Citation Nr: 21029519 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-35 178A DATE: May 13, 2021 ORDER A disability rating greater than 30 percent for seborrheic dermatitis is denied. A disability rating greater than 10 percent for right knee patellofemoral pain syndrome is denied. A disability rating greater than 10 percent for left knee chondromalacia patella is denied. A disability rating greater than 10 percent for right ankle post traumatic arthritis is denied. A compensable disability rating for septal deviation with vasomotor rhinitis is denied. Service connection for hemorrhoids, claimed as secondary to a service-connected disability, is granted. Service connection for hypertension is denied. Service connection for a left ankle disorder is denied is denied. Service connection for nerve problems of the left leg, claimed as secondary to a service-connected lumbar spine disability, is denied. Service connection for frequent urination, claimed as secondary to service-connected lumbar spine disability, is denied. REMANDED The claim of entitlement to service connection for a cervical spine disorder is remanded. The claim of entitlement to service connection for right shoulder degenerative joint disease is remanded. The claim of entitlement to service connection for left shoulder degenerative joint disease is remanded. The claim of entitlement to service connection for a right hip disorder is remanded. The claim of entitlement to service connection for right upper extremity radiculopathy, claimed as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for left upper extremity radiculopathy, claimed as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for right wrist carpal tunnel, claimed as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for left wrist carpal tunnel, claimed as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected lumbar spine disability, is remanded. The claim of entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to a service-connected disability, is remanded. The claim of entitlement to service connection for sleep disturbances, to include as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's seborrheic dermatitis has not involved 40 percent or less of the entire body and/or 40 percent or less of exposed areas affected and has not required systemic therapy. Furthermore, the schedular criteria are adequate to rate the skin disability under consideration at points pertinent to this appeal. 2. Throughout the appeal period, the Veteran's right knee disability has been manifested by, at worst, flexion to 90 degrees and extension to 5 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There is no demonstration of ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 3. Throughout the appeal period, the Veteran's left knee disability has been manifested by, at worst, flexion to 120 degrees and extension to 0 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There is no demonstration of ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 4. Throughout the appeal period, the Veteran's right ankle disability has been manifested by at least 10 degrees of dorsiflexion and at least 20 degrees of plantar flexion with subjective reports of swelling and pain and objective reports of some tenderness to palpation considered to be no more than moderately disabling. 5. Throughout the appeal period, the Veteran's septal deviation with vasomotor rhinitis has been manifested by no obstruction of the nasal passage greater than 50 percent. 6. Resolving all doubt in his favor, the Veteran has a current diagnosis of hemorrhoids which has been related to medication used to treat his service-connected disabilities. 7. While the Veteran contends that he experiences hypertension, the probative evidence does not support a current diagnosis of hypertension as defined by regulation. 8. While the Veteran contends that he experiences a left ankle disorder, there is no evidence of a current diagnosis of a left ankle disorder to account for his symptoms or any functional impairment caused by such symptoms. 9. While the Veteran contends that he experiences a nerve problem of the left leg, there is no evidence of a current diagnosis to account for his symptoms or any functional impairment caused by such symptoms. 10. There is no evidence of frequent urination in service and no competent medical evidence linking the Veteran's current frequency of micturition with his period of service, to include a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 30 percent for seborrheic dermatitis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.31, 4.118, Diagnostic Code (DC) 7806. 2. The criteria for a disability rating greater than 10 percent for right knee patellofemoral pain syndrome are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5260-5010. 3. The criteria for a disability rating greater than 10 percent for left knee chondromalacia patella are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5260-5262. 4. The criteria for a disability rating greater than 10 percent right ankle post traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271. 5. The criteria for a compensable disability rating for septal deviation with vasomotor rhinitis have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, DCs 6599-6502. 6. The criteria for service connection for hemorrhoids as secondary to service-connected disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 8. The criteria for service connection for a left ankle disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. 9. The criteria for service connection for nerve problems of the left leg are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. 10. The criteria for service connection for frequent urination are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS These matters come before the Board of Veterans' Appeals (Board) from March 2014 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Specifically, the March 2014 rating decision, in part, continued 10 percent disability ratings for each knee disability, continued a noncompensable disability rating for septal deviation, continued a noncompensable disability rating for seborrheic dermatitis, and denied service connection for frequent urination, erectile dysfunction, hemorrhoids, sleep disturbances, nerve problems of the bilateral legs, bilateral carpal tunnel syndrome, hypertension, radiculopathy of the upper extremities, and GERD. The May 2014 rating decision, in part, denied service connection for a left ankle disability, a cervical spine disability, bilateral shoulder disabilities, and a right hip disability. Subsequently, by rating decision dated in June 2016, the RO increased the disability rating for the Veteran's seborrheic dermatitis from noncompensable to 30 percent disabling effective March 26, 2013. Also, by rating decision dated in January 2021, the RO granted a separate 10 percent rating for right knee meniscal tear effective July 30, 2018. As these increases did not represent a full grant of the benefits sought, the Veteran's appeals with regard to seborrheic dermatitis and the right knee have not been abrogated and the matters remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in June 2019. A transcript of this proceeding has been associated with the claims file. This case was previously before the Board in September 2019 at which time the Board, in pertinent, reopened a previously denied claim of entitlement to service connection for GERD and remanded this claim along with the other issues noted on the cover page of this decision for additional development. Notably, the issues of entitlement to service connection for a lumbar spine disability as well as nerve problems of right leg were remanded by the Board at that time as well, however, these issues are no longer on appeal as service connection was granted for lumbosacral strain with intervertebral disc syndrome as well as right lower radiculopathy by rating decision dated in July 2020. As a preliminary matter, the Board notes that, in a January 2020 VA ankle examination, it was noted that the Veteran was an unemployed truck driver and had lost a week or less of work in the last 12 months due to pain with prolonged walking and standing secondary to his right ankle disability. As it appears that the Veteran is currently unemployed, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) has been raised as part and parcel of the increased rating claims on appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Board declines to take jurisdiction of the TDIU issue at this time as there were no allegations of unemployability due to the Veteran's service-connected skin, bilateral knee, right ankle, and sinus disabilities. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 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. A veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. 38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). 38 C.F.R. § 4.45. The United States Court of Appeals for Veterans Claims (Court) has held that when a diagnostic code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Also, the Court has held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38 C.F.R. § 4.59 states that "[t]he joints involved should be tested 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." As such, pursuant to Correia, an adequate VA joints examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Effective February 7, 2021, several changes to the diagnostic codes used for rating musculoskeletal disabilities were made. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. Only the former criteria can be applied for the period prior to the effective date of the new criteria. However, both the old and new criteria can be applied as of that date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114. While the Veteran has not yet been notified of all applicable regulatory changes and considered his claim under such regulations, the Board notes that the rating criteria prior to February 7, 2021 pertaining to the knees and ankles are significantly more favorable to the Veteran. As such, there is no prejudice to the Veteran in the Board considering the claims at this time. 1. A disability rating greater than 30 percent for seborrheic dermatitis is denied. By way of history, service treatment records show that the Veteran was diagnosed and treated for skin problems as early as 1987. In January 1997, the Veteran submitted a claim for service connection for "upper body skin rash." He was afforded a VA examination in September 1997 which noted a current diagnosis of seborrheic dermatitis. By rating decision dated in April 2000, the RO granted service connection for seborrheic dermatitis, assigning a 10 percent disability rating for this disability effective January 16, 1997. Subsequently, by rating decision dated in October 2007, the RO increased the Veteran's disability rating for seborrheic dermatitis from 10 to 30 percent disabling effective August 30, 2002. The Veteran was scheduled for a periodic examination for his seborrheic dermatitis and, when he failed to report to this examination, by rating decision dated in January 2010, the RO proposed to reduce the Veteran's disability rating for seborrheic dermatitis from 30 percent to noncompensably disabling. This decrease was effectuated in an April 2010 rating decision effective July 1, 2010. The Veteran disagreed with this decision but failed to perfect an appeal. The Veteran submitted the current claim for an increase in March 2013 and, by rating decision dated in March 2014, the RO continued a noncompensable disability rating for seborrheic dermatitis. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in June 2016, the RO increased the Veteran's disability rating for seborrheic dermatitis from noncompensable to 30 percent disabling effective March 26, 2013. Throughout the rating period on appeal, the Veteran's seborrheic dermatitis has been rated under 38 C.F.R. § 4.118, DC 7806. Additionally, dermatitis can alternatively be rated as disfigurement of the head, face or neck (DC 7800) or scars (DC's 7801-7805) depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7806. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, DC's 7801-7806. Under DC 7801, a 10 percent rating is assigned for scars not of the head, face, or neck that are deep and nonlinear with an area of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is assigned for scars with an area of at least 12 square inches (77 square centimeters) but less than 72 square inches (465 square centimeters). A 30 percent rating is assigned for scars with an area of at least 72 square inches (465 square centimeters) but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned for scars with an area of 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, DC 7801. Under DC 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (2) under that code provides that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent evaluation. A 20 percent rating is assigned for three or four scars that are unstable of painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. Note (2) for that code provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) under that provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7803, when applicable. DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-04 under an appropriate DC. 38 C.F.R. §§ 4.118, DCs 7801-7805. DC 7806 pertains to dermatitis or eczema. Under the criteria of DC 7806, dermatitis or eczema covering less than 5 percent of the entire body, affecting less than 5 percent of exposed areas; and requiring no more than topical therapy during the past 12-month period warrants a noncompensable rating. Dermatitis or eczema covering at least 5 percent, but less than 20 percent, of the entire body; affecting at least 5 percent, but less than 20 percent, of exposed areas; of requiring intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12- month period warrants a 10 percent rating. Dermatitis or eczema covering 20 to 40 percent of the entire body, affecting 20 to 40 percent of exposed areas, or requiring systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warrants a 30 percent rating. Dermatitis or eczema warrants a 60 percent rating if it covers more than 40 percent of the entire body, more than 40 percent of exposed areas are affected, or if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806. Evidence relevant to the level of severity of the Veteran's seborrheic dermatitis includes VA skin examination reports dated in January 2014, February 215, and December 2019. During the January 2014 VA examination, the examiner reviewed the claims file and continued a diagnosis of seborrheic dermatitis. The Veteran reported that his skin condition was getting worse and, while he had previously used prescribed medications to treat the condition, he was no longer using prescribed medications but was using over the counter creams and ointments. He reported experiencing red/dry skin, with an itchy/burning sensation during the breakout and reported that his breakouts can last from three to four weeks. The examiner noted that the skin condition did not cause scarring or disfigurement of the head, face, or neck. There were no benign/malignant skin neoplasms and no systemic manifestations due to the skin disease (such as fever, weight loss, or hypoproteinemia associated with skin conditions such as erythroderma). It was noted that the Veteran had not been treated with oral or topical medications in the past 12 months for his skin condition and had not undergone any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. There were no debilitating or non-debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. On physical examination it was noted that the Veteran's dermatitis affected less than 5 percent of his total body area and less than 5 percent of his exposed area. It was also noted that the Veteran's skin condition affected both his face (erythematous skin to both cheeks and the forehead) and anterior chest over the sternal region (four to five erythematous circular areas averaging two to three centimeters in diameter). There was no benign or malignant neoplasm or metastases related to the Veteran's skin disorder and no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the skin condition. With regard to functional impact, the examiner wrote that the Veteran's skin condition did not impact his ability to work. During the February 2015 VA examination, the examiner reviewed the claims file and noted a diagnosis of psoriasiform seborrheic dermatitis. Significantly, the Veteran reported that he was now experiencing scaling/peeling on his face and hairline. He was being treated for his condition at VA and was currently using hydrocortisone and Ketoconazole shampoo. The examiner noted that the skin condition did not cause scarring/disfigurement of the head, face, or neck. There were no benign/malignant skin neoplasms and there were no systemic manifestations due to the skin disease. It was noted that the Veteran had been treated with oral or topical medications in the past 12 months for his skin condition. Specifically, the Veteran had used hydrocortisone constantly or near-constantly due to his seborrheic dermatitis. On physical examination it was noted that the Veteran's dermatitis affected 20 to 40 percent of his total body area and 20 to 40 percent of his exposed area. Specifically, examination of the face, scalp, and chest revealed diffuse white scaling plaques with red base-worse on malar aspect of eyebrows and eyelids, face to include entire cheeks, bilaterally. This, according to the examiner, was consistent with the shave bx done in 2009 for psoriasiform seborrheic dermatitis. There was no benign or malignant neoplasm or metastases related to the Veteran's skin disorder and no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the skin condition. With regard to functional impact, the examiner wrote that the Veteran's skin condition impacted his ability to work in that the Veteran experienced mild itching and burning skin. During the December 2019 VA examination, the examiner reviewed the claims file and noted a diagnosis of seborrheic dermatitis. At that time, the Veteran reported that his skin disability had gotten worse since his last VA examination but had not been seen by dermatology since 2008. He continued to use a prescription shampoo and hydrocortisone for his condition and stated that it was worse with changes in the weather. He reported experiencing discoloration of the forehead and indicated that his skin will bleed and crack at times when it is at its worst. It was noted that the Veteran had been treated with topical medications in the past 12 months for his skin condition, approximately 6 weeks or more, but not constant, in the past 12 months. The Veteran had not undergone any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. On physical examination it was noted that the Veteran's dermatitis affected less than 5 percent of his total body area and less than 5 percent of his exposed area. Specifically, the condition was manifested by dry scaly areas at the face with some hypopigmentation at the forehead. There was no benign or malignant neoplasm or metastases related to the Veteran's skin disorder. There was also no scarring (regardless of location) or disfigurement of the head, face, or neck. Furthermore, there were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the skin condition. With regard to functional impact, the examiner wrote that the Veteran's skin condition did not impact his ability to work. Notably, during the June 2019 Board hearing, the Veteran reported that his skin condition worsens at certain times of the year based on the weather, that he constantly used corticosteroids to treat his condition, and that he experiences cracking/bleeding three to four times per year. After thorough consideration of the evidence of record, the Board concludes that an increased rating greater than 30 percent for the Veteran's seborrheic dermatitis is not warranted in this case. Initially, with regard to DC 7806, the evidence does not show that the Veteran's skin disability covers more than 40 percent of the entire body or more than 40 percent of exposed areas are affected. As above, the January 2014, February 215, and December 2019 VA examinations indicate that less than 40 percent of the Veteran's entire body is affected by his skin disability. In fact, both the January 2014 and December 2019 VA examination reports show that less than 5 percent of the Veteran's entire body is affected by his skin disability. The evidence also does not show constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs have been required during the past 12-month period. Significantly, while the February 2015 VA examination report shows that the Veteran was using hydrocortisone, a topical corticosteroid, on a constant or near-constant basis, the Board questions whether this was actually the case as, during the December 2019 VA examination, the Veteran reported that he had not been seen by dermatology since 2008. Furthermore, during the December 2019 VA examination, it was noted that the Veteran had been treated with topical medications in the past 12 months for his skin condition, approximately 6 weeks or more, but not constant, in the past 12 months. As such, the Board finds that the findings regarding the frequency of corticosteroid use reported in February 2015 VA examination to be not supported by the record. With regard to DC 7800, the evidence does not show scarring/disfigurement of the head, face, or neck. With regard to DC 7804, even if the Veteran's atopic dermatitis resulted in painful scars, a higher rating is not warranted based on DC 7804. DC 7804 provides for, at most, a 30 percent rating; so the Veteran could not be awarded a rating higher than the rating already assigned under DC 7806. A separate rating cannot be assigned as that would constitute pyramiding. See 38 C.F.R. § 4.14. As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report his own symptoms, or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, the Veteran has complained of a skin disorder affecting his body. However, the Veteran has not endorsed any symptomatology that would warrant a compensable rating under any applicable diagnostic code. As the preponderance of the evidence is against a rating in excess of 30 percent for seborrheic dermatitis at any time during the appeal period, the claim is denied. 2. Disability ratings greater than 10 percent for right knee patellofemoral pain syndrome and greater than 10 percent for left knee chondromalacia patella are denied. The Veteran seeks higher disability ratings for his service-connected bilateral knee disabilities. By way of history, the Veteran's service treatment records show that the Veteran was seen for multiple injuries involving the right knee as early as December 1985 and was treated for bilateral knee pain as early as August 1992. He submitted an initial claim for service connection for a bilateral knee disability in January 1997 and, by rating decision dated in April 2000, the RO granted service connection for patellofemoral joint pain syndrome of the right knee, assigning a 10 percent disability rating effective January 16, 1997. While the RO initially denied service connection for a left knee disability, by rating decision dated in January 2007, the RO granted service connection for left knee chondromalacia patella, assigning a 10 percent disability rating effective July 24, 1997. The Veteran submitted the current claim for increased ratings for his knee disabilities in March 2013 and, as above, by rating decisions dated in March 2014 and May 2014, the RO continued the separate 10 percent disability ratings for each of the Veteran's knees. The Veteran disagreed with these decisions and perfected this appeal. Subsequently, by rating decision dated in June 2019, the RO increased the Veteran's disability rating for the right knee from 10 to 20 percent disabling effective April 26, 2019 but, by rating decision dated in July 2019, the RO found that the increase to 20 percent was in error and continued a 10 percent disability rating for the right knee. More recently, by rating decision dated in January 2021, the RO granted a separate 10 percent rating for right knee meniscal tear effective July 30, 2018. The Veteran's right knee disability is currently rated under 38 C.F.R. § 4.71a, DCs 5260-5010 and his left knee disability is current rated under 38 C.F.R. § 4.71a, DCs 5260-5262. