Citation Nr: 21031795 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 13-04 129 DATE: May 24, 2021 ORDER Entitlement to a rating in excess of 10 percent for left knee osteoarthritis is denied. Entitlement to a rating in excess of 20 percent for a low back disability is denied. Entitlement to an initial rating in excess of 10 percent for left hip strain with superimposed arthritis (hereinafter referred to as a left hip disability) is denied. Effective May 20, 2009, an initial separate rating of 10 percent, but no higher, for a left hip disability on the basis of limitation of extension is granted. Effective March 6, 2009, a 30 percent rating for left achilles tendonitis is granted. REMANDED Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for bilateral hand swelling and numbness is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's left knee disability has been manifested by range of motion no worse than flexion limited to 65 degrees and extension other than normal, even after repetitive motion testing, with no evidence of recurrent or lateral instability. 2. Throughout the appeal period, the Veteran's low back disability has demonstrated at worst 50 degrees of forward flexion, even after repetitive motion testing, and no evidence of thoracolumbar ankylosis. 3. Throughout the appeal period, the Veteran's left hip disability has been manifested by range of motion no worse than flexion limited to 95 degrees and abduction to 15 degrees, even after repetitive motion testing, with no evidence of inability to cross either leg or limitation of rotation such that the Veteran cannot toe out more than 15 degrees. 4. Throughout the appeal period, the Veteran's left hip disability reflects limitation of extension to 5 degrees. 5. Throughout the appeal period, the Veteran's left achilles tendonitis more nearly approximates a severe foot injury with marked limitation of motion. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, 5263. 2. The criteria for a rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. The criteria for an initial rating in excess of 10 percent for a left hip disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253. 4. Effective May 20, 2009, the criteria for an initial separate rating of 10 percent for a left hip disability with limitation of extension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253. 5. Effective March 6, 2009, the criteria for a 30 percent rating for left achilles tendonitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.71a, Diagnostic Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from February 1974 to September 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a September 2016 video conference hearing. These matters were previously before the Board in October 2019 when they were remanded for additional development. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 1. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis. The Veteran's left knee osteoarthritis is rated 10 percent disabling under Diagnostic Codes 5010-5260 (for degenerative arthritis and limitation of flexion). (Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the rating assigned.) Under Diagnostic Code 5260, flexion limited to 45 degrees is assigned a 10 percent rating, flexion limited to 30 degrees is assigned a 20 percent rating, and flexion limited to 15 degrees is assigned a 30 percent rating. Normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. When extension is limited to 5 degrees, a 0 percent rating is assigned under Diagnostic Code 5261. A 10 percent rating will be assigned for limitation of extension to 10 degrees; a 20 percent rating will be assigned for limitation of extension to 15 degrees; a 30 percent rating will be assigned for limitation of extension to 20 degrees; a 40 percent rating will be assigned for limitation of extension to 30 degrees; and a 50 percent rating will be assigned for limitation of extension to 45 degrees. Effective February 7, 2021, the diagnostic codes pertaining to the knee and leg were amended. For purposes of this decision, the rating schedule for Diagnostic Codes 5260 and 5261 did not change, and the other potential amended diagnostic codes are not applicable in this case. See 85 Fed. Reg. 76,453 (Nov. 30, 2020) (as corrected at 85 Fed. Reg. 85,523 (Dec. 29, 2020), as corrected at 86 Fed. Reg. 8,142 (Feb. 4, 2021). As noted above in the Introduction, this matter was most recently remanded by the Board in October 2019, to include for a new VA examination. The Board finds that the only adequate VA examination during the pendency of this appeal is the January 2020 VA examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158, 166 (2016). Therefore, the Board will solely address the findings of the January 2020 VA examination. