Citation Nr: 21031859
Decision Date: 05/24/21	Archive Date: 05/24/21

DOCKET NO. 20-24 635
DATE: May 24, 2021

ORDER

Entitlement to service connection for PTSD with major depressive disorder is granted.

Entitlement to service connection for right hand joint pain is denied.

Entitlement to service connection for left hand joint pain is denied.

Entitlement to service connection for cellulitis of the digits of the right hand is denied.

Entitlement to service connection for cellulitis of the digits of the left hand is denied.

Entitlement to service connection for acute sinusitis is denied.

Entitlement to service connection for dermatitis is denied.

Entitlement to service connection for folliculitis is denied.

Entitlement to service connection for seborrhea capitis is denied.

Entitlement to service connection for warts is denied.

Entitlement to service connection for a headache disorder, as secondary to service connection cervical strain, is granted.

Entitlement to service connection for a right hip disorder is denied.

Entitlement to service connection for a left hip disorder is denied.

Entitlement to service connection for chronic fatigue is denied.

Entitlement to service connection for fibromyalgia is denied.

Entitlement to service connection for a left ankle disorder is denied.

Entitlement to service connection for a right shoulder rotator cuff tear, claimed as tendonitis of the rotator cuff and tendonitis supraspinatus, is granted.

Entitlement to service connection for a left shoulder functional impairment, claimed as tendonitis of the rotator cuff and tendonitis supraspinatus, is granted.

Entitlement to service connection for numbness is denied.

Entitlement to an initial rating in excess of 50 percent for obstructive sleep apnea is denied.

Entitlement to an initial compensable rating for allergic rhinitis is denied.

Entitlement to an initial, compensable rating for eczema is denied.

Entitlement to a rating in excess of 10 percent or gastroesophageal reflux disease (GERD) is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for obstructive sleep apnea is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for pes planus is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for lumbosacral strain is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for cervical strain is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for left knee meniscal tear with patellofemoral pain syndrome is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for GERD is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for allergic rhinitis is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for eczema is denied.

Entitlement to an effective date earlier than December 1, 2016, for the grant of service connection for tinnitus is denied.

Entitlement to an effective date earlier than August 24, 2016, for the award of service connection for left upper extremity peripheral neuropathy is denied.

Entitlement to an effective date earlier than August 24, 2016, for the award of service connection for left upper extremity peripheral neuropathy is denied.

REMANDED

Entitlement to service connection for atypical chest pain is remanded.

Entitlement to service connection for palpitations is remanded.

Entitlement to service connection for costochondritis is remanded.

Entitlement to an initial rating in excess of 10 percent for lumbosacral strain is remanded.

Entitlement to an initial rating in excess of 10 percent for cervical strain is remanded.

Entitlement to a rating in excess of 20 percent for right upper extremity peripheral neuropathy, claimed as hypoesthesia of both hands, is remanded.

Entitlement to a rating in excess of 20 percent for left upper extremity peripheral neuropathy, claimed as hypoesthesia of both hands, is remanded.

Entitlement to a rating in excess of 10 percent for left knee meniscal tear with patellofemoral syndrome is remanded.

Entitlement to a rating in excess of 30 percent for pes planus is remanded.

Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU) is remanded.

FINDINGS OF FACT

1. The Veteran has PTSD with major depressive disorder attributable to an in-service stressor involving a plane crash of a friend.

2. The Veteran does not have a right or left-hand joint disability.

3. The Veteran does not a residual disability of cellulitis of the right or left hand.

4. Acute sinusitis resolved prior to the pendency of the claim. The Veteran does not have sinusitis or residuals thereof, outside of the service-connected allergic rhinitis.

5. Dermatitis resolved prior to the pendency of the claim. The Veteran does not have dermatitis or residuals thereof, outside of the service-connected eczema.

6. The Veteran does not have folliculitis or residuals thereof, outside of the service-connected eczema.

7. The Veteran does not have seborrhea capitis or residuals thereof, outside of the service-connected eczema.

8. The documented in-service warts resolved prior to the pendency of the claim; no current warts or residuals thereof 

9. The Veteran's headaches are related to his service-connected cervical spine strain.

10. The Veteran does not have a right or left hip disability.

11. The Veteran does not have chronic fatigue syndrome; fatigue is not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness, including chronic fatigue syndrome.

12. The Veteran does not have fibromyalgia; his musculoskeletal pain is not a symptom of an undiagnosed or medically unexplained chronic multisymptom illness, including fibromyalgia.

13. The Veteran does not have a left ankle disability.

14. Right shoulder rotator cuff tear onset in service.

15. Left shoulder functional impairment onset in service.

16. The Veteran does not have a disability manifested by numbness or residuals thereof, outside of the service-connected neuropathy of the right and left upper extremities.

17. The Veteran's sleep apnea requires the use of a CPAP machine when sleeping, but there is no evidence of chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy.

18. The Veteran's allergic rhinitis is not manifested by polyps or greater than 50-percent obstruction in both nasal passages or total obstruction in one nasal passage.

19. The Veteran's eczema does not cover 10 at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, and is not shown to require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during any 12-month period during the appeal period.

20. The Veteran's GERD is not manifested by nausea, vomiting and digestive pain, or other symptoms productive of considerable impairment of health.

21. The Veteran filed claims for service connection for GERD, eczema, obstructive sleep apnea, flat feet, allergic rhinitis, cervical spine disability, lumbar spine disability, tinnitus, left knee disability, and numbness of the hands/fingers in August 2016, during active service and prior to his discharge therefrom.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for PTSD with major depressive disorder have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304(f) (2020).

2. The criteria for service connection for right hand joint pain are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

3. The criteria for service connection for left hand joint pain are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

4. The criteria for service connection for cellulitis of the digits of the right hand are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

5. The criteria for service connection for cellulitis of the digits of the left hand are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

6. The criteria for service connection for acute sinusitis are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

7. The criteria for service connection for dermatitis are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

8. The criteria for service connection for folliculitis are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

9. The criteria for service connection for seborrhea capitis are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

10. The criteria for service connection for warts are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

11. 2The criteria for entitlement to service connection for headaches, as secondary to service-connected cervical strain, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020).

12. The criteria for service connection for right hip disability are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

13. The criteria for service connection for left hip disability are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

14. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020).

15. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020).

16. The criteria for service connection for left ankle disability are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

17. The criteria for service connection for right shoulder rotator cuff tear have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

18. The criteria for service connection for left shoulder functional impairment have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

19. The criteria for service connection for numbness are not met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020).

