Citation Nr: 21024694 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 18-02 869 DATE: April 23, 2021 ORDER Entitlement to service connection recurrent bilateral cerumen impaction is granted. Entitlement to service connection for vitamin D deficiency is denied. Entitlement to service connection for left foot ingrown toenails is denied. Entitlement to service connection for right foot ingrown toenails is denied. Entitlement to an initial compensable rating for boutonniere deformity of the right 5th digit is denied. Entitlement to an initial compensable rating for allergic rhinitis is denied. Entitlement to an initial compensable rating for external hemorrhoids is denied. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to an initial 20 percent rating for right knee instability prior to September 21, 2020 is granted. Entitlement to a 30 percent for right knee instability from September 21, 2020 is granted. Entitlement to an initial 20 percent rating for left knee instability prior to September 21, 2020 is granted. Entitlement to a 30 percent for left knee instability from September 21, 2020 is granted. Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis is denied. Entitlement to an initial rating in excess of 10 percent for left knee osteoarthritis is denied. Entitlement to total disability based on individual unemployability (TDIU) is granted. REMANDED Entitlement to an initial compensable rating for bilateral cortical cataracts is remanded. Entitlement to an initial rating in excess of 10 percent right elbow olecranon bursitis is remanded. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) is remanded. FINDINGS OF FACT 1. The Veteran has had recurrent episodes of cerumen impaction with onset in service. 2. The Veteran had a laboratory finding of vitamin D deficiency in service, without clinical manifestation. Vitamin D deficiency is not a disability; it is a laboratory finding indicative of a risk factor for the development of disability. 3. The preponderance of the evidence of record is against finding that the Veteran has had left ingrown toenails/residuals of ingrown toenails at any time during or approximate to the pendency of the claim. 4. The preponderance of the evidence of record is against finding that the Veteran has had right ingrown toenails/residuals of ingrown toenails at any time during or approximate to the pendency of the claim. 5. The Veteran’s right 5th finger boutonniere deformity is assigned a noncompensable rating, which is the maximum rating possible under the diagnostic code that evaluates limitation of motion of the little finger; there is no evidence of ankylosis or symptoms analogous to amputation. 6. The Veteran’s allergic rhinitis had not manifested in nasal obstructions or polyps. 7. During the period on appeal, the Veteran’s external hemorrhoids have been mild to moderate in severity. The preponderance of the evidence is against finding that his hemorrhoids have been large or thrombic, irreducible with excessive redundant tissue, with frequent recurrences. 8. Continuous medication for hypertension was prescribed in November 2015. During the claim period, the evidence does not support diastolic pressure that was predominately 110 or more, or systolic pressure that was predominately 200 or more. 9. Prior to September 21, 2020, the Veteran’s right knee manifested in moderate lateral instability. 10. From September 21, 2020, the Veteran’s right knee manifested in severe lateral instability. 11. Prior to September 21, 2020, the Veteran’s left knee manifested in moderate lateral instability. 12. From September 21, 2020, the Veteran’s left knee manifested in severe lateral instability. 13. The Veteran’s right knee osteoarthritis manifested in painful range of motion, flexion to 90 degrees at worst, extension with loss of 5 degrees at worst. 14. The Veteran’s left knee osteoarthritis manifested in painful range of motion, flexion to 90 degrees at worst, extension with loss of 5 degrees at worst. 15. Resolving reasonable in favor of the Veteran, his service-connected disabilities render him unable to secure and maintain a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to recurrent bilateral cerumen impaction have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2021). 2. The criteria for entitlement to service connection for vitamin D deficiency have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 3. The criteria for entitlement to service connection for left foot ingrown toenails have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 4. The criteria for entitlement to service connection for right foot ingrown toenails have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 5. The criteria for an initial compensable rating for boutonniere deformity of the right 5th digit have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5230. 6. The criteria for an initial compensable rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, DC 6522. 7. The criteria for an initial compensable rating for external hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.14, 4.114, DC 7336. 8. The criteria for an initial 10 percent rating, and no higher, for hypertension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, DC 7101. 9. Prior to September 21, 2020, the criteria for an initial 20 percent rating for right knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, DCs 5003, 5257. 10. From September 21, 2020, the criteria for a 30 percent rating for right knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, DCs 5003, 5257. 11. Prior to September 21, 2020, the criteria for an initial 20 percent rating for left knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, DCs 5003, 5257. 12. From September 21, 2020, the criteria for a 30 percent rating for left knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, DCs 5003, 5257. 13. The criteria for an initial rating in excess of 10 percent for right knee osteoarthritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, Diagnostic Codes 5003, 5260, 5261. 14. The criteria for an initial rating in excess of 10 percent for left knee osteoarthritis have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.14, 4.20, 4.71a, Diagnostic Codes 5003, 5260, 5261. 15. From January 18, 2016, the criteria for entitlement to a TDIU due to service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to September 2014. His awards include the Purple Heart Medal and the Combat Action Badge. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 RO decision. Some of these issues were previously before the Board; in May 2020 the Board remanded the issues so that the RO could review additional evidence and issue a supplemental statement of the case (SSOC). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to recurrent bilateral cerumen impaction is granted. A July 30, 2014 service treatment record noted that the Veteran had right ear cerumen debridement performed. After cerumen removal, careful inspection of cartilaginous and boney externa auditory canal performed. He was assessed with right ear cerumen impaction. No follow-up required. The Veteran participated in an April 3, 2015 VA evaluation for his claimed service connection claims. Regarding his cerumen blockage claim, the Veteran reported that he first had bilateral cerumen blockage in 2005 when he noticed itching and muffled hearing. He had his ears “flushed” and his symptoms resolved. “Since that time, the Veteran reported he had required bilateral ear flushing [approximately once per year] the last time was in August 2014.” He applied ear wax drops once per month as well. The Veteran was “currently asymptomatic.” A June 20, 2015 VA audiological examination diagnosed mild left ear hearing loss due to noise exposure; however, the veteran did not meet the standards for a hearing loss disability at that time. The examination did not include any abnormal findings on evaluation of his ears. Walter Reed medical records included active medication prescribed for ear wax treatment (carbamide peroxide otic solution), last filled in September 8, 2016 (the medical record was from 2016). On July 3, 2017, the Veteran submitted a statement that he continued to use carbamide peroxide to treat his ear wax build up. As the Veteran first suffered from cerumen impaction in service, and he has credibly reported ongoing treatment for wax build up and cerumen impaction post-service, the Board finds that the evidence is at least in equipoise that the Veteran has recurrent cerumen impaction that began in service. The criteria for service connection for recurrent cerumen impaction are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Entitlement to service connection for vitamin D deficiency is denied. The Veteran sought entitlement to service connection for vitamin D deficiency. He participated in an April 3, 2015 VA general medical evaluation, wherein he reported that he was found to have low vitamin D levels during routine laboratory findings. He was “prescribed some kind of supplement that was taken for 2-3 months to bring the vitamin D level up.” After supplement, his vitamin D level was “sufficient” (November 27, 2012 record noted that his vitamin D deficiency “resolved”). The Veteran stated he was told to “get more sunlight.” The examiner noted that the Veteran had not had “in past nor present, clinical manifestation of vitamin D deficiency.” An October 2, 2018 VA treatment records include a letter to the Veteran which noted that his vitamin D level was “a little low” and informed the Veteran which foods were high in vitamin D. The Veteran’s diagnosed vitamin D deficiency itself is not a service-connectable disability. The term “disability,” as used for VA purposes, refers to a condition resulting in an impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Instead, vitamin D deficiency is a mere laboratory finding. It is a risk factor for development of bone disorder, and not actually a symptom. The Veteran was noted to not have any clinical manifestations of his vitamin D deficiency. It is specifically excluded from service connection. See Schedule for Rating Disabilities; Musculoskeletal System; Infectious Diseases, Immune Disorders and Nutritional Deficiencies, 38 C.F.R. Part 4. As such, entitlement to service connection for vitamin D deficiency is not warranted. 3. Entitlement to service connection for left foot ingrown toenails is denied. 4. Entitlement to service connection for right foot ingrown toenails is denied. The Veteran is seeking entitlement to service connection for ingrown toenails of both feet. Service treatment records included that on May 21, 2009, the Veteran was seen for complaint of ingrown toenail on right foot first toe. It was too painful just to wear his boot. He was referred for possible toenail removal. A partial nail removal was done due to right great toe medial side ingrown toenail. He was seen on July 19, 2012 from complaints of pain and mass to the right foot for 2-3 months. He was noted to have a history of ingrown toenail of the right foot from 2009. He was assessed with metatarsal spur. This record indicates that he did not have additional ingrown toenails between 2009 and 2012, as only the 2009 occurrence was listed in the medical history. The Veteran participated in April 3, 2015 VA foot and skin examinations. The foot examination diagnosed metatarsalgia, hallux rigidus, plantar fasciitis, degenerative arthritis of the right foot, status post spur/bunion resection surgery right foot, residual hallux rigidus. The Veteran noted that in 2004 he was in an IED explosion that resulted in foot damage, mostly to the right foot. He developed metatarsalgia with spur and bunion of the right foot, osteoarthritis of the right ankle/foot, and ingrown toenails of the right foot. He underwent spur/bunion surgery in March 2013 and then developed hallux rigidus. During the skin examination, the Veteran reported he underwent “procedures” on his ingrown toenails and they “resolved.” Diagnosis of ingrown toenails (right foot) resolved, no residuals was given. He had not received any treatments or procedures, to include oral or topical medications, in the past 12 months. Regarding the physical examination portion of the report, the examiner wrote “the Veteran does not have any of the above listed visible skin conditions” and he did not have “any of the specific skin conditions listed.” Under the “other pertinent physical findings” the examiner noted that the right foot examined, and no ingrown toenails were found. “No residuals of ingrown toenails found.” In a May 2015 statement attached to his substantive appeal, the Veteran reported that he still suffered from “these conditions” (referring to vitamin D deficiency, cerumen blockage, and ingrown toenails) on a “daily basis.” A review of the private and VA treatment records did not reveal treatment for, complaints of, or diagnosis of ingrown toenails during the period on appeal. The Board notes that the Veteran suffered from ingrown toenails on his right foot in service, in 2004 (as reported by the Veteran) and 2009. His ingrown toenails were excised in service. There is no indication that they recurred after his 2009 treatment. A 2012 record indicated the prior 2009 history of ingrown toenail on the right, but did not indicate there had been other occurrences. There is no indication the Veteran had left foot ingrown toenails in service or post service. As the evidence is against finding that the Veteran had ingrown toenails, or residuals thereof, during the period on appeal or chronically during service, the Board finds that entitlement to service connection for ingrown toenails of the right or left foot are not warranted. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). 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; 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 criteria.”). The rating schedule is intended to recognize actually painful, unstable, or malaligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Case law and VA guidelines anticipate that VA examiners will use information procured from relevant sources, including lay statements, to estimate additional functional loss during flare-ups of musculoskeletal disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). 5. Entitlement to an initial compensable rating for boutonniere deformity of the right 5th digit is denied. The Veteran is seeking a compensable rating for his boutonniere deformity of the right 5th/little finger. An April 3, 2015 VA hand and finger examination showed that the Veteran’s right little finger had had maximum extension of MCP of 0 degrees, PIP to 45 degrees (normal is 0 degrees) and DIP to 0 degrees. He had maximum flexion of MCP to 90 degrees, PIP to 100 degrees, and DIP to 55 degrees (normal is 70 degrees). There was no objective evidence of pain with use of the hand. There was no localized tenderness or pain with palpation. The examiner found that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Full muscle strength throughout. The examiner cited a June 4, 2003 x-ray which noted the Veteran had injured his finger playing basketball, and his finger remained swollen with decreased range of motion. The x-ray showed a volar plate fracture at the proximal interphalangeal articulation of the fifth finger. The Veteran’s disability has been rated as noncompensable under 38 C.F.R. § 4.71a, DC 5230. Under this provision, a limitation of motion of the ring or little finger is assigned a noncompensable rating. 38 C.F.R. § 4.71a. As set forth above, DC 5230 does not provide for a compensable rating. An initial compensable rating pursuant to 38 C.F.R. § 4.59 is not for application when the applicable Diagnostic Code does not provide a compensable rating. See Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2015) (a compensable rating is warranted for joint pain pursuant to 38 C.F.R. § 4.59 for orthopedic disabilities, but only if they are rated under diagnostic codes containing a compensable rating). Therefore, an initial compensable rating under DC 5230 is not warranted. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis the interphalangeal, metacarpal, and carpal joints are considered a group of minor joints. 38 C.F.R. § 4.45. The evidence does not show degenerative arthritis with involvement of two or more minor joints. Accordingly, an increased rating is not warranted under Diagnostic Code 5003. 6. Entitlement to an initial compensable rating for allergic rhinitis is denied. The Veteran is seeking an initial compensable rating for allergic rhinitis. He has reported seasonal runny nose, sneezing, and itchy/watery eyes, particularly in the spring and summer. The Board notes that the 2015 examination was provided in the spring. While DC 6522 does not provide for a noncompensable disability evaluation, 38 C.F.R. § 4.31 provides for zero percent evaluations in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code and the requirements for a compensable evaluation are not met. Under DC 6522, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. A 30 percent evaluation is warranted for allergic or vasomotor rhinitis with polyps. See 38 C.F.R. § 4.97. A 30 percent evaluation is the maximum rating permitted under DC 6522. On April 3, 2015, the Veteran participated in a VA rhinitis examination. He reported a diagnosis of allergic rhinitis in the 1980s when he was initially stationed “in the DC area.” At that time, he developed a “runny nose, sneezing, itchy watery eyes.” He was prescribed medication for his newly developed allergies. He stated his symptoms have “waxed and waned over the years depending on geographical station.” He reported spring and summer were the primary months when his allergies were “bad.” At the time of the examination, he took over-the-counter Zyrtec as needed. He avoided working outside during pollen seasons. He stated that his allergies felt like “having a cold” and he had missed “a few days” of work due to symptoms. On physical examination, the Veteran did not have greater than 50 percent obstruction of the nasal passage on both sides, complete obstruction of either side, permanent hypertrophy of the nasal turbinates, nasal polyps, or any granulomatous conditions due to his rhinitis. During November 17, 2016 sleep clinic care for his obstructive sleep apnea (service-connected), the Veteran denied a history of nasal congestion. The Veteran participated in a second VA rhinitis examination on October 24, 2017. He stated that his rhinitis had been the same since it began as he “still gets the runny nose, sneezing, and watery eyes.” He continued to treat his rhinitis with Zyrtec. On examination, he did not have greater than 50 percent obstruction of the nasal passage on either side, complete obstruction of either side, permanent hypertrophy of the nasal turbinates, nasal polyps, and did not have any granulomatous conditions. Again, October 17, 2019 VA sleep clinic records included the Veteran’s denial of symptoms of nasal congestion. A review of private and VA treatment records did not include treatment for allergic rhinitis which included evidence of obstruction of nasal passages, nasal polyps, or hypertrophy of the nasal turbinates. The Board notes that the Veteran has reported that his allergic rhinitis symptoms are worse depending on geographical location, with his symptoms beginning when stationed in the “DC area,” and during the spring and summer. His 2015 examination was performed in spring (April), and his 2017 examination was performed in the fall (October). Both examinations occurred in the DC area. He did not present with compensable symptoms of allergic rhinitis during either examination. His VA and private treatment records do not indicate that he suffered from compensable symptoms of allergic rhinitis during the period on appeal. Although the Veteran has credibly reported symptoms of allergic rhinitis (sneezing, running nose, etc.), these symptoms do not meet the criteria for a compensable rating under the diagnostic code for allergic rhinitis. As such, entitlement to a compensable rating for allergic rhinitis is not warranted. 