Citation Nr: 21042049 Decision Date: 07/11/21 Archive Date: 07/11/21 DOCKET NO. 15-11 293 DATE: July 11, 2021 ORDER Entitlement to an initial rating higher than 30 percent for degenerative disc disease of the cervical spine is denied. Prior to October 30, 2020, an initial rating of 40 percent, but no higher, for radiculopathy of the right upper extremity (right arm) disability, is granted. Since October 30, 2020, a rating higher than 40 percent for a right arm disability, is denied. Entitlement to service connection for bilateral hearing loss is granted, subject to controlling regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for right knee disability, to include as secondary to a service-connected left knee disability, is remanded. Entitlement to service connection for Gulf War Syndrome or undiagnosed illness to include persistent headaches, cognitive dysfunction, mood and sleep disturbance, dermatological symptoms, chemical sensitivities, and gastrointestinal symptoms is remanded. Entitlement to service connection for gastroenteritis is remanded. Entitlement to service connection for irritable bowel syndrome (claimed as colon cancer), including as secondary to a service-connected psychiatric disorder or medications used to treat migraine headaches, is remanded. Entitlement to service connection for sleep apnea or any respiratory disability is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for tinea pedis is remanded. Entitlement to service connection for plantar warts is remanded. Entitlement to service connection for cardiovascular disability is remanded. FINDINGS OF FACT 1. The most probative evidence demonstrates that the Veteran's cervical spine disability has been manifested by limitation of forward flexion of the cervical spine to no less than 10 degrees; IVDS has not been diagnosed. 2. The Veteran's dominant hand is his right hand. 3. Throughout the entire period on appeal, the Veteran's right arm disability has been manifested by no more than moderate incomplete paralysis of the upper radicular group. 4. The evidence is at least in equipoise as to whether the Veteran's bilateral hearing loss is etiologically related to his active service. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 30 percent for a neck disability, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242. 2. Prior to October 30, 2020, an initial rating of 40 percent, but no higher, is warranted for a right arm disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DC 8510. 3. Since October 30, 2020, the criteria for a rating higher than 40 percent for a right arm disability, are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, DC 8510. 4. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Marine Corps from February 1986 to February 1992. These matters are on appeal from June 2013 and June 2014 rating decisions. In March 2019, the Veteran and his spouse testified before the undersigned Veterans Law Judge at a Central Office hearing. A transcript of this hearing is of record. In June 2019, these matters, in addition to claims of entitlement to service connection for a facial fistula, acquired psychiatric disorder, tinnitus, and radiculopathy of the left arm, were remanded by the Board for further development. The claims for service connection for facial fistula, acquired psychiatric disorder, tinnitus, and radiculopathy of the left arm were granted in a December 2020 rating decision. The Veteran did not disagree with the disability evaluations or the effective date assigned. Therefore, these matters are no longer considered to be in appellate status. Increased Rating Claims Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical and industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). When determining the severity of musculoskeletal disabilities, which are at least partly rated on the basis of range of motion, VA must consider the extent of additional functional impairment a veteran may have above and beyond the limitation of motion objectively demonstrated due to pain, limited or excess movement, weakness, incoordination, and premature or excess fatigability, etc., particularly when symptoms "flare up," to include periods of prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shulkin, 29 Vet. App. 26 (2017). 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). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Neck disability The Veteran contends that his service-connected neck disability is more severe than his initial 30 percent evaluation, would indicate. Spine disabilities can be evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Code 5243. The criteria for rating disabilities of the spine are listed under DCs 5235 to 5243. The code for intervertebral disc syndrome (DC 5243), permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Effective February 7, 2021, a portion of the rating schedule for evaluating musculoskeletal disabilities of the spine was revised. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243, 5244). Specifically, Diagnostic Code 5242 for degenerative arthritis of the spine was revised to apply to degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (IVDS). Diagnostic Code 5243 for IVDS was revised to include an instruction to use this Diagnostic Code only when there is disc herniation with compression and/or irritation of the adjacent nerve root. Diagnostic Code 5242 should be assigned for all other disc diagnoses. Significantly, the actual rating criteria (the General Rating Formula for Diseases and Injuries of the Spine and the Formula for Rating IVDS Based on Incapacitating Episodes) were not changed. Under the General Rating Formula for Diseases or Injuries of the Spine, in pertinent part, a rating of 30 percent is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A rating of 40 percent is assigned for unfavorable ankylosis of the entire cervical spine. A rating of 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243. For purposes of VA compensation, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateroflexion is 0 to 45 degrees, and left and right lateral rotation is 0 to 80 degrees; normal combined ROM of the cervical spine 340 degrees. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Moreover, "chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. When rating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). IVDS (preoperatively or postoperatively) will be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5243. According to the Formula for Rating IVDS Based on Incapacitating Episodes, a 20 percent rating is warranted where there are incapacitating episodes with a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. The maximum 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. However, the Board notes that the Veteran has not been diagnosed with intervertebral disc syndrome (IVDS), that is, he is not shown to have "incapacitating episodes" as defined at DC 5243. Service connection is not currently in effect for intervertebral disc syndrome. Although in March 2019 the Veteran testified that he had been provided a doctor's note related to being bedridden due to his neck disability, on January 2020 VA examination, the examiner stated that the Veteran does not have IVDS of the thoracolumbar spine. Therefore, the provisions at 38 C.F.R. § 4.71a, DC 5243, and the "Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes" are not for application. Turning to the evidence, on May 2013 VA cervical spine Disability Benefits Questionnaire (DBQ) examination, the Veteran presented with complaints of radiating pain from the neck to the right shoulder and thumb if he tilted his head the wrong way. He also complained of flare-ups impacting the function of the neck. The Veteran missed one day of work every month or so for severe neck pain. The Veteran was employed as a clerk in the post office and ran a computerized machine and was able to perform light lifting up to 10 pounds. Range of motion measurements of the cervical spine indicated 10 degrees flexion, with pain; 30 degrees extension, with pain; 20 degrees right lateral flexion, with pain at 10 degrees; 25 degrees left lateral flexion, with pain; 45 degrees right lateral flexion, with pain at 35 degrees; and 45 degrees left lateral rotation, with pain. The combined range of motion was 200 degrees. Following repetitive use testing there was no additional limitation in range of motion of the cervical spine. There was localized tenderness over the midline at approximately C4 level without guarding or muscle spasm. There was no significant impact on employment due to the neck disability. The Veteran was able to sort mail and run a computerized machine as long as he avoided heavy lifting. The examiner indicated a diagnosis of status post cervical spine surgery. A May 2013 addendum indicates an X-ray examination indicated mild degenerative changes with neural foraminal narrowing bilaterally C5 to C7. The addendum changed the initial diagnosis from status post cervical spine surgery to degenerative joint disease of the cervical spine. VA treatment records include a November 2014 report which shows that the Veteran's neck pain was rated 7 to 8 out of 10 on the pain scale. Pain was worse with prolonged activity described as dull, aching, tingling, and numbness and moderate in severity. In January and November 2016, the Veteran received steroid injections in the cervical spine. In January 2017 the Veteran sought emergency room care for neck pain. A January 2018 report shows that a February 2016 MRI of the cervical spine indicated multilevel spondylosis of the cervical spine with no significant change when compared to an April 2014 MRI. The assessment was cervical spine disease. In March 2019, the Veteran testified that he had shoots of electricity from his upper neck down to the tips of his toes. He only took a small amount of Motrin due to issues with his GI tract. He testified that he missed work due to his neck and right arm disabilities and that had been provided a doctor's note related to being bedridden due to his neck disability. The Veteran testified that he had missed 30 percent of workdays since he began employment at the post office in 1993. Pursuant to the Board's June 2019 remand, on January 2020 VA neck disability DBQ examination the Veteran presented with complaints of pain and stiffness and denied any flare-ups. He also complained of an inability to turn his head left or right. Functional loss or functional impairment of the cervical spine were described as an inability to turn head left and right without pain. Range of motion measurements indicated 40 degrees flexion; 45 degrees extension; and 40 degrees right and left lateral flexion and rotation, with pain throughout. The combined range of motion was 245 degrees. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examiner diagnosed degenerative arthritis of the spine and multi-level degenerative disc and joint disease of the cervical spine with radiculopathy. The examiner opined that the Veteran did not have IVDS of the cervical spine. However, the examiner opined that the neck disability impacted his ability to work. The Veteran was employed with the US Postal Service and had been in customer service for 28 years. The Veteran lost 2 to 4 weeks of work in the last 12 months due to his neck disability. A MRI indicated small osteophytes C5-C7 consistent with DJD and narrowing C5-6 and C6-C7 disc with early degenerative disc disease. It otherwise indicated a negative cervical spine. After review of all the evidence regarding the orthopedic manifestations of the Veteran's neck disability, the Board finds that an initial rating higher than 30 percent is not warranted. There is no evidence of record that the Veteran's neck disability has been manifested by unfavorable ankylosis of the entire cervical spine. Accordingly, the next higher rating of 40 percent is not warranted. In sum, while the Veteran clearly has problems with the neck, the most probative evidence of record does not indicate that the Veteran's neck disability is manifested by unfavorable ankylosis of the entire cervical spine. Accordingly, the 30 percent evaluation is warranted. Regarding the DeLuca factors, the Board observes that the VA examiner noted the Veteran's complaints such as pain and stiffness. The Board has taken those complaints into consideration in its above discussion. However, the objective medical evidence of record is of greater probative value as to the Veteran's level of impairment than his assertions. Even considering his subjective complaints of pain and other symptoms described in DeLuca, unfavorable ankylosis of the entire cervical spine has not been shown such that a higher rating would be warranted. See Thompson v. McDonald, 815 F.3d 781, 786 (Fed. Cir. 2016) (holding that provision describing functional loss due to disability of the musculoskeletal system does not supersede requirements for a higher rating specified in the Rating Schedule). The Board finds that the evidence does not support a finding that the Veteran's neck disability more closely approximates a 40 percent rating. In sum, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 30 percent for the orthopedic manifestations of the Veteran's neck disability. While the Board accepts the contentions of the Veteran that his neck disability causes him to experience pain, providing the basis for the initial 30 percent evaluation, the Board has taken that into account in its consideration of the range of motion of the Veteran's cervical spine. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Accordingly, a greater rating is not warranted based on functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Right arm disability The Veteran contends his service-connected right arm peripheral neuropathy is more severe than his initial 20 percent rating prior to October 30, 2020, and 40 percent rating since October 30, 2020, indicates. The Veteran's right hand is his dominant hand. See, October 2020 VA examination. Historically, a June 2014 rating decision granted service connection for peripheral neuropathy of the right arm and assigned a 20 percent rating effective August 5, 2013, under DC 8510. In a December 2020 rating decision, the RO increased the rating for the right arm disability to 40 percent, effective October 30, 2020, the date of the most recent VA examination. As this increase does not represent a total grant of the benefits sought on appeal, the claim remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Under 38 C.F.R. § 4.124a, DCs 8510 (paralysis), 8610 (neuritis), and 8710 (neuralgia) neurologic impairment of the upper radicular groups of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 30 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete an 60 percent rating is warranted. Neurologic impairment of the dominant extremity when incomplete and mild warrants a 20 percent rating; when moderate a 40 percent rating is warranted; when severe a 50 percent rating is warranted; and when complete a 70 percent rating is warranted. An additional note provides that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. Turning to the evidence, on May 2013 VA cervical spine DBQ examination, the Veteran presented with complaints of radiating pain from the neck to the right shoulder and thumb if he tilted his head the wrong way. The Veteran missed work about once day every month due to neck and thumb pain. He also noted some mild weakness in the right fist. On April 2014 VA peripheral nerves conditions DBQ examination the Veteran presented with a diagnosis of C5-C6 radicular pains of the right arm status/post cervical spine disc disease. Symptoms included mild paresthesias and/or dysesthesias and numbness and moderate intermittent pain of the right arm. On muscle strength testing, the right arm was 4/5 (active movement against some resistance). Reflex examination of the right arm was normal. Sensory testing for light touch was decreased in the right shoulder, but normal on the inner/outer forearm and hand/fingers. There was mild incomplete paralysis of the right upper radicular group (5th and 6th cervicals). Regarding