Citation Nr: 21029436 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-34 208 DATE: May 13, 2021 ORDER 1. Prior to May 27, 2019, an initial rating in excess of 10 percent for right lower extremity sciatica is denied. 2. Prior to May 27, 2019, an initial rating in excess of 10 percent for left lower extremity sciatica prior is denied. 3. Since May 27, 2019, a rating of 20 percent for right lower extremity sciatica is granted. 4. Since May 27, 2019, a rating of 20 percent for left lower extremity sciatica is granted. 5. An initial rating in excess of 20 percent for right upper extremity radicular nerve is denied. 6. An initial rating in excess of 20 percent for left upper extremity radicular nerve is denied. 7. An initial rating in excess of 10 percent for groin and axilla folliculitis with tinea cruris is denied. REMANDED 1. An initial rating in excess of 10 percent prior to August 27, 2020, and in excess of 20 percent thereafter, exclusive of the temporary total rating period from May 12, 2016 to February 28, 2017, for multilevel spondylosis of the cervical spine. 2. An initial rating in excess of 10 percent for degenerative joint disease (DJD) of the thoracolumbar spine. 3. A rating in excess of 20 percent for right shoulder strain. 4. A rating in excess of 20 percent for DJD of the left shoulder. 5. An initial rating in excess of 10 percent for a right knee strain. 6. Service connection for a left knee strain. 7. A rating in excess of 10 percent for left Achilles tendon status post repair. 8. Service connection for a right Achilles tendon disorder. 9. A total disability rating based on individual unemployability (TDIU). FINDINGS OF FACT 1. Prior to May 27, 2019, the Veteran's right lower extremity sciatica manifested in mild, but not moderate or worse, incomplete paralysis. 2. Prior to May 27, 2019, the Veteran's left lower extremity sciatica manifested in mild, but not moderate or worse, incomplete paralysis. 3. Since May 27, 2019, the Veteran's right lower extremity sciatica has manifested in moderate, but not severe, incomplete paralysis. 4. Since May 27, 2019, the Veteran's left lower extremity sciatica manifested in moderate, but not severe, incomplete paralysis. 5. The Veteran's right upper extremity radicular nerve has manifested in mild, but not moderate or worse, incomplete paralysis. 6. The Veteran's left upper extremity radicular nerve has manifested in mild, but not moderate or worse, incomplete paralysis. 7. The Veteran's groin and axilla folliculitis with tinea cruris does not affect 20 percent or more of his entire body area or exposed body area and does not result in the use of systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. Prior to May 27, 2019, the criteria for an initial rating in excess of 10 percent for right lower extremity sciatica were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8520. 2. Prior to May 27, 2019, the criteria for an initial rating in excess of 10 percent for left lower extremity sciatica were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8520. 3. Since May 27, 2019, the criteria for a 20 percent rating, but no higher, for right lower extremity sciatica are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8520. 4. Since May 27, 2019, the criteria for a 20 percent rating, but no higher, for left lower extremity sciatica are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8520. 5. The criteria for an initial rating in excess of 20 percent for right upper extremity radicular nerve are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8710. 6. The criteria for an initial rating in excess of 20 percent for left upper extremity radicular nerve are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 8710. 7. The criteria for an initial rating in excess of 10 percent for groin and axilla folliculitis with tinea cruris are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DCs 7806, 7813. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1979 to January 1999. The case is on appeal from a May 2014 rating decision. In August 2019, the Veteran testified at a Board hearing. In a December 2019 decision, the Board denied a compensable rating for scarring of the axilla and groin, granted initial ratings for a left ankle scar, bilateral shoulder disabilities, and a right knee strain, and remanded the claims on appeal for additional development. In a December 2020 rating decision, the RO increased the Veteran's cervical spine rating to 20 percent effective August 27, 2020 and his bilateral lower extremity sciatica ratings to 20 percent each effective December 4, 2020. These staged ratings do not represent the maximum disability rating assignable for the disabilities, and the Veteran has not indicated that the current staged ratings are the maximum benefit sought. As higher ratings are available and a claimant is presumed to be seeking the maximum available rating for disabilities, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Additional evidence was received subsequent to the supplemental statement of the case (SSOC) issued in December 2020. As the evidence is not pertinent to the claims decided herein, a remand for RO consideration of the evidence is not necessary. See 38 C.F.R. § 20.1305(c). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Ratings General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 1. An initial rating in excess of 10 percent prior to December 4, 2020, and in excess of 20 percent thereafter, for right lower extremity sciatica. 2. An initial rating in excess of 10 percent prior to December 4, 2020, and in excess of 20 percent thereafter, for left lower extremity sciatica. 3. An initial rating in excess of 20 percent for right upper extremity radicular nerve. 4. An initial rating in excess of 20 percent for left upper extremity radicular nerve. Specific Legal Criteria The Veteran's right and left lower extremity sciatica are rated under the peripheral nerve impairment provisions of 38 C.F.R. § 4.124a, DC 8520. A 10 percent rating is warranted where there is mild incomplete paralysis of the sciatic nerve; a 20 percent rating is warranted where there is moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is warranted where there is moderately severe incomplete paralysis of the sciatic nerve; a rating of 60 percent is warranted for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy; and the highest rating of 80 percent is warranted with complete paralysis of the sciatic nerve (where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or lost). The Veteran's right and left upper extremity radicular nerve disabilities are rated under peripheral nerve impairment provisions of 38 C.F.R. § 4.124a, DC 8710. DC 8710 provides compensation for conditions of the upper radicular group. A 20 percent rating is warranted where there is mild incomplete paralysis of the major or minor limb; a 40 percent rating is warranted for the major limb and a 30 percent rating is warranted for the minor limb where there is moderate incomplete paralysis; a 50 percent rating is warranted for the major limb and a 40 percent rating is warranted for the minor limb where there is severe incomplete paralysis; and a 70 percent rating is warranted for the major limb and a 60 percent rating is warranted for the minor limb for complete paralysis with all shoulder and elbow movements lost or severely affected, but hand and wrist movements not affected. A Note following diseases of the peripheral nerves states combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. 38 C.F.R. § 4.124a. For rating disease of the peripheral nerves, the term "incomplete paralysis," indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. For the purposes of evaluating these disabilities, moderate is "tending toward the mean or average amount or dimension" and "severe" is "of a great degree." See www.merriam-webster.com/dictionary/moderate; www.merriam-webster.com/dictionary/severe. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, an effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). In determining when an increase is "factually ascertainable," all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, "it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Analysis The Veteran is seeking higher initial ratings for his bilateral lower and upper extremity disabilities. During the August 2019 Board hearing, he reported experiencing bilateral lower extremity tingling, numbness, and moderate pain resulting in a need to take medication. He also reported experiencing bilateral upper extremity numbness and tingling resulting in difficulty dressing. In April 2014, the Veteran underwent back and cervical spine examinations performed by a nurse practitioner (NP). During the back examination, the NP reported normal bilateral lower extremity reflexes, sensory examination, and muscle strength. She also reported mild bilateral paresthesias and numbness as well as mild left lower extremity intermittent pain. She denied right and left lower extremity constant pain. The NP rated the severity of the bilateral lower extremity radiculopathies as mild. The April 2014 NP also examined the Veteran for radiculopathy related to the cervical spine disability. She reported normal bilateral upper extremity reflexes, sensory examination, and muscle strength. She denied the presence of right or left upper extremity constant pain. The NP also reported moderate bilateral intermittent pain, paresthesias, and numbness. She rated the severity of the bilateral upper extremity condition moderate. The Veteran was afforded a peripheral nerve examination performed by a physician in regard to these conditions in January 2016. The Veteran reported bilateral pain going down both arms and numbness in his hands. He also reported that the symptoms had gotten worse. The physician reported normal bilateral upper and lower extremity reflexes, sensory examination, and muscle strength. She also reported severe constant left upper extremity constant pain, paresthesias, and numbness, moderate right upper extremity intermittent pain and numbness, moderate bilateral lower extremity intermittent pain, paresthesias, and numbness, and mild right upper extremity paresthesias. She denied right upper extremity and bilateral lower extremity constant pain. She also denied the use of assistive devices for walking. The physician rated the severity of the bilateral upper extremity middle and upper radicular groups as