Citation Nr: 21031577 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 15-46 634 DATE: May 24, 2021 ORDER A compensable disability rating for tension headaches is denied. A disability rating in excess of 10 percent for cervical spine degenerative joint disease (cervical spine disability) for the period prior to August 7, 2020 is denied. A disability rating in excess of 20 percent for the cervical spine disability for the period from August 7, 2020 is denied. A disability rating in excess of 10 percent for right knee chondromalacia patella with meniscus tear, status-post arthroscopic surgery, (right knee disability) is denied. A compensable disability rating for bilateral pes planus for the period prior to August 7, 2020 is denied. A disability rating in excess of 10 percent for bilateral pes planus for the period from August 7, 2020 is denied. A compensable disability rating for service-connected chronic acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) and social anxiety disorder, (psychiatric disability) for the period prior to July 24, 2020 is denied. A disability rating in excess of 30 percent for the psychiatric disability for the period from July 24, 2020 is denied. REMANDED Entitlement to service connection for a right upper extremity disability is remanded. Entitlement to service connection for a left upper extremity disability is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's tension headaches have not been productive of characteristic prostrating attacks averaging one in two months over the last several months. 2. Prior to August 7, 2020, the Veteran's cervical spine disability was not productive of incapacitating episodes due to intervertebral disc syndrome (IVDS), ankylosis, forward flexion limited to 30 degrees or less, combined range of motion limited to 170 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or the functional equivalent thereof. 3. From August 7, 2020, the Veteran's cervical spine disability has not been productive of forward flexion limited to 15 degrees or less, ankylosis, incapacitating episodes as defined by VA regulation, or the functional equivalent thereof. 4. For the entire rating period on appeal, the Veteran's right knee disability has not been productive of ankylosis, recurrent subluxation or lateral instability, dislocation or removal of the semilunar cartilage, flexion limited to 30 degrees or less, extension limited to 10 degrees or more, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. 5. For the period prior to August 7, 2020, the Veteran's bilateral pes planus was not productive of moderate unilateral or bilateral acquired flat foot. 6. For the period from August 7, 2020, the Veteran's bilateral pes planus has not been productive of severe unilateral or bilateral acquired flat foot. 7. For the period prior to July 24, 2020, the severity, frequency, and duration of the Veteran's psychiatric symptoms did not more closely approximate occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 8. For the period from July 24, 2020, the severity, frequency, and duration of the Veteran's psychiatric symptoms have not more closely approximated occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an award of a compensable disability rating for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 44.1-4.14, 4.124a, Diagnostic Code 8100. 2. For the period prior to August 7, 2020, the criteria for an award of a disability rating in excess of 20 percent for cervical spine degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5242. 3. For the period from August 7, 2020, the criteria for an award of a disability rating in excess of 20 percent for cervical spine degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5242. 4. The criteria for a disability rating in excess of 10 percent for right knee chondromalacia patella with meniscus tear, status-post arthroscopic surgery, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5256-5263. 5. The criteria for an award of a compensable disability rating for bilateral pes planus for the period prior to August 7, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5276. 6. The criteria for an award of a disability rating in excess of 10 percent for bilateral pes planus for the period from August 7, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5276. 7. The criteria for an award of a compensable disability rating for service-connected psychiatric disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.126, 4.130, Diagnostic Code 9403-9411. 8. The criteria for an award of a disability rating in excess of 30 percent for service-connected psychiatric disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.126, 4.130, Diagnostic Code 9403-9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran's DD Form 214 reflects that he served on active duty in the United States Marine Corps from December 1998 to November 2012, with 7 years, 5 months, and 12 days of active service prior to that time. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In October 2019, the Board remanded the issues currently on appeal to the agency of original jurisdiction (AOJ) for additional development. The case has been returned to the Board for further appellate consideration. See August 2019 supplemental statement of the case. An August 2020 rating decision granted higher ratings of 30 percent for the psychiatric disability effective July 24, 2020, 20 percent for the cervical spine disability effective August 7, 2020, and 10 percent for bilateral pes planus effective August 7, 2020. Although higher disability ratings have been assigned for the acquired psychiatric disability, the cervical spine disability, and bilateral pes planus, as reflected in the August 2020 rating decision, the issues remain in appellate status as the maximum ratings have not been assigned for any period. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Veteran's claim for a higher rating for his psychiatric disability was decided by the AOJ, appealed by the Veteran, and remanded by the Board under the legacy system. A Veteran can opt into the Appeals Modernization Act (AMA), by filing a VA Form 10182, notice of disagreement with an initial decision under 38 C.F.R. § 3.2400(a)(1). In September 2020, the Veteran filed a VA Form 10182 in response to the August 2020 rating decision that increased his rating for his psychiatric disability to 30 percent effective August 7, 2020 to request an earlier effective date for the grant of service connection. However, as the August 2020 rating decision was a partial grant of the higher rating claim for the psychiatric disability, issued during the pendency of the Veteran's legacy appeal, it is not an initial decision under 38 C.F.R. § 3.2400(a)(1) for which the AMA would apply. Accordingly, the Veteran's September 2020 VA Form 10182 is not a valid AMA appeal of the issue of entitlement to a higher rating for the service-connected psychiatric disability. As such, the appeal of that issue will remain in the legacy system. Higher Ratings Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). With any form of arthritis, painful motion is an important factor of disability; the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. 1. A compensable disability rating for tension headaches is denied. The Veteran seeks to establish a compensable rating for his service-connected tension headaches. The service-connected tension headaches disability has been evaluated as analogous to migraine headaches pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Under that diagnostic code, a 0 percent disability rating is assigned for less frequent attacks than for a 10 percent rating. A 10 percent disability evaluation is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent disability rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The United States Court of Appeals for Veterans Claims (Court) held in Johnson v. Wilkie, 30 Vet. App. 245 (2018), that Diagnostic Code 8100 contains successive rating criteria, as each disability level builds on another in terms of duration and frequency and requires that a veteran rated at a higher level satisfy all of the requirements at the lower level. While the criteria for a 50 percent rating therefore contain a frequency requirement, they additionally require that a veteran have "completely" prostrating and "prolonged" attacks which are "productive of severe economic inadaptability." 38 C.F.R. § 4.124a, Diagnostic Code 8100. In determining whether the Veteran experiences the type and frequency of prostrating attacks of migraine headaches necessary for a higher rating under Diagnostic Code 8100, the Board observes that the rating criteria do not define "prostrating," nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quoted Diagnostic Code 8100 verbatim but did not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to Webster's New World Dictionary of American English, Third College Edition (1986), page 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in Dorland's Illustrated Medical Dictionary (28th Ed. 1994), page 1367, in which "prostration" is defined as "extreme exhaustion or powerlessness." The Veteran underwent a pre-discharge VA examination in connection with his claim in September 2012. The examiner diagnosed tension headaches, noting that the Veteran reported that he experienced headaches every couple of weeks that lasted three to four hours, which were relieved with Motrin. The Veteran further reported that headaches were not accompanied by photophobia, nausea, vomiting, or vision changes. The examiner indicated that the Veteran's treatment plan included taking Motrin for his headaches, and that the duration of typical headache pain was less than one day. The examiner assessed that the Veteran did not have characteristic prostrating attacks of migraine/non-migraine headache pain, and that he also did not have very prostrating and prolonged attacks of migraine/non-migraine pain. The examiner opined that the condition did not impact the Veteran's ability to work. The Veteran underwent another VA examination of his headaches in August 2020. The examiner diagnosed tension headaches, noting that the Veteran reported that he experienced headaches two times per week that lasted for hours, which were relieved with Tylenol. The examiner further reported that the headaches were accompanied by sensitivity to light. The examiner indicated that the Veteran's treatment plan included taking Tylenol for his headaches, and that the duration of typical headache pain was less than one day. The examiner further indicated that the Veteran did not have characteristic prostrating attacks of migraine/non-migraine headache pain, and that he also did not have very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability. The examiner opined that the condition did not impact the Veteran's