functional impact, the examiner opined that the Veteran's peripheral nerve disability impacted his ability to work due to neck and right arm pain. VA treatment records include an October 2014 EMG which indicated diffuse demyelinating sensorimotor peripheral neuropathy in the upper extremities. The Veteran complained of sharp and achy pain that shot down his arms. He was unable to do yardwork or workout due to pain. Pain sometimes woke him up at night and in the morning during which time he experienced about 2 hours of stiffness. Cervical radiculopathy was diagnosed. In November 2014, neck pain was rated 7 to 8 out of 10 on the pain scale. Pain was worse with prolonged activity described as dull, aching, tingling, and numbness with moderate severity. Sensation was inconsistent to soft touch. Strength was normal. A January 2015 neurology report indicates that the Veteran complained of a loss of right arm strength and weakness since his neck injury. The Veteran stated that his right arm had been weak since neck injury. Over the past 5 years he experienced shooting pains and sensitivity through his limbs. He noted decreased strength over time which prevented him from doing yardwork. Work at the postal office exacerbated his symptoms. On December 2018 VA peripheral nerves conditions DBQ examination the examiner diagnosed upper radicular group neuropathy. The Veteran's symptoms included mild intermittent pain, paresthesias and/or dysesthesias, and numbness of the upper extremities. Muscle strength testing and deep tendon reflexes were normal. Mild incomplete paralysis of the upper extremities was noted. Pursuant to the Board's June 2019 remand, on January 2020 VA cervical spine examination muscle strength testing was normal. Reflex examination of the upper extremities was normal. There was no evidence of ankylosis. Sensory examination was normal. Radiculopathy symptoms included mild paresthesias/and or dysesthesias and numbness. There was involvement of the C5/C6 and C7 nerve roots. Radiculopathy was mild. On January 2020 VA peripheral nerves DBQ examination there was mild incomplete paralysis of the ulnar nerve and musculocutaneous nerve. An October 2014 EMG was abnormal. The examiner stated that there was electrophysiology evidence of a diffuse demyelinating sensorimotor peripheral neuropathy in the upper extremities. There was no evidence of a right superimposed median neuropathy at the wrist. Muscle strength testing, sensory examination, and reflex examination of the upper extremities was normal. There was no evidence of ankylosis. Radiculopathy symptoms included mild paresthesias/and or dysesthesias and numbness. There was involvement of the C5/C6 and C7 nerve roots. The examiner opined that indicated that the Veteran's peripheral nerve disability did not impact his ability to work. On October 2020 VA peripheral nerve conditions DBQ examination, the examiner diagnosed C5-C6 radiculopathy, right and left arm. Symptoms included moderate constant pain, paresthesias and/or dysesthesias, and numbness. Muscle strength testing was normal, but deep tendon reflexes indicated hypoactivity for the biceps, triceps, and brachioradialis and sensory examination indicated decreased sensation for light touch of the upper extremities. There was moderate incomplete paralysis of the upper radicular group. The examiner opined that the peripheral nerve disability impacted the Veteran's ability to work. At the Post Office, the Veteran worked in bar code reading, but began working in customer service in 2008 as a reasonable accomodation for disabilities ,including bilateral peripheral neuropathy of the arms. After review of the evidence, including medical records and VA examinations, and lay statements and testimony from the Veteran, the Board finds that prior to October 30, 2020, resolving reasonable doubt in favor of the Veteran, the evidence warrants the assignment of an initial rating of 40 percent, but no higher, for moderate incomplete paralysis of the right arm. In this regard, although the April 2014 and December 2018 VA examinations indicated mild incomplete paralysis of the right arm, in October 2014 the Veteran complained of right arm symptoms so severe that pain woke him up at night and made him unable to perform yardwork. On October 2020 VA examination the Veteran indicated that the employer's accommodations for his disabilities, including his right arm disability, had been in effect since 2008. However, the Board finds that prior to and since October 30, 2020, a higher rating of 50 percent is not warranted as the evidence of record does not show that the Veteran's symptoms rise to the level of severe incomplete paralysis. None of the VA examiners have opined that the Veteran's neurological symptoms are manifested by severe incomplete paralysis of all radicular groups. As such, the Board also finds that the preponderance of the evidence is against a rating higher 40 percent prior to or since October 30, 2020, for the Veteran's right arm disability. Additional considerations In this case, the Veteran is competent to report complaints such as difficulty turning his head and right arm pain and numbness, as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that his symptoms are of such severity as to warrant higher ratings and has taken these contentions seriously (this is the basis for the increased rating for peripheral neuropathy