mild, incomplete paralysis. She also rated the severity of the bilateral lower extremity sciatica as mild, incomplete paralysis. In May 2019, the Veteran submitted back and cervical spine Disability Benefit Questionnaires (DBQs) from a private physician dated May 27, 2019. The physician normal bilateral lower extremity reflexes, sensory examination, and muscle strength. He also reported the presence of moderate bilateral lower extremity constant pain, paresthesias, and numbness and noted the use of a cane. He found that the Veteran experiences moderate bilateral lower extremity radiculopathy. The physician reported normal bilateral upper extremity reflexes and sensory examinations. He also denied the presence of right and left upper extremity radicular pain or other subjective symptoms due to radiculopathy. Pursuant to a December 2019 Board remand, the Veteran was afforded back and cervical spine examinations performed by an NP in August 2020. She reported normal bilateral upper and lower extremity reflexes, sensory examination, and muscle strength. She also denied the presence of right and left upper extremity radicular pain or other subjective symptoms due to radiculopathy. In December 2020, the Veteran was afforded a peripheral nerve examination performed by a physician pursuant to the December 2019 Board remand. The Veteran reported burning pain in the lower back radiating from his lower back down both legs to his ankles and also in the neck radiating into both arms. The physician reported normal bilateral upper and lower extremity sensory examination. She also reported normal bilateral upper and lower extremity muscle strength, except 4 out of 5 for bilateral hand pinching and bilateral dorsiflexion. She further reported normal bilateral upper and lower extremity reflexes except for bilateral hypoactive reflexes of the bilateral triceps and ankles. The physician noted regular use of a cane. She found symptoms attributable to the peripheral nerves of moderate bilateral lower extremity intermittent pain, mild bilateral lower extremity constant pain and paresthesias, and mild bilateral upper extremity intermittent pain and paresthesias. She concluded that the Veteran experiences bilateral lower and upper extremity radiculopathies. She rated the bilateral lower extremity sciatica as resulting in moderate incomplete paralysis and anterior and posterior tibial symptoms as resulting in mild incomplete paralysis. She rated the bilateral upper extremity ulnar nerve and lower radicular group as resulting in mild incomplete paralysis. The Board finds that higher ratings for right and left lower extremity sciatica prior to May 27, 2019 and higher ratings for right and left upper extremity radicular nerve are not warranted. In this regard, the examinations of record do not show reduced muscle strength, reflexes, or sensory examinations prior to the December 2019 examination, when only mild reduction in muscle strength and sensation were shown on testing. In addition, the April 2014 and January 2016 examiners reported that the bilateral upper and lower extremity conditions result in mild incomplete paralysis. To the extent that the April 2014 examiner found the bilateral upper extremity disabilities to be moderate, this examination was performed by a NP. The Board finds that this evaluation is less probative than the findings of the January 2016 physician, May 2019 private physician, and December 2020 physician. The physicians all reported mild incomplete paralysis or denied the presence of upper extremity radiculopathy. The physicians' findings are more probative in light of their additional medical training when compared to the April 2014 NP. In addition, the Veteran reported that his symptoms had worsened at the time of the January 2016 examination. In conclusion, while some moderate symptoms were noted for the upper extremity conditions, and the lower extremity conditions prior to May 27, 2019, the preponderance of the evidence indicates that the severity of the conditions constituted mild, incomplete paralysis. Furthermore, although multiple nerve involvements were noted by some of the examinations, the combined nerve injuries are properly rated by reference to the relevant major nerve or nerve group involvement. See 38 C.F.R. § 4.124a. However, since May 27, 2019, 20 percent ratings for right and left lower extremity sciatica are warranted. In this regard, the private physician DBQ conducted on such date indicates the presence of moderate, incomplete paralysis. The presence of moderate, incomplete paralysis is also supported by the findings of the December 2020 examiner. While a 20 percent rating is warranted, the evidence does not indicate the presence of muscle atrophy or severe incomplete paralysis at any time during the appeal period. Id. In addition, an earlier effective date for the 20 percent ratings is not warranted because May 27, 2019 is the first date that moderate sciatica symptoms are shown. See Swain, 27 Vet. App. at 224; DeLisio, 25 Vet. App. at 56. The preponderance of the evidence shows that the Veteran's bilateral lower extremity sciatica manifested in mild, but not moderate or severe, incomplete paralysis prior to May 27, 2019, and manifested in moderate, but not severe, incomplete paralysis since May 27, 2019. The preponderance of the evidence also shows that the Veteran's bilateral upper extremity radicular nerves have manifested in mild, but not moderate or severe, incomplete paralysis. Therefore, 20 percent ratings since May 27, 2019 for bilateral lower extremity sciatica are warranted, but there is no additional doubt to be resolved, and additional higher ratings for the bilateral lower extremity sciatica or higher ratings for the bilateral upper extremity radicular nerves are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding other claims for additional development, remand is not necessary for these issues as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). 