7. Entitlement to an initial compensable rating for external hemorrhoids is denied. The Veteran is seeking entitlement to an initial compensable rating for his external hemorrhoids. Currently, the Veteran maintains a 0 percent disability rating, which is assigned to mild or moderate hemorrhoids, pursuant to 38 C.F.R. § 4.114, DC 7336. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, DC 7336. On April 3, 2015, the Veteran participated in a VA hemorrhoids examination. He was assessed with hemorrhoids (diagnosed in 2004), and benign colon polyp (diagnosed in 2012). He reported the onset of symptoms of hemorrhoids in 2004 with painful bowel movement and blood on the toilet tissue. He self-medicated with Preparation H ointment. In 2012, he underwent a colonoscopy where external hemorrhoids were diagnosed, and a benign tubular adenoma was removed. He reported flare-ups of hemorrhoids 2 to 4 times per year with symptoms of painful bowel movement, blood on the toilet tissue, and occasional itching. He reported “better relief using Neosporin ointment rather than Preparation H.” He stated that his flare-ups occur more often now (2-4 times per year) than they did in 2004 (at onset). The examiner selected that the Veteran had mild to moderate external hemorrhoids, with a description of the severity as occurring 2 to 4 times per year “painful passage of stool, blood on the toilet tissue, occasional itching.” On physical examination, the Veteran had small or moderate external hemorrhoids. He had no other signs or symptoms of hemorrhoids. The Veteran participated in a second VA examination on October 21, 2017. He was diagnosed with external hemorrhoids. He reported that his hemorrhoids had worsened over time; during flare-ups he increases the fiber in his diet and uses an ointment. He was not on any continuous medications for treatment of his hemorrhoids. The examiner selected that the Veteran had mild to moderate hemorrhoids. He did not have large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. He did not have persistent bleeding, secondary anemia, or fissures. He did not have impairment of sphincter control, stricture, fecal incontinence, rectal prolapse, or other symptoms associated with his hemorrhoids. On physical examination, the Veteran had small or moderate external hemorrhoids. There were no other pertinent findings on physical examination. VA and private treatment records do not include treatment for, evaluation of, or complaint related to hemorrhoids during the period on appeal. The Veteran has reported flare-ups of hemorrhoids, initially occurring 2 to 4 times per year, and possibly more frequently by 2017 as he had noted his symptoms had “worsened.” He described his flare-ups of hemorrhoids as resulted in pain with stool passage, blood on tissue, and occasional itching. He self-treated his hemorrhoids with increased fiber diet to reduce straining and over-the-counter medication. The VA examinations both noted small to moderate external hemorrhoids. The record does not include medical evidence of large or thrombic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. Additionally, the Veteran’s lay descriptions of his hemorrhoids, including during flare-ups, does not meet the standard for a 10 percent rating. As such, entitlement to an initial compensable rating for hemorrhoids is not warranted. 8. Entitlement to an initial 10 percent rating for hypertension is granted. The Veteran is seeking an initial compensable rating for his hypertension. The Board notes that the Veteran separated from service in September 2014. On November 23, 2015, the Veteran was prescribed Lisinopril (continuous medication) for his hypertension. Although there is this gap of slightly more than a year prior to medication prescription, and the evidence does not that the Veteran had a history of diastolic pressure predominantly 100 or more, the Board will resolve reasonable doubt in the Veteran’s favor and provide the 10 percent rating for the entire period on appeal. Under DC 7101, a 10 percent evaluation is warranted when diastolic pressure is predominately 100 or more, or when systolic pressure is predominately 160 or more. A 10 percent disability rating is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent evaluation is warranted when diastolic pressure is predominately 110 or more, or when systolic pressure is predominately 200 or more. A 40 percent disability rating requires that diastolic pressure be predominantly 120 or more. A 60 percent evaluation is warranted when diastolic pressure is predominantly 130 or more. Id. An April 3, 2015 VA hypertension examination noted that the Veteran was diagnosed with hypertension in 2004 when he was found to have elevated blood pressure while deployed to Iraq, which was “very stressful.” He was not put on medication at that time. After returning to the states, his blood pressure readings would “fluctuate.” He was told to monitor his blood pressure, and he was attempting to stay off of medication by following a diet and exercise regimen. His home monitoring had been “borderline high.” The examiner reviewed the record and cited the following blood pressure readings from January to November 2014: 144/94, 136/92, 126/72, 128/77, 133/82, 139/93, 152/98, and 142/96. His treatment at the time of the examination did not include taking continuous medication for his hypertension or isolated systolic hypertension. He did not have a history of diastolic blood pressure elevation to predominantly 100 or more. His blood pressure readings at the time of the examination were: 150/90, 148/90, and 148/90. On November 23, 2015, the Veteran was noted to have a history of elevated blood pressure that he was attempting to manage with a low salt diet and regular exercise. His blood pressure reading was 139/87. He was assessed with stage I hypertension and started on Lisinopril, 5 mg daily. Ongoing VA treatment records included multiple readings in the 130s/high 80s. On October 26, 2016 his Losartan dose was increased because his diastolic numbers were close to 90. In October 2017, the Veteran reported home blood pressure readings were in the 130s/80s. The Veteran participated in a VA hypertension examination in October 2017. He reported his hypertension had worsened since the 2015 examination and was not under control with his medication as his systolic blood pressure was still over 150. The examiner selected that the Veteran’s