ability to work. Following review of the record, the Board finds that the evidence does not support the assignment of a compensable disability rating for the Veteran's tension headaches. The evidence of record does not demonstrate that the Veteran's headaches are severe enough to warrant a compensable rating. The September 2012 and August 2020 VA examiners noted that the duration of typical headache pain was less than one day, and that the Veteran did not have any characteristic prostrating attacks of migraine/non-migraine headache pain. Importantly, there is no evidence of record that contradicts the findings of the VA examinations, or that could be relied upon to warrant a higher rating. In sum, the evidence does not establish that the Veteran's headaches caused characteristic prostrating attacks averaging one in two months over the last several months. As such, a compensable rating is not warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8100. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). However, as the preponderance of the evidence is against the assignment of a compensable rating, that doctrine does not apply. The appeal of this issue is denied. 2. A disability rating in excess of 10 percent for the cervical spine disability for the period prior to August 7, 2020 is denied. 3. A disability rating in excess of 20 percent for the cervical spine disability for the period from August 7, 2020 is denied. The Veteran seeks to establish higher ratings for the service-connected cervical spine disability. The current ratings for the Veteran's cervical spine degenerative joint disease have been assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Cervical spine disabilities are evaluated either upon application of the General Rating Formula for Diseases and Injuries of the Spine ("General Formula"), or as IVDS under the Formula for Rating IVDS Based on Incapacitating Episodes ("IVDS Formula"), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. The IVDS Formula provides for ratings when there is disc herniation with compression and/or irritation of the adjacent nerve root. Under the General Formula, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the cervical spine greater than 170 degree but not greater than 335 degrees; muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. The next higher rating of 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 30 percent rating is assignable for forward flexion of the cervical spine 15 degrees or less, or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Moreover, under the General Formula, any associated objective neurologic abnormalities are to be evaluated separately under an appropriate diagnostic code. Under the IVDS Formula, ratings are based on evidence of incapacitating episodes, defined as periods of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician. A 10 percent disability rating is assigned with incapacitating episodes having a total duration of at least 1 weeks but less than 2 weeks during the past 12 months; a 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent disability rating is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Additionally, the Board notes that there was a recent regulatory update to the VA rating criteria for evaluating musculoskeletal disorders, effective February 7, 2021. See 85 Fed. Reg. 230 (Nov 30, 2020). The Veteran's service-connected cervical spine disability is rated under Diagnostic Code 5242. Although the portion of the rating schedule that addresses the musculoskeletal system was revised from February 7, 2021 onwards, this diagnostic code was not changed. The Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the cervical spine disability for the period prior to August 7, 2020. Upon VA examination in September 2012, the examiner considered the Veteran's report of symptoms and reviewed the claims file. The VA examiner recorded cervical spine forward flexion to 45 degrees, extension to 45 degrees, right lateral flexion to 35 degrees, left lateral flexion to 30 degrees, right lateral rotation to 65 degrees, and left lateral rotation to 70 degrees, to include as due to pain and other orthopedic factors and after repetitive use testing. It was assessed that the Veteran did not have muscle spasm or guarding. There was no ankylosis, and the Veteran did not have IVDS. Based on the foregoing, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran's cervical spine disability for the period prior to August 7, 2020. His current 10 percent rating is based on limitation of motion of the cervical spine. Higher evaluations are available for incapacitating episodes, ankylosis, forward flexion limited to 30 degrees or less, combined range of motion limited to 170 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or the functional equivalent thereof. The evidence weighs against such manifestations. Forward flexion was not measured at less than 30 degrees and combined range of motion was not measured at less than 170 degrees at any point during the period prior to August 7, 2020. The September 2012 VA examination report shows that the Veteran's forward flexion was measured at 45 degrees, and combined range of motion of the cervical spine was measured at 290 degrees, to include as due to pain and other orthopedic Deluca factors and after repetitive use testing. Moreover, the record does no show medical findings of muscle spasm or guarding severe enough to cause to result in abnormal gait or abnormal spinal contour. There is also no indication of ankylosis at any point during the period prior to August 7, 2020. Importantly, there is no evidence of record that contradicts the findings of the VA examination, or that could be relied upon to warrant a higher rating. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to less movement than normal and pain on movement during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that flare-ups caused a decreased range of motion is not shown to have more nearly approximated forward flexion of 15 degrees but not greater than 30 degrees or combined range of motion of the cervical spine not greater than 170 degrees. The Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 20 percent for the cervical spine disability for the period from August 7, 2020. Upon VA examination in August 2020, the examiner considered the Veteran's report of symptoms and reviewed the claims file. The examiner recorded cervical spine forward flexion to 30 degrees, extension to 45 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 60 degrees, and left lateral rotation to 60 degrees, to include as due to pain and other orthopedic factors and after repetitive use testing. There was no additional limitation of motion due to pain, weakness, fatigability, or incoordination with flare-ups or with repetitive use over time. It was assessed that the Veteran did not have muscle spasm or guarding. There was no ankylosis, and the Veteran did not have IVDS. Based on the foregoing, the Board finds that a disability rating in excess of 20 percent is not warranted for the Veteran's cervical spine disability for the period from August 7, 2020. His 20 percent rating during this period is based on limitation of motion of the cervical spine. Higher evaluations are available for incapacitating episodes, ankylosis, forward flexion limited to 15 degrees or less, or the functional equivalent thereof. The evidence weighs against a finding of such manifestations. There is no indication of ankylosis, or incapacitating episodes as defined by VA regulation at any point during this period. Forward flexion was not measured at less than 20 degrees, and the Veteran is not otherwise shown to have exhibited the functional equivalent of the criteria for a higher rating during this period. Deluca, 8 Vet. App. at 204-07. Importantly, there is no evidence of record that contradicts the findings of the VA examination, or that could be relied upon to warrant a higher rating. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain and lack of endurance during flare-ups, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has discomfort, locking, and difficulty moving his head fast during flare-ups would not result in limitation of motion more nearly approximating forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. Consideration has also been given to assigning a rating under the IVDS Formula. However, at no point during the appeal period has the Veteran been shown to have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, IVDS Formula. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has had any neurological abnormality associated with his cervical spine disability during the appeal period. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claims for a rating in excess of 10 percent for the cervical spine disability prior to August 7, 2020, and in excess of 20 percent from August 7, 2020. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 55-56. However, as the preponderance of the evidence is against the claims, that doctrine does not apply. The appeal of these issues is denied. 4. A disability rating in excess of 10 percent for the right knee disability is denied. The Veteran seeks to establish a disability rating in excess of 10 percent for his service-connected right knee disability. As an initial matter, there have been changes to the musculoskeletal regulations effective February 7, 2021. The Board may continue the old rating criteria to rating periods prior to February 7, 2021 but may apply whichever set of criteria is more favorable to periods after February 7, 2021 if the claim was pending prior to that date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Veteran's right knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Prior to February 7, 2021, the rating criteria for the knee were as follows: Diagnostic Code 5256 provided that a 30 percent rating was warranted for ankylosis with favorable angle in full extension, or in slight flexion between 0 and 10 degrees. Under Diagnostic Code 5257, a 10 percent rating was warranted for slight recurrent subluxation or lateral instability. A 20 percent rating was warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating was warranted for severe recurrent subluxation or lateral instability Diagnostic Code 5258 provided that a 20 percent rating was warranted for cartilage, semilunar dislocated with frequent episodes of locking, pain, and effusion into the joint. Diagnostic Code 5259 provides that a 0 percent rating was warranted for symptomatic removal of the semilunar cartilage. Under Diagnostic Code 5260, a noncompensable rating was warranted for flexion limited to 60 degrees. A 10 percent rating was warranted for flexion limited to 45 degrees. A 20 percent rating was warranted for flexion limited to 30 degrees. A 30 percent rating was warranted for