20. The criteria for an initial rating in excess of 50 percent for sleep apnea have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.97, Diagnostic Code 6847 (2020).

21. The criteria for an initial, compensable rating for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.97, Diagnostic Code 6522 (2020).

22. The criteria for an initial, compensable rating for eczema have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2019). 

23. The criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2020).

24. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020). 

25. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for pes planus have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020). 

26. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for cervical strain have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020). 

27. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for lumbosacral strain have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

28. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for GERD have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020). 

29. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for left knee meniscal tear with patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

30. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for allergic rhinitis have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

31. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for eczema have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

32. The criteria for an effective date earlier than December 1, 2016, for the award of service connection for tinnitus have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020). 

33. The criteria for an effective date earlier than August 24, 2016, for the award of service connection for left upper extremity peripheral neuropathy not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

34. The criteria for an effective date earlier than August 24, 2016, for the award of service connection for right upper extremity peripheral neuropathy not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.159, 3.400 (2020).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1992 to September 1996 and from May 2000 to November 2016.

In a January 2021 remand, the Board noted that the Veteran had requested a personal hearing before a Decision Review Officer (DRO) and an informal conference, but one had not been held. In addition, the Board had not received response to a letter asking the Veteran to clarify whether he still wanted a hearing. Therefore, the claims were remanded to schedule the Veteran for a DRO hearing and informal conference. However, a December 2020 response letter associated with the file after the remand reflects that the Veteran did not want a hearing. In addition, after the file was returned to the Board, the Veteran's representative indicated that the Veteran wanted to waive any request for DRO hearing currently pending. Accordingly, the Board will proceed with appellate disposition in this matter.

The Board notes that in various filings the Veteran has indicated his intent to seek a higher rating for his service-connected right knee disability; however, that matter was not addressed in the 2017 rating decisions or statements of the case pertinent to the current appeal. Accordingly, this matter will not be addressed by the Board. The Veteran may work with the Regional Office if he desires to file a claim for increase for his right knee disability.

Service Connection

Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he or she files the a claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency.

With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). However, 38 C.F.R. § 3.303 (b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. With respect to the current appeal, this list includes arthritis, cardiovascular-renal disease, and organic disease of the nervous system. See 38 C.F.R. § 3.309(a).

Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, cardiovascular-renal disease, and organic disease of the nervous system, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable (10 percent) degree within one year of separation from service. See 38 C.F.R. § 3.307.

Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b).

Service connection can be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). 

A "qualifying chronic disability" includes an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2).

An "undiagnosed illness" is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). In the case of claims based on undiagnosed illness, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id.   

Manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to fatigue; signs or symptoms involving skin; headache; muscle pain; joint pain; neurological signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the respiratory system (upper or lower); sleep disturbances; gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. 38 C.F.R. § 3.317(b). 

For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(3), (4).

As a threshold issue, it is undisputed that the Veteran served in Southwest Asia. Accordingly, he is a "Persian Gulf" veteran within the meaning of § 3.317.

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

1. Acquired Psychiatric Disorder

The Veteran contends that he is entitled to service connection for an acquired psychiatric disordernamely, PTSDas a result of his in-service traumatic experiences.

In addition to the above-noted criteria for establishing service connection, there are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Those requirements are: (1) a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. 38 C.F.R. § 3.304(f).

Service treatment records do not document formal diagnosis of a psychiatric disorder, but do include several notations of complaints related to depression and anxiety. A 2008 post-deployment questionnaire reflects that the Veteran responded that emotional problems, such as feeling depressed or anxious, made it "somewhat difficult" to do his work, take care of things at home, or get along with others. In September 2009, the Veteran reported atypical chest pain, with the treatment provider indicating that the chest pain may have been associated with anxiety that resolved. In October 2013, the Veteran expressed that he experienced his heart racing at night with palpitations. He denied significant stressors or anxiety at that time.

The Veteran also submitted the obituary of a fellow pilot and friend killed in a plane crash in Jacksonville, Florida, in September 2005.

On VA examination in October 2017, the Veteran reported depressive symptoms stemming from the death of his friend in 2005. He also described symptoms of nightmares, irritability and anxiety.

With respect to in-service stressors, the Veteran reported that he was involved in a near crash while coming in for a landing, and also that his friend died in a plane crash involving a plane he had last used and conducted a flight check. He felt guilt and responsibility for the cause of the crash. He also expressed that it could have been him.

The examiner indicated that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5, but that a diagnosis of other specified trauma-and stressor-related disorder was appropriate. She opined that the other specified trauma disorder is at least as likely as not incurred in or caused by the recent discharge from service. His service treatment records indicated that he presented for medical care with complaints of racing heart that could be indicative of anxiety. He also presented with similar concerns to a VA physician in February 2017. 

On VA treatment in December 2017, the Veteran presented for treatment for difficulties with feeling hopeless, helpless, and worthless since service, with lack of energy and inability to concentrate. He was also extremely irritable and experienced panic attacks. After mental status examination, the Veteran was diagnosed with depression and anxiety disorder, rule out PTSD.

A June 2018 VA mental health report reflects assessment of major depressive disorder and PTSD. The Veteran indicated that he wanted help with treatment to get back to a more stable level of functioning.

A buddy statement from a friend and fellow pilot dated in February 2020 reflects that the Veteran had confided with him about the plane and his feelings of responsibility. He noted that the Veteran was still very nervous around planes and airports. The friend also described witnessing the Veteran's symptoms of irritability, isolation, and panic attacks.

In a February 2020 evaluation report from a private psychologist, the examining psychologist indicated that she reviewed the Veteran's claims file, noting pertinent records of treatment in and following service, as well as the VA psychiatric examination. She also conducted a clinical interview. The Veteran reported that his mental health issues began in 2010 after his buddy was killed during a functional check flight. The Veteran was the last person to fly the plane before his friend, and he had conducted an inspection following the flight.  He started experiencing guilt, nightmares, and depression following this incident. He described symptoms such as sleep disturbances, irritability, hypervigilance, detachment, avoidance, panic attacks, and depression.

Upon conclusion of the review and examination, the examiner indicated that the Veteran met the DSM-V criteria for a diagnosis of PTSD due to the plane crash that killed his friend, as well as secondary major depressive disorder as a result of chronic pain imposed by his service-connected condition and specifically his pain symptomatology. The examiner specifically listed out the criteria for diagnosis of PTSD, indicating that each had been met.