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding the Veteran's left knee disability warrants a rating in excess of 10 percent based on limitation of motion. For an increased rating based on limitation of motion, the evidence must minimally establish that the Veteran's left knee disability is manifested by flexion limited to 30 degrees (Diagnostic Code 5260), and/or by extension limited to 15 degrees (Diagnostic Code 5261). At no time during the appeal period has the Veteran's left knee extension shown to be other than normal, or left knee flexion shown to be less than 65 degrees (January 2020 VA examination), even with consideration of pain on range of motion testing, after repetitive range of motion testing, and with consideration of limitation of motion during flare-ups. See January 2020 VA examination. Hence, the criteria for an increased rating under either Diagnostic Code 5260 or 5261 are not met. In addition, the Veteran has never demonstrated or been diagnosed with ankylosis of the left knee, impairment of the tibia and fibula (other than the already service-connected post-operative left tibia and fibula fracture), recurrent subluxation or lateral instability (joint stability testing found to be normal on January 2020 examination despite use of assistive devices such as a knee brace), genu recurvatum, or shown to have dislocated semilunar cartilage. Therefore, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263 are not applicable. In sum, the evidence of record fails to reflect a basis for awarding an increased rating greater than 10 percent for the Veteran's left knee disability. Accordingly, the preponderance of the evidence is against the Veteran's claim for an increased rating in excess of 10 percent for his left knee disability. Thus, there is no reasonable doubt to resolve on the Veteran's behalf, and a rating greater than 10 percent for the Veteran's left knee disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Entitlement to a rating in excess of 20 percent for a low back disability. The Veteran's low back disability is rated 20 percent disabling under Diagnostic Code 5237 (for lumbosacral strain). Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 20 percent rating is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a, Plate V. There are several notes following the General Rating Formula criteria, which provide: (1) Associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. (5) Unfavorable ankylosis is a condition in which the entire cervical spine, or the entire spine, is fixed in flexion or extension. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a. The Board notes that there is no evidence of incapacitating episodes based on the low back disability, and intervertebral disc syndrome of the low back has not been found during the appeal period. The Board acknowledges the Veteran's testimony that he has had approximately six days of prescribed bed rest over the course of a year (consistent with, at worst, a 10 percent disability rating). The Board finds that such criteria is of no benefit to the Veteran's claim and will not be addressed further. Effective February 7, 2021, the diagnostic codes pertaining to the spine were amended. For purposes of this decision, the rating schedule for Diagnostic Code 5237 did not change. See 85 Fed. Reg. 76,453 (Nov. 30, 2020) (as corrected at 85 Fed. Reg. 85,523 (Dec. 29, 2020), as corrected at 86 Fed. Reg. 8,142 (Feb. 4, 2021). As noted above in the Introduction, this matter was most recently remanded by the Board in October 2019, to include for a new VA examination. The Board finds that the only adequate VA examination was conducted in January 2020. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158, 166 (2016). Therefore, the Board will solely address the findings of that examination. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding the Veteran's low back disability warrants a rating in excess of 20 percent. For a rating in excess of 20 percent, the evidence must establish the Veteran's low back disability is manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. At no time during the appeal period has the Veteran's lumbar spine flexion shown to be less than 50 degrees, even with consideration of pain on range of motion testing, after repetitive range of motion testing, and with consideration of limitation of motion during flare-ups. See January 2020 VA examination. In addition, there is no evidence of ankylosis of the thoracolumbar spine. With regard to whether a separate rating is warranted for any neurological manifestations of the Veteran's low back disability, the record fails to reflect any neurologic impairment of the Veteran's lower extremities, nor is there any evidence of bowel or urinary incontinence or any other spinal-related neurological impairments. See January 2020 VA examination. Accordingly, a separate evaluation for any such low back related neurological impairment is not warranted. In sum, the evidence of record fails to reflect a basis for awarding an increased rating greater than 20 percent for the orthopedic manifestations of the Veteran's low back disability, or for awarding a separate rating for any related neurological manifestations. Accordingly, the preponderance of the evidence is against the Veteran's claim for an increased rating in excess of 20 percent for his low back disability. Thus, there is no reasonable doubt to resolve on the Veteran's behalf, and a rating greater than 20 percent for the Veteran's low back disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 3. Entitlement to an initial rating in excess of 10 percent for a left hip disability. The Veteran's left hip disability is rated 10 percent disabling under Diagnostic Codes 5003-5252 (for degenerative arthritis and thigh limitation of flexion). (Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the rating assigned.) Ratings for hip disabilities based on limitation of motion may be assigned under 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5251, 5252 5253, 5254 and 5255. Under Diagnostic Code 5251, a 10 percent rating is warranted for limitation of extension to 5 degrees. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A 40 percent rating is warranted for flexion limited to 10 degrees. Under Diagnostic Code 5253, a 10 percent rating is warranted where a claimant cannot "toe-out" more than 15 degrees. A 10 percent rating is also warranted where a claimant cannot cross his or her legs. A 20 percent rating is warranted for limitation of abduction to 10 degrees or less. Normal hip range of motion is defined as 0 to 125 degrees hip flexion and 0 to 45 degrees hip abduction. 38 C.F.R. § 4.71, Plate II. Effective February 7, 2021, Diagnostic Code 5255 was amended. See 85 Fed. Reg. 76,453 (Nov. 30, 2020) (as corrected at 85 Fed. Reg. 85,523 (Dec. 29, 2020), as corrected at 86 Fed. Reg. 8,142 (Feb. 4, 2021). Under the revised rating criteria for Diagnostic Code 5255, impairment of the femur warrants a 60 percent for fracture of the shaft or anatomical neck with nonunion, without loose motion, weightbearing preserved with aid of brace; and the highest rating of 80 percent is warranted for fracture of shaft or anatomical neck with nonunion, with loose motion (spiral or oblique fracture). As noted above in the Introduction, this matter was most recently remanded by the Board in October 2019, to include for a new VA examination. The Board finds that the only adequate VA examination was conducted in January 2020. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158, 166 (2016). Therefore, the Board will solely address the findings of that examination. The Board notes that the evidence does not suggest any hip disabilities besides those outlined above are present in this case, to include a flail joint issue, impairment of the femur, ankylosis, or a prior fracture or malunion (other than the already service-connected post-operative left tibia and fibula fracture). Hence, Diagnostic Codes 5250, 5254, and 5255 will not be considered in this case. Regarding the multiple ratings for each hip based upon motion loss, separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59,990 (2004). The basis for the opinion is that the knee has separate planes of movement, each of which is potentially compensable. Id. The Board finds that such holding would apply to the various ranges of motion of the hip and thigh as well as delineated in the rating criteria. Cf. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013) (finding separate ratings not warranted for limitation of motion in different planes of the shoulder because not warranted under the applicable diagnostic codes, but that diagnostic codes addressing joints other than the shoulder assign different codes to limitation of motion in different planes, or to limitation of motion in different directions within a single plane). After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a finding the Veteran's left hip disability warrants an initial rating in excess of 10 percent based on limitation of motion for flexion and abduction. For a rating in excess of 10 percent under these criteria, the evidence must establish the Veteran's left hip disability is manifested by flexion of the hip 30 degrees or less (Diagnostic Code 5252), or abduction 10 degrees or less. At no point during the appeal period has the Veteran's left hip disability shown to have been manifested by abduction range of motion limited to less than 15 degrees or flexion less than 95 degrees, even with consideration of pain on range of motion testing, after repetitive range of motion testing, and with consideration of limitation of motion during flare-ups. See January 2020 VA examination. However, on January 6, 2020 VA examination, it was found that the Veteran's left hip disability was manifested by limitation of extension to 5 degrees due to pain during a flare-up. Such is consistent with an initial 10 percent rating under Diagnostic Code 5251. As this is the only adequate VA examination during the appeal period, the Board finds that the Veteran is entitled to a separate initial 10 percent rating, but no higher, for limitation of extension throughout the appeal period (i.e., May 20, 2009). In sum, the evidence of record fails to reflect a basis for awarding an initial increased rating based on limitation of motion for flexion and abduction greater than 10 percent. On the other hand, the evidence of record supports awarding a separate initial rating of 10 percent, but no higher, based on limitation of extension. 4. Entitlement to a rating in excess of 20 percent for left achilles tendonitis. The Veteran's left achilles tendonitis is rated 20 percent disabling under Diagnostic Code 5284. Under Diagnostic Code 5284, a 20 percent rating is warranted for a moderately severe foot injury, and a 30 percent rating is warranted for a severe foot injury. 38 C.F.R. § 4.71a. The words "moderate" and "severe" as used in the various diagnostic codes are not defined in the Rating 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. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Effective February 7, 2021, the diagnostic codes pertaining to the feet and ankle were amended. For purposes of this decision, the rating schedule for Diagnostic Code 5284 did not change. See 85 Fed. Reg. 76,453 (Nov. 30, 2020) (as corrected at 85 Fed. Reg. 85,523 (Dec. 29, 2020), as corrected at 86 Fed. Reg. 8,142 (Feb. 4, 2021). As noted above in the Introduction, this matter was most recently remanded by the Board in October 2019, to include for a new VA examination. The Board finds that the only adequate VA examinations were those conducted in January 2020, October 2020, and January 2021. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158, 166 (2016). Therefore, the Board will solely address the findings of those examinations. After a review of the evidence of record, the Board finds that the preponderance of the evidence supports an increased 30 percent disability rating for the Veteran's service-connected left achilles tendonitis throughout the appeal period. On October 2020 VA ankle conditions examination, the Veteran's left ankle dorsiflexion was limited to 5 degrees, and his plantar flexion was limited to 10 degrees. The examiner estimated that due to pain and lack of endurance during flare-ups and with repeated use over time, the Veteran's dorsiflexion and plantar flexion would be limited to 5 degrees. In combination with the Veteran's reports of pain with standing, walking and sitting, constant use of an ankle brace and a corrective shoe to ease his pain, and flare-ups lasting up to three to five days and occurring three to four times per month, the Board finds that the evidence is at least in equipoise to warrant a 30 percent rating for a severe foot injury. See also October 2020 VA ankle conditions examination. Resolving reasonable doubt in the Veteran's favor, he is entitled to a 30 percent rating for his left achilles tendonitis throughout the appeal period. The Board notes that Diagnostic Code 5284 does provide for a 40 percent rating for actual loss of use of the foot. However, the Board finds that the preponderance of the evidence is against a 40 percent rating for loss of use of the foot. In this regard, the Board notes that loss of use of the foot has not been found in any adequate VA examination during the appeal period. See January 2020 ankle conditions examination; October 2020 ankle conditions examination; January 2021 foot conditions examination. Hence, the preponderance of the evidence is against a finding the Veteran warrants a rating in excess of 30 percent under Diagnostic Code 5284. The Board has considered whether a higher rating could be assigned under an alternative diagnostic code. The evidence does not reflect the Veteran has ankylosis of the ankle, and thus Diagnostic Codes 5270 and 5272 are not applicable. As this decision awarded a 30 percent rating for his disability, Diagnostic Code 5271 for limitation of motion of the ankle is of no benefit to the Veteran as 20 percent is the maximum rating under the code. In addition, there is no evidence of malunion of the os calcis or astragalus or astragalectomy, and thus Diagnostic Codes 5273 and 5274 are also not applicable. Accordingly, the preponderance of the evidence supports an increased 30 percent rating, but no higher, throughout the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. REASONS FOR REMAND 5. Entitlement to service connection for diabetes mellitus is remanded. 6. Entitlement to service connection for hypertension is remanded. As noted above in the Introduction, these matters were previously before the Board in October 2019 when they were remanded for additional development. After a review of the evidence of record, the Board finds that these matters must be again remanded for additional development. The Veteran contends that he developed diabetes and hypertension as a result of inactivity, and subsequent obesity, due to his service-connected musculoskeletal disabilities. In addition, the Veteran had a significant in-service weight gain. Service treatment records in September 1980 confirm that the Veteran was placed in a weight control program that he was on very limited activity due to orthopedic surgery. Service treatment records also show significant weight gain during service as the Veteran weighed 180 in December 1973, prior to his service; 198 in May 1980; 209.5 in September 1980; and 207 in February 1983, after service. The Board remanded these matters in October 2019 to obtain a VA opinion addressing the Veteran's contention. In a January 2020 VA opinion, it was opined that there was no medical evidence in the record showing the Veteran's service-connected musculoskeletal disabilities caused or aggravated his hypertension or diabetes. However, the examiner did not adequately address whether the Veteran's service-connected musculoskeletal disabilities caused inactivity, and resulting obesity, and thereby caused the Veteran to develop diabetes and hypertension. See Atencio v. O'Rourke, 30 Vet. App. 74, 89 (2018) (a VA medical opinion must address the medical question at issue in enough detail that the Board can make a fully informed evaluation of the claim). Although obesity is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability. See VAOPGCPREC 1-2017; see also Garner v. Tran, 33 Vet. App. 241 (2021); Walsh v. Wilkie, 32 Vet. App. 300 (2020). In a secondary service connection claim, a theory of obesity as an intermediate step is raised when there is some evidence in the record which draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service-connected condition. Garner v. Tran, 33 Vet. App. 241 (2021). In this case, the Board finds that a theory of obesity as an intermediate step has been raised but has not been adequately addressed in a VA opinion. Accordingly, the Board finds that these matters must be remanded another VA opinion to determine the etiology of the Veteran's diabetes and hypertension. 