5. An initial rating in excess of 10 percent for groin and axilla folliculitis with tinea cruris. Specific Legal Criteria The Veteran's groin and axilla folliculitis with tinea pedis is rated under DCs 7813-7806. DC 7813 is used to rate dermatophytosis, specifically including tinea pedis. See 38 C.F.R. § 4.118. Prior to August 13, 2018, DC 7813 was to be rated as disfigurement of the head, face or neck, scars, or dermatitis, depending upon the predominant disability. Id. The Veteran's predominant disability more closely represents dermatitis than the other two. Since August 13, 2018, both DC 7806 and DC 7813 are rated under the General Rating Formula for Skin. Id. Under the General Rating Formula for Skin, a noncompensable rating is warranted when less than 5 percent of the entire body, or less than 5 percent of exposed area, is affected, and no more than topical therapy is required during the past 12-month period; a 10 percent rating is warranted when there is at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period; a 30 percent rating is warranted when there is 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period; and a 60 percent rating is warranted when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required during the past 12-month period. Id. Note (a) states: For the purposes of this section, systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. Note (b) states: two or more skin conditions may be combined in accordance with § 4.25 only if separate areas of skin are involved. If two or more skin conditions involve the same area of skin, then only the highest evaluation shall be used. The rating criteria detailed above were made effective as of August 13, 2018. See 83 Fed. Reg. 32592 (July 13, 2018). The pertinent part of the rating criteria as to the percentage of area covered is essentially identical to the prior version. See 38 C.F.R. § 4.118, DCs 7806, 7813 (2018). Thus, this change does not affect the outcome of the issue on appeal. Topical treatment can potentially be akin to systemic therapy if it is a corticosteroid that affects the entire body system, such as through the bloodstream, or if it is non-corticosteroid but operates "like" a corticosteroid. See Burton v. Wilkie, 30 Vet. App. 286, 295 (2018); cf. Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). Analysis The Veteran is seeking a higher rating for groin axilla folliculitis with tinea cruris. During the August 2019 Board hearing, the Veteran denied that this condition is worsening and using any medication or ointments for treatment. The Veteran was afforded a VA skin examination in April 2014. The Veteran reported experiencing a rash under the arms and in the groin intermittently. The examiner diagnosed the Veteran with groin and axilla folliculitis and tinea cruris. She reported the use of topical medication of Gold Bond Power as needed under the arms and in the groin for less than 6 weeks in the past 12 months. She also reported dermatitis present on 5 percent to less than 20 percent of the Veteran's total body area and none on his exposed body area. The examiner denied the use of systemic or topical medications, debilitating episodes, and non-debilitating episodes in the past 12 months. She also denied that functional impact from the skin conditions affects the Veteran's ability to work. Pursuant to the Board's December 2019 remand, the Veteran was afforded another skin examination in August 2020. The examiner noted diagnoses of groin and axilla folliculitis and tinea cruris. She reported that there were not skin conditions present on the Veteran's body or exposed body area at the time of the examination. She denied treatment with medication, use of systemic or topical medications, debilitating episodes, and non-debilitating episodes in the past 12 months. The examiner also denied that functional impact from the skin conditions affects the Veteran's ability to work. The Board finds that an initial rating in excess of 10 percent is not warranted. In this regard, the Veteran has not claimed and the evidence does not show that his groin and axilla folliculitis with tinea cruris affects 20 percent or more of his entire body area or exposed body area. In addition, he has not claimed and the evidence does not show the use of systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. To the extent that the Veteran reported treating the condition during the April 2014, he reported using over the counter powder that has not been found to constitute systemic corticosteroids or other immunosuppressive medication. See Johnson, 862 F.3d at 1354-56. Therefore, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable and an initial rating in excess of 10 percent is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Although the Board is remanding other claims for additional development, remand is not necessary for this issue, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND 1. An initial rating in excess of 10 percent prior to August 27, 2020, and in excess of 20 percent thereafter, exclusive of the temporary total rating period from May 12, 2016 to February 28, 2017, for multilevel spondylosis of the cervical spine. 