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Pursuant to DC 5260, a noncompensable rating is warranted when there is limitation of flexion of a leg to 60 degrees. A 10 percent disability rating is warranted if flexion is limited to 45 degrees. A 20 percent disability rating is warranted if flexion is limited to 30 degrees. A 30 percent disability rating is warranted if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Also, pursuant to DC 5261, a noncompensable rating is warranted when there is limitation of extension of a leg to 5 degrees. A 10 percent disability rating is warranted if extension is limited to 10 degrees. A 20 percent disability rating is warranted if extension is limited to 15 degrees. A 30 percent disability rating is warranted if extension is limited to 20 degrees. A 40 percent disability rating is warranted if extension is limited to 30 degrees. A 50 percent disability rating is warranted if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Where a claimant has both limitation of flexion and limitation of extension of the same leg, he must be rated separately under DC's 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (September 17, 2004). Under certain circumstances, a separate disability evaluation may be assigned for arthritis of the knee under DC 5003 in addition to the rating for instability under DC 5257. VAOPGCPREC 9-98 and VAOPGCPREC 23-97. A number of other diagnostic codes also potentially apply to knee ratings. Under DC 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension or slight flexion between 0 degrees and 10 degrees. Under DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. Under DC 5258, dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint, is rated as 20 percent disabling. Under DC 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. Under DC 5262, a malunion of the tibia and fibula of either lower extremity warrants a 20 percent evaluation if there is a marked knee or ankle disability. Notably, beginning February 7, 2021 DC 5257 clarifies the meaning of slight, moderate, and severe instability and requires that the condition be diagnosed based on objective medical findings. Prior to February 7, 2021, DC 5010 pertained to traumatic arthritis which was rated as degenerative arthritis under DC 5003. Pursuant to DC 5003, degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a , DCs 5003, 5010. Beginning February 7, 2021, DC 5010 provides that post-traumatic arthritis is rated under limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Evidence relevant to the current level of severity of the Veteran's bilateral knee disabilities includes VA knee examinations dated in January 2014, May 2014, June 2019, and December 2019. During the January 2014 VA knee examination (which only pertains to the right knee), the examiner reviewed the claims file and noted a diagnosis of patellofemoral syndrome of the right knee. At that time, the Veteran reported that his right knee condition had gotten worse in that it had increased in intensity and frequency. He described constant pain and reported that his range of motion had decreased over time. He also heard crunching noises when he bent down and reported that the knee gives way on occasion. There was occasional swelling and, when this happens, it is hard to bend the knee. He used pain medication, anti-inflammatories, ice, and elevation for relief. The Veteran reported experiencing flare-ups of the knees. During the flare-ups, he refrains from routine activities (except activities of daily living) and chores. According to the Veteran, these flare-ups result in diminished flexion/extension by at least 80 to 90 percent of his normal range of motion. However, the examiner noted that the decrease in range of motion during flare-ups was merely speculative and was highly subjective as neither the VA examiner not any other medical provider was present to objectively and repetitively measure the change in range of motion during flare-ups. Also, the Veteran denied ever objective and repetitively measuring range of motion in his knee during flare-ups. Range of motion testing of the right knee revealed flexion to 130 degrees (with pain beginning at 90 degrees) and extension to zero degrees. The Veteran was able to perform repetitive use testing with three repetitions. Flexion remained to 130 degrees and extension remained to zero degrees after repetitive testing. The examiner noted that there was no additional limitation of motion of the right knee following repetitive use testing but there was functional loss and/or functional impairment of the left knee, specifically less movement than normal and pain on movement. The examiner also noted tenderness or pain to palpation of the joint line or soft tissues of the right knee. Range of motion testing of the left knee was not performed. Muscle strength as well as joint stability testing was normal. There was no evidence or history of recurrent patellar subluxation or dislocation. There was also no history of "shin splints" (medial tibial stress syndrome), stress fracture, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There were no meniscal conditions or surgical procedures for a meniscal condition. There was also no history of total knee joint replacement or any other knee surgery. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms, to include scars. The Veteran reported using an assistive device, specifically occasional use of a cane. The examiner noted that the Veteran's right knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were negative for both arthritis and patellar subluxation. The examiner found that the Veteran's right knee disability impacted his ability to work in that he had difficulty standing, walking, lifting, and carrying for an extended period of time. However, the examiner noted that the Veteran would most likely function well in predominantly sedentary work which involved sitting most of the time but may involve walking or standing for brief periods of time. During the May 2014 VA knee examination, the examiner reviewed the claims file, continued a diagnosis of right knee patellofemoral pain syndrome, and diagnosed left knee chondromalacia patella. At that time, the Veteran reported that his knees ache all the time, the right knee more than the left and worse with movement. He was told that he had "synovitis." Also, his job as a truck driver causes his knees to "pop and catch" and that city truck driving was worse. He can only walk about two times around the block before experiencing a severe burning sensation in his knees. He uses knee braces and a cane when over-compensating (putting more pressure on the left knee due to right knee pain). The Veteran reported experiencing flare-ups of the knees described as occurring with excess use of the knees such as prolonged standing or walking, especially walking upstairs, which will result in an increase in knee pain. However, the accurate determination of degrees on reduction of knee motion with pain flare-up was not possible without resort to mere speculation. Range of motion testing of the right knee revealed flexion to 130 degrees and extension to 0 degrees. Range of motion testing of the left knee revealed flexion to 125 degrees and extension to 0 degrees. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. There was also functional loss/impairment of the knees, described as less movement than normal and pain on movement. There was no tenderness or pain to palpation for joint line or soft tissue of either knee. Muscle strength and joint stability testing was normal. There was no evidence of history of recurrent patellar subluxation/dislocation. There was no indication that the Veteran had ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was also no indication that the Veteran had or had ever had a meniscus condition or had ever undergone surgery on his knees. There were no other pertinent findings, to include scars. The Veteran used an assistive device to aid with locomotion, specifically occasional use of braces and a cane. The examiner noted that the Veteran's bilateral knee disorders did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were performed and were negative for arthritis and/or patellar subluxation. The examiner found that the Veteran's bilateral knee disabilities impacted the Veteran's ability to work, specifically, he was unable to perform a job with excess walking or climbing up stairs. During the June 2019 VA knee examination (which only pertains to the right knee), the examiner continued a diagnosis of right knee patellofemoral pain syndrome. At that time, the Veteran reported experiencing increased right knee pain and underwent right knee arthroscopic surgery in February 2019 due to degenerative joint disease and meniscus tear. He experienced daily pain with swelling and had trouble walking upstairs. He used oral pain medication/topical pain creams and treated the knee with rest and elevation to help alleviate the pain. The Veteran denied flare-ups of the knees but did report experiencing functional loss/impairment, described as limiting stairs and walking more than 15 minutes. Range of motion testing of the right knee revealed flexion to 90 degrees and extension to 5 degrees. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, specifically patellofemoral joint tenderness to palpation related to inflammation. There was also evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. The Veteran's right knee was not examined immediately after repetitive use over time and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. Range of motion testing of the left knee was not performed. Additional factors contributing to disability included antalgic gait due to right knee pain. Muscle strength testing was normal and there was no muscle atrophy. There was also no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed and was negative for any instability. There was a history of bilateral "shin splints" (medial tibial stress syndrome) but no indication of recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was evidence of a meniscal condition, specifically meniscal tear, frequent episodes of joint pain, and frequent episodes of joint effusion, and it was noted that the Veteran underwent arthroscopic right knee surgery in February 2019 due to symptoms of meniscectomy. The Veteran did have scars due to this surgery but there was no objective evidence that the scars were painful, unstable, or had a total area equal to or greater than 39 square centimeters. The Veteran used an assistive device to assist with locomotion, specifically occasional use of a right knee brace. The examiner noted that the Veteran's right knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed right knee arthritis. The examiner found that the Veteran's right knee disability impacted his ability to perform occupational tasks, specifically, he experienced right knee pain with repetitive use of stairs and prolonged walking. With regard to Correia, the examiner noted that neither passive range of motion testing nor non-weight bearing testing could not be performed or was not medically appropriate. During the December 2019 VA knee examination, the examiner reviewed the claims file and continued diagnoses of right knee patellofemoral pain syndrome and left knee chondromalacia. At that time, the Veteran reported experiencing worsened right knee pain and underwent surgery on the right knee earlier in 2019 due to a torn meniscus. He still experienced shooting pain in his right knee if he steps the wrong way and reported that the range of motion in his right knee was not the same. His left knee was worse as well due to shifting his weight to accommodate the right knee. He treated these conditions with Tramadol and Tylenol. The Veteran denied experiencing flare-ups of the knee but did report functional loss/impairment off the knees, described as motion pain. Range of motion testing of the right knee revealed flexion to 110 degrees and extension to 0 degrees. There was evidence of pain with weight bearing but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and no objective evidence of crepitus. Range of motion testing of the left knee revealed flexion to 120 degrees and extension to 0 degrees. There was no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of motion. The Veteran's knees were not examined immediately after repetitive use over time and the examiner found that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength testing was normal and there was no muscle atrophy. There was also no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed and was negative for any instability. There was no evidence of recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was a history of a meniscal tear with arthroscopic repair in 2019. There were no other pertinent findings other than right knee scars which were neither painful, unstable, nor had a total area equal to or greater than 39 square centimeters. The Veteran did use an assistive device to aid with locomotion, specifically regular use of a right knee brace. The examiner noted that the Veteran's right knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed right knee arthritis. The examiner found that the Veteran's knee disabilities impacted his ability to perform occupational tasks, specifically moderate pain with prolonged walking and standing. With regard to Correia, the examiner noted that neither passive range of motion testing nor non-weight bearing testing could not be performed or was not medically appropriate. Notably, during the June 2019 Board hearing, the Veteran reported that he experiences constant pain in his knees and has trouble walking up and down stairs. Also, of record are VA treatment records dated through January 2021. These records show treatment for the Veteran's knees but are negative for any range of motion findings. First, with regard to the right knee, the Board finds that a disability rating greater than 10 percent is not warranted. Significantly, the Veteran had flexion to 130 degrees (90 degrees with pain) during the January 2014 VA examination, flexion to 130 degrees during the May 2014 VA examination, flexion to 90 degrees during the June 2019 VA examination, and flexion to 110 degrees during the December 2019 examination. Pursuant to DC 5260, a 20 percent evaluation is only warranted if flexion is limited to 30 degrees or less. As such, a disability rating greater than 10 percent is not warranted for the Veteran's loss of right knee flexion pursuant to DC 5260. Furthermore, a separate compensable rating is not warranted under DC 5261 as the Veteran had extension to 0 degrees during the January 2014, May 2014, as well as December 2019 VA examinations and had flexion to 5 degrees during the June 2019 VA examination. With regard to the left knee, the Board finds that a disability rating greater than 10 percent is also not warranted. Significantly, the Veteran had flexion to 125 degrees during the May 2014 VA examination and flexion to 120 degrees during the December 2019 examination. Pursuant to DC 5260, a 20 percent evaluation is only warranted if flexion is limited to 30 degrees or less. As such, a disability rating greater than 10 percent is not warranted for the Veteran's loss of left knee flexion pursuant to DC 5260. Furthermore, a separate compensable rating is not warranted under DC 5261 as the Veteran had extension to 0 degrees during the May 2014 and December 2019 VA examinations. With regard to the potential for a higher rating for either knee based on additional loss of motion due to flare-ups of the knee pursuant to Sharp, while the Veteran reported experiencing flare-ups during the January/May 2014 VA examinations, he specifically denied flare-ups during the June/December 2019 VA examinations. Furthermore, even if the Veteran currently experiences flare-ups, the guidance on how to evaluate flare-ups has not been particularly clear and, pursuant to Mitchell, flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated. The statements made in this case do not show that any flare-ups or repeated use over time additionally limited function in a quantifiable way, nor did they show that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. In particular, the June/December 2019 VA examiners attempted to elicit information from the Veteran in this regard, and the Veteran specifically denied experiencing flare-ups. The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for higher ratings. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned 10 percent ratings are warranted and no more. With regard to DC 5257, while the Veteran suggested possible instability of the right knee during the January 2014 VA examination when he reported that his right knee "gives way" on occasion the January/May 2014 and June/December 2019 VA examination reports are negative for a history of instability and testing was also negative for instability. Also, while pursuant to English v. Wilkie, 30 Vet. App. 347, 349 (2019), objective evidence of lateral instability is not required to assign a rating under DC 5257, the Board finds no other subjective complaints of instability in the claims file. As such, a separate rating is not warranted under DC 5257. Moreover, apart from the Veteran's already service connected right knee meniscal tear which is separately rated as 10 percent disabling, there is no evidence of ankylosis, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5258, 5262, and 5263 are not for application. As the preponderance of the evidence is against disability ratings in excess of 10 percent for either knee at any time during the appeal period, the claims are denied. 3. A disability rating greater than 10 percent for right ankle post traumatic arthritis is denied. The Veteran seeks a higher disability rating for his service-connected right ankle post traumatic arthritis. By way of history, the Veteran's service treatment records show that he sprained his right ankle in September 1984. He submitted an initial claim for service connection for a right ankle disability in January 1997 and, by rating decision dated in January 2007, the RO granted service connection for right ankle post traumatic arthritis, assigning a 10 percent disability rating effective July 24, 1997. This 10 percent rating was confirmed by rating decision dated in January 2013. The Veteran submitted the current claim for increased ratings for his right ankle disability in March 2013 and, as above, by rating decision dated in March 2014, the RO continued a 10 percent disability rating for the Veteran's right ankle disability. The Veteran disagreed with this decision and perfected this appeal. The Veteran's right ankle disability is currently rated under 38 C.F.R. § 4.71a, DC 5271 for ankle limitation of motion. Specifically, DC 5271 provides for a 10 percent rating where there is moderate limitation of ankle motion and a 20 percent rating where there is marked limitation of ankle motion. Notably, normal ankle dorsiflexion is from 0 to 20 degrees and normal plantar flexion is from 0 to 45 degrees. 38 C.F.R. § 4.71a. Plate II. Also relevant are DCs 5270, 5272, 5273, and 5274. DC 5270 pertains to ankylosis of the ankle and provides for a 20 percent rating where there is ankylosis of the ankle in plantar flexion, less than 30 degrees. A 30 percent rating is warranted where there is ankylosis of the ankle in plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between zero degrees and 10 degrees. A 40 percent rating is warranted where there is ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. DC 5272 pertains to ankylosis of the subastragalar or tarsal joint, and provides for a 10 percent rating where such is in good weight-bearing position and a 20 percent rating where such is in poor weight-bearing position. DC 5273 pertains to malunion of the os calcis or astragalus, and provides for a 10 percent rating where there is moderate deformity and a 20 percent rating where there is marked deformity. DC 5274 provides for a 20 percent rating for an astragalecotmy. Notably, beginning February 7, 2021 DC 5271 clarifies the meanings of marked and moderate. Specifically, a 10 percent rating where there is moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) limitation of ankle motion and a 20 percent rating where there is marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) limitation of ankle motion. Evidence relevant to the severity of the Veteran's right ankle disability during the appeal period includes VA examination reports dated in January 2014, May 2014, December 2019, and January 2020. During the January 2014 VA examination, the examiner reviewed the claims file and diagnosed post traumatic arthritis of the right ankle. At that time, the Veteran reported that his right ankle pain had increased in intensity and frequency. He described a constant dull/achy pain and felt that his range of motion had decreased over time. He also reported an occasional tingling sensation in the right ankle. He used pain medication and anti-inflammatories for relief and used ice and elevation as needed. The Veteran reported experiencing flare-ups of the right ankle. During the flare-ups, he refrains from routine activities (except activities of daily living) and chores. According to the Veteran, these flare-ups result in diminished flexion/extension by at least 80 to 90 percent of his normal range of motion. However, the examiner noted that the decrease in range of motion during flare-ups was merely speculative and was highly subjective as neither the VA examiner not any other medical provider was present to objectively and repetitively measure the change in range of motion during flare-ups. Also, the Veteran denied ever objective and repetitively measuring range of motion in his knee during flare-ups. On range of motion testing, the Veteran had right ankle plantar flexion to 40 degrees (pain beginning at 30 degrees) and dorsiflexion to 15 degrees (pain beginning at 10 degrees). The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions. The Veteran reported experiencing functional loss/impairment of the ankle, described as less movement than normal and pain on movement. Range of motion testing was not reported regarding the left ankle. There was localized tenderness or pain on palpation of the joints/soft tissue of the right ankle. Muscle strength and joint stability testing were normal and there was no ankylosis. There was no evidence of "shin splints," stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There was no history of joint replacement or other surgical procedures. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right ankle, to include scars. The Veteran did not use an assistive device as a normal mode of locomotion. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed degenerative arthritis of the right ankle. Significantly, the examiner found that the Veteran's right ankle disability impacted his ability to work as the Veteran had difficulty with standing, walking, lifting, or carrying for an extended period of time. During the May 2014 VA examination, the examiner reviewed the claims file and continued a diagnosis of right ankle arthritis. At that time, the Veteran reported that his right ankle swells with a lot of movement and the change of weather. He is only able to walk short distances and could not stand for a long period of time due to right ankle pain. The Veteran reported experiencing flare-ups of the right ankle. Flare-ups generally occur with excess use of the ankles such as prolonged standing and walking. This will result in an increase in ankle pain. However, an accurate determination of degrees of reduction of ankle motion with pain flare-up was not possible without resort to mere speculation. Unfortunately, range of motion testing was not performed for the right ankle. There was no localized tenderness or pain on palpation of the joints/soft tissue of the right ankle. Muscle strength and joint stability testing were normal and there was no ankylosis. There was no evidence of "shin splints," stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There was no history of joint replacement or other surgical procedures. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right ankle, to include scars. The Veteran used an assistive device as a normal mode of locomotion, specifically he occasionally used a brace. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were not performed. Significantly, the examiner found that the Veteran's right ankle disability impacted his ability to work as the Veteran was unable to perform at a job with prolonged walking due to ankle pain. During the December 2019 VA examination, the Veteran reviewed the claims file and continued a diagnosis of right ankle post traumatic arthritis. At that time, the Veteran reported that he continued to experience right ankle pain, particularly if he steps the wrong way. He also experienced pain with prolonged walking and standing. He treated his condition with Tramadol, Tylenol, lidocaine cream, and Capaicin. The Veteran denied experiencing flare-ups of the ankle but did report experiencing functional loss/impairment, specifically pain with motion. On range of motion testing, the Veteran had right ankle dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. There was no evidence of pain with weight bearing and no objective evidence of localized tenderness or pain on palpation of the joint associated with soft tissue. There was also no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions. The Veteran's right ankle was not examined immediately after repetitive use over time and/or during a flare-up but the examiner found that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Neither pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability with repeated use over a period of time. Muscle strength testing was normal and there was no muscle atrophy. There was no ankylosis and neither right ankle instability nor dislocation were suspected. There was no evidence of "shin splints," stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right ankle, to include scars. The Veteran did not use an assistive device as a normal mode of locomotion. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were not performed and there were no other significant diagnostic test findings. Significantly, the examiner found that the Veteran's right ankle disability impacted his ability to perform occupational tasks such as standing, walking, lifting, and sitting. Specifically, the Veteran had mild pain with prolonged walking and standing. With regard to Correia, the examiner noted that neither passive range of motion testing nor non-weight bearing testing could not be performed or was not medically appropriate. During the January 2020 VA examination, the Veteran reviewed the claims file and continued a diagnosis of right ankle arthritis. At that time, the Veteran reported that he continued to experience right ankle pain with walking and standing and described the pain as "aching and stiff" and of a severity of 4 on a scale from 1 to 10. The Veteran reported experiencing flare-ups of the right ankle with prolonged activity, such as mowing the grass, and prolonged walked. According to the Veteran, these flare-ups were of a severity of 6 or 7 on a scale from 1 to 10 and lasted 25 to 30 minutes. The Veteran also reported experiencing functional loss/impairment of the right ankle, described as pain with prolonged walking and activities such as mowing the grass. On range of motion testing, the Veteran had right ankle dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 20 degrees. There was no objective evidence of localized tenderness or pain on palpation of the joint associated with soft tissue, no evidence of pain with weight bearing, and no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions. The Veteran's right ankle was not examined immediately after repetitive use over time and/or during a flare-up and the examiner found that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during a flare-up. Neither pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability with repeated use over a period of time and/or during a flare-up. Notably, following further review of the Veteran's medical records, giving consideration to the subjective complaints and objective examination findings, and given the examiner's clinical knowledge and expertise, the examiner opined that there remained no rational basis to make a notation regarding any additional losses of function or motion during a flare-up. There were no additional factors contributing to disability. Muscle strength testing was normal and there was no reduction in muscle strength or muscle atrophy. There was no ankylosis. While right ankle instability/ dislocation were suspected, joint stability testing was normal. There was no evidence of "shin splints," stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy (astragalectomy). There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right ankle, to include scars. The Veteran did use an assistive device as a normal mode of locomotion, specifically occasional use of a brace on the right knee. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed arthritis but there were no other significant diagnostic test findings. Significantly, the examiner found that the Veteran's right ankle disability impacted his ability to perform occupational tasks such as standing, walking, lifting, and sitting. Specifically, it was noted that the Veteran was an unemployed truck driver and had lost a week or less of work in the last 12 months due to pain with prolonged walking and standing secondary to his right ankle disability. With regard to Correia, the examiner noted that there was objective evidence of pain on passive range of motion testing as well as objective evidence of pain when the joint is used in non-weight bearing. Notably, during the June 2019 Board hearing, the Veteran reported that his right ankle swells and gets stiff, depending upon how much activity that is on it. Also, of record are VA treatment records dated through January 2021. These records show treatment for the Veteran's right ankle but are negative for any range of motion findings. Based on the foregoing, the Board finds that a disability rating greater than 10 percent for the Veteran's right ankle disability is not warranted. Significantly, the Veteran's right ankle disability is productive of no more than moderate limitation of motion. As above, during the January 2014 VA ankle examination, the Veteran had dorsiflexion to 15 degrees (pain beginning at 10 degrees) and plantar flexion to 40 degrees (pain beginning at 30 degrees). During the December 2019 VA examination, the Veteran had full range of motion of the right ankle, dorsiflexion to 20 degrees and plantar flexion to 45 degrees. And, during the January 2020 VA examination, the Veteran had dorsiflexion to 20 degrees and plantar flexion to 20 degrees. Such findings demonstrate only moderate limitation of motion, even considering the Veteran's complaints of pain. Therefore, the overall disability picture presented by the Veteran's right ankle disability is that of moderate limitation of motion, which is appropriately rated as 10 percent disabling under DC 5271. The Veteran's disability picture does not present such severe limitation of motion to the ankle to be characterized as marked limitation. Thus, a 20 percent disability rating under DC 5271 is not warranted. Furthermore, there is no indication of either ankylosis, ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy such that DCs 5270, 5272, 5273, and 5274 are not for application. There are no other alternative diagnostic codes under 38 C.F.R. § 4.71a that could apply to the Veteran's right ankle disorder. With regard to the potential for a higher rating based on additional loss of motion due to flare-ups of the right ankle pursuant to Sharp, while the Veteran reported experiencing flare-ups during the January/May 2014 VA examinations as well as the January 2020 VA examination, he specifically denied flare-ups during the December 2019 VA examination. Furthermore, even if the Veteran currently experiences flare-ups, the guidance on how to evaluate flare-ups has not been particularly clear and, pursuant to Mitchell, flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated. The statements made in this case do not show that any flare-ups or repeated use over time additionally limited function in a quantifiable way, nor did they show that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. In particular, the January 2020 VA examiner found that there remained no rational basis to make a notation regarding any additional losses of function or motion during a flare-up. The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned 10 percent rating is warranted and no more. As the preponderance of the evidence is against a rating in excess of 10 percent for right ankle at any time during the appeal period, the claim is denied. 4. A compensable disability rating for septal deviation with vasomotor rhinitis is denied. The Veteran seeks a higher disability rating for his service-connected septal deviation with vasomotor rhinitis. By way of history, the Veteran's service treatment records show that the Veteran was treated for head congestion in 1983 and a post-service September 1997 VA examination shows a saddle nose deformity with slight deviation and deviated septum to the right with airway obstruction. At that time, the Veteran reported that he had been kicked in the nose in 1993. He submitted an initial claim for service connection for a sinus disorder in January 1997 and, by rating decision dated in January 2007, the RO granted service connection for acquired nasal deformity, nasal obstruction, septal deviation, and vasomotor rhinitis, assigning a noncompensable disability rating effective July 24, 1997. This noncompensable rating was continued by rating decision dated in December 2009. The Veteran submitted the current claim for increased ratings for his septal deviation with vasomotor rhinitis in March 2013 and, as above, by rating decision dated in March 2014, the RO continued a noncompensable disability rating for the Veteran's septal deviation with vasomotor rhinitis. The Veteran disagreed with this decision and perfected this appeal. The Veteran's septal deviation with vasomotor rhinitis is currently rated as noncompensably disabling under 38 C.F.R. § 4.97, DCs 6599-6502. Use of the "99" series and a hyphenated diagnostic code reflects that there is no specific diagnostic code applicable to the disability, and it must be rated by analogy. 