flexion limited to 15 degrees. Under Diagnostic Code 5261, a noncompensable rating was assigned when extension was limited to 5 degrees, a 10 percent rating when limited to 10 degrees, a 20 percent rating when limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Normal range of motion of the knee is to 0 degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5262 addressed tibia and fibula impairment and provided a 10 percent rating for malunion with slight knee disability, a 20 percent rating for malunion with moderate knee disability, a 30 percent rating for malunion with marked knee disability, a 40 percent rating for nonunion of, with loose motion, requirement a brace. Diagnostic Code 5263 provided a 10 percent rating for genu recurvatum (acquired traumatic with weakness and insecurity in weight bearing objectively demonstrated). Under the new rating criteria effective February 7, 2021, no changes were made to Diagnostic Code 5256, or Diagnostic Codes 5258-5261. On the other hand, significant changes were made to Diagnostic Code 5257 and Diagnostic Code 5262. Effective February 7, 2021, Diagnostic Code 5257 provides the following: For patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or walker. For recurrent subluxation or instability, a 10 percent rating is warranted for sprain, incomplete ligament tear or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device (e.g. cane(s), crutches(es), walker) or brace for ambulation. A 20 percent rating is warranted for one of the following: a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive devices (e.g. cane(s), crutch(es), walker) for ambulation. b) Unrepaired or failed repair of complete ligament tear causing persistent instability and medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), or a walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tera causing persistent instability and a medical provider prescribe both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Effective February 7, 2021, Diagnostic Code 5262 provides that for malunion, evaluate under Diagnostic Code 5256, 5257, 5260, or 5261 for the knee, whichever results in the highest evaluation. For medial tibial stress syndrome (MTSS) or shin splints, a noncompensable rating for treatment less than 12 consecutive months, one or both lower extremities. A 10 percent rating is warranted for treatment requiring no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent rating is warranted for treatment requiring no less than 12 consecutive months and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A 30 percent rating is warranted for treatment requiring no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. A 40 percent rating is warranted for nonunion of, with loose motion, requiring brace. The Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the right knee disability. The Veteran underwent a pre-discharge VA examination of the right knee in September 2012. The Veteran reported that he had pain with running and some swelling. Flexion of the right knee was to 130 degrees, and extension to zero degrees, to include as due to pain and other orthopedic factors and after repetitive use testing. The examiner assessed that the Veteran's condition led to less movement than normal. It was further noted that joint stability testing was normal, and that there was no evidence or history of recurrent patellar subluxation. The examiner indicated that the Veteran had a history of a meniscal tear with frequent episodes of joint pain and effusion but not locking. The Veteran underwent his most recent VA examination in August 2020. He reported that the right knee swelled from time to time, and that he was unable to run. Flexion of the right knee was to 130 degrees, and extension to zero degrees, to include as due to pain and other orthopedic factors and after repetitive use testing. The examiner assessed that pain, fatigue, and lack of endurance significantly limited functional ability with flare-ups and with repetitive use over time, and resulted in right knee flexion to 120 degrees, with no additional limitation of extension. It was further noted that joint stability testing was normal, and that there was no evidence or history of recurrent patellar subluxation. The examiner indicated that the Veteran had a history of a meniscal tear with resulting pain and swelling. Based on the foregoing, the Board finds that the preponderance of the evidence is against the assignment if a disability rating in excess of 10 percent for the right knee disability. The disability has not been productive of ankylosis, limitation of flexion to 45 degrees or less or limitation of extension to 15 degrees or more. The evidence reflects limitation of right knee flexion, but not to less than 120 degrees, and no limitation of extension, even when considering factors such as pain and other orthopedic factors, as well as flare-ups. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, less movement than normal, fatigue, and lack of endurance, to include during flare-ups and with repetitive use over time, etc. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has right knee pain and swelling and is unable to run would not result in limitation of motion more nearly approximating flexion limited to 30 degrees or less, or extension limited to 10 degrees or more. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). In this regard, the finds that higher or separate ratings under Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5257 (recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocation of the semilunar cartilage), Diagnostic Code 5259 (removal of the semilunar cartilage), Diagnostic Code 5262 (impairment of tibia and fibula) and Diagnostic Code 5263 (genu recurvatum) are not applicable, as the presence of ankylosis of the right knee, recurrent subluxation or lateral instability, dislocation or removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum have not been demonstrated. While the Veteran's history of a meniscal condition is shown to have resulted in frequent episodes of pain and effusion, it is not shown that the condition resulted in frequent episodes of locking. Therefore, a higher rating by analogy to Diagnostic Code 5258 is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the service-connected right knee disability. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 55-56. However, as the preponderance of the evidence is against the claim, that doctrine does not apply. The appeal of this issue is denied. 5. A compensable disability rating for bilateral pes planus for the period prior to August 7, 2020 is denied. 6. A disability rating in excess of 10 percent for bilateral pes planus for the period from August 7, 2020 is denied. The Veteran seeks to establish higher ratings for his service-connected bilateral pes planus. The Veteran is in receipt of a noncompensable rating for his bilateral pes planus for the period prior to August 7, 2020, and a 10 percent rating from August 7, 2020 under 38 C.F.R. § 4.71a, Diagnostic Code 5276, for acquired flatfoot. Under Diagnostic Code 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All of the evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes, that the definition for "mild" includes not very severe. See Webster's II New College Dictionary at 694 (1995). In addition, a synonym for "mild" is "slight" and definitions for "slight" include small in size, degree, or amount. Id. at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Definitions for "severe" include extremely intense. Id. at 1012. The Board finds that the preponderance of the evidence is against a compensable rating for bilateral pes planus for the period prior to August 7, 2020. Throughout this period, the Veteran's bilateral pes planus was not productive of moderate acquired flat foot. The Veteran underwent a pre-discharge VA examination of his bilateral pes planus in September 2012. He reported that during his retirement physical examination, he was told that he had flat feet, and indicated that he had no pain in the feet and that he had not been prescribed any orthotics. The examiner noted that the Veteran did not have pain on use or pain on manipulation of the feet. There was no swelling on use and the Veteran did not otherwise have characteristic calluses. The examiner indicated that the Veteran had decreased longitudinal arch height on weight-bearing in both feet, and the weight-bearing line fell over or medial to the great toe. There was no evidence of marked deformity or marked pronation of either foot. The Veteran did not have inward bowing of the Achilles tendon, or marked inward displacement or severe spasm of the Achilles tendon on manipulation. Based on the foregoing, the Board finds that, for the period prior to August 7, 2020, the bilateral pes planus was not productive of moderate unilateral or bilateral acquired flat foot. While the September 2012 VA examiner indicated that the weight-bearing line fell over or medial to the great toes, there was no inward bowing of the tendo achillis or pain on manipulation and use of the feet. This evidence is consistent with mild acquired flat feet, and not moderate acquired flat feet. The Board has considered whether a higher rating is warranted pursuant to 38 C.F.R. § 4.59, Burton, and Southall-Norman; however, the September 2012 VA examination report noted that the Veteran reported that he had no pain in the feet and that he had not been prescribed any orthotics for his condition. Importantly, there is no evidence of record that contradicts the findings of the VA examination, or that could be relied upon to warrant a higher rating. The Board also finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for bilateral pes planus for the period from August 7, 2020. The Veteran underwent a VA examination of his pes planus in August 2020. He reported occasional left foot pain when walking. The examiner noted that the Veteran had pain on use of the feet, which was accentuated on use of the left foot. The Veteran did not have pain on manipulation of the feet. There was no swelling on use and the Veteran did not otherwise have characteristic calluses. The examiner indicated that the Veteran had decreased longitudinal arch height on weight-bearing in both feet, and the weight-bearing line fell over or medial to the great toe. There was no evidence of marked deformity or marked pronation of either foot. The Veteran did not have inward bowing of the Achilles tendon, or marked inward displacement or severe spasm of the Achilles tendon on manipulation. There was no functional loss in the lower extremities as a result of his pes planus. The examiner noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups or when the feet were used repeatedly over a period of time. There was no pain during active motion or passive motion, or with weight-bearing. Based on the foregoing, the Board finds that, for the period from August 7, 2020, the service-connected bilateral pes planus has been manifested by symptoms and functional impairment consistent with a disability rating of no more than 10 percent. While the August 2020 VA examiner noted the Veteran had pain on use of the feet, which was accentuated on use of the left foot, there was no objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation, indication of swelling on use, or characteristic callosities. Stated differently, although the Veteran's pes planus meets a part of the criteria for a 20 percent rating (pain accentuated on use) under Diagnostic Code 5276, the rest of the results from the August 2020 VA examination more closely reflect the 10 percent rating. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements that he had occasional left foot pain when walking would not result in symptoms more nearly approximating severe unilateral or bilateral acquired flatfoot. Moreover, the August 2020 VA examiner assessed that there was no functional loss in the lower extremities as a result of the Veteran's pes planus, and that that pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups or when the feet were used repeatedly over a period of time. Importantly, there is no evidence of record that contradicts the findings of the VA examination, or that could be relied upon to warrant a higher rating. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. 259; see also Lyles, 29 Vet. App. 107. In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran's disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different diagnostic code. In conclusion, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for bilateral pes planus prior to August 7, 2020, or the assignment of disability rating in excess of 10 percent from August 7, 2020. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, at 55-56. However, as the preponderance of the evidence is against the claim, that doctrine does not apply. The appeal of these issues is denied. 7. A compensable rating for service-connected psychiatric disability for the period prior to July 24, 2020 is denied. 8. A disability rating in excess of 30 percent for service-connected psychiatric disability for the period from July 24, 2020 is denied. The Veteran seeks to establish higher ratings for his service-connected psychiatric disability. The Veteran is in receipt of a noncompensable rating for his psychiatric disability for the period prior to July 24, 2020, and a 30 percent rating from July 24, 2020 under 38 C.F.R. § 4.71a, Diagnostic Code 9403-9411. However, all psychiatric disabilities are evaluated under a general rating formula for mental disorders (general rating formula). Under the general rating formula, a noncompensable rating is warranted a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or where symptoms are controlled by continuous medication A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, or recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms is meant to be an example of symptoms that would warrant a particular rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. The rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Board finds that the preponderance of the evidence is against the assignment of a compensable disability rating for the Veteran's psychiatric disability for the period prior to July 24, 2020. The Veteran underwent a pre-discharge VA mental health examination in September 2012. He reported that he had been married to his second wife for 17 years, that things were perfect in his current relationship, and that his relationships with his 3 children were normal. The Veteran indicated that he had friends with whom he talked daily, and that he kept in touch with his family. The Veteran maintained that he played and coached soccer and that he fished when he could. In terms of psychiatric symptoms, the Veteran reported that he had anxiety around large groups or when attention was centered on him, but denied problems with mood, depression, memory, or concentration. The examiner diagnosed social phobia, an anxiety disorder, and assessed that the symptoms were not severe enough either to interfere with occupational nad social functioning or to require continuous medication. Following review of the record, the Board finds that the evidence does not support the assignment of a compensable disability rating for the Veteran's psychiatric disability for the period prior to July 24, 2020. The evidence demonstrates that the Veteran experienced anxiety as a symptom of his psychiatric disability during this period. However, the evidence of record does not establish that his anxiety was of such frequency, severity, or duration that it interfered with the Veteran's occupational or social functioning. The record also does not establish that the Veteran required continuous medication for his psychiatric disability for the period prior to July 24, 2020. See also September 2012 VA examination report (noting the examiner's assessment that the Veteran's psychiatric symptoms were not severe enough either to interfere with occupational nad social functioning or to require continuous medication). Importantly, there is no evidence of record that contradicts the findings of the VA examinations, or that could be relied upon to warrant a compensable rating for the period prior to July 24, 