In sum, these medical records confirm the Veteran's diagnosis of PTSD in accordance with the DSM-5. The Board acknowledges that the VA examiner indicated that such a diagnosis was not appropriate; however, given that both the VA examiner and private physician reviewed the record, conducted clinical interview and mental status examination, and provided diagnosis in consideration of the DSM-5, the Board finds that the evidence is at least in equipoise as to whether a diagnosis of PTSD is warranted.

Moreover, the 2020 private examiner linked the Veteran's symptoms to his claimed in-service stressor. Accordingly, the Board finds that the first and third criterion for entitlement to service connection for PTSD have been meta diagnosis of PTSD in accordance with 38 C.F.R. § 4.125 and medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor.

As for the remaining criterion, credible supporting evidence that the claimed in-service stressor actually occurred, the Board notes that the Veteran has been credible and consistent in describing the incident, submitted an obituary in support of his contention regard the plane crash. Personnel records confirm his duty station at the time of the event and his duties as a Naval flight officer. Evaluations from that time frame reflect that he supervised plane captains in the launch, recovery, servicing, and inspection of aircraft and facilitated in aircraft transfer.

Accordingly, based upon the foregoing, the Board finds that there is credible supporting evidence that the claimed in-service stressor actually occurred. The 2020 private examiner specifically linked the Veteran's PTSD, in part, to this stressor. In addition, the examiner found the Veteran's major depressive disorder be secondary to his service-connected physical disorders, including his knees, back, and cervical spine, and there is no opinion to the contrary. As such, the benefit of the doubt will be conferred in the Veteran's favor, and his claim for service connection for PTSD with major depressive disorder is granted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2.-5. Cellulitis of the Digits of the Hands and Hand Joint Pain

Service treatment records document a few complaints related to the hands/fingers. A November 2006 report indicates complained of pain to the palmar aspect of the right hand to area of the second metacarpophalangeal joint region for 4 months. X-ray was normal. He was assessed with joint pain in the fingers. In March 2015, the Veteran was treated for cellulitis of the left index finger.

In his October 2016 statement, the Veteran reported joint pain in his right-hand fingers.

On VA examination in February 2017, the Veteran claimed service connection for unspecified, undiagnosed joint pain in the fingers with no known history of trauma or specific mechanism of injury. The Veteran also stated that he was treated for cellulitis years ago, but the symptoms resolved without residual and with appropriate treatment.

Objectively, range of motion of the hands/fingers was normal. Imaging studies revealed no abnormal findings.

The examiner concluded that there was no objective evidence of diagnosis of any chronic disability with regard to the claimed joint pain in the fingers or cellulitis of the digits of the hand. The cellulitis was acute and isolated and resolved without residuals during active military service.

A July 2017 hand and finger conditions disability benefits questionnaire reveals no diagnosis related to the hands or fingers.

The Veteran is service connected for neuropathy of the right and left upper extremity involving both hands; however, a separate disability has not been diagnosed.

The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for warts. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

The Board has considered the Veteran's report of joint pain. However, the Veteran has not alleged, and the evidence does not reflect, that his finger/hand condition is productive of functional impairment of earning capacity outside of his already service-connected neuropathy involving the hands. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018).

The Veteran has not provided any particular contentions in support of his claims for service connection of a bilateral hand/fingers of the hands condition other than to identify the record of treatment in service, which has been discussed above. 

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

6.-8. Folliculitis, Dermatitis and Seborrhea Capitis

The Veteran's service treatment records reflect treatment of folliculitis, dermatitis, and seborrhea capitis during active service. A January 2006 report notes diagnosis of seborrhea capitis. In August 2008, the Veteran was seen for treatment of long-standing follicular tender papules on his scalp. A June 2015 report notes assessment of dermatitis.

On VA examination in February 2017, the examiner noted that the Veteran was claiming service connection for folliculitis of the scalp, seborrhea capitis, and dermatitis of the scalp, along with eczema. He did not require any care of these disabilities at the time of examination.

The examiner noted that the Veteran's claimed folliculitis of the scalp, seborrhea capitis, dermatitis of the scalp, and eczema of the scalp are all the claimed disabilities using different terms, and were all essentially the same disability diagnosed using different terms at different times during the Veteran's service.

The examiner diagnosed eczema.

In sum, while the Veteran's service treatment records reflect assessment of folliculitis, dermatitis, and seborrhea capitis, there is no post-service, current diagnosis of these disorders. The VA examiner indication that these claimed disorders are essentially encompassed in the diagnosed eczema, for which the Veteran is service-connected.

The Board again emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for these skin disorders. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

In making this determination, the Board acknowledges the June 2015 assessment of dermatitis in considering whether current disability existed at the time the claim was filed or during its pendency. However, as there are no further assessments of dermatitis and the examiner indicated that the condition was essentially encompassed as eczema with no dermatitis residuals, the Board finds that this condition had resolved.

The Veteran has not provided any particular contentions in support of his claims for service connection other than to identify the records of treatment in service, which has been discussed above.

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

9. Warts

The Veteran's service treatment records reflect assessment and treatment of warts in 2007. 

On VA examination in February 2017, the examiner noted that the Veteran claimed direct service connection for verruca vulgaris (claimed as warts) as a chronic disability diagnosed during active service. The Veteran stated that he had been treated for warts years ago, but had no recurrence.

After examination, the examiner did not diagnose warts or residuals thereof. The examiner opined that the Veteran's verruca vulgaris was acute and isolated and resolved without residual during active service with appropriate medical care. There was no current evidence of claimed disability.

Again, Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for warts. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

The Veteran has not provided any particular contentions in support of his claim for service connection other than to identify the record of treatment in service, which has been discussed above.

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

10. Sinusitis

The Veteran's service treatment records from his first period of active service reflect assessment of sinusitis, with report in May 1994 indicating that the Veteran's acute sinusitis had resolved. Treatment records from the Veteran's second period of active service also reflect various complaints related to viral syndrome and upper respiratory infection. 

On VA examination in February 2017, the examiner noted that the Veteran claimed service connection for allergic rhinitis and chronic acute sinusitis. After physical examination and testing, the examiner diagnosed allergic rhinitis. The examiner indicated that the claimed acute sinusitis was acute and transitory and resolved during active military service without residual. He indicated that the condition no longer existed. The examiner diagnosed allergic rhinitis, for which the Veteran has been granted service connection.

The Board again emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for warts. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

The Veteran has not provided any particular contentions in support of his claim for service connection other than to identify the record of treatment in service, which has been discussed above. Further, the Veteran identified a date of treatment of June 9, 1999, when he was not on active duty.

