Citation Nr: 21028021 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 16-15 337A DATE: May 10, 2021 ORDER Entitlement to service connection for a left wrist disability, to include as secondary to the service-connected right achilles tendon disability, is denied. Entitlement to service connection for a right wrist disability, to include as secondary to the service-connected right achilles tendon disability, is denied. Entitlement to a 20 percent, but not higher, for the service-connected right achilles tendon disability from August 15, 2013, is granted, subject to the law and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left arm disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. Entitlement to service connection for a right arm disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. Entitlement to service connection for a left elbow disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. Entitlement to service connection for a right elbow disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. Entitlement to service connection for a right hip disability, to include as secondary to the service-connected right achilles tendon disability, is remanded. Entitlement to a total evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's left wrist disability is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 2. The Veteran's right wrist disability is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 3. The Veteran's right achilles tendon disability has been characterized by marked limitation of ankle motion on functional use. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist disability, to include as secondary to the service-connected right achilles tendon disability, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for a right wrist disability, to include as secondary to the service-connected right achilles tendon disability, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 3. The criteria for a 20 percent, but not higher, rating for a right achilles tendon disability from August 15, 2013, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5009-5024 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from May 1974 to May 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo, Puerto Rico. This claim was previously before the Board in January 2021, at which time it was remanded for further development. The January 2021 Board decision remanded the issues of entitlement to service connection for a left ankle disability and entitlement to service connection for a left hip disability. The RO granted the Veteran's claims in a February 2021 rating decision, but the Veteran did not file a notice of disagreement with the assigned evaluations. As such, these claims are no longer before the Board. Finally, the Board notes that with respect to four additional issues that were part of the original appeal and remanded in January 2020 for further development following the Veteran's appeal of the denial of those claims to the United States Court of Appeals for Veterans Claims (Court), while the Veteran's representative has recently submitted a brief as to those claims, the issues have yet to be addressed in a supplemental statement of the case or otherwise returned to the Board for further appellate review. The Board will therefore not address these issues at this time. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence as to any issue material to a determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to service connection for a left wrist disability, to include as secondary to the service-connected right achilles tendon disability Entitlement to service connection for a right wrist disability, to include as secondary to the service-connected right achilles tendon disability Dr. C. M. Q. submitted correspondence in July 2014 indicating that the Veteran had osteoarthritis of the wrists. He found that the Veteran's musculoskeletal disorders were more probable than not secondary to his military service performance. Pursuant to the January 2021 Board remand, the Veteran received a VA examination in February 2021 and the examiner noted a diagnosis of mild degenerative osteoarthritis bilaterally. The Veteran stated that he developed wrist pain since using crutches for ambulation several years earlier. He described the pain as dull, intermittent, and of variable frequency depending on the activity. Based on the results of the examination, the examiner concluded that the bilateral wrist disorder was less likely as not related to service. He noted the Veteran's lay statements that he developed bilateral wrist pain since using assistive devices for ambulation, and the evidence reflected that the Veteran starting using such devices in 2013. However, the imaging studies correlated with the normal atraumatic degenerative changes of the aging process, and there was no evidence in medical literature to support the statement that degenerative changes of joints were caused by the use of assistive devices. Furthermore, the examiner found that the bilateral wrist disorder was less likely than not caused or aggravated by the service-connected right achilles tendon disability, as the wrist and ankle joints were at unrelated anatomical locations. The ankle was a weight-bearing joint, whereas the wrist was a nonweight-bearing joint, and there was no evidence in medical literature to support the statement that degenerative changes of joints were caused by the use of assistive devices. At the outset, the Board notes that Dr. C. Q. M. linked the Veteran's condition to his military service. He did not, however, provide a rationale for his conclusion. "[M]ost of the probative value of a medical opinion comes from its reasoning" and the Board "must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Therefore, his conclusion is of diminished probative value. On the contrary, the Board finds the February 2021 VA examination results to be the most probative evidence of record. The examiner's findings are credible and competent, as they were provided with thorough rationales