2020. The Board also finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 30 percent for the Veteran's psychiatric disability for the period from July 24, 2020. The Veteran underwent a VA mental health examination in July 2020. He reported that he lived with his wife and daughter and that he worked for the Marine Corps. The examiner assessed that the Veteran's psychiatric disability was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation due to symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. Following review of the record, the Board finds that the evidence does not support the assignment of a disability rating in excess of 30 percent for the Veteran's psychiatric disability for the period from July 24, 2020. A higher 50 percent would be warranted for occupational and social impairment with reduced reliability and productivity. The evidence weighs against such manifestations. While the July 2020 VA examiner noted that the Veteran had panic attacks more than once a week, impairment of short- and long-term memory, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting, the examiner assessed that the overall frequency, duration, and severity of the Veteran's symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, which is consistent with a 30 percent rating under the general rating formula. Although the Board is not bound by the VA examiner's assessment, the Board finds such assessment to be supported by the record and persuasive. Importantly, there is no evidence of record that contradicts the findings of the VA examination, or that could be relied upon to warrant a disability rating in excess of 30 percent for the period from July 24, 2020. In conclusion, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for the Veteran's psychiatric disability for the period prior to July 24, 2020, or the assignment of disability rating in excess of 30 percent from July 24, 2020. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, at 55-56. However, as the preponderance of the evidence is against the claims, that doctrine does not apply. The appeal of these issues is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right upper extremity disability is remanded. 2. Entitlement to service connection for a left upper extremity disability is remanded. The Veteran seeks to establish service connection for right and left upper extremity disabilities. The October 2019 Board remand requested that the AOJ schedule the Veteran for a VA examination of his upper extremities. Specifically, the Board requested the examiner identify any disabilities of the upper extremities that the Veteran has had at any time since his separation from service, to include any disabilities of an orthopedic or neurological nature (emphasis added). Upon remand, the Veteran was provided with a VA muscle injuries examination in August 2020 wherein the examiner concluded that there is insufficient evidence for a diagnosis of a left upper extremity disorder or a right extremity disorder, but that the Veteran may be having early signs of carpal tunnel syndrome and left thumb trigger finger. Moreover, an August 2020 VA neck examination concluded that the Veteran did not have any neurologic abnormalities of the upper extremities. However, the Veteran was not provided with an orthopedic examination of his upper extremities. Moreover, it is unclear if the August 2020 notation that the Veteran may be having early signs of carpal tunnel syndrome and left thumb trigger finger constitute diagnoses of these conditions or a recommendation for further neurological and orthopedic testing of the Veteran's upper extremities. Based on the foregoing, the Board finds that there has not been substantial compliance with the October 2019 Board remand directives, and that remand for further neurological and orthopedic testing of the Veteran's upper extremities is, therefore, warranted. See Stegall v. West, 11 Vet. App. 268, 271 (2011). The matters are REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran may have received during his lifetime, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development has been completed, arrange to have the Veteran scheduled for an examination of his upper extremities, to include orthopedic and neurological examination of the upper extremities. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should identify any disabilities of the upper extremities that the Veteran has had at any time since his separation from service, to include any disabilities of an orthopedic or neurological nature. Then, with respect to each such disability, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disability had its onset in, or is otherwise attributable to, the Veteran's periods of active service. If it is the examiner's opinion that it is unlikely that an identified disability of either upper extremity had its onset in, or is otherwise attributable to, service, the examiner should offer a further opinion as to whether it is at least as likely as not that such disability has been (a)caused or (b) aggravated (i.e., worsened beyond natural progression)by the Veteran's service-connected cervical spine disability. A complete medical rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues remaining on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Neely M. Peden Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Ragheb, 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.