Citation Nr: 21024492 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 20-03 238 ORDER The application to reopen the previously denied claim of service connection for residuals of testicular injury is granted. Service connection for residuals of testicular injury is denied. Service connection for hypertension is denied. Service connection for erectile dysfunction is denied. Service connection for bilateral cataract is denied. Service connection for psychiatric disability, to include depression, is denied. Service connection for obstructive sleep apnea is granted. A disability rating greater than 10 percent for degenerative arthritis of right knee is denied. A disability rating greater than 10 percent for degenerative arthritis of left knee is denied. A disability rating greater than 10 percent for osteoarthritis of right ankle is denied. A disability rating greater than 10 percent for osteoarthritis of left ankle is denied. A disability rating greater than 10 percent for degenerative arthritis of spine is denied. A disability rating greater than 10 percent for radiculopathy of right lower extremity (sciatic nerve) is denied. A disability rating greater than 10 percent for radiculopathy of left lower extremity (sciatic nerve) is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for degenerative arthritis of right knee is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for degenerative arthritis of left knee is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for osteoarthritis of right ankle is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for osteoarthritis of left ankle is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for degenerative arthritis of spine is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for radiculopathy of right lower extremity is denied. An effective date earlier than November 21, 2017, for award of service connection and compensation for radiculopathy of left lower extremity is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a November 2013 rating decision, the Agency of Original Jurisdiction (AOJ) denied service connection for residuals of testicular injury on the grounds that no current disability was shown. 2. Evidence received since November 2013 was not previously considered by an agency decision maker, is not cumulative or redundant of the evidence already of record and provides an alternative theory of entitlement to service connection for residuals of testicular injury. 3. Episodes of testicular pain in active duty were acute and transitory, and the Veteran has not been diagnosed with current residuals of testicular injury. 4. The Veteran’s hypertension was not manifest during active service or within the first year after separation and is not attributable to service. 5. The Veteran’s erectile dysfunction was not manifest during active service and is not attributable to service or related (causation or aggravation) to a service-connected disease or injury. 6. The Veteran’s bilateral cataract was not manifest during active service and is not attributable to service. 7. Depression was not manifest during active service or within the first year after separation, and the Veteran has not been diagnosed with a current psychiatric disability. 8. The evidence supports a link between the Veteran’s current obstructive sleep apnea and weight gain from reduced exercise due to service-connected disease or injury. 9. Throughout the rating period, the Veteran’s degenerative arthritis of right knee is manifested by functional flexion of leg to 140 degrees and by pain; functional flexion of leg is better than 45 degrees, and neither limited extension of leg nor instability is demonstrated. 10. Throughout the rating period, the Veteran’s degenerative arthritis of left knee is manifested by functional flexion of leg to 140 degrees and by pain; functional flexion of leg is better than 45 degrees, and neither limited extension of leg nor instability is demonstrated. 11. Throughout the rating period, the Veteran’s osteoarthritis of right ankle is manifested by moderate limitation of motion and by pain; marked limitation of motion is not demonstrated, and neither version of the rating criteria is favorable to the Veteran. 12. Throughout the rating period, the Veteran’s osteoarthritis of left ankle is manifested by moderate limitation of motion and by pain; marked limitation of motion is not demonstrated, and neither version of the rating criteria is favorable to the Veteran. 13. Throughout the rating period, the Veteran’s degenerative arthritis of spine has been manifested by nearly full ranges of motion, and by complaints of constant low back pain. Incapacitating episodes (i.e., doctor-prescribed bed rest), muscle spasms, guarding, and flexion limited to 60 degrees are not shown. 14. Throughout the rating period, neurological deficits are shown to be manifested by mild incomplete paralysis of sciatic nerve of right lower extremity; moderate or severe incomplete paralysis, or complete paralysis is not shown. 15. Throughout the rating period, neurological deficits are shown to be manifested by mild incomplete paralysis of sciatic nerve of left lower extremity; moderate or severe incomplete paralysis, or complete paralysis is not shown. 16. The December 5, 2013 communication from the Veteran did not meet the requirements for a claim and was never adjudicated. On November 21, 2017, the Veteran notified VA of an intent to file for VA benefits. 17. There was no pending claim prior to November 21, 2017, pursuant to which service connection and compensation for degenerative arthritis of right knee and left knee could have been awarded. 18. There was no pending claim prior to November 21, 2017, pursuant to which service connection and compensation for osteoarthritis of right ankle and left ankle could have been awarded. 19. There was no pending claim prior to November 21, 2017, pursuant to which service connection and compensation for degenerative arthritis of spine could have been awarded. 20. The effective date of the award of service connection and compensation for radiculopathy of right lower extremity cannot be earlier than the effective date of the grant of service connection for degenerative arthritis of spine—that is, November 21, 2017. 21. The effective date of the award of service connection and compensation for radiculopathy of left lower extremity cannot be earlier than the effective date of the grant of service connection for degenerative arthritis of spine—that is, November 21, 2017. CONCLUSIONS OF LAW 1. The AOJ’s November 2013 decision, denying service connection for residuals of testicular injury, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Evidence submitted since November 2013 with regard to service connection for residuals of testicular injury is new and material; and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. Residuals of testicular injury were not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. Hypertension was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 5. Erectile dysfunction was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. Bilateral cataract was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. Psychiatric disability, to include depression, was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 8. Obstructive sleep apnea is proximately due to or a result of service-connected disease or injury. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 9. Throughout the rating period, the criteria for a disability rating greater than 10 percent for degenerative arthritis of right knee are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5260. 10. Throughout the rating period, the criteria for a disability rating greater than 10 percent for degenerative arthritis of left knee are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5260. 11. Throughout the rating period, the criteria for a disability rating greater than 10 percent for osteoarthritis of right ankle are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5271. 12. Throughout the rating period, the criteria for a disability rating greater than 10 percent for osteoarthritis of left ankle are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5271. 13. Throughout the rating period, the criteria for a disability rating greater than 10 percent for degenerative arthritis of spine are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 14. Throughout the rating period, the criteria for a disability rating greater than 10 percent for radiculopathy of right lower extremity (sciatic nerve) are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8620. 