38 C.F.R. § 4.20. DC 6502 provides that a 10 percent evaluation is assignable for traumatic deviation of the nasal septum with 50 percent obstruction of the nasal passage on both sides to complete obstruction on one side. Evidence relevant to the severity of the Veteran's septal deviation with vasomotor rhinitis during the appeal period includes VA examination reports dated in May 2014 and December 2019. During the May 2014 VA examination, the examiner reviewed the claims file and noted diagnoses of deviated nasal septum (traumatic) as well as vasomotor rhinitis. At that time, the Veteran reported experiencing constant and clear drainage of the sinuses. It was worse with change of air temperature. The Veteran denied using nose sprays and indicated that nothing would help. He did not recall any treatment with antibiotics but did note a previous surgery for his deviated nasal septum which helped him get more air on one side. With regard to the Veteran's rhinitis, the examiner noted that there was no obstruction of the nasal passage due to rhinitis greater than 50 percent. There was also no complete obstruction of either side due to rhinitis. There was no permanent hypertrophy of the nasal turbinates, nasal polyps, or granulomatous conditions. While the Veteran did have scars pertaining to his septal deviation, the scars were neither painful nor unstable and did not have a total area greater than 39 square centimeters. There were no other pertinent physical findings but it was noted that the Veteran had undergone septoplasty in March 2009. The examiner found that the Veteran's septal deviation with vasomotor rhinitis did not impact his ability to work. During the December 2019 VA examination, the examiner reviewed the claims file and noted diagnoses of allergic rhinitis as well as deviated nasal septum (traumatic). At that time, the Veteran reported that, prior to his septoplasty in 2009, he had difficulty breathing out of his left nostril and experienced snoring. Since his last VA examination, his left nostril is "so open" that he experienced "brain freeze" as well as nasal drip. He reportedly used Flonase and saltwater solution to treat his condition. The examiner noted that there was no obstruction of the nasal passage greater than 50 percent. There was also no complete obstruction of either side. There was no permanent hypertrophy of the nasal turbinates, nasal polyps, or granulomatous conditions. There were no other pertinent physical findings, to include scars, loss of part of those nose or other scars of the nose exposing both nasal passages, causing loss of part of one ala, or causing other obvious disfigurement. The examiner found that the Veteran's septal deviation with vasomotor rhinitis did not impact his ability to work. Notably, during the June 2019 Board hearing, the Veteran reported that he had trouble breathing at night and experienced snoring. Also of record are VA treatment records dated through January 2021. These records show treatment for the Veteran's septal deviation with vasomotor rhinitis but are negative for any pertinent findings with regard to the rating criteria noted above. Based on the foregoing, the Board finds that the criteria for a compensable disability rating for septal deviation with vasomotor rhinitis have not been met. As above, both the May 2014 and December 2019 VA examinations show that there was no obstruction of the nasal passage greater than 50 percent. As above, a compensable rating under DC 6502 requires a 50 percent obstruction of the nasal passage on both sides to complete obstruction on one side. The Board has also considered whether a separate or higher rating is warranted under any other code. 38 C.F.R. § 4.97, DC 6504 provides that scars of the nose or loss of part of the nose may be assigned a 10 percent rating if there is loss of part of one ala, or other obvious disfigurement; or a 30 percent rating if the scarring or loss of part of the nose results in exposure of both nasal passages. Here, while the Veteran was noted to have a scar on his nose secondary to septoplasty, there is no evidence of loss of part of the nose or any disfigurement. Therefore, there is no appropriate basis for rating the disability under DC 6504. In addition, the Board has found no other schedular basis for assigning a separate rating or a compensable rating. As the preponderance of the evidence is against a compensable disability rating for septal deviation with vasomotor rhinitis at any time during the appeal period, the claim is denied. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 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). 5. Service connection for hemorrhoids is granted. The Veteran contends that hemorrhoids are related to his military service as secondary to a service-connected disability. Specifically, during the June 2019 Board hearing, the Veteran testified as to his belief that he experienced hemorrhoids secondary to constipation from pain medications used to treat his service-connected disabilities. Notably, the Veteran is currently service-connected for various joint disabilities, to include lumbar spine, bilateral knee, and right ankle disabilities. Service treatment records are negative for any indication of hemorrhoids. In connection with this claim, the Veteran was afforded a VA anus/rectum examination in January 2020 at which time he was diagnosed with hemorrhoids. Significantly, the January 2020 VA examiner noted that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation. Upon review of the evidence, the Board finds that the evidence of record is in favor of secondary service connection for hemorrhoids. As an initial matter, the Board finds that the Veteran has a current diagnosis of hemorrhoids. Furthermore, there is medical evidence that such disability is related to medication used to treat the Veteran's service-connected disabilities. As above, the January 2020 VA examiner noted that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation. The Board finds the opinion highly probative on the inherently medical matter before it. The evidence is sufficient to grant the claim. 6. Service connection for hypertension is denied. The Veteran alleges that he experiences hypertension as a result of his military service. Specifically, during the June 2019 Board hearing, the Veteran testified as to his belief that he experienced hypertension secondary to pain caused by his service-connected disabilities. Hypertension is defined as high arterial blood pressure. Dorland's Illustrated Medical Dictionary 801 (28th ed. 1994). Various criteria for its threshold have been suggested, ranging from 140 systolic and 90 diastolic to as high as 200 systolic and 110 diastolic. Id. For purposes of rating the disease, VA defines the term as meaning "that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm." See 38 C.F.R. § 4.104, DC 7101, Note (1). Service treatment records are negative for hypertension. Significantly, the Veteran's May 1993 separation examination shows a blood pressure reading of 124/66 and in a May 1993 report of medical history, the Veteran specifically denied a history of "high or low blood pressure." In connection with this claim, the Veteran was afforded a VA hypertension examination in January 2020. At that time, the Veteran reported that he had previously been told that he had borderline high blood pressure but then he lost weight and this has no longer been an issue. Upon examination of the Veteran and review of the claims file, the examiner found that the Veteran did not meet the criteria for a diagnosis of hypertension, nor had he ever met the criteria for this diagnosis. The question for the Board is whether the Veteran has hypertension that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this case, the Board concludes that the Veteran does not have a current diagnosis of hypertension and has not had such a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). While the Veteran contends that he experiences hypertension, the medical evidence of record does not show a current diagnosis of hypertension. Furthermore, while the Veteran may have previously experienced borderline blood pressure, he is not competent to provide a diagnosis in this case, and such intermittent elevated blood pressure readings do not support a diagnosis of hypertension. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for hypertension. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Service connection for a left ankle disorder and nerve problems of the left leg, claimed as secondary to a service-connected lumbar spine disability, is denied. The Veteran alleges that he experiences a left ankle disorder and a nerve problem of the left leg as a result of his military service. Specifically, with regard to the left ankle, during the June 2019 Board hearing, the Veteran testified that he has experienced left ankle pain since his military service due to jumping out of planes and carrying heavy bags in service. The record also suggests that a left ankle disorder may be secondary to the Veteran's lumbar spine, bilateral knee, and/or right ankle disorders. With regard to the nerve problems of the left leg, during the June 2019 Board hearing, the Veteran testified to his belief that such is due to his service-connected lumbar spine disability. Notably, the Veteran is currently service connected for radiculopathy of the right lower extremity secondary to service-connected lumbar spine disability. With regard to the left ankle, a May 2014 VA ankle examination shows a diagnosis of right ankle arthritis and includes complaints of left ankle pain but is negative for a diagnosed left ankle disorder. However, this examination report does show some loss of motion in the left ankle and it appears that an X-ray of the left ankle was not performed. As such, the Veteran was afforded a second VA ankle examination in January 2020. Significantly, this examination is also negative for a diagnosed left ankle disorder and X-ray of the left ankle was normal. Furthermore, the examiner noted that while the Veteran's range of motion was only 40 out of 45 degrees on plantar flexion of the left ankle, this was a normal variation and the Veteran denied left ankle pain on examination. With regard to nerve problems of the left leg, the Veteran was afforded a VA lumbar spine examination in January 2020 and was diagnosed with lumbar strain with intervertebral disc syndrome and was found to have mild radiculopathy of the right lower extremity. Significantly, the January 2020 VA examiner found no evidence of radiculopathy of the left lower extremity. The treatment records support such finding. The question for the Board is whether the Veteran has a left ankle disorder and/or a nerve problem of the left leg that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this case, the Board concludes that the Veteran does not have a current diagnosis of either condition and has not had such a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton, 557 F.3d at 1366; Romanowsky, 26 Vet. App. at 294; McClain, 21 Vet. App. at 321; 38 C.F.R. § 3.303 (a), (d). While the Veteran believes he has a current diagnosis of a left ankle disorder and/or a nerve problem of the left leg, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1372, 1377, 1377 n.4. Consequently, the Board gives more probative weight to the competent medical evidence. furthermore, while the Veteran may have subjective complaints of left leg pain that he believes are due to his back disability, objective medical testing has confirmed no such nerve problem. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for a left ankle disorder and/or a nerve problem of the left leg. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Service connection for frequent urination, claimed as secondary to a service-connected lumbar spine disability, is denied. The Veteran alleges that he experiences frequent urination as a result of his military service. Specifically, during the June 2019 Board hearing, the Veteran testified that such is due to his service-connected lumbar spine disability. Service treatment records are negative for frequent urination. Significantly, the Veteran's May 1993 separation examination shows a normal genito-urinary system and in a May 1993 report of medical history, the Veteran specifically denied a history of "frequent or painful urination." In connection with this claim, the Veteran was afforded a VA urinary examination in December 2020. Significantly, this examination report shows a diagnosis of frequency of micturition. At that time, the Veteran reported that he could not remember when his urinary frequency began but that he had been told by doctors that this might be related to his lumbar spine disability. Notably, the examiner opined that it was less likely than not that the Veteran's frequency of micturition was either secondary to and/or aggravated by a service-connected disability. As rationale for this opinion, the examiner noted that there was no clear evidence that the Veteran has a urinary condition or only frequency due to his back condition in his available medical records. There are no links mentioned by the Veteran's providers in available medical records of urinary symptoms due to a back condition or at least complaints of urinary symptoms in available medical records. While there is medical literature suggesting that spinal conditions can cause urinary conditions such as urinary incontinence, the Veteran does not have either. Significantly, the Veteran does not have MRI (magnetic resonance imaging) findings of any severe spinal condition. The Veteran is 56 years old which is a major risk factor for developing urinary symptoms such as benign prostatic hyperplasia (BPH). Significantly, medical treatise evidence shows that BPH occurs in about half of men over age 51. To review, the Veteran has no documentation of a spinal condition causing urinary symptoms, does not have a spinal condition that typically causes urinary symptoms, and is the age of normally developing urinary symptoms. Initially, the claim is denied on a direct basis. First, there is no evidence of frequent urination in service. Furthermore, as above, during the June 2019 Board hearing, the Veteran related his frequent urination not to service directly but to a post-service lumbar spine disability. Finally, there is no probative medical evidence in the record that links frequent urination to an incident of the Veteran's active military service. The claim is also denied on a secondary basis. As above, the December 2020 VA examiner opined that the Veteran's frequent urination is not related to his service-connected lumbar spine disability, either on a secondary basis or an aggravation basis because the Veteran did not have a spinal condition such as spinal surgery, severe stenosis or spinal injury that would lead to or aggravate his frequent urination. Rather, the examiner opined that the Veteran's frequent urination is due to the Veteran's age. While the Veteran has alleged that frequent urination is related to his military service, the Board finds that the question regarding the potential relationship between the Veteran's claimed disorder and any instance of his military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). Furthermore, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation of frequent urination involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for frequent urination. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. The claims of entitlement to service connection for a cervical spine, right shoulder, left shoulder, and right hip disorders are remanded. The Veteran contends cervical spine, bilateral shoulder, and right hip disorders are related to his military service. Specifically, during the June 2019 Board hearing, the Veteran testified that he was a paratrooper during his military service and has experienced neck, shoulder, and right hip pain since his military service due to jumping out of planes and carrying heavy bags in service. The Veteran was afforded VA neck, shoulder, and hip examinations in May 2014. The May 2014 VA neck examination shows a diagnosis of cervical degenerative arthritis. The May 2014 VA shoulder examination shows diagnoses of impingement syndrome of the right shoulder status post SLAP repair with capsulitis status post tenotomy and lysis of adhesions and includes complaints of left shoulder pain but is negative for a diagnosed left shoulder disorder. The May 2014 VA hip examination shows a diagnosis of mild degenerative arthritis of both hips. Significantly, the examiner reviewed the claims file and opined that such disabilities were not secondary to the Veteran's in-service parachute jumping. Pursuant to the September 2019 Board remand, the Veteran was afforded additional VA neck, shoulder, and hip examinations in January 2020. Significantly, the examiners opined that it was less likely than not that the Veteran's claimed cervical spine, bilateral shoulder, and right hip disabilities are due to the Veteran's military service. As rationale for these opinions the examiner wrote that there was no documentation of these conditions or pain in service in the claims file. The Veteran's testimony that neck/shoulder/right hip pain is secondary to carrying heavy bags and jumping out of planes does not create a nexus because pain would have manifested during service and (other than left shoulder pain which was an acute strain) this was not reported in the claims file and many years have passed since the veteran's service and reporting neck pain. The examiner noted that arthritis occurs with aging and is not secondary to jumping out of planes and carrying heavy bags in service. Furthermore, the Veteran did not seek post-service treatment for the right shoulder until 1998. However, in a separate medical opinion, also dated in January 2020, regarding the Veteran's claim for service connection for a lumbar spine disability, also claimed as due to in-service jumping out of planes and carrying heavy bags, the examiner opined that it was at least as likely as not that the Veteran's claimed lumbar spine disability was due to his military service. As rationale for this opinion, the examiner noted that, to be certified as a Senior Parachutist, soldiers must participate in a minimum of 30 jumps, including at least 15 jumps with combat equipment. The 30 jumps must also include two night jumps, and one of these jumps must be as the jumpmaster of a group of jumpers. There is also a requirement for two mass tactical jumps. Graduation from the Army's Jumpmaster Course and 24 months of service with an airborne unit are also required for Senior Parachutist certification. Paratroopers can exit the plane at speeds up to 180 knots with a landing speed around 15 kilometers per hours. The Veteran earned a Senior Parachutist badge during his active service and complained of back pain in 1997, approximately four years after his discharge from service. Airborne operations entail high impact activity as well as carrying at least 70 pounds of gear. Although the Veteran did not complain of back pain while in service nor get evaluated for a back condition, it is conceivable that his current back pain had its origin while in service. The amount of weight the Veteran carried worth of combat equipment and/or parachute equipment along with the repetitive jumps more than likely causes back pain and it is within the realm of medical possibility that the Veteran's lumbar spine disability was caused by his active service. Initially, the Board is perplexed as to the disparity between the January 2020 VA lumbar spine examiners' medical opinion as compared to the medical opinions of the January 2020 VA cervical spine, shoulder, and hip examiners pertaining to the damage caused by the Veteran's in-service parachute jumping and carrying heavy bags. As such, an addendum medical opinion regarding the etiology of the Veteran's claimed cervical spine, bilateral shoulder, and right hip disorders that considers the extensive reasoning in favor of orthopedic problems in the January 2020 medical opinion pertaining to the etiology of the Veteran's lumbar spine disability. Furthermore, given the anatomical proximity between the newly service-connected lumbar spine disability and the claimed cervical spine/bilateral shoulder disabilities, a medical opinion regarding whether the claimed cervical spine/bilateral shoulder disabilities are secondary to the Veteran's service-connected lumbar spine disability is warranted. 2. The claims of entitlement to service connection for right upper extremity radiculopathy, left upper extremity radiculopathy, right wrist carpal tunnel, and left wrist carpal tunnel, claimed as secondary to a service-connected disability, are remanded. The Veteran contends that radiculopathy of the upper extremities and bilateral carpal tunnel are related to his military service. Specifically, during the June 2019 Board hearing, the Veteran testified that such are due to a cervical spine disability for which he was seeking service connection. As above, the January 2020 VA neck examination shows a diagnosis of bilateral upper extremity radiculopathy and VA treatment records show an assessment of carpal tunnel syndrome as early as May 2002. The Board is remanding the cervical spine issue for an addendum medical opinion. As such, the Board finds that these issues are inextricably intertwined with cervical spine issue. Harris v. Derwinski, 1 Vet. App. 180 (1991). 3. The claim of entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected disability, is remanded. The Veteran alleges that he experiences erectile dysfunction as a result of his military service. Specifically, during the June 2019 Board hearing, the Veteran testified that such is due to his service-connected lumbar spine disability. In connection with this claim, the Veteran was afforded a VA male reproductive examination in December 2020. This examination report shows a diagnosis of erectile dysfunction. At that time, the Veteran reported that the condition began in 1993, after starting psychiatric and pain medication. Notably, the examiner opined that it was less likely than not that the Veteran's erectile dysfunction was either secondary to and/or aggravated by a service-connected disability. As rationale for this opinion, the examiner noted that there was no mention in the Veteran's medical records by his medical providers that his erectile dysfunction was due to his back condition. Although there is medical literature suggesting spinal conditions can cause erectile dysfunction, it is not universally thought to cause erectile dysfunction unless there is a severe spinal injury or surgeries affecting the spinal cord, which the Veteran has no history of nor does the Veteran have MRI (magnetic resonance imaging) findings of any severe spinal condition. Erectile dysfunction is a common condition for men over 40 years old and the Veteran is well over 40. As suggested in the article below, 40 percent of men over the age of 40 have erectile dysfunction. Specifically, with regard to aggravation, the examiner noted that the Veteran does not have a spinal condition such as spinal surgery, severe stenosis or spinal injury that would lead to aggravation of erectile dysfunction. The Veteran is of the age of typical erectile dysfunction. Making a statement that the Veteran's erectile dysfunction was aggravated by his spinal condition would only be based on speculation. Unfortunately, the Board finds that the December 2020 VA opinion is inadequate. Initially, while the December 2020 medical opinion discusses the possible connection between the Veteran's erectile dysfunction and his service-connected lumbar spine disability, the opinion does not discuss whether the Veteran's erectile dysfunction may be related to medications used to treat the Veteran's service-connected joint disabilities. As above, during the December 2020 VA examination, the Veteran reported that his erectile dysfunction began in 1993, after starting psychiatric and pain medication. As such, VA must obtain an addendum medical opinion that provides an adequate discussion as to whether the Veteran's claimed erectile dysfunction can be related to medications used to treat his service-connected disabilities. 