diastolic blood pressure was not predominantly 100 or more. His current blood pressure reading during the examination were 158/95, 153/101, and 164/96, for an average reading of 158/97. On February 23, 2018, the Veteran reported to VA treatment providers that his home blood pressure readings were in the 120s/70-80s. A September 26, 2018 treatment record included his report of home readings of 130s to low 140s/80s. His blood pressure reading in the office was 131/82. A November 14, 2018 cardiology record included that the Veteran reported atypical chest pain. His blood pressure was 137/83. During a cardiac stress test, the Veteran had a peak blood pressure of 170/80, “representing a normotensive response to exercise.” On April 20, 2020, the Veteran reported home blood pressure readings of the high 120s-130s/80. He attributed his higher systolic blood pressures to being unable to exercise due to covid restrictions. A June 29, 2020 VA primary care physician record included that the Veteran’s home blood pressures were better controlled previously (120-130s/high 80s). Probably eating a good deal of salt. Less active than usual due to covid. He was to continue on his Losartan 25 mg. As noted above, the Board is providing a 10 percent rating for the entire period on appeal. A rating in excess of 10 percent is not warranted as the evidence does not show that his diastolic pressure is predominantly 110 or more, nor is his systolic pressure predominately 200 or more. Indeed, the Veteran’s diastolic pressure has remained below 90 and his systolic pressures have remained below 150 since beginning medication in November 2015. Entitlement to a rating in excess of 10 percent is not warranted. 9. Entitlement to an initial 20 percent rating for right knee instability prior to September 21, 2020 is granted. 10. Entitlement to a 30 percent for right knee instability from September 21, 2020 is granted. 11. Entitlement to an initial 20 percent rating for left knee instability prior to September 21, 2020 is granted. 12. Entitlement to a 30 percent rating for left knee instability from September 21, 2020 is granted. 13. Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis is denied. 14. Entitlement to an initial rating in excess of 10 percent for left knee osteoarthritis is denied. The Veteran is seeking increased ratings for his bilateral knee disabilities. On his April 2020 substantive appeal, he reported he was in chronic daily pain and discomfort due to his knee osteoarthritis and instability. He stated that there were days he could not get out of bed and/or walk. He felt that his left knee warranted a 30 percent rating for “severe limited range of flexion/motion and pain” and his right knee warranted a 40 percent rating for the same. He also argued that his left knee instability warranted a 30 percent rating for instability and 20 percent rating for his right knee instability. The Board notes that the Amputation Rule holds that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elected level. Amputation of the lower extremity not improvable by prosthesis controlled by natural knee action warrants a 60 percent rating. At a lower level, permitting prosthesis warrants a 40 percent rating. See 38 C.F.R. § 4.71a, DCs 5264, 5165. The Veteran has separate 10 percent ratings for his right and left knee osteoarthritis with limitation of range of motion that does not meet the compensable rating criteria under DC 5003. He also has separate 10 percent rating for left knee instability for the entire period on appeal, and a staged (10 percent prior to September 21, 2020, and 20 percent thereafter) ratings for right knee instability. The 20 percent rating was provided from the date of his most recent VA examination. As described below, the Board finds that the Veteran’s right and left knee osteoarthritis do not warrant ratings in excess of 10 percent, and the Veteran’s left and right knee instability warrant separate 20 percent ratings prior to September 21, 2020, and 30 percent thereafter. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, lateral instability and recurrent subluxation of the knee, and meniscal disabilities. The Board will explore all possibilities in this case. The Veteran’s bilateral knee osteoarthritis ratings are provided under DC 5003. DC 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint (such as the knee) or group of minor joints affected by limitation of motion. The 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. Notably, although the knee rating criteria allows for separate ratings for limitation of flexion and extension, the 10 percent rating provided for noncompensable loss of motion is assigned for each major joint. As such, a 10 percent rating will be assigned (as in this case) for noncompensable loss of flexion and extension of the right knee under DC 5003. Standard range of knee motion is from zero degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. Under DC 5260, a 0 percent (noncompensable) disability rating is assigned for flexion limited to 60 degrees, a 10 percent disability rating is assigned for flexion limited to 45 degrees, a 20 percent disability rating is assigned for flexion limited to 30 degrees, and a 30 percent disability rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a 0 percent (noncompensable) disability rating is assigned for extension limited to 5 degrees, a 10 percent disability rating is assigned for extension limited to 10 degrees, a 20 percent disability rating is assigned for extension limited to 15 degrees, a 30 percent disability rating is assigned for extension limited to 20 degrees; a 40 percent disability rating is assigned for extension limited to 30 degrees; a 50 percent disability rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a. As above, separate ratings may be awarded for limitation of flexion and limitation of extension of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). In a precedent opinion by VA General Counsel, it held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under DC 5260 and a compensable limitation of extension under DC 5261, provided that the degree of disability is compensable under each set of criteria. Id. Under DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted to moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. The terms “slight,” “moderate,” and “marked” are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. Under DC 5259, a 10 percent rating is available for removal of the semilunar cartilage (meniscus) that is symptomatic. Under DC 5258, a symptomatic meniscus is described as “locking,” pain, and effusion into the joint. Here, the record does not show that the Veteran has a history of meniscus/semilunar cartilage disability. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.”. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. On April 3, 2105, the Veteran participated in a VA knee examination. He reported he was in a vehicle that was hit by an IED and he was “picked up and twisted around”/jostled in the vehicle. He hit his knees and was “bruised” and “limping,” but was able to continue the mission because he was the leader. He reported that since the injury he has had constant, sometimes severe pain in his knees, and that they would “sometimes give out just walking up the stairs or just walking.” He had been to physical therapy and was prescribed Capsaicin cream and Naprosyn, which “helped.” He stated his baseline was a pain of 2 out of 10, with dull pain at rest. As the day would go on, his pain increased depending on activity level. Regarding his functional capacity, he was able to sit in a confined space for 30 minutes and had to stretch his legs out, move around, and use capsaicin cream; stretch his knees every 30 minutes. With standing, he had to move his knees around after 30 minutes so that they would not “lock up.” He was able to walk 2 miles, but beyond that he would “be in some pain.” He was no longer able to run. He had to hold onto the railings when using stairs because his knees might give out on him. He felt he would eb able to complete 2 flights of stairs. He had missed 3-4 days of work in the prior 12 months due to knee pain. Range of motion testing revealed the Veteran had a normal range of motion of his knees (zero to 140 degrees). Objective pain was not noted on examination. There was no evidence of pain with weight bearing. He had localized pain (moderate tenderness) of the inferior margin of the patella of both knees. There was crepitus of both knees. He completed repeat range of motion tests without loss of range of motion. The examiner noted that prolonged repetition was precluded due to time limits of a VA examination. Additionally, the Veteran was not having a “flare up at the time of the examination and therefore it would be speculative to comment regarding the effect that a flare would have on any aspect of joint function or the Veteran’s quality of life.” The examiner noted that there was no change in range of motion after 3 repetitions, and “beyond that” he was “unable to render an opinion regarding effect of repetitive use on the joint. The Veteran had full (5/5) muscle strength in both knees. The examiner selected that the Veteran did not have a history of recurrent subluxation or lateral instability. Joint stability tests were noted to be normal throughout. He did not have a history of a meniscus (semilunar cartilage) condition. The Board notes that the examiner’s findings that he would be unable to estimate loss of range of motion during repetitive use over time or during flare-ups without resorting to mere speculation were not supported with an adequate rationale. As such, the range of motion findings in this examination are adequate for rating purposes. The examiner’s findings related to muscle strength, ankylosis (none), the Veteran’s reports of symptoms and functional limitations, and the findings related to instability are all adequate and may be taken into consideration in determining the appropriate rating for the Veteran. During a February 24, 2017 treatment, the Veteran reported he was able to walk 12-15 minutes on a treadmill with no difficulty. He used Capsaicin for knee pain, and they were “stable.” On October 21, 2017, the Veteran participated in a second VA knee examination. He stated his knee condition had worsened over time, with frequent knee instability. He took Ibuprofen for pain, and was in pain management. He also used Capsaicin cream on his knees. He stated that his “knee gives out all the time” (unspecified). The functional impact of his knee disabilities was the inability to stand, walk, or sit for a “long time.” On range of motion testing, both knees had full extension (zero) with flexion to 90 degrees. There was objective evidence of pain with flexion and extension. He also had tenderness to palpation of the kneecap due to his moderate degenerative joint disease. He did not have crepitus. Passive range of motion was the same as active range of motion. There was no pain when the joint was used in nonweight-bearing. Repeat range of motion testing was completed, his range of motion did not change. The examiner noted that the Veteran’s knees were not examined after repeated use over time, but that pain, weakness, fatigability or incoordination would not significantly limit functional ability with repeated use over time. Because of this finding, the examiner did not complete the part of the examination related to estimating range of motion loss with repeated use over time. The same findings were made regarding flare-ups. He had full (5/5) muscle strength on evaluation. He did not have ankylosis. He had slight recurrent subluxation of both knees and moderate lateral instability of both knees. Joint stability testing showed 1+ (0-5 mm) anterior, posterior, lateral, and medial instability of both knees. The examiner selected that he did not have a history of shin splints. He regularly used knee braces. Here, the 2017 examiner noted that the Veteran had moderate lateral instability of both knees. During the 2015 and 2017 examinations, the Veteran reported knee instability with stairs and walking. He reported frequent feelings as though his knees would “give way.” Although the 2015 examiner found that the Veteran’s knees were stable on testing, the Board will resolve reasonable doubt in the Veteran’s favor that he suffered from moderate lateral instability for the entire period on appeal. As such, entitlement to separate 20 percent ratings for moderate lateral instability under DC 5257 are warranted for the entire period on appeal. A September 26, 2018 VA treatment record included the Veteran’s complaint of bilateral knee pain, left greater than right. He was using a brace on his left knee to help with pain and instability. He was able to walk on the treadmill without difficulty. He had some relief of his pain from Acetaminophen and Capsaicin. On September 21, 2020, the Veteran participated in a fee-basis (private contractor) VA examination. He reported a “persistent worsening of symptoms since initial injury.” He reported his knees locked, popped, regularly swelled, and “gave out.” He also reported flare-ups of severe throbbing knee pain. He had multiple rounds of physical therapy and pain management over the