15. Throughout the rating period, the criteria for a disability rating greater than 10 percent for radiculopathy of left lower extremity (sciatic nerve) are not met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8620. 16. The December 5, 2013 claim was abandoned. 38 U.S.C. §§ 501, 5110(a); 38 C.F.R. § 3.158. 17. The criteria for an effective date earlier than November 21, 2017, for service connection and compensation for degenerative arthritis of right knee and left knee are not met. 38 U.S.C. §§ 1110, 5110; 38 C.F.R. § 3.400. 18. The criteria for an effective date earlier than November 21, 2017, for service connection and compensation for osteoarthritis of right ankle and left ankle are not met. 38 U.S.C. §§ 1110, 5110; 38 C.F.R. § 3.400. 19. The criteria for an effective date earlier than November 21, 2017, for service connection and compensation for degenerative arthritis of spine are not met. 38 U.S.C. §§ 1110, 5110; 38 C.F.R. § 3.400. 20. The criteria for an effective date earlier than November 21, 2017, for service connection and compensation for radiculopathy of right lower extremity are not met. 38 U.S.C. §§ 1110, 5110; 38 C.F.R. § 3.400. 21. The criteria for an effective date earlier than November 21, 2017, for service connection and compensation for radiculopathy of left lower extremity are not met. 38 U.S.C. §§ 1110, 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1965 to October 1967. He timely appealed these matters from September 2018 and February 2019 rating decisions. In August 2020 and in December 2020, the Board of Veterans' Appeals (Board) granted the Veteran’s requests for additional time to submit evidence. In January 2021, the Veteran’s attorney submitted additional evidence and waived initial consideration of the evidence by the AOJ. In this case, all available records identified by the Veteran as relating to claims decided below have been obtained, to the extent possible. The record does not otherwise indicate any existing pertinent evidence that has not been obtained. Regarding reopening of a previously denied claim, the Veteran is not entitled to examination prior to submission of new and material evidence. Regarding higher rating claims, there is no evidence indicating a material change in severity of disabilities since last examination. As to service connection claims, examination reports and opinions generally are thorough and adequate for the Board to render the following decisions in the Veteran’s appeal. 38 U.S.C. § 5103A(a)(2). Specifically, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). Regarding claims of service connection for hypertension and for cataracts and for depression, there is neither evidence of pertinent disability in active service, nor competent medical evidence suggesting a relationship between current disabilities and active service. Based solely on these facts, VA has no duty to provide further VA examination or obtain medical opinions, even under the low threshold of McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Reopening VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). The AOJ originally denied service connection for residuals of testicular injury in November 2013 based on the absence of evidence showing current disability. Since then, the Veteran reported having no problems until about age 50, when his testicle randomly swelled up to about the size of a basketball; and he required surgery on both testicles. He also reported intermittent right testicular pain. The additional evidence includes several VA examination reports, which are new and not previously considered, and are neither duplicative nor redundant of other medical evidence. Given the presumed credibility, the Veteran’s statements and VA examination reports considered in connection with evidence previously assembled create a more complete picture of the Veteran’s claim and present alternative theories of entitlement. The evidence is both new and material, and raises a reasonable possibility of substantiating the claim. Reopening of the previously denied claim for service connection for residuals of testicular injury is appropriate. Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some chronic diseases, to include hypertension and psychoses and headaches, may be presumed to have been incurred in service if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331, 1338-39 (Fed. Cir. 2013). The applicable presumptive period is one year from separation. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). In this case, the Veteran was presumed sound at service entry. Clinical evaluation at pre-induction examination in September 1965 was normal, and no disability was recorded. Nor is there medical evidence of any disability prior to active service. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Residuals of Testicular Injury The Veteran contends that service connection for residuals of testicular injury is warranted on the basis that he injured his right testicle after a parachute accident in active service. He reported swelling at the time of the accident and being told to keep an eye on it. His DD Form 214 reflects the Veteran’s primary specialty as a parachute rigger and award of a parachute badge. The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Furthermore, his statements are consistent with the circumstances of his service as a parachute rigger; and the Board finds that there is credible evidence of in-service acute right testicular injury. No residuals of testicular injury were noted at the Veteran’s separation examination from active service in August 1967. VA examination in October 2013 reveals insufficient evidence to warrant or confirm a current diagnosis of residuals of testicular injury. The examiner explained that the diagnosis in 1998 of bilateral hydrocele was more than two decades after service, making it very unlikely as due to self-reported right testicle contusion; and that service treatment records did not indicate hydrocele. An ultrasound study in 1998 also showed normal testicles. Moreover, the examiner noted no functional impact. VA records in July 2018 show that the Veteran had a history of hydrocele, which resolved following surgery in 1998. Although he now had no swelling, he did describe intermittent pains in the right testicle. Examination revealed testicles were descended bilaterally, without mass. Assessments were bilateral hydrocele, asymptomatic, and erectile dysfunction. A December 2018 VA (contract) examination report reveals no diagnosis of either testicle. The Veteran reported a medical history of injuring his right testicle after a parachute accident in active service. He reported that the swelling eventually went away, and that he was told to keep an eye on it. He reported having no problems until age 50 when it randomly swelled up and required surgery on both testicles. The Veteran reported no voiding dysfunction. His testes were not examined per Veteran’s request; normal anatomy with no testicular deformity or abnormality was reported. There were no other pertinent findings and the examiner noted no functional impact. An ultrasound in February 2018 revealed septated left epididymal cyst, most likely spermatocele. The Veteran awaited referral to urology to treat blockage in left testicle. Here, there is no evidence of current residuals of testicular injury. The concept of continuity does not apply because testicular disability is not listed as a chronic disease under 38 C.F.R. § 3.309 and is not shown to be such by current medical evidence. Walker, 708 F.3d at 1338-39. The Board has considered whether the Veteran’s intermittent right testicular pain may be considered a disability in and of itself but finds it does not. Pain alone, without any functional impairment or underlying diagnosis, is not a service-connectable disability. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part, dismissed in part by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Pain has been recognized as a potential disability in Saunders v. Wilkie, 886 F. 3d (Fed. Cir. 2018), but only where there is impaired function and earning capacity. Here, in addition to no showing of pathology, there is no showing of impairment. The presence of a service-connectable disability is not established. To the extent that the Veteran asserts a nexus to active service or to service-connected disease or injury, he is competent to report symptoms affecting the right testicle both in service and after service. He is not, however, competent to diagnose residuals of testicular injury. In this case, there is no showing of current residuals of testicular injury. The evidence weighs against granting service connection for residuals of testicular injury. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Hypertension Service treatment records do not reflect any findings or complaints of elevated blood pressure. There is no evidence of treatment in active service for hypertension. Hypertension was not demonstrated in active service. His blood pressure reading was 118/78 at the separation examination in August 1967. Therefore, the in-service element has not been met. Nor is there evidence of hypertension within the first year after service. Hypertension first was noted several years after service. This also means a gap of several years between the Veteran’s separation from active service and the onset of symptoms of hypertension; hence, the concept of continuity does not apply. Walker, 708 F.3d at 1338-39. VA records show longstanding hypertension in October 2002. Laboratory tests in January 2008 include an assessment of hypertension. Unspecified essential hypertension was assessed in July 2018. The Veteran first filed a claim for service connection for hypertension in November 2018. He has not since reported in the context of his claim that he experienced any elevated blood pressure in service. Specifically, he checked “no” in response to whether he ever had or now had high or low blood pressure at his separation examination in August 1967. Contemporaneous treatment records are not simply silent regarding the Veteran’s claim. Thus, the fact that the Veteran specifically denied symptoms is what the Board finds probative. To date, the Veteran submitted no evidence or information linking active service to the currently diagnosed hypertension. While he may fervently believe in such a connection, as a layperson the Veteran lacks the competence to render a nexus opinion on such a complex medical question. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Here, post-service records show the onset of disability well after service. The first credible showing of pertinent disability is not within a period of active service, and no presumptive provisions are applicable. In the absence of evidence, there cannot be even equipoise, and there can be no resolution of doubt. The Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006). As there is no evidence to support any finding of a nexus between service and current hypertension, entitlement to the benefit sought is not warranted. Erectile Dysfunction Service treatment records do not reflect any findings or complaints of erectile dysfunction. The Veteran had three small sebaceous cysts on scrotum in August 1967, which were noted at separation examination in August 1967. There is no evidence of treatment for erectile dysfunction in active service. Therefore, the in-service element has not been met. Rather, post-service records show the onset of disability several years after service. VA records first show an assessment of erectile dysfunction in the early 2000’s. A November 2013 VA examination report reveals a medical history of erectile dysfunction; and indicates that the Veteran also had diagnoses of hyperlipidemia, diabetes mellitus, and hypertension. The Veteran was diagnosed with bilateral hydrocele in 1998, which was more than two decades after service; and he underwent bilateral hydrocelectomy with favorable results. Following examination in November 2013, the examiner opined that the cause of erectile dysfunction was multiple and included natural aging of 67 years old, dyslipidemia, hypertension, history of chronic smoking, etc. The history of sebaceous cysts at scrotum noted in service treatment records apparently resolved; there were no findings or complaints of such for the next four decades. VA records show medications for erectile dysfunction in June 2015. A December 2018 VA examination report includes diagnoses of erectile dysfunction, date of diagnosis as 1990’s; and bilateral hydrocele, date of diagnosis as 1998. The Veteran reported jumping out of airplanes in active service, and injuring his right testicle after a parachute accident. There was swelling at the time; the Veteran was told to keep an eye on it. He reported no problems until about age 50, when it randomly swelled up to about the size of a basketball; he required surgery on both testicles. During the year following the surgery, the Veteran started experiencing erectile dysfunction. As to etiology of erectile dysfunction, the examiner noted the Veteran’s history of hydrocele with surgical repair and history of diabetes mellitus; hyperlipidemia; and hypertension. The examiner found it impossible to identify sole cause with mixed etiologies present. No other pertinent findings were noted. Following examination in December 2018, the examiner opined that erectile dysfunction was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of the opinion, the examiner reasoned that the Veteran had diagnoses of both erectile dysfunction and bilateral cyst; and there was no medical evidence to state that presence of cysts leads to or causes erectile dysfunction. Further, the Veteran’s erectile dysfunction had not started until after surgical repair of cysts. While residuals of surgery could be the cause, the Veteran’s erectile dysfunction more likely was caused by his longstanding history of diabetes mellitus and hyperlipidemia and hypertension. While impossible to single out a cause, the fact that erectile dysfunction had not started until after the bilateral hydrocelectomy in 1998 does rule out by default the cysts as the cause. The Veteran, even as a layman, is competent to report that he experienced bilateral cysts during active service and post-service because such statements regard his first-hand knowledge of a factual matter. Specifically, the Veteran stated that the onset of erectile dysfunction was within the year after the 1998 surgery to remove bilateral cyst. What the Board finds probative is the fact that symptoms of erectile dysfunction first occurred decades after service, as reported by the Veteran. Accordingly, the first credible showing of pertinent disability is many years after service with no competent evidence that erectile dysfunction is related to active service. The December 2018 examiner found no medical evidence that the presence of cysts led to or caused erectile dysfunction. Regarding secondary service connection, the Board finds the December 2018 opinion and rationale to be persuasive. The examiner opined that the more likely causes of the Veteran’s erectile dysfunction was his longstanding history of diabetes mellitus and hyperlipidemia and hypertension—none of which are service-connected disabilities. The opinion is given a high degree of probative value. There is no evidence demonstrating causation or aggravation by a service-connected disability to warrant a grant of secondary service connection. The opinion is consistent with the evidence of record. Specifically, the competent evidence relates neither the Veteran’s bilateral cyst, surgical residuals, nor erectile dysfunction to the in-service right testicular injury. In short, the evidence weighs against granting service connection for erectile dysfunction. The preponderance of evidence is against the claim; the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Cataracts VA records, dated in June 2013, first show an assessment of bilateral cataract. In 2018, the Veteran’s bilateral cataract worsened and required surgery; one lens was replaced in October 2018, and the other lens was replaced in December 2018. The Veteran first filed a claim for service connection for bilateral cataract in November 2018. He has not since reported in the context of his claim that he experienced bilateral cataract in service. Here, service treatment records do not reflect any findings or complaints of bilateral cataract, nor is there evidence of trauma or injury to the eyes. Clinical evaluation of the Veteran’s eyes, other than visual acuity (refractive error), was normal at separation examination from active service in August 1967. Refractive error of the eye is not considered a disease or injury for an award of VA compensation benefits. 