of the right arm prior to October 30, 2020 assigned herein). He is not, however, competent to identify a specific level of disability of his neck and right arm disabilities, according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's neck and right arm disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Claim Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, certain diseases, such as sensorineural hearing loss, are presumed to have been incurred in service if manifested to a compensable degree within one year after service. The presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). When chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303 (b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran presented testimony that he was a "plane caption, crew chief, constantly on the flight line" and exposed to loud jet engines such as "high tempo operations, constantly launching jets, recovering jets" for six continuous years. See Hearing Transcript at 14-15. On May 2013 VA examiner found "no hearing loss present" and indicated that the Veteran's tinnitus is less caused as a result of noise exposure in the military. The rationale provided was no evidence of an in-service noise injury. However, since normal hearing at separation from service does not by itself preclude an award of service connection, in June 2019 the Board remanded the claim for an appropriate opinion. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Pursuant to the Board's remand, on January 2020 VA hearing loss and tinnitus DBQ examination the audiologist diagnosed bilateral sensorineural hearing loss which the audiologist opined was not related to his active service. The rationale was that there was no significant shift in thresholds beyond test variability from entrance to separation. There was no report of complaint/treatment for hearing decrease in the STRs. Although noise exposure was conceded and the relationship of noise, auditory damage, and hearing loss was well-established, auditory damage and hearing los was not conceded based on noise alone. There must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology. However, the audiologist related the Veteran's tinnitus to his service. The rationale was that the Veteran was exposed to excessive noise during service, the onset of tinnitus was reported to be on active duty, and excessive noise exposure is known to cause tinnitus. Notably, in an October 2020 rating decision, the RO granted service connection for tinnitus, based on in-service noise exposure. Resolving all doubt in favor to the Veteran, the Board finds that the criteria for service connection for bilateral hearing loss are met. See 38 U.S.C. § 1507; 38 C.F.R. § 3.102. The nature and extent of this disability caused by service is not currently before the Board. REASONS FOR REMAND Right knee The Veteran contends that he has a right knee disability that is either related to his service or secondary to his service-connected left knee disability. Pursuant to the Board's June 2019 remand, on October 2020 VA knee and lower leg conditions DBQ examination the examining nurse practitioner opined that the Veteran's right knee osteoarthritis was not related to service or to his service-connected left knee disability based, in part, on the opinion that there was no chronic issue with the left knee during service. When addressing the issue of service connection on a secondary basis, the correct legal standard to apply is whether it is at least as likely as not that his right knee disability is (a) proximately due to or the result of the Veteran's service-connected left knee disability, or (b) aggravated by his service-connected left knee disability. The chronicity of the Veteran's left knee disability during service is not relevant. Accordingly, the October 2020 VA medical opinion is inadequate for adjudication purposes. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As it remains unclear whether the Veteran's right knee disability is related to his service-connected left knee disability, another medical opinion must be obtained. Remaining claims on appeal As noted in the June 2019 remand, the Veteran contends that the Gulf War Syndrome or undiagnosed illness to include persistent headaches, cognitive dysfunction, mood and sleep disturbance, dermatological symptoms, chemical sensitivities, and gastrointestinal symptoms; gastroenteritis; respiratory disability; cardiovascular disability; and migraines. Specifically, he contends that these disabilities are directly related to his service in Desert Storm and Desert Shield, including his exposure to environmental agents. See Hearing Transcript at 19. The Board noted that during April 2014 VA examinations the examiner opined that there was no evidence or finding of chronic fatigue syndrome, fibromyalgia, a respiratory disability, cardiovascular disability, or any undiagnosed illness. Similarly, the Veteran contends that his gastroenteritis, irritable bowel syndrome, hemorrhoids, and skin disorders, including, tinea pedis, and plantar warts, are directly related to his service in Desert Storm. Based on the Veteran's March 2019 testimony the Board remanded the claims for examinations and etiological opinions which considered both the lay and medical evidence of record. However, the examiners failed to follow this directive. Pursuant to the Board's remand, in February 2020 a VA