years, but his symptoms continued to worsen. He had swelling when he attempted to run or walk for long distances. Regarding his flare-ups, he reported his right knee had weakly flare-ups of throbbing/pinching pain (9/10 intensity) for 24 hours. His left knee had weakly flare-ups of throbbing/pinching pain (9/10 intensity) for 24 hours. Regarding functional impact, the Veteran reported that both knees “pop out” and that he could not “do anything.” He stated he “hobbl[ed] to the chair” and would stay in it until his knees “calm down.” Range of motion of the right knee was 5 to 110 degrees, with pain on flexion. The Veteran had moderate tenderness to palpation of the right anterior of the knee. There was objective evidence of crepitus. His left knee range of motion was zero to 110 degrees, with objective pain with flexion, moderate discomfort to palpation of the left anterior of the knee, and crepitus. There was no objective evidence of pain with weightbearing of either knee. There was no change in range of motion after repeat testing. The Veteran was not being examined immediately after repeated use over time. The examiner noted that pain would significantly limit the Veteran’s functional ability with repeated use over time, which was described in terms of additional range of motion loss to 5 degrees of extension loss and 100 degrees of flexion for the right knee, and 5 degrees of extension loss and 105 degrees of flexion for the left knee. Similarly, the knees were not being examined during a flare-up, but pain would significantly limit the functional ability of his knees during flare-up, which was described in terms of additional loss of range of motion of 5 to 100 degrees right and 5 to 105 degrees left. Muscle strength testing showed active movement against gravity (3/5) strength with flexion and extension of both knees. He did not have muscle atrophy or ankylosis. The examiner selected that the Veteran had a history of recurrent subluxation, moderate right and slight left. He also had a history of lateral instability, moderate right and slight left. Regarding recurrent effusion, the Veteran reported his knees would sell up at least 4-5 times a week after walking or being on his feet for long periods of time. Joint stability tests were not completed because the Veteran was guarding his knees due to a fear of pain. He was unable to relax his knees in order for the examiner to be able to conduct the joint stability tests. The Veteran had a history of bilateral shin splints; however, this did not affect range of motion of his knees or ankles. The shin splints were “acute/resolved.” The Veteran regularly used a brace for his knees. X-rays showed degenerative arthritis of both knees. His knees were noted to impact his ability to perform occupational tasks. The Veteran was retired, and used to be employed as a military police officer. He reported missing 0 to 1 week per 12 months due to his knees. “Due to his bilateral knee instability and osteoarthritis, Veteran used to take off from work whenever the knee pain was severe. There was objective evidence of pain on passive range of motion testing. There was no objective evidence of pain when the joint was used in non-weight bearing. Resolving reasonable doubt in the Veteran’s favor, the Board finds that his bilateral knee instability worsened to a “severe” level, first demonstrated in the September 21, 2020 examination. The Veteran reported frequent giving way, fear of doing physical activities due to instability, and guarded his knees against testing due to fear of pain and instability. He also used bilateral knee braces due to instability. As such, from September 21, 2020, the Veteran’s bilateral knees warranted separate 30 percent ratings for instability. The Board finds that ratings in excess of 10 percent for bilateral knee osteoarthritis are not warranted. The Veteran’s range of motion for his bilateral knees have remained at noncompensable levels during the appeal period. Although the 2017 and 2020 examinations have demonstrated that his range of motion have worsened over the years, the range of motion has not reached the criteria for a compensable rating for flexion or extension. The Veteran is in receipt of 10 percent ratings for both knees due to x-ray evidence of arthritis with objective pain and noncompensable loss of range of motion for major joints (knees). The Board finds that ratings in excess of 20 percent for bilateral knee instability prior to September 21, 2020 are not warranted. The record included 2017 examination showing moderate lateral instability on testing. The 2020 examination did not include testing due to the Veteran’s guarding and inability to relax to participate due to fear of pain with instability testing. The Veteran has provided lay statements that his knee disabilities have worsened with time, which is demonstrated in the examinations. However, records do not show that the Veteran’s instability reached a “severe” level until the September 21, 2020 examination. Additional separate ratings for the knees are not warranted. The Veteran’s symptoms of pain, instability, and effusion are addressed by his current ratings. The Veteran reported a feeling of “locking” in the 2020 examination. The medical evidence does not demonstrate that the Veteran has had meniscus/semilunar cartilage diagnoses/disability such that a separate rating under DCs 5258/5259 are warranted. TDIU 15. Entitlement to total disability based on individual unemployability (TDIU) The Veteran argues that he is unable to obtain and maintain substantially gainful employment due to his service-connected disabilities. On his August 21, 2018 TDIU claim form, the Veteran stated he became too disabled to work on January 18, 2016. He was disabled from obtaining substantially gainful employment due to the pain and discomfort from his numerous disabilities. He could not sit or walk for long periods, frequent trips to the restroom, unable to concentrate due to pain. The Veteran did not provide a list of his prior employment. Records show that he had active duty service for 30 years, with a MOS of military police for the entirety of his service. Total disability ratings for compensation may be assigned where the Schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Marginal employment is not considered substantially gainful employment. 38 C.F.R. §§ 3.340, 4.16(a). Substantially gainful employment means, essentially, that the work provides income above the poverty level established by the United States Department of Commerce, without benefit of protected family employment or a sheltered workshop. 