2. An initial rating in excess of 10 percent for DJD of the thoracolumbar spine. The Veteran is seeking higher ratings for his service-connected neck and back disabilities. During the August 2019 Board hearing, he reported that his back symptoms are worsening. In a December 2019 decision, the Board remanded these claims to obtain an updated assessment of the current severity and retrospective findings in regard to estimated ranges of motion during flareups at the time of the April 2014 examination. The Veteran was afforded examinations for these conditions in August 2020. However, another remand is warranted to obtain an opinion as to the ranges of motion during flareups at the time of the April 2014 examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 3. A rating in excess of 20 percent for right shoulder strain. 4. A rating in excess of 20 percent for DJD of the left shoulder. The Veteran is seeking higher ratings for his service-connected bilateral shoulder disabilities. In a December 2019 decision, the Board remanded these claims to assess the severity of the service-connected shoulder disabilities, to include complying with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The Veteran was afforded examinations for these conditions in August 2020. However, another remand is warranted to obtain an opinion as the ranges of motion during flareups at the time of the July 2013 and April 2014 examinations. 5. An initial rating in excess of 10 percent for a right knee strain. 6. Service connection for a left knee strain. The Veteran contends that he should have a higher initial rating for a right knee strain and that he has a left knee disorder due to service. In this regard, during the August 2019 Board hearing, he reported that he has a left knee disorder due to in-service injuries from lifting heavy backpacks and making long road marches while wearing heavy backpacks. He also reported ongoing intermittent left knee pain since service. The Veteran's STRs show that he was treated for left knee pain in October 1986 and was assessed with a ligament strain. An October 1989 STR notes a hyperextended left knee two years earlier and assessed him with left knee pain. In August 1996, the Veteran was treated for left knee pain and patellar-femoral grinding. The treatment provider assessed him with retropatellar pain syndrome. The Veteran was afforded a knee examination in April 2014. The examiner diagnosed him with bilateral knee strains. The examiner found that the Veteran's right knee strain was due to service. Thereafter, another examiner provided an addendum opinion in May 2014. He found that the Veteran's left knee disorder is not related to service. In December 2019, the Board remanded these claims to assess the severity of the service-connected right knee disability, to include complying with Correia and Sharp and to obtain another opinion in regard to his left knee claim. The Veteran was afforded an examination for these conditions in August 2020. The Veteran stated that he experiences left knee pain due to compensating for his right knee disability. The Board finds that a remand is warranted for another examination and to obtain opinions in regard to whether the left knee condition is related to service or the right knee disability and an estimate of the right knee range of motion during flareups at the time of the April 2014 examination. 7. A rating in excess of 10 percent for left Achilles tendon status post repair. 8. Service connection for a right Achilles tendon disorder. The Veteran contends that he should have a higher initial rating for a left Achilles tendon disability and that he has a right Achilles tendon disorder due to service. The Veteran's STRs show that he was treated for right Achilles pain in September 1993. The treatment provider assessed him with right Achilles tendonitis. The Veteran was afforded a VA examination in regard to these claims in April 2014. The examiner diagnosed the Veteran with left Achilles tendon status post repair since 1986. The examiner did not diagnose him with a right Achilles tendon disorder. In December 2019, the Board remanded these claims to assess the severity of the service-connected right knee disability, to include complying with Correia and Sharp and to obtain another opinion in regard to the right Achilles tendon claim. The Veteran was afforded an examination for these conditions in August 2020. The Veteran reported that he experiences intermittent bilateral Achilles tendon pain. He also stated that his right Achilles tendon condition is due to compensating for his left Achilles tendon disability. The Board finds that a remand is warranted for another examination and to obtain opinions in regard to whether he has a right Achilles tendon condition is related to service or the left Achilles tendon disability and to obtain an estimate of the ranges of motion during flareups at the time of the April 2014 examination. 