38 C.F.R. § 3.303(c). Here, the in-service element has not been met. Regarding bilateral cataract, the Board recognizes the Court’s decision in Romanowsky v. Shinseki, 26 Vet. App. 303 (2013), which held that a Veteran satisfies the current disability threshold when a disability exists at the time his claim was filed, even if the disability resolves prior to VA’s adjudication of the claim. To date, the Veteran submitted no evidence or information linking active service to the currently diagnosed bilateral cataract. While he may fervently believe in such a connection, as a layperson the Veteran lacks the competence to render a nexus opinion on such a complex medical question. Kahana, 24 Vet. App. at 435. No medical professional has indicated even a possible link between current disability and active service. In the absence of evidence, there cannot be even equipoise, and there can be no resolution of doubt. The Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer, 455 F.3d at 1350-1351. As there is no evidence to support any finding of a nexus between service and current bilateral cataract, entitlement to the benefit sought is not warranted. Depression Service treatment records do not reflect any findings or complaints of depression. There is no evidence of treatment in active service for an acquired psychiatric disability or depression. Disability manifested by depression was not demonstrated in active service. Clinical evaluation of the Veteran’s psychiatric system was normal at the separation examination in August 1967. Therefore, the in-service element has not been met. Nor is there evidence of psychoses or depression within the first year after service. VA records show that the Veteran was screened regularly for depression, starting post-service in 2008. This also means a gap of several years between the Veteran’s separation from active service and the onset of symptoms, if any, of depression; hence, the concept of continuity does not apply. Walker, 708 F.3d at 1338-39. The Veteran first filed a claim for service connection for depression in November 2018. He has not since reported in the context of his claim that he experienced any psychiatric disability in service. Specifically, he checked “no” in response to whether he ever had or now had depression or excessive worry or nervous trouble of any sort, at his separation examination in August 1967. Contemporaneous treatment records are not simply silent regarding the Veteran’s claim. Thus, the fact that the Veteran specifically denied symptoms is what the Board finds probative. Here, there is no evidence of current psychiatric disability, to include depression. To the extent that the Veteran asserts a nexus to active service, he is not competent to diagnose an acquired psychiatric disability. In this case, there is no showing of a current psychiatric disability, to include depression. The evidence weighs against granting service connection for depression. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Sleep Apnea The Veteran has submitted clear evidence of a diagnosis of obstructive sleep apnea, as reflected in an August 2018 VA (contract) examination report. A sleep study done in March 2018 revealed mild obstructive sleep apnea; a CPAP machine was prescribed. However, there is no evidence of sleep apnea in service. His separation examination in August 1967 reveals neither symptoms nor manifestations of obstructive sleep apnea. Specifically, there is no indication of snoring, choking, daytime hypersomnolence, or similar manifestations documented in service treatment records. An August 2018 VA (contract) examiner opined that obstructive sleep apnea was at least as likely as not incurred in or caused by claimed in-service injury, event, or illness. The examiner reasoned that the Veteran had no issues with sleep apnea prior to active service; and noted, mistakenly, the onset of sleep apnea as documented in service treatment records. Given the lack of such documentation or of any symptoms of sleep apnea in service treatment records, the August 2018 examiner’s opinion has no probative value. The overall evidence does not support the onset of obstructive sleep apnea in active service. As such, the Veteran is not entitled to direct service connection. Rather, in November 2020, a private physician conducted a review of the Veteran’s claims file and interviewed the Veteran. The physician noted that the Veteran had been diagnosed with obstructive sleep apnea over the last three years, and that the condition had worsened with weight gain. The physician opined that the Veteran’s obstructive sleep apnea was as likely as not related to service-connected knee, ankle, and spine disabilities. In support of the opinion, the physician reasoned that the Veteran’s chronic low back and knee and ankle pains limited his ability to achieve appropriate physical activity and resulted in increased difficulties in weight reduction and maintenance; and noted that weight is one of the greatest predictors for developing obstructive sleep apnea. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds the November 2020 private physician’s opinion to be persuasive in finding as likely as not that the Veteran’s chronic pains from service-connected disabilities affected his ability to exercise, resulting in weight gain. Because weight is one of the greatest predictors of developing obstructive sleep apnea, the opinion is consistent with the evidence of record showing chronic daily pains for service-connected disabilities and a body mass index greater than 30 since 2018. There is no evidence to the contrary—namely, the possible effect of nonservice-connected disabilities on weight gain. Under such circumstances, the November 2020 opinion is afforded significant probative value because it is based on a review of the Veteran’s medical history and is supported by evidence of record. Id. at 304. Accordingly, resolving all doubt in favor of the Veteran, secondary service connection for obstructive sleep apnea is warranted. Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings.” Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Moreover, joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). Pursuant to Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated based on limitation of motion under appropriate diagnostic codes for specific joint or joints involved. When limitation of motion under appropriate diagnostic codes is noncompensable, a 10 percent evaluation is assignable. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. §§ 4.71a, Diagnostic Code 5003. Evaluating the same manifestations under a separate diagnosis would violate the anti-pyramiding provisions of 38 C.F.R. § 4.14. However, separate ratings under different diagnostic codes may be assigned where none of the symptomatology is duplicative or overlapping. Specifically in the context of evaluating disabilities based on limited motion, separately evaluating a manifestation of disability is not considered pyramiding if that manifestation had not resulted in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to principles set forth in Deluca, supra. See Lyles v. Shulkin, 29 Vet. App. 107, 109 (2017). In this regard, separate disability ratings may be assigned for knee disabilities resulting in functional impairment due to limited flexion, limited extension, instability, and for dislocation or removal of the meniscus or semilunar cartilage. See Lyles, supra; VAOPGCPREC 9-98; VAOPGCPREC 9-2004. VA revised criteria for evaluation of musculoskeletal system and muscle injuries, effective February 7, 2021. 85 Fed. Reg. 76,453-76,469 (Nov. 30, 2020). VA has a duty to adjudicate the claims under the former criteria during the entire appeal period, and to consider the revised criteria for the period beginning on the effective date of the new provisions—that is, from February 7, 2021. DeSousa v. Gober, 10 Vet. App. 461, 467 (1997); see also VAOPGCPREC 3-2000 (2000) and 7-2003 (2003). Degenerative Arthritis of Right Knee and Left Knee Throughout the rating period, the service-connected degenerative arthritis of right knee and left knee currently are rated separately as 10 percent disabling under Diagnostic Code 5003-5260 for limited flexion of each leg. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, neither Diagnostic Code 5003 nor Diagnostic Code 5260 nor Diagnostic Code 5261 nor Diagnostic Code 5258 was changed. X-rays taken in August 2018 revealed early osteoarthritis of both knees in the patellofemoral and medial compartments with minor effusions. At an August 2018 VA (contract) examination, the Veteran reported increasing aching and bilateral knee pain, which awakened him at night. He took medication for some relief and used a cane for walking. He described knee pain as a Level 5 on a scale of 10. He reported no flare-ups and no functional loss. The August 2018 examination report reveals that ranges of motion of right knee and left knee were to 140 degrees on flexion of each leg and to 0 degrees on extension of each leg. Pain was noted in flexion and in extension and at rest. There was no additional loss of function or range of motion on repetitive use of each knee. No additional factors contributed to disability, and there was no reduction in muscle strength of each knee. There was neither instability nor patellar abnormality. No meniscus condition was noted, and the Veteran had no knee surgery. There were no other pertinent findings. There was no impact on occupational activities. Diagnostic testing revealed degenerative arthritis of each knee. A VA examination was provided in November 2018; the Veteran described additional functional loss, particularly on right side. Both knees hurt and he often had to sit for approximately twenty or thirty minutes before he was able to move. He used a cane to steady himself. He reported that both knees gave way, right more than left; and reported no flare-ups. The examination report reveals that ranges of motion of right knee and left knee were to 130 degrees on flexion of each leg, and to 0 degrees on extension of each leg. There was objective evidence of painful motion; pain caused functional loss. There was no additional loss of function or range of motion on repetitive use. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. There was no reduction in muscle strength of either knee. The examiner noted body habitus, consisting of a body mass index of 32.23, contributed to disability. Examination revealed neither instability nor patellar abnormality. The Veteran occasionally used a cane. There was no impact on occupational activities, such as standing and walking and lifting and sitting. Flexion of Right Knee and Left Knee The current 10 percent evaluation for each knee contemplates pain on motion. Also, it is consistent with limitation of flexion of each leg to 45 degrees. Higher evaluations may be assigned if there is the functional equivalent of limitation of flexion of each leg to 30 degrees or less. In this case, the evidence reveals that the Veteran has functional flexion of each leg far better than 45 degrees. The evidence reveals that the Veteran has painful motion in flexion of each leg, which warrants at least a minimum compensable rating pursuant to provisions of 38 C.F.R. § 4.59. In this regard, VA examiners appropriately evaluated ranges of motion, pain, additional limitation of motion and functional loss upon repetitive testing, and limitation on weight-bearing. Although both knees are damaged and show limited motion, all ranges of motion testing reflect that the Veteran retained flexion of each leg far better than 45 degrees. The preponderance of evidence, therefore, is against disability ratings greater than the currently assigned 10 percent rating for each knee under Diagnostic Code 5260. Extension of Right Knee and Left Knee Separate evaluations may be assigned for compensable limitation of flexion of each leg or extension of each leg. Here, all examiners found full extension of each leg. Neither the lay nor medical evidence suggests limitation of extension of each leg to the extent contemplated by a 10 percent evaluation under Diagnostic Code 5261. There is no indication that the Veteran has limitation of extension of each leg that meets or approximates the criteria for separate, compensable disability ratings under Diagnostic Code 5261. Extension limited to 10 degrees is not demonstrated. Even with consideration of functional loss due to pain, fatigue, incoordination, or the like, no examiner has found additional limitation of motion following repetitive use or flare-ups. Accordingly, separate, compensable disability ratings under Diagnostic Code 5261 are not warranted. Instability of Right Knee and Left Knee Separate evaluations may be assigned for recurrent subluxation or lateral instability. The revised portions of the rating schedule changed the evaluation criteria for knee instability under Diagnostic Code 5257, effective February 7, 2021. Pursuant to former Diagnostic Code 5257, slight impairment of the knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent rating requires moderate impairment. A 30 percent rating requires severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Pursuant to revised Diagnostic Code 5257, a 10 percent evaluation is warranted for sprain or for incomplete ligament tear or for complete ligament tear causing persistent instability, without prescribed assistive device or bracing for ambulation. A 20 percent rating requires a prescribed assistive device or bracing for ambulation for sprain, for incomplete ligament tear, or for repaired complete ligament tear causing persistent instability; or requires a prescribed assistive device or bracing for ambulation for unrepaired or failed repair of complete ligament tear causing persistent instability. A 30 percent rating requires that a medical provider prescribe both an assistive device and bracing for ambulation for unrepaired or failed repair of complete ligament tear causing persistent instability. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). However, such is effective February 7, 2021. Here, throughout the rating period, all joint stability tests of each knee were normal. There is no evidence or history of recurrent patellar subluxation or dislocation. The Board has considered the Veteran’s lay assertions regarding severity and finds that his symptoms do not meet or approximate the criteria for separate, compensable evaluations for each knee under Diagnostic Code 5257. Ultimately, the Board places the most probative weight on the results of objective physical examination by medical professionals, which fail to show any evidence of recurrent subluxation or instability; and are against the assignment of separate, compensable evaluations for each knee under former or revised Diagnostic Code 5257. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Meniscus Complications of Right Knee and Left Knee Where there is current evidence of cartilage damage; and objective evidence of frequent episodes of locking, pain, and effusion into the joint, a separate compensable rating for each knee may be assigned under Diagnostic Code 5258 for associated meniscus complications of knee disability that result in additional functional impairment. Here, the objective evidence does not support separate compensable disability ratings for each knee based on meniscus complications under Diagnostic Code 5258. The evidence does not reveal that the Veteran had a meniscectomy of either knee in active service. There is no evidence of dislocated semilunar cartilage involving either knee joint. While examiners noted some effusion, and the Veteran reported both knees giving way at times, the evidence of record does not support separate compensable ratings for associated meniscus complications of either knee resulting in additional functional impairment at any time throughout the rating period. Osteoarthritis of Left Ankle and Right Ankle Throughout the rating period, the service-connected osteoarthritis of right ankle and left ankle currently are rated separately as 10 percent disabling under Diagnostic Code 5003-5271 for moderate limitation of motion of each ankle. The revised portions of the rating schedule changed the evaluation criteria for limited motion of ankle under Diagnostic Code 5271, effective February 7, 2021. Pursuant to former Diagnostic Code 5271, moderate limitation of motion of an ankle warrants a 10 percent evaluation. A 20 percent rating requires marked limitation of motion, and is the maximum rating under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Pursuant to revised Diagnostic Code 5271, a 10 percent evaluation is warranted for moderate limitation of motion of ankle, defined as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. A 20 percent rating requires marked limitation of motion of ankle, defined as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5271.) The standard ranges of motion of the ankle are 20 degrees dorsiflexion and 45 degrees plantar flexion. 