Citation Nr: 21023834 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-23 127A DATE: April 21, 2021 ORDER A rating higher than 10 percent for painful loss of range of motion of the right arm as a gunshot residual is denied. A compensable rating for the right elbow scar as a gunshot residual to the right arm is denied. REMANDED Entitlement to service connection for a skin disability on the feet is remanded. Entitlement to service connection for the thoracolumbar spine disability is remanded. Whether a separate rating is warranted for right upper extremity carpal tunnel and/or ulnar nerve entrapment at the elbow as a residual of a gunshot wound is remanded. Entitlement to rating higher than 50 percent for the service-connected posttraumatic stress disorder (PTSD) is remanded. Prior to November 7, 2013, entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The gunshot wound to the right arm has manifested as pain, stiffness, and decreased right arm motion that includes flexion to no less than 125 degrees, extension to zero degrees, pronation to no less than 80 degrees, and supination to no less than 45 degrees. 2. A preponderance of the evidence is against a finding that the gunshot wound residuals includes a currently diagnosed muscular or tendon disability. 3. A preponderance of the evidence is against a finding that the scar from the gunshot wound on the right arm is painful. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for loss of range of motion for the right arm as a gunshot residual are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5205-5213. 2. The criteria for a compensable rating for a right arm gunshot wound scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1966 to November 1968. The Veteran was awarded a Purple Heart and a Vietnam Service Medal with two bronze stars, among other award, for meritorious combat service in Vietnam. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in Atlanta, Georgia. A copy of the hearing transcript is of record and has been reviewed. The VLJ complied with her duties as a hearing officers, and neither the Veteran nor his attorney have alleged that there were any deficiencies in the Board hearing under 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). As a procedural matter, these issues were previously before the Board in July 2019. As to the issues being adjudicated herein, the RO substantially complied with the Board’s prior remand directives, and the claims have now been returned to the Board for further appellate consideration. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating As an initial matter, the Board notes that VA has amended the rating criteria for musculoskeletal system disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. 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. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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). “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). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). 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. 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). In rendering a decision on appeal, the Board must 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 favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes through the senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As a foundational matter, ratings based on function impairment of the upper extremities are predicated upon which extremity is the major extremity, with only one extremity being considered major. 38 C.F.R. § 4.69. The medical evidence in this case reflects that the Veteran is right-hand dominant. Therefore, his right upper extremity is his major extremity. The Rating Schedule distinguishes between the major/dominant extremity and the minor/non-dominant extremity for rating purposes. 38 C.F.R. § 4.69. In this case, the record shows that the Veteran is right-handed, and therefore, his right elbow disability affects his major extremity. 1. Entitlement to a rating higher than 10 percent for the right elbow disability is denied. The Veteran contends that a rating higher than 10 percent is warranted for residuals for a gunshot wound to the right arm for loss of range of motion. He also alleges that a separate rating is warranted for neurological symptoms of numbness in the right third, fourth, and fifth fingers, which is addressed in the remand section below. Limitation of motion of the elbow is evaluated under Diagnostic Codes 5206 (flexion), 5207 (extension), and 5213 (supination and pronation). With respect to disabilities of the elbow and forearm, 38 C.F.R. § 4.71a, Diagnostic Codes 5205 through 5213 set forth the relevant provisions. The Board notes that the diagnostic codes pertaining to the elbow and forearm were not changed by the February 7, 2021 amendments. Diagnostic Code 5206 provides that forearm flexion to 100 degrees warrants a 10 percent rating; forearm flexion to 90 degrees warrants a 20 percent rating; forearm flexion to 70 degrees warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity; forearm flexion to 55 degrees warrants a 30 percent rating for the minor extremity and a 40 percent rating for the major extremity; and forearm flexion to 45 degrees warrants a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Full forearm flexion is to 145 degrees. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5207 provides that forearm extension from 45 to 60 degrees warrants a 10 percent rating; forearm extension to 75 degrees warrants a 20 percent rating; forearm extension to 90 degrees warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity; forearm extension to 100 degrees warrants a 30 percent rating for the minor extremity and a 40 percent rating for the major extremity; and forearm extension to 110 degrees warrants a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. 38 C.F.R. § 4.71a. Full forearm extension is to zero degrees. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5213 provides that limitation of supination to 30 degrees or less warrants a 10 percent rating. Pronation lost beyond the last quarter of the arc, where the hand does not approach full pronation, warrants a 20 percent rating. Pronation lost beyond the middle of the arc warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Moderate pronation or the hand fixed near the middle of the arc warrants a 20 percent rating. The hand fixed in full pronation warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. The hand fixed in supination or hyperpronation warrants a 30 percent rating for the minor extremity and a 40 percent rating for the major extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Full pronation is to 80 degrees, and full supination is to 85 degrees. 38 C.F.R. § 4.71a, Plate I. In a July 2010 VA examination, the examiner, a physician, noted the Veteran was shot in the right arm during Vietnam, and his elbow had become increasingly tight over many years. On physical examination, the examiner determined there was no deformity, giving way, instability, pain, weakness, incoordination, episodes of dislocation or subluxation, locking, effusion, inflammation, or ankylosis. The Veteran denied flareups in the right elbow. His current symptoms included stiffness, decreased speed in the joint motion, and decreased range of motion in the right elbow. The elbow was not a weight bearing joint and there was no loss of bone or inflammatory arthritis. The examiner found crepitus and mild tenderness that radiated from the right elbow when palpated. No pain, fatigue, weakness, or incoordination was noted on examination. The Veteran had right elbow flexion to 130 degrees with pain beginning at 125 degrees, supination to 70 degrees with pain beginning at 65 degrees, and pronation to 80 degrees with pain beginning at 75 degrees. The range of motion measurements were the same on active and passive motion. July 2007 x-ray studies showed that all bones, joints, and soft tissue were intact. Tiny gunshot fragments were noted in the antecubital region. Otherwise, the x-ray studies were normal. The Veteran had retired in 2000 due to his age. The residuals of the right upper extremity gunshot wound were that he would have difficulty lifting and carrying with decreased strength in the upper extremity. It had a moderate effect on his ability to complete chores, shipping, exercise, play sports, and recreation, and a mild effect on travelling. A July 2010 VA muscles examination indicated that, during service, the right flexor carpi radialis and flexor digitorum radialis muscle groups were affected by the gunshot. He was shot by a single high velocity large caliber missile, which was treated in the field with debridement and dressing. He was not hospitalized, and he immediately returned to duty. It was a through and through injury and healed without infection. No bone, nerve, vascular, or tendon injuries were found at the time of injury. At the time of the examination, he denied pain, decreased coordination, fatigability, weakness, and uncertainty of movement but endorsed tightness of motion at the right elbow. The examiner indicated that group 7 muscles, specifically the flexors of the carpus and long flexors of the fingers/thumb, had been injured in the right arm/forearm. Muscle strength was normal without tissue loss. No intermuscular scarring, nerve damage, tendon damage, bone damage, muscle herniation, or loss of deep fascia or muscle substance was found. He had limited range of motion in the right elbow. In April 2012, the Veteran was afforded another VA examination of the elbow and forearm. The examiner, a nurse practitioner, noted the Veteran had residuals of a gunshot wound to the right forearm. The Veteran reported that his current symptoms were numbness and weakness in the 3rd, 4th, and 5th fingers, which had progressed. He denied experiencing numbness or weakness in the right forearm. He was right hand dominant. He denied having flareups of the elbow or forearm. The Veteran had flexion to 145 degrees, extension to 0 degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees in both active and passive motion. On repetitive motion testing, the Veteran did not have additional functional loss or additional loss of range of motion. No localized tenderness on palpation of the joints or soft tissue, ankylosis, flail joint, joint fracture, or impairment of supination or pronation was found. The right elbow muscle strength was normal (5/5) on flexion and extension. The Veteran had not undergone a total joint replacement or had arthroscopic surgery. The Veteran reported that the functional loss due to the gunshot residuals of the right arm included his ability to type for his parttime job as a private investigator. He was also unable to shoot a gun in his dominant hand due to the numbness in the third, fourth, and fifth fingers. Private treatment records from May 2013 to September 2014 diagnosed the Veteran with bilateral carpal tunnel and bilateral ulnar nerve entrapment at the elbow. Dr. R.W.M., an orthopedist, did not determine that either condition was a residual of the right elbow gunshot wound from service, did not discuss