Citation Nr: 21028877 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-18 985A DATE: May 12, 2021 ORDER Entitlement to a rating in excess of 30 percent for pes planus is denied. Service connection for left hip arthritis is denied. Service connection for right hip arthritis is denied. Service connection for left leg arthritis is denied. Service connection for right leg arthritis is denied. Service connection for right shoulder arthritis is denied. Service connection for arthritis of the neck is denied. Service connection for left foot arthritis is granted. Service connection for right foot arthritis is granted. Service connection for arthritis of the right foot first metatarsal phalangeal joint is granted. Service connection for arthritis of the left foot first metatarsal phalangeal joint is granted. Service connection for headaches, to include as secondary to multiple joint arthritis, is remanded. REMANDED Service connection for sleep disturbance, to include as secondary to multiple joint arthritis, is remanded. Service connection for atopic dermatitis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's pes planus is manifested by pain on use and manipulation that is accentuated on use and manipulation and decreased longitudinal arch heigh of both feet. 2. The preponderance of the evidence is against finding that the Veteran has a current neck, right shoulder, bilateral hip, and/or bilateral leg disability that was shown as chronic in service; or, manifested to a compensable degree within a presumptive period following separation from service; or, was noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease; or, is otherwise related to an in-service injury, event, or disease. 3. Competent medical evidence shows degenerative arthritis of the bilateral feet and degenerative joint disease of the bilateral first metatarsophalangeal joints are a progression of the Veteran's service-connected bilateral pes planus disability. 4. There is competent and credible report of headaches that onset in service with recurrence since discharge. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for pes planus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5276. 2. The criteria for service connection for left hip arthritis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for right hip arthritis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for left leg arthritis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for right leg arthritis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for right shoulder arthritis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for arthritis of the neck have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for degenerative arthritis of the right foot have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 9. The criteria for service connection for degenerative arthritis of the left foot have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 10. The criteria for service connection for degenerative joint disease of the right foot first metatarsophalangeal joint have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 11. The criteria for service connection for degenerative joint disease of the left foot first metatarsophalangeal joint have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 12. The criteria for service connection for recurrent headaches have been met. 38 U.S.C. §§ 1110, 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to December 1979. He also served on active duty from December 1979 to February 1982 but was discharged under other than honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in June 2019 but was remanded for further development. There has been substantial compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to a rating in excess of 30 percent for pes planus is denied. The Veteran contends that he is entitled to a higher rating for his service-connected pes planus. In December 2014, the Veteran filed an informal claim for increased rating for his service-connected pes planus. Thus, the period on appeal begins December 31, 2013, one year prior to receipt of the Veteran's claim for an increased rating. The Veteran's pes planus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). February, June, and October 2014 VA treatment records also reflect foot pain. January, February, and July 2015 VA treatment records note foot pain. The Veteran underwent a VA foot examination in December 2019. The examiner noted diagnoses of pes planus, metatarsalgia, and degenerative arthritis. During the examination, the Veteran reported pain in his feet 'all the time.' He denied flare-ups that impact the function of the foot. The examiner indicated the Veteran's bilateral pes planus causes pain on use and manipulation of the feet that is accentuated on use and manipulation. There was no indication of swelling on use or characteristic calluses. The examiner noted the Veteran tried bilateral arch supports but remains symptomatic. The Veteran did not have extreme tenderness of plantar surfaces on either foot; however, there was decreased longitudinal arch height of both feet on weight-bearing. There was no objective evidence of marked deformity of one or both feet or marked pronation of one or both feet. The weight-bearing line for one or both feet does not fall over or medial to the great toe. The Veteran does not have inward bowing of the Achilles' tendon of or marked inward displacement and severe spasm of the Achilles' tendon on manipulation of one or both feet. While the Veteran has metatarsalgia, he does not have Morton's neuroma. No symptoms due to a hallux valgus condition was found on examination. The examiner indicated the Veteran does have pain in bottom of feet that contributes to functional loss, including pain on weight bearing that interferes with standing. The examiner indicated pain, weakness, fatigability, or incoordination do not significantly limit functional ability during flare-ups or when the feet are used repeatedly over a period of time. During the examination, the Veteran reported regular use of a cane. The Veteran's subsequent VA treatment records reflect flatfeet as an active problem. See, e.g., January 2020 VA treatment record. After a review of the evidentiary record, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for pes planus. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that his associated pain interferes with standing would not result in symptoms more nearly approximating pronounced bilateral acquired flatfoot. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran's disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, while the December 2019 VA examination reflects the Veteran's metatarsalgia is directly related to his service-connected pes planus, the Board notes that the evidence of record is against a finding that the disabilities have distinct manifestations from those that are already being compensated. See 38 C.F.R. § 4.14. In conclusion, the Board finds that the preponderance of the evidence is a rating in excess of 30 percent for pes planus. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Service Connection 2. Service connection for arthritis of the neck, right shoulder, bilateral hips and bilateral legs is denied. The Veteran seeks service connection for arthritis of the neck, right shoulder, bilateral hips, and bilateral legs. The Veteran contends his arthritis onset during active service and has continued since his separation from active duty. For the reasons that follow, the Board finds entitlement to service connection is not warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). In addition to complaints of right shoulder and neck pain, the Veteran has a current diagnosis of degenerative arthritis of the hips and bilateral knees as evidenced by his VA treatment records and examinations. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, was not noted in service with attributable continuity of symptomatology, and is not otherwise related to service. VA and private treatment records are silent for bilateral knee and hip arthritis until December 2012 and October 2014, respectively, decades after his separation from service and decades outside of the applicable presumptive period. The Veteran's service treatment records are silent for complaints of, treatment for, and/or a diagnosis of arthritis. His enlistment report of medical examination reflects a normal clinical evaluation. His August 1980 periodic physical indicates he denied a history of swollen or painful joints; cramps in legs; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; painful or trick shoulder or elbow; trick or locked knee; and recurrent back pain. His January 1982 separation report of medical examination reflects a normal clinical evaluation of the upper and lower extremities and the spine and other musculoskeletal system. His separation report of medical history similarly reflects he denied swollen or painful joints; cramps in legs; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; painful or trick shoulder or elbow; recurrent back pain; and trick or locked knee. A March 1977 service treatment record notes pain in both legs and neck with no injuries or accident. Post-service, a January 1991 treatment record notes shoulder and neck pain following a fall from a telephone pole assessed as myofascial pain syndrome. A March 1991 private treatment record notes complaints of bilateral thigh numbness, decreased sleep, and increased back pain. A March 1991 private treatment record also notes a May 1990 fall at work and continued complaints of neck, back, left arm, and bilateral lower extremity pain. A September 1992 private treatment record notes complaints of pain in the head down to the neck, left shoulder and arm, and back dating to May 1990 when he sustained a fall on the job. A September 1992 cervical spine imaging report notes no acute bony abnormality. A February 1993 private treatment record notes cervical spine pain for the last three years after a fall on the job in 1990 with pain to the top of his head. An April 1993 private treatment record notes complaints of neck and shoulder pain after attempting to lift some groceries. An August 1993 private treatment record notes complaints of headache pain traveling down left arm and back for two and a half years assessed as chronic pain syndrome. An October 1993 private treatment record notes chronic head, neck, and shoulder pain since 1990. A November 1993 private treatment record notes neck pain. A March 1994 private treatment record notes pain in the back of the head that radiates down to his shoulders and his back into both hips. A July 1994 private consultation report notes the Veteran was hurt on the job four years prior to examination and complains of stiffness and pain in neck into his upper spine, shoulder, and arm that occasionally goes down into his hip. The consulting physician noted his chronic neck pain is perhaps related to some arthritic changes in his neck. An August 1994 private treatment record notes neck and shoulder pain associated with a headache status post trauma to shoulder and neck from two to three feet fall at his job. The treatment record notes frozen right shoulder and rule out traumatic osteoarthritis (cervical). A September 1994 private x-ray report found a negative cervical spine examination, and a September 1994 computed tomography (CT) report notes a negative pre and post contrast CT scan of the head. A January 1995 private treatment record notes chronic neck pain assessed as presumed fibromyalgia. A June 1995 private treatment record notes complaints of headaches from top of head down into neck, shoulder pain, and bilateral hip pain for one day with a three year history of flares of chronic