9. A TDIU. The Veteran is seeking a TDIU based on his service-connected back, neck, foot, and upper and lower extremity disabilities. The claim is remanded as it is intertwined with the remanded increased rating claims. These claims are REMANDED for the following actions: 1. Forward the claims file to an appropriate examiner to assess the Veteran's cervical spine and back disabilities. Following a review of the claims file, the examiner should estimate the amount in degrees of ranges of motion lost due to flare-ups experienced by the Veteran at the time of the examination conducted in April 2014. If the examiner cannot provide some or all of the requested opinions regarding flareups, he or she should explain why such opinions cannot be provided. A rationale should be provided for opinions expressed. 2. Forward the claims file to an appropriate examiner to assess the Veteran's right and left shoulder disabilities. Following a review of the claims file, the examiner should estimate the amount in degrees of ranges of motion lost due to flare-ups experienced by the Veteran at the time of the examinations conducted in July 2013 and April 2014. If the examiner cannot provide some or all of the requested opinions regarding flareups, he or she should explain why such opinions cannot be provided. A rationale should be provided for opinions expressed. 3. Schedule a VA examination by an appropriate medical professional to assess the nature and etiology of his left knee disorders and the current severity of his service-connected right knee strain. The record, including a complete copy of this remand, should be made available for review in connection with the examination. The examiner should then: (a.) Identify all current left knee disorders present since June 2013, including the diagnosed left knee strain. (b.) For each left knee disorder, state whether it is at least as likely as not that it had its onset during service, within one year of discharge, or is otherwise related to service, to include lifting heavy backpacks and making long road marches while wearing heavy backpacks. (c.) For each left knee disorder, state whether it is at least as likely as not that it is caused or aggravated by the service-connected right knee strain. Aggravation means an increase in severity beyond the natural progress of the disease. (d.) The examiner should include testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. (e.) If there are flare-ups, but if the examination is not conducted during a flare-up, the functional impact of a flare-up in terms of degrees of range of motion should be estimated. (f.) The examiner should also estimate the amount in degrees of range of motion lost due to flare-ups experienced by the Veteran at the time of the examination conducted in April 2014. If the examiner cannot provide some or all of the requested opinions regarding flareups, he or she should explain why such opinions cannot be provided. A rationale should be provided for opinions expressed. 4. Schedule a VA examination by an appropriate medical professional to assess the nature and etiology of his right Achilles tendon disorders and the current severity of his service-connected left Achilles tendon disability. The record, including a complete copy of this remand, should be made available for review in connection with the examination. The examiner should then: (a.) Identify all the current right Achilles tendon disorders since June 2013, including intermittent pain. (b.) For each right Achilles disorder, state whether it is at least as likely as not that it had its onset during service, within one year of discharge, or is otherwise related to service, to include lifting heavy backpacks and making long road marches while wearing heavy backpacks. (c.) For each right Achilles tendon disorder, state whether it is at least as likely as not that it is caused or aggravated by the service-connected left Achilles tendon status post repair. Aggravation means an increase in severity beyond the natural progress of the disease. (d.) The examiner should include testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. (e.) If there are flare-ups, but if the examination is not conducted during a flare-up, the functional impact of a flare-up in terms of degrees of range of motion should be estimated. (f.) The examiner should also estimate the amount in degrees of range of motion lost due to flare-ups experienced by the Veteran at the time of the examination conducted in April 2014. If the examiner cannot provide some or all of the requested opinions regarding flareups, he or she should explain why such opinions cannot be provided. A rationale should be provided for opinions expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Jimerfield 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.