whether there were any muscle injuries, and did not provide range of motion measurements for the right elbow or forearm. A September 2016 private treatment record indicated the Veteran had right elbow pain after lifting weights, which caused right medial epicondylitis. A December 2019 VA examination for the muscles was afforded to the Veteran. The examiner, a physician, noted the Veteran experienced a gunshot wound in 1967 when he was shot in the right forearm, which was a penetrating muscle injury. The Veteran reported it caused numbness along the ulnar side of the arm and into fingers three, four, and five. On examination, there was no current muscle injury. He was right hand dominant. Muscle strength was normal in all bilateral upper extremity muscle groups. No muscle atrophy was found. No other pertinent physical findings were noted. Imaging studies and electrodiagnostic studies had not been performed. The examiner indicated that the Veteran was able to do anything he wanted with his hands. In December 2020, the Veteran was again afforded a VA examination for the right elbow gunshot wound residuals. The examiner, a nurse practitioner, indicated that the condition had stayed the same since onset. He was right hand dominant. He took Lyrica. The Veteran denied flare ups of the right elbow and did not report any functional loss or impairment of the right elbow or forearm. He had flexion to 125 degrees, extension to 0 degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees on active range of motion. Passive range of motion testing showed the Veteran had 135 degrees of flexion, 0 degrees of extension, 85 degrees of forearm supination, and 85 degrees of forearm pronation. No objective signs of pain were noted on active or passive motion. The slightly abnormal active range of motion did not contribute to functional loss, and no pain was noted on examination. No localized pain to palpation of the joint or associated soft tissue was noted. No pain on weight bearing or non-weight bearing was found. The Veteran did not have crepitus. The Veteran was able to perform repetitive use testing with three repetitions with no additional loss of range of motion. Pan, fatigue, weakness, lack of endurance, or incoordination did not cause additional functional loss of the right elbow on repetitive use testing. The Veteran was not examined after repeated use over time, but the examiner found that the Veteran’s statements describing his functional loss were consistent with the examination. Pain, fatigue, weakness, lack of endurance, or incoordination did not cause significant functional loss or impairment of the right elbow with repeated use over time. In terms of degrees, the Veteran’s range of motion was the same with repeated use over time as it was on initial range of motion testing. There were no additional contributing factors related to loss of range of motion to consider for the right elbow gunshot wound residuals. Muscle strength testing was normal (5/5) with no reduction in strength. There was no muscle atrophy, ankylosis, flail joint, joint fracture, ununited fracture, malaligned fractures, or impairment of the supination or pronation. He had not had any surgical procedures. Imaging studies had not been performed, and there were no other significant diagnostic findings or results. The gunshot residuals to the right elbow and forearm did not affect his ability to work. A December 2020 medical opinion was provided to determine whether there were any muscle residuals of the right arm gunshot wound. The examiner recited a thorough history of the injury in service and pertinent post-service medical records, including a July 2007 x-ray study done at a prior VA compensation examination. The Veteran also had reported numbness in the third, fourth, and fifth fingers after being shot in the arm during the 2007 examination. The 2007 x-ray studies showed a normal right elbow with intact and normal bone joints and soft tissue. Tiny gunshot metal fragments were noted at the antecubital fossa. The examiner indicated that the Veteran’s right arm gunshot wound residuals had stayed the same since onset in 1967. The Veteran reported that the gunshot wound healed without complaint, except for the numbness in the third, fourth, and fifth fingers. After a physical examination, the examiner determined that the Veteran did not have any current injuries to any muscle groups. The Veteran did not exhibit cardinal signs of a muscle disability, such as loss of power, weakness, lowered fatigue threshold, fatigue and/or pain, impairment of incoordination, or uncertainty of movement. Muscle strength testing was 5/5 (normal) in all measurements. No muscle atrophy was found. No other pertinent physical findings, complications, signs, or symptoms related to a muscle disability was found. The examiner concluded that there were no residuals involving the muscle tissue, there was not a significant penetrating muscle injury, and no diagnosis of a muscle condition was warranted. Here, the RO assigned the initial 10 percent rating for the residuals of a right arm gunshot wound based on objective evidence of painful non-compensable limitation of motion. Based on the evidence, both lay and medical, the Board finds that the Veteran does not meet the criteria for a higher rating for a loss of range of motion. In this regard, the Veteran can flex his right forearm to 125 degrees, at worst, as demonstrated during the July 2010 and December 2020 VA examinations. Accordingly, a higher rating is not warranted under DC 5206. The Veteran also exhibits normal extension in the right forearm. Thus, a higher or separate rating is not warranted under DC 5207. Moreover, given his normal right forearm extension and flexion limited to no worse than 125 degrees, a higher rating is not warranted under DC 5208. Diagnostic Code 5213 does not provide for a higher rating as the Veteran’s supination of the right forearm is limited to no worse than 65 degrees during the appellate period, and limitation of pronation is no worse than 75 degrees. 