pain since a work accident. A June 1995 private treatment record notes x-rays of cervical spine revealed particular fossette hypertrophy at C2 and C3 but remainder of plain x-rays appear to be unremarkable other than some loss of normal cervical lordosis. A January 1998 correspondence from the Veteran's private physician notes treatment for chronic back pain and ongoing complaints of feet and calf pain for nearly two and half years that he reports has continued since he left the service in 1982. A September 1998 VA treatment record notes the Veteran reported falling from a bunk and hurting hishead, neck, shoulder, and back; a cervical spine radiology report reflects no significant abnormality. A September 1998 VA back examination also reflects the Veteran reported falling out of a bunk in 1977 or 1978 and injuring his neck, shoulder, and back. The September 1998 VA examiner noted painful spine from the cervical to the lumbosacral with marked limitation of motion, severe pain, with rapid relaxation phase of the right ankle reflex, and no ankle reflex on the left. A February 1999 private treatment record notes complaints of severe pain of both shoulder and the upper back. A December 2001 VA back examination notes a diagnosis of postural muscular strain but an otherwise normal examination. An August 2002 correspondence from the Veteran's physician notes chronic back pain, headaches, and leg pain. A November 2003 VA treatment record notes the Veteran reported his disc and arthritis problems began thirteen years ago with a job injury as a telephone lineman. A September 2004 private treatment record notes feet and leg pain assessed as 'chronic back pain/myofascial pain/foot pain.' A September 2011 VA treatment record notes osteoarthrosis localized to the ankle and foot. December 2011 and December 2012 VA knee examinations reflect bilateral mild degenerative joint disease. During his knee examinations, the Veteran reported his knee pain began approximately two to three years prior to the examination. A July 2013 VA letter notes tests for rheumatoid arthritis were negative. In a February 2014 VA treatment record, the Veteran reported diffuse pain throughout the bilateral knees, calves, thighs, hips, shoulders, and neck; however, he did not recall any specific injury and indicated experiencing such pain since the military. A February 2014 VA treatment record notes complaints of bilateral knee pain since 1977 and bilateral hip, spine, shoulder, and neck pain since the military. An October 2014 VA treatment record notes mild degenerative changes or arthritis of the bilateral hips. An October 2014 VA treatment record also notes chronic arthritis for 25 years with pain primarily in the feet, ankle, legs, hips, lower back, left shoulder, and neck. After a review of the evidentiary record, the Board finds entitlement to service connection for arthritis of the neck, right shoulder, bilateral hips, and bilateral legs is not warranted. Initially, the Board concludes that the Veteran does not have a current diagnosis of cervical or right shoulder arthritis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In reaching this conclusion, the Board acknowledges Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. While the Veteran has reported that his neck and right shoulder pain causes functional impairment, he has not specifically asserted that it affects his earning capacity, although such is certainly plausible. Considering the paucity of the evidence though, the claimed conditions are not conclusively found to rise to the level of a disability under Saunders. Even if the Board were to find that the Veteran's neck and right shoulder pain rise to the level of a disability under Saunders, the Board finds there is not sufficient evidence to show such disabilities began during service or are at least as likely as not related to an in-service injury, event, or disease. Similarly, the Board finds the preponderance of the evidence is against finding that the Veteran's bilateral knee and hip arthritis were shown as chronic in service; manifested to a compensable degree within a presumptive period following separation from service; or, were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease; or are otherwise related to an in-service injury, event, or disease. The available service treatment records are negative for any complaints, diagnoses, or treatment for chronic neck, right shoulder, hip, or leg conditions. The Veteran denied joint pain and arthritis throughout service, and his post-service treatment records are silent for such symptoms until May 1990. While the Veteran is competent to report having experienced symptoms of musculoskeletal pain since service and consistently since service, the Board finds the reports of continuity of symptomatology not credible. The Veteran's reports are internally inconsistent with his reports in contemporaneous treatment records, which show that he denied experiencing joint pain and arthritis during service and initially reported the onset of symptoms in May 1990, outside of the presumptive period and following a May 1990 work injury. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The only evidence of record associating the Veteran's claimed conditions with his active duty service are his own general lay statements; no objective medical evidence indicates a continuation of symptoms nor does the record contain any credible evidence to corroborate the Veteran's general lay statements of in-service incurrence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Board further finds the Veteran is not competent to diagnose an orthopedic disability such as arthritis or offer a nexus opinion relating such to service. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing, and the Veteran has not demonstrated the necessary medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). To the extent the Veteran has asserted his claimed conditions are secondary to his service-connected pes planus and a VA opinion has not been obtained regarding direct or secondary service connection, the Board acknowledges that a VA examination and/or opinion has not been obtained but finds a VA examination and/or opinion is not warranted in this case. The evidence of record fails to show a neck, leg, right shoulder, or hip condition during active service, a credible assertion of continuity of such symptoms since service, and/or competent and credible evidence of record suggesting that the Veteran's current conditions are related to service. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) (a mere conclusory generalized lay statement that service caused the claimant's current condition is insufficient to require the Secretary to provide an examination). Thus, the low standard of McLendon has not been met and a VA examination or opinion is not warranted. Id. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for arthritis of the neck, right shoulder, bilateral hips, and bilateral legs is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 3. Service connection for arthritis of the bilateral feet and bilateral first metatarsophalangeal joints is granted. The Veteran seeks service connection for bilateral foot and toe arthritis. A December 2019 VA foot conditions examination reflects diagnoses of degenerative arthritis of the bilateral feet and bilateral degenerative joint disease of the first metatarsophalangeal joints. The examiner indicated that these additional conditions are directly due to or related to the service-connected pes planus diagnosis. The rationale was that the pes planus increases the risk of injury or pain to the musculoskeletal system. The pes planus has been exacerbated and progressed. Pes planus or flat feet causes inflammation of soft tissue; foot, arch, and leg fatigue; and heel, foot, and ankle pain. This opinion and rationale were proffered by a VA clinician who reviewed the file and examined the Veteran. There are no contrary opinions of record. Hence, service connection is warranted for degenerative arthritis of the bilateral feet and bilateral degenerative joint disease of the first metatarsophalangeal joints. 4. Service connection for headaches, to include as secondary to multiple joint arthritis, is remanded. The Veteran contends his headaches onset in service. Service treatment records in January 1977 reflect complaints of headaches assessed as post-concussion syndrome. In addition to competently reporting headaches since service, the Veteran's post-service treatment record reflect treatment for headaches since February 1989. As the evidence of record shows treatment for headaches during active service, a credible lay assertion of recurrent headache symptoms since service, and post-service treatment records showing a longstanding history of recurrent headache since 1989, the Board resolves all reasonable doubt in the Veteran's favor to find service connection for headaches is warranted. 38 C.F.R. § 3.303(a), 3.303(d). REASONS FOR REMAND 1. Service connection for sleep disturbances, to include as secondary to multiple joint arthritis, is remanded. The Veteran contends his sleep disturbances onset during his active service or, alternatively, are secondary to his multiple joint arthritis. The June 2019 Board decision found this issue to be inextricably intertwined with the Veteran's claim for arthritis. As the Board has granted service connection for arthritis of the bilateral feet and of the bilateral first metatarsophalangeal joints, an opinion regarding service connection on a secondary is necessary. 2. Service connection for atopic dermatitis is remanded. The Veteran seeks service connection for atopic dermatitis. In compliance with the Board's prior remand directives, a VA skin examination was obtained in December 2019. In providing a positive nexus opinion, the examiner noted that the Veteran's January 1982 separation examination shows mild eczema, and eczema is a chronic condition that has continued to this day. However, the Board notes that the Veteran was discharged under other than honorable conditions from his second period of service (from December 1979 to February 1982), such that he is barred from receiving VA benefits arising out of this period of service. Accordingly, on remand, an addendum opinion should be obtained that does not consider this period of service in providing the requested opinion. 3. Entitlement to a TDIU is remanded. The Veteran contends his feet conditions preclude him from obtaining and maintaining substantial employment. The Board has granted service connection for bilateral feet and toe arthritis, and the RO's effectuation of that action could significantly impact a decision on the issue of entitlement to a TDIU particulary as the Veteran does not currently meet the schedular critieria for entitlement to a TDIU. Thus, the issues are inextricably intertwined. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has a chronic sleep disorder that is at least as likely as not EITHER proximately due to OR aggravated beyond its natural progression by his service-connected bilateral pes planus. Opinions and rationale for both proximate causation and aggravation must be provided. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's current atopic dermatitis or eczema is at least as likely as not related to his first period of active service. A rationale must be provided. The examiner is advised the Veteran was discharged under other than honorable conditions from his second period of service, which is from December 1979 to February 1982. This period of service should not be considered in providing the requested opinion. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, Associate 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.