with regards to the Veteran's left and right wrist disabilities and their lack of connection to his service-connected right achilles tendon disability. The examiner provided a thorough opinion explaining why it was less likely than not that it was the result of his military service or his service-connected disability. While the examiner relied on his medical expertise to offer his opinion with regards to the etiology of the Veteran's left and wrist right disabilities, he also noted the lack of medical literature to support the statement that degenerative changes of joints were caused by the use of assistive devices. Furthermore, the examiner competently linked the Veteran's bilateral osteoarthritis to the natural aging process. As a result of the competent medical opinions regarding causation and aggravation based on an accurate interpretation of the record, the Board finds that the claim is not in equipoise and that service connection for a left wrist disorder and service connection for a right wrist disorder is therefore not warranted. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or the illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Right Achilles Tendon The Veteran contends that he is entitled to a higher rating for his right achilles tendon disability. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In August 2013, the Veteran filed a claim for a rating in excess of 10 percent for his right achilles tendon injury and the RO continued the 10 percent rating in a March 2014 rating decision under Diagnostic Code 5099-5024. Following a new VA examination in January 2015, the RO again continued the 10 percent rating in a February 2015 rating decision. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after the hyphen. The hyphenated diagnostic code indicates that the Veteran's right achilles tendon disability was rated as analogous to a musculoskeletal system disease under the criteria for tenosynovitis (Diagnostic Code 5024), which provided that the right achilles tendon disability was to be rated on limitation of motion of the affected parts or as degenerative arthritis. Accordingly, the Veteran's disability was assigned a rating under Diagnostic Code 5271 consistent with VA regulations. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not considered to be contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The Court has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. For purposes of this decision, the Board notes that the average normal range of motion of the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. 38 C.F.R. § 4.71. The Court has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Significantly, regulations pertaining to musculoskeletal disabilities were recently amended and new criteria for rating musculoskeletal disabilities became effective on February 7, 2021. When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3- 2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The recently revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, for the period beginning February 7, 2021, the version more favorable to the veteran will apply. Prior to February 7, 2021 Tenosynovitis was rated under Diagnostic Code 5024. The diseases under diagnostic codes 5013 through 5024 were to be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which was to be rated under diagnostic code 5002. Diagnostic Code 5271 assigns a 10 percent disability rating for moderately limited range of motion of the ankle and a 20 percent disability rating for markedly limited range of motion of the ankle. Diagnostic Code 5270 provided the following disability ratings for ankylosis of the ankle: 20 percent for in plantar flexion of less than 30 degrees; 30 percent for in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 (zero) and 10 degrees; and 40 percent for in plantar flexion at more than 40 degrees, in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a. Diagnostic Code 5272 provided a 10 percent disability rating for subastragalar or tarsal joint ankylosis in good weight-bearing position and a 20 percent disability rating for ankylosis in poor weight-bearing position. See 38 C.F.R. § 4.71a. Diagnostic Code 5273 provided a 10 percent disability rating for moderate deformity resulting from the malunion of the os calcis or astragalus and a 20 percent disability rating for a marked deformity resulting from the malunion of the os calcis or astragalus. Diagnostic Code 5274 provided a 20 percent disability rating for astragalectomy. Beginning February 7, 2021 As of February 7, 2021, changes have been implemented to the musculoskeletal rating criteria. The title of Diagnostic Code 5024 has been changed to "Tenosynovitis, tendonitis, tendinosis, or tendinopathy," and now diseases under diagnostic codes 5013 through 5024 are to be evaluated as degenerative arthritis, based on limitation of motion of affected parts. For limitation of motion of the ankle under Diagnostic Code 5271, a 10 percent evaluation is warranted for moderate limitation of motion (less than 15 degrees dorsiflexion and less than 30 degrees plantar flexion) and a 20 percent evaluation is warranted for marked limitation of motion (less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion). No change was made to Diagnostic Code 5270 or Diagnostic Code 5272-5274. Entitlement to a rating in excess of 10 percent for the service-connected right achilles tendon disability The Veteran has been continually pursuing this increased rating claim since the filing of his claim on August 15, 2013. The Veteran received a VA examination in March 2014 and stated that he continued with severe pain and swelling on his right achilles tendon. Range of motion testing revealed right dorsiflexion to 15 degrees and right plantar flexion to 35 degrees. Pain could significantly limit function ability during flare-ups or during use over an extended period of time, but there was no evidence of weakness, fatigability, or incoordination. The Veteran received a VA examination in January 2015 and stated that his condition