Regardless, in the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

11. Headaches

The Veteran's service treatment records reflect several occasions of complaints of headaches, generally in association with other symptoms such as fever and diagnoses such as upper respiratory infection. In addition, The Veteran was assessed with headache syndrome in November 2014, with impression that the Veteran had headaches secondary to temporomandibular joint disorder (TMJ).

On VA examination in February 2017, the examiner indicated that the Veteran did not have a headache condition. There was no objective evidence of a diagnosis of chronic disability with regard to headaches. The Veteran's headaches as described in service treatment records were considered at that time to be more consistent with TMJ. Diagnosis was not established.

A January 2019 VA treatment report reflects the Veteran's complaint of throbbing headaches, which he had had a history of since service.

A February 2020 report from Dr. S. reflects the Veteran's report that he developed headaches in January 2008. Initially, the headaches were located in the right temporal region of his skull. The impression was that he had developed TMJ. However, since that time, he had not developed symptoms of TMJ such as jaw pain or clicking, but the headaches continued. The Veteran indicated that he got relief of his headaches by performing stretching exercise of his cervical spine. Citing to literature from the International Headache Society on cervicogenic headaches and based upon evaluation of the Veteran, Dr. S. concluded that it is at least as likely as not that the Veteran's headaches are caused by his service-connected cervical strain.

In sum, the record reflects that the Veteran has been diagnosed with a headaches, as indicate by the February 2020 private physician. In addition, that physician determined that it is at least as likely as not that the Veteran's headaches were secondary to his service-connected cervical spine. There is no opinion to the contrary.

Accordingly, and resolving all reasonable doubt in favor of the Veteran, the Board concludes that the Veteran's headaches are caused by his service-connected cervical strain. Service connection for headaches is therefore warranted. 38 C.F.R. § 3.310.

12. & 13. Right and Left Hip

A July 2015 service treatment report reflects complaint of right hip pain after playing with his daughter. Pain was located to the anterior right hip which he rated as a 0 on a scale to 10, and at worse a level of 3. His pain increased with crossing his legs or with end range rotation movements. He also had some pain following running activities. After physical exam and testing, the treatment provider noted right anterior hip pain with possible labral involvement. He showed deficits in hip girdle strength and lower extremity flexibility. Physical therapy was recommended.

On VA examination in February 2017, the examiner indicated that the Veteran was seeking service connection for an undiagnosed/unspecified right and left hip pain disorder with no known trauma or specific mechanism of injury. He related an abrupt onset of right hip pain after playing with his daughter. He required no care of the claimed disability.

Range of motion testing revealed normal range of motion, full muscle strength, and no other pertinent physical findings. Imaging studies revealed no degenerative or traumatic arthritis.

The examiner indicated that the Veteran did not have a current diagnosis associated with the claimed bilateral hip disorder.

Again, Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for right and left hip disabilities. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

The Board has considered the Veteran's report of joint pain. However, the Veteran has not alleged, and the evidence does not reflect, that his hip condition is productive of functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Rather, no functional impairment was identified on examination in 2017, and the Veteran reported on examination that he receives no treatment for the claimed disability.

The Veteran has not provided any particular contentions in support of his claims for service connection of a bilateral hip disability other than to identify the record of treatment in service, which has been discussed above. 

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claims, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

14. Chronic Fatigue

The Veteran's service treatment records include notation of fatigue in the active problems list. Fatigue was also noted in conjunction with other symptoms, such as headache, and diagnoses such as viral syndrome. In October 2013 the Veteran was seen with complaint of fatigue.

On VA examination in February 2017, the Veteran reported that he had daytime hypersomnolence because of obstructive sleep apnea. He stated that he had never been diagnosed with or evaluated for chronic fatigue syndrome. After examination, the examiner indicated that the Veteran did not have, nor had ever been diagnosed with chronic fatigue syndrome.

An October 2017 VA Gulf War examination, the examiner indicated that the Veteran did not have additional signs or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multisymptom illness.

The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v, 3 Vet. App. 223, 225 (1992). As there is no disability, the Board does not reach the issue of whether the claimed disability is related to service.

The Board has considered the Veteran's lay statements regarding his symptomatology. As a lay person, the Veteran is competent to report on that which he has personal knowledge, including symptoms such as fatigue, and the Board deems him credible in that regard. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Indeed, in this case, the medical evidence reveals that the Veteran's fatigue has been related to other disabilities. In particular, the Veteran has been diagnosed with and is service-connected for obstructive sleep apnea.

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert 1 Vet. App. at 49.

15. Fibromyalgia

The Veteran's service treatment records include complaints related to headaches, fatigue, and joint pain, but do not document specific diagnosis of fibromyalgia in service.

On VA examination in October 2017, the Veteran reported that he experienced fatigue around 2008 while in the Navy. He thought he was diagnosed with fibromyalgia but was unsure. He was not currently receiving treatment for fibromyalgia.

The examiner noted that findings pertinent to fibromyalgia included widespread musculoskeletal pain, fatigue, and headache. He did not have tender points for the pain present. After testing and review of the record, the examiner concluded that the Veteran does not have fibromyalgia, and that his symptoms were otherwise attributable to known conditions.

The record otherwise does not indicate diagnosis or treatment of fibromyalgia.

The Board again point out that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v, 3 Vet. App. 223, 225 (1992). As there is no disability, the Board does not reach the issue of whether the claimed disability is related to service.

The Board has considered the Veteran's lay statements regarding his symptomatology. As a lay person, the Veteran is competent to report on that which he has personal knowledge, including symptoms such as fatigue, headaches, and joint and the Board deems him credible in that regard. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Indeed, in this case, the medical evidence reveals that the Veteran's that these conditions have been related to other disabilities and that a diagnosis of fibromyalgia is not warranted. 

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49.

16. Left Ankle

A February 1993 report from the Veteran's first period of active service reflects inversion injury to the left ankle. He was assessed with mild left ankle sprain with no evidence of fracture or dislocation. He was also assessed with left ankle sprain in March 1996. Treatment records dated in 2016 reflect assessment of right ankle pain, but not the left.

On VA examination in February 2017, the Veteran indicated that he was seeking service connection for an acute left ankle sprain that occurred in 2015. The Veteran denied history of surgery or other invasive procedures. He did not require any care for the claimed disability. Objectively, the left ankle was normal with normal range of motion and muscle strength. The examiner indicated that there was no objective evidence of diagnosis of chronic disability with regard to either ankle in the service treatment records. The sprained ankle noted in the Veteran's service treatment records resolved without residual.

VA treatment records reflect complaint of pain stemming from the Veteran's pes planus through his left ankle, where he underwent injection. X-ray revealed rectus ankle with no evidence of fracture.