38 C.F.R. § 4.71a. Consideration has been given to the functional impairment and any effects of pain on functional abilities due to the Veteran’s service-connected loss of range of motion in the right elbow and forearm as a residual of the gunshot disability. The Board acknowledges the Veteran’s complaints of reduced range of motion with pain and stiffness in the right elbow. There was no evidence of additional functional loss after repetitive use during any of the VA examinations, and the Veteran has not reported any additional functional loss or impairment with repeated use over time. Considering the foregoing, the Board finds that a rating higher than 10 percent for the loss of range of motion in the right elbow and forearm disability is not warranted. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-06. Finally, DCs 5209 through 5212 address upper extremity disabilities such as flail joints, non-union, or malunion of the radius and ulna. These diagnostic codes are not applicable here. The Board also considered whether a separate or higher rating was warranted for a muscle disability associated with the gunshot wound in service. The Board acknowledges that the July 2010 examination found that the right flexor carpi radialis and flexor digitorum radialis muscle groups were affected by the gunshot wound in service. However, multiple VA examinations both before and after the July 2010 VA examination have found that there are no current muscle disabilities. See 2007, April 2012, December 2019, and December 2020 VA examinations. Furthermore, although the Veteran was noted to have right elbow epicondylitis in a September 2016 private treatment record, the Veteran’s private physician attributed this symptom to the Veteran’s lifting weights and there is no evidence that it was a manifestation of the service-connected gunshot wound. The remaining private and VA treatment records are silent as to any muscle symptoms or medical findings in the right arm. Based on a totality of the evidence, the Board assigns lower probative weight to the July 2010 VA examiner’s findings and assigns higher probative weight to the April 2012, December 2019, and December 2020 VA examinations that show he does not have a currently diagnosed muscle disability in the right arm associated with the gunshot wound in service. Therefore, a preponderance of the evidence is against a finding that the Veteran has a muscle or tendon disability related to the gunshot wound at any time during the appellate period. In absence of proof a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board also notes the Veteran contends that a separate rating is warranted for numbness and tingling of his third, fourth, and fifth fingers, which is being remanded and is discussed below. Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. A compensable rating for the right elbow scar as a residual of a gunshot wound is denied. The Veteran contends that he is entitled to a higher rating for the scar on his right arm, a residual of the gunshot wound in service. The Veteran’s right arm scar is rated under Diagnostic Code 7802. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. 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. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7802, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 was otherwise unchanged by the August 13, 2018 amendments. A July 2010 VA scar examination showed the Veteran had a residual scar on the right forearm from a gunshot wound. There were no burn scars. The scar was not painful, there was no skin breakdown, or any other symptoms. He had no limitations on his daily routine due to the scar. The scar was located on the right volar forearm 4 centimeters below the antecubital fossa. The scar was 1.9 centimeters by 4.2 centimeters. It was non-linear and was an elliptical shape. It was less than 6 square inches (less than 39 square centimeters). There was no pain on palpation, and the scar was not unstable, defined as whether the skin over the scar was subject to frequent ulcerations or breakdown). The scar did not result in limitation of motion, there was no adherence to underlying tissue, inflammation, edema, and/or keloid formation associated with the scar. There was no soft tissue damage, underlying tissue loss, or elevation of scar, depression of the scar, and induration or inflexibility. The texture of the area was normal. The scar was hypopigmented and the hypopigmentation covered an area of less than 6 square inches (less than 39 square centimeters). No scar was found on the right side, flank, abdomen, or chest. An April 2012 VA examination indicated the Veteran had a scar on his right arm that was not painful, not unstable, and did not cover an area greater than 6 square inches (39 square centimeters). A December 2019 VA examination noted the Veteran had a minimal, entrance and exit scar, indicating the track of the missile through the muscle tissue. The scars were not painful or unstable. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under Diagnostic Code 7802 because the Veteran’s right arm scar has not manifested as an area or areas of 144 square inches (929 sq. cm.) or greater. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s right arm gunshot wound scar is not on the head, face, or neck, is not deep, and is not associated with underlying soft tissue damage. Moreover, the right arm gunshot wound scar is not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered under Diagnostic Codes 7800-7804. See pre- and post-August 13, 2018, Diagnostic Code 7805. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he has not asserted, and the medical records and lay statements do not show, that the right arm gunshot wound scar manifested by an area or areas of 144 square inches (929 sq. cm.) or greater, was painful, or was unstable. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for an additional compensable rating for the right arm gunshot wound scar. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for the thoracolumbar spine disability is remanded. While on remand, the Veteran submitted a release of information for Tallahassee Memorial Hospital and requested that VA obtain his treatment records. On the release of information, instead of listing a date range of when he received treatment at this facility, he only listed the date he signed the release of information. VA attempted to obtain the records and notified the Veteran in a March 2020 letter that they had requested the records but had not yet received. The letter also indicated that the RO would make additional attempts to get these records. In a subsequent March 2020 Report of Contact, the RO spoke to a representative at Tallahassee Memorial Hospital. The hospital’s representative noted that the release of information only listed October 17, 2019 as the dates of treatment, they would only search for that one date, they could not release records outside that date without a new release of information, and they could not make an exception in this case. The RO closed out the request as date of treatment discrepancy, indicating there are records available outside of only October 17, 2019. The RO did not communicate this information to the Veteran. No notification letter was sent to him or his attorney informing them that these records were not obtained or explaining the issue. Further, although the February 2021 SSOC notes that records were not provided by Sircy Chiropractic, there is no mention of the results of the request for the Tallahassee Memorial Hospital Records. The February 2021 SSOC mentions records received from Tallahassee Community Hospital, but a brief internet search indicates that this facility is not the same as Tallahassee Memorial Hospital. Thus, on remand, the RO must inform the Veteran that the records from Tallahassee Memorial Hospital could not be obtained, explain the error with the date of treatment, and request an additional corrected medical release for these records. If the Veteran returns the additional release, efforts should be undertaken to obtain these medical records. Additionally, a contract medical opinion was obtained as the nature and etiology of the Veteran’s thoracolumbar spine disability in December 2019. The examiner, a physician, concluded the Veteran’s thoracolumbar spine disabilities less likely than not had onset during or were otherwise related to service. The examiner noted the Veteran’s 1968 separation examination was normal, and he had a post-service helicopter crash in 1989, long after he was discharged from service. This medical opinion is inadequate in its current form. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). An examiner cannot rely solely on a lack of symptoms, diagnosis, or treatment in service of a thoracolumbar spine disability to support a negative nexus. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); Dalton v. Nicholson, 21 Vet. App. 23 (2007). Additionally, the Board specifically instructed in the July 2019 Board decision that the examiner was to discuss the significance of the Veteran’s symptoms prior to the 1989 post-service helicopter crash. See May 2019 hearing transcript. However, the examiner did not do so in the rationale of the medical opinion. Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to service connection for a skin disability on the feet (claimed as jungle rot) is remanded. As noted above, there are outstanding private treatment records from Tallahassee Memorial Hospital that should be obtained and associated with the claims file if the Veteran returns an additional medical release. In addition, the Veteran was afforded a December 2019 VA medical examination as to nature and etiology of the skin disability on the feet (claimed as jungle rot). The examiner, a physician concluded that, after reviewing 3,068 pages of medical records, it was less likely than not that the diagnosed tinea pedis or tinea unguium was due to anything that occurred in the military. Although the Board appreciates the thorough record review, the December 2019 VA medical opinion is inadequate in its current form. An examiner cannot rely solely on a lack of symptoms, diagnosis, or treatment in service of a skin disability on the feet to support a negative nexus. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); Dalton v. Nicholson, 21 Vet. App. 23 (2007). In addition, the examiner failed to provide any rationale to support the conclusion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). On remand, an additional VA medical opinion should be obtained. 