38 C.F.R. § 4.71, Plate II. X-rays taken of right ankle in August 2018 revealed plantar calcaneal spur and minor enthesophyte at the Achilles insertion; there was neither acute pathology nor significant arthritic change for age. X-rays taken of left ankle in August 2018 revealed remote avulsion with 3- or 4-millimeter chronic avulsed fracture fragment adjacent to the medial margin of talus distal to medial malleolus. Plantar calcaneal spur was noted. There was neither acute pathology nor significant arthritic change for age. At an August 2018 VA (contract) examination, the Veteran reported no flare-ups of ankle pain. He described neither functional loss nor functional impairment of each ankle. The August 2018 examination report reveals that ranges of motion of right ankle and left ankle were to 20 degrees on dorsiflexion of each ankle and to 45 degrees on plantar flexion of each ankle. Pain was noted in dorsiflexion and in plantar flexion and at rest. There was no additional loss of function or range of motion on repetitive use of each ankle. No additional factors contributed to disability, and there was no reduction in muscle strength of each ankle. There was no ankle instability, and the Veteran had no ankle surgery. There were neither other pertinent findings nor any impact on occupational activities. A VA examination was provided in November 2018; the Veteran described additional functional loss. Both ankles hurt all the time; and he often sprained his ankles, especially the right ankle. He reported flare-ups. Sometimes he soaked his ankles with ice and took pressure off his ankles for approximately 24 hours; this last happened two weeks ago. The examination report reveals that ranges of motion of right ankle were to 10 degrees on dorsiflexion, and to 35 degrees on plantar flexion. Ranges of motion of left ankle were to 20 degrees on dorsiflexion, and to 40 degrees on plantar flexion. There was no evidence of pain with weight-bearing for each ankle. There was no additional loss of function or range of motion on repetitive use. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use of each ankle over a period of time. There was no reduction in muscle strength of either ankle. Joint instability of each ankle was suspected, although anterior drawer test and talar tilt test were negative. There was no impact on occupational activities. In this case, osteoarthritis of each ankle has been manifested primarily by objective evidence of decreased dorsiflexion and flare-ups. There is no evidence of pain with weight-bearing. The Board acknowledges the Veteran’s complaints of pain; however, the overall severity, frequency, and duration of the Veteran’s symptoms for each ankle throughout the rating period are not on par with the level of severity contemplated by disability ratings greater than 10 percent under former Diagnostic Code 5271 or under alternative diagnostic codes. Although both ankles are damaged and show limited motion, neither ankylosis nor marked limitation of motion of each ankle is demonstrated. Moreover, none of the lay or medical evidence suggests that limited motion of each ankle is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. In this regard, the criteria for a 20 percent rating under revised Diagnostic Code 5271 for osteoarthritis of each ankle are not met or approximated. The preponderance of the evidence, therefore, is against disability ratings greater than 10 percent for osteoarthritis of each ankle under both former and revised Diagnostic Code 5271. Ultimately, the Board places the most probative weight on the results of objective physical examination by medical professionals, which fail to show any evidence of marked ankle disability throughout the rating period. Degenerative Arthritis of Spine Throughout the rating period, the service-connected degenerative arthritis of spine is rated as 10 percent disabling under former Diagnostic Code 5242 based on limitation of motion. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the rating criteria for degenerative arthritis of spine were not changed; rather, Diagnostic Code 5242 was re-defined to include only certain spinal disabilities. Spinal disabilities are primarily evaluated under a general rating formula (which provides the criteria for rating orthopedic disability, and authorizes separate evaluations of its chronic neurologic manifestations). The current 10 percent evaluation contemplates pain on motion. It is also consistent with forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A higher evaluation of 20 percent may be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A higher evaluation of 40 percent may be assigned for the functional equivalent of forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A higher evaluation of 50 percent may be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability evaluation is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Alternatively, intervertebral disc syndrome is evaluated (preoperatively or postoperatively) either based on incapacitating episodes over the past 12 months, or under the general rating formula for spinal disabilities—whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. A higher evaluation of 20 percent may be assigned if there are incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months. A higher evaluation of 40 percent may be assigned if there are incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months. A maximum, 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (Note 1). X-rays taken of lumbar spine in December 2017 revealed multi-level degenerative disc disease and degenerative facet disease. The Veteran underwent physical therapy for chronic lumbar pain in January 2018. At an August 2018 VA (contract) examination, the Veteran reported increasing aching and daily back pain, which awakened him at night. He reported no bowel or bladder issues. He described low back pain as a dull and aching pain, and as a Level 6 on a scale of 10. He reported flare-ups, but no functional loss. The August 2018 examination report reveals that ranges of motion of thoracolumbar spine were to 90 degrees on flexion, to 30 degrees on extension, to 30 degrees on bending to right and left, and to 30 degrees on rotation to right and left. There was no objective evidence of localized tenderness of thoracolumbar spine. There was no additional loss of function or ranges of motion after three repetitions or during flare-ups. Muscle strength testing was normal; there was no atrophy. There was no ankylosis. There was no impact on occupational activities. A VA examination was provided in November 2018; the Veteran was diagnosed with degenerative arthritis of spine, and mild functional limitations were noted. Functional ability was not significantly limited with repeated use over a period of time due to pain, weakness, fatigability, or incoordination. The Veteran reported no flare-ups. He described functional loss as his back hurting constantly, and that his low back was tender. He had difficulty arising after sitting in the same spot for a while; once up, he moved around, and his low back felt better. Ranges of motion of the thoracolumbar spine in November 2018 were to 75 degrees on flexion; to 20 degrees on extension; to 25 degrees on bending to right; to 30 degrees on bending to left; to 25 degrees on rotation to right; and to 30 degrees on rotation to left. There was no objective evidence of localized tenderness of thoracolumbar spine. There was no additional loss of function or ranges of motion after three repetitions. Muscle strength testing was normal; there was no atrophy. There was no ankylosis. There was no functional impact on the Veteran’s ability to work. In this case, the most probative evidence shows that the Veteran had nearly full ranges of motion throughout the rating period. Pain was shown as the primary factor impairing the Veteran’s function. The Board finds that the evidence meets the criteria for no more than the currently assigned 10 percent disability rating under the general rating formula. The Veteran can flex his thoracolumbar spine beyond 60 degrees. There is no evidence that the Veteran has muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour as a result of service-connected disability; nor