remained the same, as he continued to deal with pain and stiffness in his right achilles tendon. He reported flare-ups and had increased pain after walking for exercise. The pain, however, did not cause functional loss. Range of motion testing revealed right dorsiflexion to 13 degrees and right plantar flexion to 35 degrees. The Veteran received a VA examination in March 2017 and reported flare-ups of the ankle on cold days and after prolonged walking or standing. Upon examination, right ankle dorsiflexion was to 15 degrees and plantar flexion was to 30 degrees. There was pain in both ranges of motion, objective evidence of localized tenderness on palpation of the joint, and objective evidence of crepitus. The Veteran's muscle strength testing was normal and there was no muscle atrophy or ankylosis. There was also no ankle instability or dislocation suspected, and the Veteran constantly used crutches. The Veteran received a VA examination in February 2020 and reported that the pain in his right foot had increased to an intensity of 6 out of 10. When he experienced flare-ups, the pain increased to 9 out of 10 weekly, lasting hours. The pain caused functional loss, including less movement than normal, excess fatigability, pain on weight-bearing, pain on nonweight-bearing, disturbance of locomotion, and lack of endurance. Range of motion testing revealed right ankle dorsiflexion to 5 degrees and plantar flexion to 20 degrees. The Veteran received a VA examination in December 2020 and indicated that he continued to have localized pain and limitation of motion. The pain was 9 out of 10, but there were no flare-ups of the ankle. The pain also did not cause functional loss. Range of motion testing revealed right ankle dorsiflexion to 10 degrees and plantar flexion to 25 degrees. There were no additional contributing factors of disability. Muscle strength testing was normal, and there was no ankylosis or joint instability. He also continued to use crutches regularly. Based on the findings above, the Board finds that although the actual clinical findings obtained at the various VA examination since 2014 are most consistent with the current 10 percent rating, except for the Veteran's most recent examination, the Veteran has continually complained of flares of pain and no estimate either contemporaneous to the exams or retrospectively has even been made as to the extent of additional limitation of motion that may occur with flares. Therefore, given the consistent reports of flares and significant limitation of dorsiflexion and/or plantar flexion beginning in January 2015 and ending in more recent findings of dorsiflexion and plantar flexion at 5 and 10 degrees, respectively, the Board will give the Veteran the benefit of the doubt and find that this disability warrants the next and highest rating for limited motion of 20 percent pursuant to 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995), since August 15, 2013. The Board further finds that since the amended provisions actually more specifically provide that marked limitation of motion is less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion, the new criteria are not any more favorable to the Veteran than the prior provisions and would not permit a higher rating. In assessing the severity of the right achilles tendon disability, the Board has now fully considered the Veteran's assertions regarding his symptoms, to include pain, which he is competent to provide. See e.g. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Veteran's statements as to history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability rating that has been assigned. Moreover, the Board finds that all of the Veteran's symptoms have now been contemplated in the new rating and entitlement to an extraschedular rating is therefore not warranted. REASONS FOR REMAND Entitlement to service connection for a right ankle disability Pursuant to the January 2021 Board remand, the Veteran received a VA Ankle Conditions examination in February 2021. The examiner noted a diagnosis of left Achilles' tendonitis, a right Achilles' tendon injury, status post repair, with residual Achilles' tendonitis, and a small left calcaneal spur. However, imagining studies of the ankle were completed in February 2021 that revealed right ankle degenerative or post-traumatic arthritis. Specifically, the examiner noted remodeling and mild deformity of the distal end of the right tibia likely representing old posttraumatic changes. Not only did the examiner not note this current diagnosis of right ankle arthritis, but he also did not provide an opinion with regard to the etiology of the Veteran's currently diagnosed right ankle disability. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision."). Therefore, even though the symptoms of this disability may already be contemplated by the 20 percent rating now assigned for his right achilles tendon disability, this claim must be remanded for a new examination. Entitlement to service connection for a left arm disability, to include as secondary to the service-connected right achilles tendon disability Entitlement to service connection for a right arm disability, to include as secondary to the service-connected right achilles tendon disability Pursuant to the January 2021 Board remand, the Veteran received a VA Elbow and Forearms examination and the examiner noted that he did not have a current disability. The examiner then opined that the joints were examined including forearm anatomical areas and no pathology was found at the elbow joints, and therefore an opinion of bilateral arm disorders in relation to clinical onset during service could not be rendered. The Board finds the examiner's conclusion inadequate, as the Veteran's private physician noted a diagnosis of bilateral arm arthritis in September 2014. He was also diagnosed with a left bicep tendon tear at a VA examination in February 2020. Moreover, the Board notes that the VA examiner did not opine on the etiology of the competently identified bilateral arm pain, which is noted in the Veteran's San Juan VAMC treatment records. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (holding that at pain alone, without an accompanying diagnosis or identifiable condition, can constitute a disability if it causes functional impairment of earning capacity.) As there has therefore not been substantial compliance with the remand orders, the matter must be remanded once again for compliance with the previous order/completion of the actions sought. Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not satisfied the Board itself errs in failing to ensure compliance). Entitlement to service connection for a left elbow disability, to include as secondary to the service-connected right achilles tendon disability Entitlement to service connection for a right elbow disability, to include as secondary to the service-connected right achilles tendon disability Pursuant to the January 2021 Board remand, the Veteran received a VA Elbow and Forearms examination and the examiner noted that he did not have a current disability. The examiner then opined that the no bilateral elbow pathology was found, and therefore an opinion of bilateral arm disorders in relation to clinical onset during service could not be rendered. The Board finds the examiner's conclusion inadequate, as the Veteran's private physician noted a diagnosis of bilateral elbow arthritis in September 2014. Moreover, the Board notes that the VA examiner did not opine on the etiology of the competently identified bilateral arm pain, which is noted in the Veteran's San Juan VAMC treatment records. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (holding that at pain alone, without an accompanying diagnosis or identifiable condition, can constitute a disability if it causes functional impairment of earning capacity.) As there has therefore not been substantial compliance with the remand orders, the matter must be remanded once again for compliance with the previous order/completion of the actions sought. Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not satisfied the Board itself errs in failing to ensure compliance). Entitlement to service connection for a right hip disability, to include as secondary to the service-connected right achilles tendon disability Pursuant to the January 2021 Board remand, the Veteran received a VA examination in February 2021 and the examiner noted diagnoses of mild bilateral sacroiliac osteoarthritis and left sacroiliac joint tendonitis. Based on the results of the examination, the examiner concluded that the mild bilateral sacroiliac osteoarthritis was less likely as not related to service, as there was no evidence that such changes had their onset in service and correlated with atraumatic changes of the normal aging process. While the examiner found that the mild bilateral sacroiliac osteoarthritis was less likely as not aggravated by the service-connected right achilles tendon disability, he did not offer an opinion with regards to causation. The examiner highlighted that the right achilles tendon injury promoted a defensive gait pattern that, through the years, caused weight overload to the contralateral side. The RO then granted entitlement to service connection for left hip sacroiliac joint tendonitis in February 2021. As the examiner did not offer an opinion with regards to whether this weight overload could have caused the right hip disability, the Board finds the examination inadequate. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision."). Therefore, this claim must be remanded for a new examination. Entitlement to a TDIU With respect to the Veteran's assertion that he is unable to work due to his claimed service-connected disabilities, the Board concludes that further development may provide evidence in support of his claim for TDIU. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991) (where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed right ankle disability, to include right ankle arthritis. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or more) that the Veteran's right ankle disability had its onset in service or is otherwise the result of an incident in service. The examiner is also asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's right ankle disability was caused or aggravated by his service-connected right achilles tendon disability. Aggravation is defined for these purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed left and right arm disability, to include arthritis, a left bicep tear, and pain. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or more) that the Veteran's left and right arm disability had its onset in service or is otherwise the result of an incident in service. The examiner is also asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left and right arm disability was caused or aggravated by his service-connected right achilles tendon disability. Aggravation is defined for these purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed left and right elbow disability, to include arthritis and pain. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or more) that the Veteran's left and right elbow disability had its onset in service or is otherwise the result of an incident in service. The examiner is also asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left and right elbow disability was caused or aggravated by his service-connected right achilles tendon disability. Aggravation is defined for these purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's right hip disability. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or more) that the Veteran's right hip disability had its onset in service or is otherwise the result of an incident in service. The examiner is also asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's right hip disability was caused or aggravated by his service-connected right achilles tendon disability. Aggravation is defined for these purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Daniels, 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.