3. Entitlement to a separate rating for right carpal tunnel and/or ulnar nerve entrapment at the right elbow as a neurological residual of the service-connected gunshot wound is remanded. The Veteran contends that he has numbness in his right third, fourth, and fifth fingers that he believes are related to the gunshot wound to his right elbow/forearm. See May 2019 hearing transcript. As noted above, there are outstanding private treatment records from Tallahassee Memorial Hospital that should be obtained and associated with the claims file if the Veteran returns an additional medical release. See November 2019 statement. Additionally, in a December 2020 VA peripheral neuropathy DBQ, the examiner diagnosed the Veteran with right ulnar nerve distal peripheral neuropathy (also known as cubital tunnel syndrome) and right carpal tunnel syndrome. The December 2020 medical examiner, a nurse practitioner, concluded that it was less likely than not that the right ulnar neuropathy was a manifestation of the gunshot wound to the right forearm. Nevertheless, the examiner did not offer an opinion as to whether the right carpal tunnel syndrome was related to the service-connected gunshot wound to the right arm. Thus, on remand, these additional opinions should be obtained before the claim can be adjudicated.   4. Entitlement to a rating higher than 70 percent for the service-connected PTSD is remanded. As noted above, there are outstanding private treatment records from Tallahassee Memorial Hospital that should be obtained and associated with the claims file, if the Veteran returns an additional medical release. Additionally, a February 2021 VA treatment record noted the Veteran had been referred to the Tallahassee Veterans Center. On remand, any outstanding pertinent VA treatment records at the Tallahassee Veteran’s Center, if any exist, should be obtained and associated with the claims file. 5. Prior to November 7, 2013, entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. The issue of whether a TDIU was warranted prior to November 7, 2013 is inextricably intertwined with the increased rating claims that are being remanded herein. Specifically, prior to November 7, 2013, the Veteran was service connected for PTSD (rated as noncompensable, effective April 25, 2006 and at 50 percent effective January 5, 2010); diabetes mellitus, type II (rated as 10 percent from December 6, 2011 to November 6, 2013); tinnitus (rated as 10 percent disabling effective January 5, 210); residuals of gunshot wound to the right elbow and right upper extremity (rated as 0 percent disabling effective April 25, 2006, and 10 percent from May 14, 2010); and gunshot wound scar on the right upper extremity (rated as noncompensable effective May 14, 2010). The Veteran’s combined disability rating prior to November 7, 2013, was only 60 percent; thus, the Veteran did not meet the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a). As the increased rating claims for PTSD and gunshot residuals of the right upper extremity are being remanded herein for additional record development, it would be premature to adjudicate entitlement to a TDIU prior to November 7, 2013. The matters are REMANDED for the following action: 1. Inform the Veteran and his attorney that the records requested from Tallahassee Memorial Hospital were not obtained due to the single October 17, 2019 treatment date listed in the release. Request the Veteran submit an additional medical release for these records with the correct date range for treatment. If the Veteran returns an additional release, then obtain the identified medical records and associate them with the claims file. If the records cannot be obtained for any reason, inform the Veteran and his attorney. 2. Obtain any outstanding pertinent VA treatment records and associate them with the claims file, to include any at the Tallahassee Veteran’s Center. 3. Obtain an addendum VA medical opinion regarding the nature and etiology of the thoracolumbar spine disabilities. The Veteran’s contentions should be addressed. After a thorough review of the claims file, the examiner should provide an etiology opinion as to whether each of the Veteran’s thoracolumbar spine disabilities had their onset during or were otherwise related to service, to include his reports that he participated in 129 jumps from helicopters during combat service in Vietnam, and on one jump, injured his back and had to be carried out of the jungle. See May 2019 hearing transcript. *Specifically discuss the significance of the Veteran’s back symptoms before the 1989 post-service helicopter crash when he worked for the GBI. *Review the private opinions of record, specifically the contention that the multiple jumps from helicopters in service injured his back and made it weaker and more susceptible to injury post-service and discuss this contention. See e.g., November 2006 letter. *A complete rationale must be provided for each medical conclusion. 4. Obtain an addendum opinion from an appropriate clinician for the nature and etiology of the currently diagnosed tinea pedis or tinea unguium. The Veteran’s contentions should be considered. *The examiner is reminded that a lack of symptoms, diagnosis, or treatment of a skin disability on the feet during service cannot be the sole basis for a negative nexus opinion. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); Dalton v. Nicholson, 21 Vet. App. 23 (2007). *A complete rationale must be provided for each medical conclusion. (Continued on the next page)   5. Obtain an addendum opinion as to whether the right carpal tunnel syndrome is a peripheral nerve residual of the gunshot wound that occurred in service. 6. Readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.