is there evidence of doctor-prescribed bed rest or incapacitating episodes having a total duration of at least two weeks during any past 12 months. While the Veteran indicated that his degenerative arthritis of spine has progressively worsened, the objective findings consistently fail to show that his disability meets the criteria for a disability rating greater than 10 percent at any time. In this regard, the Board has considered the Court’s holding in Deluca. Examiners have acknowledged that pain is the primary factor impairing function. However, such impaired function still does not satisfy the criteria for a higher rating for a disability of the spine. Thus, even with consideration of functional loss with constant back pain, the rating criteria applied take into account pain and other symptoms. The Veteran’s reported symptoms have been considered, and they support a 10 percent disability rating. Nor does the evidence indicate that the criteria for a 20 percent rating have been met on active or passive motion; there is no weight-bearing medico-legal standard available for the spine. See Correia, 28 Vet. App. at 170. Thus, throughout the rating period, the weight of the evidence is against the award of a disability rating greater than 10 percent at any time, based on orthopedic findings. As shown below, neurologic manifestations associated with degenerative arthritis of spine—that is, radiculopathy of right and left lower extremities—have been separately evaluated. Radiculopathy of Right and Left Lower Extremities Service connection has been established for radiculopathy of each lower extremity under Diagnostic Code 8620, pertaining to neuritis of the sciatic nerve. The criteria for rating diseases of the peripheral nerves are based on paralysis, neuritis, or neuralgia. Because the evidence shows that the Veteran’s lower extremities are functional, it is clear that the radiculopathy does not produce complete paralysis. Complete paralysis of the sciatic nerve is indicated when the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Neuritis of a peripheral nerve, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain—at times excruciating—is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia of a peripheral nerve, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (with exceptions not relevant here). Here, the currently assigned 10 percent evaluation for each lower extremity contemplates mild incomplete paralysis of the sciatic nerve. Higher evaluations of 20 percent may be assigned for moderate incomplete paralysis of the sciatic nerve of each lower extremity. Forty percent evaluations may be assigned for moderately severe incomplete paralysis of the sciatic nerve of each lower extremity. Sixty percent evaluations may be assigned for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy of each lower extremity. Eighty percent evaluations may be assigned for complete paralysis of the sciatic nerve of each lower extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8560. At an August 2018 VA (contract) examination, the Veteran reported right-sided radiculopathy occasionally, relieved to some degree with medication. He used a cane constantly for walking and reported that his legs gave out at times. He described leg pain as a 9 on a scale of 10, occurring daily, and lasting from a few minutes to hours. The August 2018 examination report reveals no muscle atrophy; reflex examination was normal for each lower extremity. Sensory examination was normal, and straight leg raising tests were negative. The Veteran described a shooting pain down to each knee. The examiner noted radicular pain, or signs or symptoms due to radiculopathy. There was mild constant pain, mild intermittent pain, mild paresthesias, and mild numbness of each lower extremity. The sciatic nerve of each lower extremity was involved. No other neurologic abnormalities were noted. A VA examination was provided in November 2018; the Veteran described additional functional loss as sitting for an hour in the same spot and having difficulty getting up. Once he was up and moved a bit, he felt better. The examination report reveals no objective findings of radiculopathy of each lower extremity. Muscle strength testing was normal; there was no muscle atrophy. Reflex examination was normal. Sensory examination was normal. Straight leg raising tests were negative. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. There were no other neurologic abnormalities. The examiner indicated that each lower extremity demonstrated no motor or sensory deficits, and the Veteran did not report symptoms. There were no objective findings to support a diagnosis of radiculopathy of each lower extremity. In this case, each examiner throughout the rating period found the level of severity of radiculopathy of each lower extremity (sciatic nerve) to be mild. Such testing results are probative and support the currently assigned 10 percent disability rating for each lower extremity. At most, the Veteran’s neuritis is equivalent to mild incomplete paralysis of each lower extremity. Neither lay nor medical evidence suggests moderate incomplete paralysis affecting the sciatic nerve. The preponderance of evidence is against disability ratings greater than 10 percent each for radiculopathy of each lower extremity (sciatic nerve) at any time. Effective Date of Awards of Service Connection The effective date for a grant of service connection is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from service. Otherwise, it is the date of receipt of claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a), (b); 38 C.F.R. § 3.400(b). The effective date of service connection based on a reopened claim is the date of receipt of the new claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(r). Although a claimant need not identify the benefit sought “with specificity,” see Servello v. Derwinski, 3 Vet. App. 196, 199-200 (1992), some intent on the part of the Veteran to seek benefits must be demonstrated. See Brannon v. West, 12 Vet. App. 32, 34-35 (1998). See also Talbert v. Brown, 7 Vet. App. 352, 356-7 (1995) (noting that while VA must interpret a claimant’s submissions broadly, VA is not required to conjure up issues not raised by claimant). The United States Court of Appeals for the Federal Circuit has emphasized VA has a duty to fully and sympathetically develop a Veteran’s claim to its optimum. Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998). This duty requires VA to “determine all potential claims raised by the evidence, applying all relevant laws and regulations,” Roberson v. West, 251 F.3d 1378, 1384 (Fed. Cir. 2001), and extends to giving a sympathetic reading to all pro se pleadings of record. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. Prior to March 24, 2015, VA recognized formal and informal claims. See 38 C.F.R. § 3.1(p). The amendments also, inter alia, eliminated the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen. See 79 Fed. Reg. 57,660 (Sept. 25, 2014), codified as amended at 38 C.F.R. §§ 3.151, 3.155. The amended regulations apply only to claims filed on or after March 24, 2015. The Veteran contends that he is entitled to an effective date earlier than November 21, 2017, for the award of service connection and compensation for degenerative arthritis of right knee and left knee; for osteoarthritis of right ankle and left ankle; for degenerative arthritis of spine; and for radiculopathy of right lower extremity and left lower extremity. On November 19, 2012, the Veteran filed claims for service connection for other disabilities to include residuals of testicular injury; bilateral hearing loss disability; and tinnitus. Each of these claims either was granted or denied by the AOJ in a November 2013 rating decision. On December 5, 2013, the Veteran notified VA by telephone of an intent to file for VA benefits. Any communication submitted by the Veteran is no longer considered an informal claim. However, and importantly, 38 C.F.R. § 3.155(a) requires VA to provide notice to the Veteran when a communication does not meet the requirements for a claim. Such notice must inform the Veteran of the information necessary to complete the appropriate application form. This is separate and distinct from a formal “intent to file” under 38 C.F.R. § 3.155(b), and in fact would require VA to notify the Veteran of the need to file such a form. Here, a VA employee’s notation of