examiner opined that the claimed disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also checked "no" in response to a question of whether there were any diagnosed illnesses for which no etiology was established. Regarding the Veteran's low back disability, pursuant to the Board's remand in a February 2020 VA medical opinion an examiner opined that the Veteran's low back disability was not related to service based, in part, on the absence of a low back disability in the STRs. In September 2020, the examiner further opined that the Veteran's low back disability (degenerative arthritis of the spine) is not related to his service based on the rationale that during service lumbar sprain was only acute. There was no evidence of chronicity of care, symptoms were subjective, and the separation examination is silent for a low back disability. However, there is no indication that the examiner considered the Veteran's lay statements or testimony regarding his low back disability. Regarding chronic fatigue syndrome, pursuant to the Board's remand on January 2020 VA examination the examiner found that there were no objective findings for chronic fatigue syndrome and indicated that the Veteran had no findings, signs, or symptoms attributable to chronic fatigue syndrome, including headaches. However, this is factually inaccurate since the Veteran has complained of headaches and the VA treatment records indicate a diagnosis of chronic fatigue syndrome in the problem list. Regarding sleep apnea, in a February 2020 VA medical opinion the examiner opined that sleep apnea had a specific etiology and diagnosis, but was not related to service based on a diagnosis 20 years post-service. However, the examiner failed to consider the Veteran's lay statements or testimony regarding his sleep apnea. Regarding a gastrointestinal disability, in February 2020 VA medical opinions the examiner opined that the Veteran's gastrointestinal disabilities, including gastroenteritis and gastritis, were less likely than not incurred in or caused by service based, in part, on the rationale that the STRs were silent for the diagnosis. However, the examiner failed to consider the Veteran's lay statements or testimony regarding his gastrointestinal disabilities. Regarding migraine headaches, in a February 2020 VA medical opinion the examiner opined that the Veteran's migraine headaches were less likely than not related to his service based on the medical evidence of record without consideration of the Veteran's lay statements or hearing testimony. Regarding fibromyalgia, in a February 2020 VA medical opinion the examiner opined that the Veteran had only subjective complaints of fibromyalgia and a normal examination, but failed to consider the Veteran's lay statements and hearing testimony. Regarding IBS, in a February 2020 VA medical opinion an examiner opined that IBS is not related to the Veteran's service based, in part, on a post-service diagnosis of colon cancer and family history of colon cancer. However, the examiner failed to consider the Veteran's lay statements and hearing testimony regarding IBS. Regarding a heart disability, in a February 2020 VA medical opinion the examiner opined that the Veteran had only subjective complaints of a heart disability, but failed to consider the Veteran's lay statements and hearing testimony. Regarding tinea pedis and plantar warts, on January 2020 VA examination the examiner indicated that no objective diagnosis of tinea pedis and plantar warts was warranted. In a February 2020 VA medical opinion the examiner opined that tinea pedis was not related to service based on a lack of treatment since service. However, the VA examiner again failed to consider the Veteran's lay statements and hearing testimony. Due to the deficiencies in the January and February 2020 medical opinions, additional addendum opinions are necessary. Barr, supra; Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following actions: 1. Obtain an appropriate addendum by an examiner, other than October 2020 VA examiner, regarding the nature and etiology of the Veteran's right knee disability. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. The claims file, including a copy of the June 2019 remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. The examiner should provide the following opinion(s): a) Is it at least as likely as not (50 percent or more probability) that a right knee disability had onset in or is etiologically-related to the Veteran's active duty service, or was manifested within the first post-service year? b) If the answer to part (a) above is "no," and the Veteran's right knee disability has been related to his service, is it at least as likely as not (50 percent probability or more) that any currently-diagnosed right knee disability is (a) proximately due to or the result of the Veteran's service-connected left knee disability, or (b) aggravated (any incremental increase in the right knee disability beyond its normal progression) by his service-connected left knee disability? The examiner is asked to consider and discuss as necessary the pertinent evidence of record to include the Veteran's lay statements, testimony, and complaints concerning the onset of his right knee disability, including those made to medical providers and as noted in the May 2021 Appellant's Post-Remand Brief. The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The report should include the complete rationale for all opinions expressed. 