The Board again emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110; see also McClain, 21 Vet. App. at 321. Accordingly, the Board finds that there is no current disability to support entitlement to service connection for a left ankle disability. See Brammer, 3 Vet. App. at 225; McClain, 21 Vet. App. at 321; Romanowsky, 26 Vet. App. 289. Discussion of the remaining criteria for service connection is therefore unnecessary.

The Veteran has not provided any particular contentions in support of his claim for service connection other than to identify the record of treatment in service, which has been discussed above. 

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366  (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49.

17. & 18. Right and Left Shoulder

The Veteran's service treatment records include various notations and complaints related to the shoulders. A December 2012 report indicates assessment of left shoulder rotator cuff tendinopathy/tendonitis supraspinatus. Treatment included subacromial injection and physical therapy. In January 2013, a continued report of left shoulder pain and left rotator cuff tendonitis was noted. He complained of crepitus and pain with crossover and internal rotation. MRI findings were normal. A May 2016 report reflects report of recurrent right shoulder pain for several years, primarily after activities that involved strenuous upper extremity use such as tennis and throwing a ball. He was assessed with right infraspinatus strain, possible partial tear of the rotator cuff. An October 2016 report notes assessment of bursitis and partial thickness rotator cuff tear, as noted on MRI, and clinical examination consistent with subacromial impingement. 

Following service, on VA examination in February 2017, the examiner noted abnormal range of motion of the right shoulder and normal range of motion of the left shoulder. However, after additional testing, the examiner indicated that there was no diagnosis related to the claimed tendonitis of the rotator cuff or supraspinatus.

A June 2017 VA treatment report reflects complaint of right shoulder impingement. It was noted that the right shoulder pain began with throwing and progressed over time.

On VA examination in February 2018, the examiner diagnosed right shoulder rotator cuff tear. The examiner opined that this condition was seen in service treatment records and had continued.

An April 2019 independent medical evaluation from Dr. S. includes notation of right and left shoulder complaints in service, as discussed above. The examiner also performed physical examination of both shoulders, who showed reduced range of motion for the right and left shoulders. The examiner conclude that it is at least as likely as not that the Veteran's right and left shoulder injuries developed during his time in service.

An August 2020 report from private physician Dr. L. also reflects reduced range of motion of both shoulders, which the examiner indicated was abnormal and contributed to a functional loss. The Veteran also reported flare-ups.

An August 2020 report from private physician Dr. M. reflects review of the record, with Dr. M. noting pertinent findings with respect to the shoulders in service as well as post-service findings, including the February 2017 VA examination report. After this review and Dr. M., conducted a clinical interview in which the Veteran reportedly provided additional details regarding his injuries that he did not discuss with the VA examiner. Dr. M. noted pertinent medical literature and discussed medical principles related to impingement syndrome and the anatomy of the shoulder.

Upon conclusion of this review and clinical interview, Dr. M. opined that it is at least as likely as not that the Veteran's current bilateral shoulder conditions are the direct result of the cumulative injuries incurred while on active duty.

With respect to the right shoulder, the record reflects diagnosis of right shoulder rotator cuff tear, as noted on VA examination in 2018. As to in-service incurrence, the Veteran's service treatment records document various complaints related to the right shoulder, with assessment of rotator cuff tear in service on 2016 MRI.

As to nexus to service, private physician Dr. M. opined that the Veteran's right shoulder disability was at least as likely as not related to service. The 2018 VA examiner also indicated that the Veteran's current right shoulder disability onset and was a continuation of the disability present in service. Given that the February 2017 VA examiner found no evidence of current disability and therefore did not provide a nexus opinion, there is no opinion to the contrary. 

With respect to the left shoulder, the Board notes that there is question as to whether the Veteran has current left shoulder disability. No disability was found on VA examination in 2017, and the 2018 VA examination only discussed the right shoulder. However, the 2019 and 2020 private evaluations indicated abnormal range of motion, with private physician Dr. L. indicated that functional impairment was present. Therefore, there Board finds that, as the Veteran's left shoulder pain/loss of motion is productive of functional impairment, a current left shoulder disability has been demonstrated. See Saunders, 886 F.3d at 1356.

There is also evidence of in-service incurrence, with demonstrated complaint and treatment for the left shoulder therein. Finally, Dr. M. also opined that, upon review of the record and clinical evaluation, the Veteran's left shoulder disability was at least as likely as not related to service.

Accordingly, as all three service connection elements have been met, service connection for right shoulder rotator cuff tear and left shoulder functional impairment is warranted. 38 C.F.R. § 3.303(a). 

19. Numbness

The Veteran also filed a claim for service connection for numbness. In a statement in support of claim, the Veteran reported that he was specifically claiming numbness of all fingertips in the right and left hand. He reported that the numbness developed in June or July of 2014 and he was seen a few months later for this condition. He indicated that he still experienced numbness of the fingertips.

During service in January 2015, the Veteran reported numbness in the fingertips and toes. He denied any trauma or wrist pain, elbow pain, or medication. Laboratory testing was normal. It was noted that the Veteran should follow-up if symptoms persisted as many times the symptoms improved with weather.

A March 2015 service treatment record reflects that the Veteran complained of tingling in the hands and feet. The Veteran further described that he had noticed numbness in fingers and had a history of numbness in the fingers for several years. He also had slight tingling in the hands and feet. An assessment of numbness was indicated, with the treatment provider indicating that further laboratory studies were needed.

Following service, on VA peripheral nerves examination in July 2017, the examiner diagnosed right and left-hand neuropathy related to the Veteran's complaints of hypoesthesia of the hands. The Veteran is serviced-connected for right and left upper extremity peripheral neuropathy (claimed as hypoesthesia).

In sum, there is no other indication of current disability manifested by numbness other than that for which service connection is already in effect. The Veteran has not provided any other statement or evidence in support of this claim.

In the absence of a current disability, service connection cannot be established. See Holton, 557 F.3d at 1366 (holding that entitlement to service connection requires, among other things, evidence of a current disability); see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (upholding VA's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49 (1990).

Increased Rating

Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3.

The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).

The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).

20. Sleep Apnea

The Veteran's sleep apnea is evaluated under the rating criteria for sleep apnea syndromes, which includes obstructive, central, and mixed sleep apneas. 

A 100 percent rating is assigned when there is chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; a tracheostomy is required. The current 50 percent rating is warranted for sleep apnea that requires the use of a breathing assistance device such as continuous airway pressure (CPAP) machine. 38 C.F.R. § 4.97, Code 6847.