information requested and given during the December 5, 2013 telephone call reflects that the Veteran was “in the process of assembling [his] claim package for submission.” VA Form 21-526EZ also was noted. The Board finds VA’s duty to inform the Veteran of the formalities required to pursue a claim for service connection were met. 38 C.F.R. § 3.155(a), (b). Specifically, no written claim for VA benefits was received by VA within one year of the December 5, 2013 telephone call; hence, the December 5, 2013 communication of intent to file for VA benefits was considered abandoned and no action, to include an adjudication, was taken on it. 38 C.F.R. § 3.158. In this regard, there was no due process violation or grave procedural error. See Hayre v. West, 188 F.3d 1327, 1333 (Fed. Cir. 1999). On November 21, 2017, the Veteran notified VA of an intent to file for VA benefits. Significantly, there is no pending claim prior to November 21, 2017, pursuant to which benefits could be granted. Moreover, an award of compensation cannot precede the effective date of the grant of service connection. Degenerative Arthritis of Right Knee and Left Knee The Veteran first filed a claim for service connection for degenerative arthritis of right knee and left knee (claimed as bilateral knee pain) on June 29, 2018. He had not submitted any communication indicating an intent to apply for service connection for degenerative arthritis of right knee and left knee prior to June 29, 2018. The evidence of record, to include private and VA treatment records, examination reports, and lay statements, provided no basis on which to infer such a claim. The AOJ correctly assigned November 21, 2017—the date of intent to file a claim—for the award of service connection and compensation for degenerative arthritis of right knee and left knee. A VA examination in August 2018 supports the Veteran’s award. Accordingly, the Veteran’s claim for an earlier effective date for award of service connection and compensation for degenerative arthritis of right knee and left knee is denied as a matter of law. Osteoarthritis of Right Ankle and Left Ankle The Veteran first filed a claim for service connection for osteoarthritis of right ankle and left ankle (claimed as bilateral ankle pain) on June 29, 2018. He had not submitted any communication indicating an intent to apply for service connection for osteoarthritis of right ankle and left ankle prior to June 29, 2018. The evidence of record, to include private and VA treatment records, examination reports, and lay statements, provided no basis on which to infer such a claim. The AOJ correctly assigned November 21, 2017—the date of intent to file a claim—for the award of service connection and compensation for osteoarthritis of right ankle and left ankle. A VA examination in August 2018 supports the Veteran’s award. Accordingly, the Veteran’s claim for an earlier effective date for award of service connection and compensation for osteoarthritis of right ankle and left ankle is denied as a matter of law. Degenerative Arthritis of Spine The Veteran first filed a claim for service connection for degenerative arthritis of spine (claimed as low back pain) on June 29, 2018. He had not submitted any communication indicating an intent to apply for service connection for degenerative arthritis of spine prior to June 29, 2018. The evidence of record, to include private and VA treatment records, examination reports, and lay statements, provided no basis on which to infer such a claim. The AOJ correctly assigned November 21, 2017—the date of intent to file a claim—for the award of service connection and compensation for degenerative arthritis of spine. A VA examination in August 2018 supports the Veteran’s award. Accordingly, the Veteran’s claim for an earlier effective date for award of service connection and compensation for degenerative arthritis of spine is denied as a matter of law. Radiculopathy of Right Lower Extremity and Left Lower Extremity As noted above, the Veteran first filed a claim for service connection for degenerative arthritis of spine (claimed as low back pain) on June 29, 2018. The effective date of the award for service connection for radiculopathy of each lower extremity was predicated on the basis of the Veteran’s award of service connection for degenerative arthritis of spine. This date corresponds with the Veteran’s claim, pursuant to which service connection for degenerative arthritis of spine was granted. The Board must emphasize that the effective date of an award of compensation cannot precede the effective date of the grant of service connection. The AOJ correctly assigned November 21, 2017—the date of intent to file a claim—for the award of service connection and compensation for radiculopathy of right lower extremity and left lower extremity. A VA examination in August 2018 supports the Veteran’s award. Accordingly, the Board concludes that the record presents a legal basis for assignment of an effective date no earlier than November 21, 2017, for the award of service connection and compensation for radiculopathy of right lower extremity and left lower extremity. REASONS FOR REMAND Headaches The Veteran has asserted that the claimed disability is secondary to his service-connected disabilities. He filed a claim for service connection in November 2018. In January 2021, a medical statement was provided from a private physician who had reviewed the Veteran’s claims file and interviewed the Veteran. The physician noted the Veteran’s long history of migraine headaches, which were described as “often debilitating occurring over the last 15 or more years.” The physician noted the Veteran had several triggers to migraines, which included (as a direct correlation) flare-ups of musculoskeletal pain due to service-connected disabilities. Another trigger was worsening of the Veteran’s service-connected tinnitus. The physician provided an opinion for secondary service connection and referenced several medical studies. During August 2018 examinations, the Veteran reported flare-ups of thoracolumbar pain; he denied flare-ups of knee pain and ankle pain. VA records show no treatment for migraine headaches from 2013 to 2019. The Board cannot make a fully informed decision on the issue of service connection for headaches because no VA examiner has opined whether the claimed disability is part and parcel of, or related to the service-connected degenerative arthritis of spine or service-connected tinnitus; or otherwise is related to service or service-connected disease or injury. The Board cannot resolve this matter without further medical clarification. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4). TDIU The Veteran may be entitled to special monthly compensation (SMC) as provided in § 1114(s), if he is found to be unemployable due solely to one of his service-connected disabilities and there is additional service-connected disability or disabilities that are independently ratable at 60 percent, which are separate and distinct from the 100 percent service-connected disability and involve different anatomical segments or bodily systems. See Bradley v. Peake, 22 Vet. App. 280 (2008). As the Board has granted service connection for obstructive sleep apnea which has yet to be rated, and has remanded service connection for headaches, the TDIU issue is inextricably intertwined and must be deferred on remand for re-adjudication. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2020 to the present. 2. Schedule a VA examination or a medical review, as appropriate, to determine the nature and etiology of any disability manifested by headaches. The claims file must be available and reviewed in this regard. Specifically, the examiner should opine as to whether any current disability is at least as likely as not related to, or part and parcel of, the degenerative arthritis of spine or tinnitus; or related to service or service-connected disease or injury. 3. Implement the grant of service connection for obstructive sleep apnea, to include assignment of initial evaluation. 4. Then, readjudicate the claims on appeal, including entitlement to TDIU. If any benefits sought remain denied, issue a supplemental statement of the case and, after appropriate time for response, return the appeal to the Board if otherwise in order. J. TUNIS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary C. Suffoletta 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.