38 C.F.R. § 4.16 (a). Factors to be considered in determining entitlement to TDIU include but are not limited to employment history, educational achievement, and vocational attainment. Age is not a factor. 38 C.F.R. § 4.16 (b). Basic eligibility is established where there is one disability rated 60 percent or more, or multiple disabilities rated at least a combined 70 percent, with one disability rated at least 40 percent. 38 C.F.R. § 4.16 (a). For the purpose of one 60 percent disability, disabilities resulting from common etiology or a single accident may be considered as one disability. 38 C.F.R. § 4.16(a). Without consideration of the increased ratings provided in this decision, the Veteran had a combined schedular rating of 90 percent from October 1, 2014 (date post retirement from service), with a 50 percent rating for obstructive sleep apnea from October 1, 2014. As such, the Veteran meets the schedular criteria for entitlement to TDIU during the entire period on appeal. The Veteran is service connected for sleep apnea (50 percent from October 1, 2014), lumbar spine arthritis (20 percent from October 1, 2014), benign prostate hyperplasia (20 percent from October 1, 2014), right knee instability, left knee instability, right knee osteoarthritis, left knee osteoarthritis, left ankle osteoarthritis (10 percent from October 1, 2014), right ankle osteoarthritis (10 percent from October 1, 2014), right elbow olecranon bursitis, plantar fasciitis (10 percent from October 1, 2014), hallux rigidus (10 percent from October 1, 2014), tinnitus (10 percent from October 1, 2014), GERD (10 percent from October 1, 2014), insomnia (10 percent from October 1, 2014), hypertension (10 percent from October 1, 2014), and a number of noncompensably rated disabilities (right finger, cataracts, allergic rhinitis, hemorrhoids, varicocelectomy, large intestine adenoma, ED, PFB, keloid acne). The evidence indicates that the Veteran’s employment history is limited to police work, and his various disabilities which limit his ability to stand, walk, run, navigate stairs (joint disabilities), and his sleep apnea and insomnia would both cause the Veteran to be less alert and focused. As such, resolving reasonable doubt in the Veteran’s favor, the Board finds that the combination of his service-connected disabilities would result in his inability to obtain and maintain substantially gainful employment. Accordingly, the claim for entitlement to a TDIU is granted. 38 C.F.R. § 4.16 (a). The Veteran’s TDIU is granted based on the combined impact of his various service-connected disabilities. None of his disabilities rise to the severity that TDIU may be based on a single disability. As such, entitlement to special monthly compensation is not indicated. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for bilateral cortical cataracts is remanded. The criteria for rating disabilities of the eye were revised in May 2018. The Veteran was last afforded a VA eye examination in 2017. On remand, an updated VA eye examination must be provided. 2. Entitlement to an initial rating in excess of 10 percent right elbow olecranon bursitis is remanded. During VA examination, the Veteran reported that his right elbow had flare-ups of pain and swelling. The examiner selected that the Veteran had no increased pain during a flare-up and did not estimate any additional loss of range of motion during a flare-up. On remand, the Veteran must be afforded an additional adequate examination. 3. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB) is remanded. During the April 2015 VA examination, the Veteran reported current symptoms of PFB were also “bumps, pus, and bleeding.” He used over the counter medication shaving gel. IN the prior 12 months, he had not sought medical care for his PFB. Regarding his keloid acne, he stated it started in 1990 during desert storm, when “hygiene was an issue” and he had to wear head gear. He developed bumps and bleeding lesions on the back of his neck/occipital scalp. The examiner selected that the Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck. At the time of the evaluation, he was not using any medications in the prior 12 months. He had “approximately 10 flesh-colored mildly erythematous papules with central hair shaft on anterior neck and submental region. No disfiguring hyperpigmentation noted. He had less than 5 percent total area and less than 5 percent exposed area for his PFB. Regarding his acne keloid the “nape of neck and occipital scalp with multiple scattered follicular papules without comedones. Few excoriated papules noted.” He had no other active bleeding or spotting. Again, his condition affected less than 5 percent of the exposed area/total body area. A January 19, 2016 private treatment record noted that the Veteran’s scalp had healed with Cleocin lotion and Betamethasone, without “more bleeding or pusturing.” He had been assessed with scalp dermatitis. An October 2017 examination included the diagnosis of PFB with use of Betamethasone as needed for his chin. Again, the examiner selected that his PFB did not cause scarring or disfigurement of the head, face, or neck. His skin was treated with “other topical medications” (Betamethasone and Clindamycin) for 6 weeks or more, but not constant/near constant duration. Less than 5 percent of his total body area, and less than 5 percent of his exposed skin was affected by his PFB. The examination report did not describe the PFB. On remand, an updated VA examination should be provided to determine the current severity of his PFB/keloid acne/dermatitis, to include and scars or disfigurement of the head/face/neck. The matters are REMANDED for the following action: 1. Ongoing VA treatment records must be associated with the electronic claims file. 2. Schedule the Veteran for an updated VA eye examination to determine the current severity of his service-connected cortical cataracts. 3. Schedule the Veteran for an updated elbow examination. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. Additionally, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups to include estimation of additional loss of range of motion during flare-ups and repeated use over time. 4. Schedule the Veteran for an updated VA examination should be provided to determine the current severity of his PFB/keloid acne/dermatitis, to include and scars or disfigurement of the head/face/neck. 5. After completing the development requested above, readjudicate the Veteran’s claims. If any of the benefits sought are not granted in full, the Veteran should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, 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.