The Veteran's service treatment records include an October 2016 sleep study noting symptoms of snoring, lack of restful sleep, witnessed apneas, and significant daytime tiredness. An assessment of sleep apnea with recommended treatment of a nasal CPAP was indicated.

On VA examination in February 2017, the examiner noted that the Veteran used a CPAP. There were otherwise no pertinent physical findings, complications, conditions, signs or symptoms.

VA treatment records reflect continued use of a CPAP machine, but no indication of other pertinent findings.

Based on the aforementioned clinical evidence of record, the Board finds that the evidence fails to demonstrate that the Veteran has chronic respiratory failure with carbon dioxide retention or cor pulmonale. Accordingly, there is no basis upon which to assign a rating in excess of 50 percent for sleep apnea at any time during the appeal period. 

Accordingly, the Board concluded that an initial rating in excess of 50 percent for sleep apnea must be denied.

21. Allergic Rhinitis

The Veteran's allergic rhinitis is rated as noncompensably disabling pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6522. Under this code, rhinitis without polyps, but with greater than 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side warrants a 10 percent rating. Rhinitis with polyps warrants a 30 percent rating.

On VA examination in February 2017, the examiner indicated that the Veteran's rhinitis was not productive of greater than 50 percent obstruction of the nasal passage on both sides, complete obstruction on the right or left side, hypertrophy of the nasal turbinates, or nasal polyps. No granulomatous conditions were noted. 

Nasal obstruction, hypertrophy, or polyps are not otherwise identified in the evidence of record.

Based on the aforementioned clinical evidence of record, the Board finds that because the evidence demonstrates that he does not have polyps and or/a greater than 50 percent obstruction of his nasal passage on both sides or complete obstruction on one side. There is no basis upon which to assign the minimum 10 percent rating for his allergic rhinitis at any time during the appeal period. 

The Board has considered the applicability of other diagnostic codes; however, the Veteran's allergic rhinitis is not shown to involve any other factor that would warrant evaluation under any other provision of the rating schedule. 

Accordingly, the Board concluded that an initial, compensable rating for allergic rhinitis must be denied.

22. Eczema

The Veteran's eczema is rated as 10 percent disabling pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806. 

Effective August 13, 2018, VA amended the regulation pertaining to ratings of the skin, specifically Diagnostic Code 7806 for dermatitis or eczema. Prior to August 13, 2018, Diagnostic Code 7806 provided that a 10 percent rating is warranted for a skin disability covering at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is given for skin disabilities affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during a 12-month period. A 60 percent rating is warranted for skin disabilities affecting more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the prior 12-month period. 38 C.F.R. § 4.118 (2020).

Beginning August 13, 2018, 38 C.F.R. § 4.118 lays out the General Rating Formula for the Skin, which includes Diagnostic Code 7806. The General Rating Formula for the Skin has the same criteria for characteristic lesions involving certain percentages of the body and exposed areas but further defines the term systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs. 38 C.F.R. § 4.118.

The Federal Circuit Court has held that systemic therapy means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied, and that nothing in Diagnostic Code 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects "only the area to which it is applied" to count as a systemic therapy under the Code. However, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case and does not automatically mean systemic therapy because Diagnostic Code 7806 distinguishes between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017).

The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects.

The Board must thus consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes "systemic therapy such as corticosteroids or other immunosuppressive drugs" under the pre-August 13, 2018 version of Diagnostic Code 7806: a) Whether the topical treatment operates by affecting the body as a whole in treating a veteran's skin condition; and b) Whether the given treatment is "like" a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic.

The Veteran's service treatment records reflect that the Veteran was treated for skin condition of the scalp on various occasions in service; however, there is no indication of treatment within one of year of his discharge from service.

On VA examination in February 2017, the Veteran reported that his eczema condition required no treatment at the time of examination. The disability was not productive of scarring or systemic manifestation. He had not been treated with oral or topical medication in the last 12 months. The examiner indicated that the disability did not affect any exposed or other body areas.

Continued VA treatment records do not indicate complaint or treatment of eczema or related skin disorder.

In sum, the evidence does not indicate skin disability covering at least 5 percent of exposed or total body area, or any treatment for the disorder.

Accordingly, based on the relevant medical evidence of record, the Board finds that the criteria for a compensable rating for eczema have not been met. See 38 C.F.R. § 4.118, Diagnostic Code 7806.

23. GERD

24. The Veteran's service-connected GERD is rated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7346. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342 and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114.

Under Diagnostic Code 7346, hiatal hernia is assigned a 10 percent rating when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating contemplates pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346.

On VA esophageal conditions examination in February 2017, the Veteran reported that he was diagnosed with GERD on 2013 endoscopy. He did not require any care for the disability at the time of examination. Signs and symptoms of the disorder included pyrosis, reflux, regurgitation, and sleep disturbance. The frequency of symptoms recurrence was 4 or more occasions per year. The average duration of episodes was less than one year. No other pertinent physical findings were indicated.

Post-service VA treatment records do not document complaint or treatment related to GERD.

In this case, the Veteran's GERD is shown to be manifested by occasional symptoms such as reflux and regurgitation; however, abdominal pain, regurgitation, nausea, vomiting, and substernal pain, which are shown to be productive of considerable impairment of health has not been demonstrated. The VA examination does not indicate that the Veteran's GERD is productive of such symptoms and the Veteran denied treatment for the disorder.

Accordingly, an initial rating in excess of 10 percent for GERD is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7346.

Effective Date

Under VA laws and regulations, a specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under laws administered by the VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). In general, the effective date of an award based on an original claim or a claim reopened after final adjudication of compensation shall be fixed in accordance with the facts found but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. However, if the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i).

"Claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-5 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). Any communication or action, indicating an intent to apply for one or more benefits under laws administered by the VA from a claimant may be considered an informal claim. Such an informal claim must identify the benefits sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a) (former regulation). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992).

24.-32. Effective date earlier than December 1, 2016, for the award of service connection for lumbosacral strain, pes planus, cervical strain, obstructive sleep apnea, GERD, left knee disability, allergic rhinitis, eczema, and tinnitus

The record reflects that the Veteran filed two VA Form 21-526 EZ, Fully Developed Claim) seeking service connection for eczema, allergic rhinitis, neck strain, and acute low back pain/lumbago, left knee synovitis, patellofemoral syndrome and osteoarthritis, esophageal reflux, in August 2016prior to his discharge from service from his second period of active duty service.

