoses of chronic pain syndrome, treated with Butrans patch (a narcotic used to treat pain). In a November 2012 record, the Veteran complained of pain in “multiple sites,” including in joints and between joints. He reported that he “aches like the flu.” The pain was noted to be “all over,” and not just in the joints. He also reported decreased energy, swelling, and stiffness in the joints. In sum, the evidence of record weighs both for and against a finding that there is a current diagnosis of chronic pain syndrome. It does not appear that the 2020 VA examiner properly considered the Veteran’s statements regarding pain in all parts of his body, and not just in the cervical spine and shoulder areas. A remand is required in order to obtain a medical opinion regarding whether the Veteran’s diagnosed chronic pain syndrome is related to service or to a service-connected disability. Cervical Spine Radiculopathy The General Formula for Diseases and Injuries of the Spine also, in pertinent part, provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, DC 5242, Note 1. The evidence is unclear as to whether the Veteran has radiculopathy of his upper extremities associated with the cervical spine disability. Although VA examination reports of record indicate that the Veteran did not have a diagnosis of radiculopathy, an April 2014 MRI report noted that the Veteran had “occasional radiculopathy symptoms down the posterior neck and occasional numbness and tingling down the right shoulder when sleeping down to the elbow.” During the January 2013 VA cervical spine examination, the Veteran reported having symptoms of pain, burning, and tingling. As such, the Board finds that the Veteran should be afforded a neurological examination to assist in determining the nature and severity of any diagnosed radiculopathy associated with his cervical spine disability. TDIU The issue of entitlement to a TDIU is intertwined with the claims being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Thus, adjudication of the TDIU claim is deferred. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination with an appropriate clinician for his chronic pain syndrome. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must provide opinions as to the following: (a.) The examiner shall assume that the Veteran has been diagnosed with chronic pain syndrome. See Private treatment records beginning in 2012 showing diagnoses of chronic pain syndrome, treated with Butrans patch. (b.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s chronic pain syndrome began during active service or is related to an incident of service. (c.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s chronic pain syndrome began was either caused or aggravated by a service-connected disability or disabilities. **It is also noted that aggravation need not be permanent. See Ward v. Wilkie, 31 Vet. App. 233 (2019). (d.) The examiner should provide a complete rationale for any opinions provided. 2. Schedule the Veteran a VA examination to assist in determining the nature and severity of his cervical spine radiculopathy, if any. A copy of the electronic claims folder must be made available and review by the examiner. A complete neurological evaluation with any tests and studies deemed necessary must be completed. For each upper extremity, the examiner must specifically identify the nerve that is involved and indicate whether there is complete paralysis. If incomplete paralysis is found, the examiner should indicate the severity of the symptoms. **The examiner should review the April 2014 MRI report noted that the Veteran had “occasional radiculopathy symptoms down the posterior neck and occasional numbness and tingling down the right shoulder when sleeping down to the elbow.” 3. Then, readjudicate the claims on appeal. T. Berry Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Casadei, 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.