4. The claim of entitlement to service connection for GERD, to include as secondary to a service-connected disability, is remanded. The Veteran alleges that he experiences GERD as a result of his military service. As was noted in the September 2019 Board remand, the Veteran submitted an original claim for service connection for stomach problems in November 1997. In connection with this claim, he was afforded a VA general examination in June 1998 and was diagnosed with GERD. The Veteran was treated for stomach problems (usually assessed as gastroenteritis) on several occasions in service but was not treated for GERD until September 1997, several years after his discharge from service. A January 2016 VA treatment record shows diagnoses of bulbar duodenitis, gastritis, and GERD and suggests that these three disorders are related. The Veteran is currently service connected for chronic gastritis and, as above, is now service connected for hemorrhoids. Pursuant to the September 2019 Board remand, the Veteran was afforded a VA GERD examination in January 2020. Significantly, the examiner continued a diagnosis of GERD, noting an onset in 1998, and opined that it was less likely than not that the Veteran's GERD is related to the Veteran's military service on a direct, secondary, or aggravation basis. As rationale for the opinion on a direct basis, the examiner wrote that there was no documentation in the claims file of "heartburn" during service. As rationale for the opinion on a secondary basis, the examiner wrote that the Veteran's GERD, gastritis, and hemorrhoids are not medically related. As per medical literature, GERD is a separate entity entirely from the service-connected conditions and unrelated to them. Specifically, GERD involves reflux of the esophageal valve, gastritis is inflammation of the stomach, and hemorrhoids are small swollen veins in the anus and rectum. These conditions and the treatment of the conditions are unrelated. Finally, as rationale for the opinion on an aggravation basis, the examiner wrote that gastritis is a separate condition that affects the stomach lining, is unrelated, and does not cause or aggravate GERD which is reflux of the lower esophageal sphincter. Unfortunately, the Board finds that the January 2020 VA opinion is inadequate. As above, the January 2020 VA anus/rectum examiner noted that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation. This finding suggests that the Veteran's GERD may be secondary to medications used to treat his service-connected disabilities. As such, VA must obtain an addendum medical opinion that provides an adequate discussion as to whether the Veteran's claimed GERD can be related to medications used to treat his service-connected disabilities. 5. The claim of entitlement to service connection for sleep disturbances, to include as secondary to a service-connected disability, is remanded. The Veteran contends that he experiences sleep disturbances secondary to chronic pain experienced due to his service-connected disabilities. As was noted in the September 2019 Board remand, VA treatment records show complaints of sleep disturbances as early as November 2001. The Veteran was afforded a sleep study in May 2011 which was negative for sleep apnea. A July 2016 VA treatment record shows that the Veteran sleeps with a pillow between his knees, suggesting that the Veteran's service-connected bilateral knee disorders may aggravate his sleep. Pursuant to the September 2019 Board remand, the Veteran was afforded a VA respiratory examination in January 2020. Significantly, the examiner diagnosed obstructive sleep apnea based on a January 2020 sleep study and opined that it was less likely than not that the Veteran's sleep apnea is related to the Veteran's military service on a direct, secondary, or aggravation basis. As rationale for the opinion on a direct basis, the examiner wrote that as there was no record of sleep complaints during service, a nexus could not be established. As rationale for the opinion on a secondary basis, the examiner wrote that sleep apnea and right knee patellofemoral joint pain syndrome are not medically related as they are separate entities and medical literature does not support a medical relationship. Specifically, obstructive sleep apnea is a sleep disorder that is characterized by periodic narrowing and obstruction of the pharyngeal airway during sleep. Patellofemoral pain syndrome is characterized by insidious onset diffuse pain originating from the anterior knee, most commonly in young active athletes, especially runners. The etiology is likely multifactorial and may include patellar maltracking, hip strength deficits, dynamic knee valgus alignment, and altered foot mechanics. Knee pain does not cause upper airway collapse; therefore the two conditions are not related. As rationale for the opinion on an aggravation basis, the examiner wrote that the Veteran's service-connected disabilities of patellofemoral pain syndrome of the right knee, scar right knee, seborrheic dermatitis, left knee chondromalacia patella, septal deviation with vasomotor rhinitis, left ankle degenerative arthritis, tinnitus, and gastritis do not result in upper airway collapse and therefore do no contribute to sleep apnea or aggravate the condition. Unfortunately, the Board finds that the January 2020 VA opinion is inadequate. Significantly, while the examiner opined that the Veteran's service-connected disabilities, particularly septal deviation with vasomotor rhinitis, do not aggravate the Veteran's sleep apnea, the only rationale for this opinion is that the Veteran's service-connected disabilities do not "result in upper airway collapse." The word "result" does not appear to contemplate the word "aggravate" and, given the physical proximity of the Veteran's septal deviation with vasomotor rhinitis to the upper airway, the Board finds that additional medical opinion would be helpful to resolve this issue. As such, VA must obtain an addendum medical opinion that provides an adequate discussion as to whether the Veteran's claimed sleep disturbances can be related to a service-connected disability, particularly the Veteran's service-connected septal deviation with vasomotor rhinitis on an aggravation basis. Finally, with regard to all of the remanded issues, the Board notes that there are likely outstanding VA treatment records as the most recent VA medical records in the claims file are dated in January 2021. Therefore, all outstanding VA treatment records should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records dated since January 2021. 2. Request an addendum from the January 2020 VA cervical spine/shoulder/hip examiner regarding the etiology of these disabilities. Access to the electronic claims file should be made available to the examiner. If the January 2020 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to the following: a. whether it is at least as likely not (50 percent probability or greater) that a current cervical spine, bilateral shoulder, and/or right hip disorder is caused by or is otherwise related to the Veteran's active duty service. b. The examiner is also asked to opine as to whether a current cervical spine, bilateral shoulder, and/or right hip disorder (i) caused, or (ii) aggravated by his service-connected disabilities (particularly his service-connected lumbar spine disability). Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The opinions should address the extensive reasoning in the January 2020 VA lumbar spine opinion that the Veteran's in-service history as a Senior Parachutist "more than likely" caused the Veteran's current lumbar spine disability. See VBMS, document labeled C&P Exam, receipt date 1/14/2020, page 1. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 3. Request an addendum from the December 2020 VA male reproductive examiner regarding the etiology of the Veteran's claimed erectile dysfunction. Access to the electronic claims file should be made available to the examiner. If the December 2020 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's erectile dysfunction is (i) caused, or (ii) aggravated by his medications used to treat his service-connected disabilities. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The opinion should address the Veteran's history in the December 2020 VA examination report that his erectile dysfunction began in 1993, after starting psychiatric and pain medication. See VBMS, document labeled C&P Exam, receipt date 1/13/2021, page 3. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 4. Request an addendum from the January 2020 VA GERD examiner regarding the etiology of the Veteran's claimed GERD. Access to the electronic claims file should be made available to the examiner. If the January 2020 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's GERD is (i) caused, or (ii) aggravated by his medications used to treat his service-connected disabilities. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The opinion should address the January 2020 VA anus/rectum medical opinion wherein the examiner noted that the Veteran was prescribed Tramadol to treat his service-connected disabilities and that Tramadol can cause constipation. See VBMS, document labeled C&P Exam, receipt date 1/24/2020, page 2. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 5. Request an addendum from the January 2020 VA respiratory examiner regarding the etiology of the Veteran's claimed sleep disorder. Access to the electronic claims file should be made available to the examiner. If the January 2020 VA examiner is not available, the claims file should be provided to an appropriate examiner to render the requested opinions. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner is asked to opine as to whether the Veteran's sleep disorder is (i) caused, or (ii) aggravated by a service-connected disability (particularly the Veteran's service-connected septal deviation with vasomotor rhinitis). Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The Board recognizes that the January 2020 VA respiratory examiner did opine that the Veteran's service-connected disabilities, including septal deviation with vasomotor rhinitis, do not aggravate the Veteran's sleep apnea; however, the only rationale for this opinion is that the Veteran's service-connected disabilities do not "result in upper airway collapse." See VBMS, document labeled C&P Exam, receipt date 1/24/2020, page 3. The word "result" does not appear to contemplate the word "aggravate" and, given the physical proximity of the Veteran's septal deviation with vasomotor rhinitis to the upper airway, the Board finds that additional medical opinion would be helpful to resolve this issue The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.