The Veteran's DD214 reflects that he was discharge from service on November 30, 2016. The AOJ assigned effect dates for the grant of service connection for lumbosacral strain, pes planus, cervical strain, obstructive sleep apnea, GERD, left knee disability, allergic rhinitis, eczema, and tinnitus on December 1, 2016, which is the day following the Veteran's discharge from service. Accordingly, no earlier effective date may be assigned. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i).

The Board has considered whether the Veteran filed an earlier claim for these disabilities following his first period of active duty; however, A VA Form 21-526 dated in May 1997 indicates that the Veteran sought compensation for a right knee disability with no other disabilities listed. The record does not contain evidence of the Veteran having filed a claim for these disabilities prior to August 2016.

Moreover, neither the Veteran nor his representative has advanced any other specific contentions in support of his claims for earlier effective dates. The Board notes that the representative indicated, and the Board agrees, that the claims were filed in August 2016; however, the date that is controlling in this case is the date of the Veteran's discharge from active service, with effective date assigned the date after discharge.

Accordingly, entitlement to effective dates earlier than December 1, 2016, for the grant of service connection for these disabilities must be denied.

33. & 34. Effective date earlier than August 24, 2016, for the award of service connection for left and right upper extremity peripheral neuropathy

In the August 2016 claim, the Veteran claimed service connection for numbness. In an October 2016, the Veteran clarified that he was claiming numbness in the fingertips of the hands.

In June 2017, the Veteran field a VA Form 21-526 EZ seeking service connection for hypoesthesia of both hands.

In an August 2017 rating decision, the AOJ granted service connection for left and right upper extremity peripheral neuropathy, claimed as hypoesthesia of both hands, effective December 5, 2016.

In June 2020, the AOJ granted an earlier effective date of August 24, 2016the date of receipt of claimfor left and right upper extremity peripheral neuropathy.

The Veteran's DD214 reflects that he was discharge from service on November 30, 2016. The AOJ assigned effect dates prior to the Veteran's discharge from active service. Even though the effective date is during service, there is no legal authority to assign an earlier effective date. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i).

Again, the Board has considered whether the Veteran filed an earlier claim for these disabilities following his first period of active duty; however, A VA Form 21-526 dated in May 1997 indicates that the Veteran sought compensation for a right knee disability with no other disabilities listed. The record does not contain evidence of the Veteran having filed a claim for these disabilities prior to August 2016.

Moreover, neither the Veteran nor his representative has advanced any other specific contentions in support of his claims for earlier effective dates.

Accordingly, entitlement to effective dates earlier than August 24, 2016, for the grant of service connection for these disabilities must be denied.

REASONS FOR REMAND

Upon review of the record, the Board finds that additional development on the remaining claims on appeal is warranted.

1. & 2. Service connection for palpitations and atypical chest pain

The Veteran's treatment records contain various notations of palpitations and atypical chest pain; however, on VA examination in February 2017, the examiner found no evidence of heart or cardiovascular disorder. In an addendum, the examiner further noted that atypical chest pain is not a diagnosis of a cardiac condition and is not generally associated with underlying cardiac etiology. Palpitations may or may not be associated with any underlying cardiac etiology.

However, since this examination, the Veteran presented for VA treatment with complaint of constant substernal pain in November 2019, which he experienced more strongly on inspiration. He underwent EKG, which confirmed non STEMI (Non-ST Segment Myocardial Infarction); however, it was indicated that final interpretation would be completed by cardiology with the final results posted in Vista Imaging. 

The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006).  Moreover, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

In light of the foregoing indicating a potential cardiovascular disorder, the Board believes that additional VA examination is warranted. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. 

In addition, updated VA treatment records, to include the final interpretation of the November 2019 EKG, should be obtained.

3. Service connection for costochondritis

The Veteran's service treatment records reflect that he was seen in October 2008 for complaint of 1-month history of right anterior chest wall discomfort that he could reproduced with palpation of his chest. He was assessed with costochondritis (Tietze's Syndrome)

On VA heart disorders examination in February 2017, the examiner indicated that costochondritis is inflammation or irritation of the cartilage connecting the ribs to the sternum and is not related to any underlying cardiac etiology. It would also not be expected to be a chronic disability.

As indicated, costochondritis is an inflammation of the cartilaginous junction between a rib or ribs and the sternum. See Dorland's Illustrated Medical Dictionary, 423 (32nd ed. 2012). Accordingly, costochondritis is generally rated as a musculoskeletal disability under 38 C.F.R. § 4.71a, or alternatively, as a muscle disability under 38 C.F.R. § 4.73. However, in this case the Veteran was afforded a heart disorders examination, but not afforded musculoskeletal/muscle examination in relation to his claim. 

In addition, as indicated above, the record reflects that after the 2017 VA examination, the presented for VA treatment with complaint of chest pain.

Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. 

4. Increased rating for lumbar strain

The Veteran was afforded VA lumbar spine examinations in February and June 2017. Since that time, the Veteran has submitted private evaluations dated in 2020 reflecting significantly worsening symptomatologyfor example, forward flexion of the spine was reduced to 25 degrees on private evaluations in 2020, while it was 70 degrees on 2017 VA examination. The 2020 private evaluation from Dr. L. also reflected report of severe pain, paresthesias, and numbness of both lower extremities, as well as assessment of intervertebral disc disease required bedrest 2-4 times per month, and sometimes more, though not prescribed by a physician.

Accordingly, the Veteran should be afforded a new examination to determine the nature and severity of his service-connected and lumbar spine disability. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the veteran with a thorough and contemporaneous medical examination).

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that an examiner must express an opinion regarding functional impairment and the examiner's determination in that regard should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. Neither the VA nor private examiners provided estimated range of motion findings on flare-up or on repeated use over time. Accordingly, remand for additional examination that is compliant with the requirements of Sharp is also warranted.

5.-7. Increased rating for cervical strain and peripheral neuropathy of the upper extremities

As with the Veteran's lumbar spine disability, the Veteran submitted an additional private medical evaluation dated in 2020 that reflects potentially worsening symptomsnamely, the Veteran reported flare-ups of the cervical spine condition that were not noted on VA examination in 2017. However, the private examiner did not portray functional impairment in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.

Accordingly, the Veteran should be afforded a new examination to determine the nature and severity of his service-connected cervical spine disability and that is consistent with Sharp. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green, 1 Vet. App. at 124.

Moreover, given that the cervical spine examination will also address radiculopathy of the upper extremities with findings potentially responsive to the rating criteria for the service-connected upper extremity peripheral neuropathy, the Board believes that deferral of the matters of entitlement to increased initial ratings for right and left upper extremity peripheral neuropathy is also warranted. 