7. Entitlement to service connection for bilateral hand swelling and numbness. This matter was previously before the Board in October 2019 when it was remanded for a VA examination and opinion to determine the onset, nature and etiology of the Veteran's bilateral hand disability. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was afforded a VA examination in January 2020. He was diagnosed with bilateral carpal tunnel syndrome (CTS), left elbow ulnar neuropathy and right hand degenerative arthritis. The examiner noted that carpal tunnel syndrome is caused by pressure on the median nerve and degenerative arthritis is a condition of aging and is an inflammation or loss of cartilage in the joints caused due to wear and tear. After reviewing the Veteran's service treatment records and the post-service evidence of record, it was opined that it was less likely than not that the bilateral hand carpal tunnel syndrome and right hand arthritis were incurred in or caused by the excision of the right hand nodule during service; no opinion was provided regarding the etiology of the Veteran's left elbow ulnar neuropathy. The Board finds the January 2020 examination and opinion to be inadequate. First, the Board notes that the examiner did not note the January 1988 operative report for excision of a ganglion cyst on the right index finger, the same hand where a ganglion cyst was excised during service in March 1976. In addition, while the examiner diagnosed only left elbow ulnar neuropathy, the evidence of record also shows a diagnosis of bilateral ulnar neuropathy during the appeal period, diagnoses which were not addressed by the examiner. See June 2014 VA treatment record (electromyography (EMG) found left upper extremity ulnar neuropathy and right CTS; June 2016 VA EMG consult (diagnosing bilateral ulnar neuropathy, right wrist and elbow new compared to 2014); see also February 2011 EMG summary report (finding bilateral median mononeuropathy, supporting a diagnosis of bilateral CTS, but no evidence of ulnar neuropathy in either upper extremity); cf. October 2011 VA treatment record (diagnosing bilateral median neuropathy (indicated as diabetic neuropathy)). Accordingly, the matter must be remanded for a new examination and opinion to determine the nature and etiology of the Veteran's bilateral hand disability. Outstanding VA treatment records should also be secured on remand. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature, onset and etiology of the Veteran's hypertension and diabetes. Specifically, the examiner is asked to opine whether it is at least as likely as not the Veteran's hypertension and diabetes are related, at least in part, to the Veteran's documented in-service weight gain. The examiner must also opine as to whether the Veteran's hypertension and diabetes were caused or aggravated by his service-connected musculoskeletal disabilities. The examiner must particularly consider whether obesity was an "intermediate step" between a service-connected musculoskeletal disability(ies), in causing or contributing to any degree to hypertension and diabetes. The examiner must also acknowledge and discuss the Veteran's competent statements as to his inability ons be active due to his service-connected musculoskeletal disabilities. 3. Schedule a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature, onset and etiology of any current bilateral hand disabilities. All indicated tests and studies should be conducted, and all findings reported in detail. The examiner is asked to address the following: (a) Provide a diagnosis for any right and left hand disability found. If bilateral ulnar neuropathy, median neuropathy, CTS and/or right hand degenerative arthritis are not found, the examiner is asked to resolve such finding with the evidence of record. (b) For any right and left hand disability diagnosed, please opine as to whether it is at least as likely as not that such disability had its onset or is otherwise related to the Veteran's active service, to include the documented March 1976 right hand excision of a ganglion cyst. (c) Is it at least as likely as not that any right and left hand disability is caused by his diabetes mellitus? (d) Is it at least as likely as not that any right and left hand disability is aggravated by his diabetes mellitus? A complete rationale should be given for all opinions and conclusions expressed. Please note that separate opinions addressing proximate cause and aggravation are needed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Marley, 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.