2. Obtain an appropriate addendum by an examiner, other than January 2020 VA examiner, regarding the nature and etiology of the Veteran's low back disability. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. The claims file, including a copy of the June 2019 remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. The examiner should provide the following opinion(s): Is it at least as likely as not (50 percent or more probability) that a low back disability had onset in or is etiologically-related to the Veteran's active duty service, or was manifested within the first post-service year? The examiner is asked to consider and discuss as necessary the pertinent evidence of record to include the Veteran's lay statements, testimony, and complaints concerning the onset of his low back disability, including those made to medical providers and as noted in the May 2021 Appellant's Post-Remand Brief. The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The report should include the complete rationale for all opinions expressed. 3. Obtain an appropriate addendum by an examiner, other than January 2020 VA examiner, regarding the nature and etiology of the Veteran's claimed Gulf War Syndrome, chronic fatigue syndrome, fibromyalgia, respiratory disability, heart disability, migraines, and skin disabilities (including tinea pedis and plantar warts) as manifestations of an undiagnosed illness. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. The claims file, including a copy of the June 2019 remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. The examiner should provide the following opinion(s): a) Whether the Veteran has a diagnosed disability of chronic fatigue syndrome, fibromyalgia, respiratory disability, heart disability, migraines, or skin disabilities (tinea pedis and plantar warts), can these symptoms be attributed to known clinical diagnoses or an undiagnosed illness? b) For each such diagnosed disability, is it at least as likely as not (50 percent probability or greater) that any current disability(ies) had onset in or is etiologically-related to the Veteran's active duty service, or was manifested within the first post-service year? The examiner is asked to consider and discuss as necessary the pertinent evidence of record to include the Veteran's lay statements, testimony, and complaints concerning the onset of his chronic fatigue syndrome, fibromyalgia, respiratory disability, heart disability, migraines, and skin disabilities (including tinea pedis and plantar warts), including those made to medical providers and as noted in the May 2021 Appellant's Post-Remand Brief. The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The report should include the complete rationale for all opinions expressed. 4. Obtain an appropriate addendum by an examiner, other than the January 2020 VA examiner, regarding the nature and etiology of the Veteran's claimed gastroenteritis and irritable bowel syndrome. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. The claims file, including a copy of the June 2019 remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. The examiner should provide the following opinion(s): a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's gastrointestinal disorder, to specifically include gastroenteritis and/or irritable bowel syndrome had onset in or is etiologically-related to the Veteran's active duty service? b) If the answer to part (a) above is "no," is it at least as likely as not (50 percent probability or more) that a gastrointestinal disorder, to specifically include gastroenteritis and/or irritable bowel syndrome, diagnosed at any point during the course of the appeal, is (a) proximately due to or the result of the Veteran's service-connected disabilities, including his psychiatric disorder or medications prescribed to treat service-connected disabilities, or (b) aggravated (any incremental increase in a gastrointestinal disorder, to include gastroenteritis and/or irritable bowel syndrome beyond its normal progression) by his service-connected disabilities, including his psychiatric disorder or medications prescribed to treat service-connected disabilities? If it is determined that a gastrointestinal disorder, to specifically include gastroenteritis and/or irritable bowel syndrome, is related to the Veteran's service-connected disabilities or medications prescribed to treat those service-connected disabilities, to the extent possible, the examiner should indicate the approximate degree of disability or baseline before the onset of aggravation. The examiner is asked to consider and discuss as necessary the pertinent evidence of record to include the Veteran's lay statements and complaints concerning the onset of his gastrointestinal problems, including those made to medical providers and as noted in the May 2021 Appellant's Post-Remand Brief, and April 2013 VA examiner's opinion that the Veteran's gastrointestinal symptoms are aggravated by anxiety and migraines, including medications used to treat migraines. The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. (Continued on the next page) The report should include the complete rationale for all opinions expressed. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Adams, 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.