8. Increased rating for left knee

Again, the Veteran has submitted private evaluations pertaining to the left knee reflecting worsening symptomatology than shown on VA examination in 2017.

In addition, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). 

The Board notes that the revise rating criteria provide for ratings based upon patellar instability and use of a physician-prescribed brace. The 2020 private report from Dr. S. reflects assessment of patellar instability and use of a brace.

Give that the record reflects potentially worsening disability that may also meet the criteria for higher/separate ratings under the revised rating criteria, the Veteran should be afforded a new examination to determine the nature and severity of his service-connected and cervical spine disability. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green, 1 Vet. App. at 124.

9. Increased rating for pes planus

The Court in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate.

Notably, with respect to the service-connected bilateral pes planus, in Southall-Norman v. McDonald, 28 Vet. App. 346 (2016), the Court further held that the plain language of § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joints that are painful, whether or not they are evaluated under a Diagnostic Code predicated on range of motion measurements. 

Review of the 2017 examination reflects that while the examiner discussed functional loss, range of motion testing, including in passive motion, weight-bearing, and nonweight-bearing situations was not conducted.

Accordingly, the Veteran should be afforded a new examination to determine the nature and severity of his service-connected pes planus and that is consistent with Correia. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green, 1 Vet. App. at 124.

10. TDIU

The law provides that a TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for individual unemployability is part of an increased rating claim when such claim is raised by the record. 

In this case, an October 2019 VA treatment report reflects that the Veteran had recently quit his job due to pain. Moreover, the private evaluation completed by Dr. L. reflects his opinion that, due to the Veteran's severe and chronic orthopedic pain and limited range of motion, he would have marked difficulty even with light duty or sedentary work, with restricts on bending, squatting, kneeling, lifting, reaching, pushing, pulling, walking, sitting, or standing.

Given the foregoing, the Board finds that a claim for TDIU has been raised by the record. On remand, the AOJ should develop the TDIU claim, including sending the Veteran the appropriate letter to ensure compliance with all notice and assistance requirements. The Veteran should be advised to submit a VA Form 21-8940 and submit any related employment records, or information and authorization to obtain any relevant records.

The matters are REMANDED for the following action:

1. The AOJ should review the record and send an appropriate letter to the Veteran to ensure compliance with all notice and assistance requirements with respect to his TDIU claim. The AOJ should forward the appropriate forms, VA Form 21-8940 and VA Form 21-4192 for completion. Any relevant employment records identified should be obtained.

2.  Assist the Veteran in associating with the claims folder updated treatment records, including updated VA treatment records.

3. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed chest pain/palpitations. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history.

The examiner should identify any disorder related to the Veteran's complaint of atypical chest pain and/or palpitations. The examiner is asked to consider and address post-service VA treatment records noting complaint of chest pain and potential non STEMI identified on EKG in November 2019. The examiner should address whether it is at least at likely as not that any heart disorder had its onset in service, or is otherwise related to service, to include the documented complaints of chest pain and palpitations therein.

The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions.

The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached.

4. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed costochondritis. Any indicated tests should be accomplished, to include consideration of muscle and/or joint examination. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history.

The examiner should identify any disorder related to the Veteran's complaint of costochondritis. The examiner is asked to consider and address post-service VA treatment records noting complaint of chest pain. The examiner should address whether it is at least at likely as not that any disorder had its onset in service, or is otherwise related to service, to include the report of costochondritis.

The examiner is also advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions.

The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached.

5. Schedule the Veteran for a VA examination(s) to ascertain the current severity and manifestations of the Veteran's service-connected lumbar and cervical spine disabilities.

The claims file should be made available to the examiner for review in connection with the examination. 

In particular, the examiner should be directed to perform range of motion testing to determine the extent of limitation of motion. Additionally, the examiner must include range of motion testing in the following areas:

Active motion;

Passive motion;

Weight-bearing; and

Nonweight-bearing.

The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the lumbar and/or cervical spine is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. 

The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. 

If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.

IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES' SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report.

The examiner should also indicate if there is ankylosis of the spine or resultant neurological impairment. If there is neurological impairment, the examiner should identify the nerve or nerves involved and determine the manifestations and severity.

The examiner should also comment on the impact of the Veteran's lumbar and cervical spine disabilities on his ability to work. 

The examiner must provide a complete rationale for all the findings and opinions.

6. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of the Veteran's service-connected left knee disability.

The claims file should be made available to the examiner for review in connection with the examination. 

In particular, the examiner should be directed to perform range of motion testing to determine the extent of limitation of motion. Additionally, the examiner must include range of motion testing in the following areas:

 Active motion;

Passive motion;

Weight-bearing; and

Nonweight-bearing.

The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the right and left knee is used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE, THE EXAMINER MUST GLEAN INFORMATION REGARDING THE FLARES' SEVERITY, FREQUENCY, DURATION, AND FUNCTIONAL LOSS MANIFESTATIONS FROM THE VETERAN, MEDICAL RECORDS, AND OTHER AVAILABLE SOURCES. EFFORTS TO OBTAIN SUCH INFORMATION MUST BE DOCUMENTED. If there is no pain and/or no limitation of function, such facts must be noted in the report.

The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. 

If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.

The examiner should also indicate if there is instability or recurrent subluxation of the knee, and if so, comment on the need for physician prescribed assistive device such as a brace, cane, or walker.

The examiner should also comment on the impact of the Veteran's knee disability on his ability to work. 

The examiner must provide a complete rationale for all the findings and opinions.

7. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of the Veteran's service-connected bilateral pes planus.

The claims file should be made available to the examiner for review in connection with the examination. 

All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should describe all current manifestations of the Veteran's pes planus. In addition, the examiner should provide range of motion findings with respect to the feet, including flexion and extension. Additionally, the examiner must include range of motion testing in the following areas:

Active motion;

Passive motion;

Weight-bearing; and

Nonweight-bearing.

The examiner should indicate whether range of motion is additionally limited due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. In doing so, the examiner should offer an opinion as to whether pain could significantly limit functional ability during flare-ups or when the feet are used repeatedly over a period of time. Such determinations should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. 

The examiner should specifically indicate whether, and at what point during, the range of motion the Veteran experienced any limitation of motion that was specifically attributable to pain. 

If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.

The examiner should also comment on the impact of the Veteran's pes planus on his ability to work. 

The examiner must provide a complete rationale for all the findings and opinions.

 

 

J. NICHOLS

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	G. E. Wilkerson, 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.