Citation Nr: 21042570 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-53 510 DATE: July 13, 2021 ORDER Service connection for chronic bronchitis is granted. For the appeal period prior to June 26, 2019, a rating in excess of 10 percent for right knee patellofemoral syndrome with osteoarthritis with painful limitation of motion is denied. For the appeal period prior to April 14, 2014, a separate 20 percent rating for a torn meniscus in the right knee is granted. For the appeal period from April 14, 2014 to September 30, 2019, a separate 10 percent rating for residuals of a right knee meniscectomy is granted. For the appeal period from October 1, 2019 to June 26, 2020, a 100 percent temporary total rating for residuals of a partial right knee replacement is granted. For the appeal period beginning June 27, 2020, a 60 percent rating, but no higher, for residuals of a partial right knee replacement is granted. A 30 percent rating for a neurological tic (claimed as hiccups and muscular twitching) is granted. REMANDED Entitlement to service connection for sinusitis is remanded. FINDINGS OF FACT 1. The Veteran's bronchitis (now recurring) first manifested in service and was incurred in service. 2. The Veteran underwent a partial right knee replacement on June 26, 2019. 3. For the appeal period prior to June 26, 2019, the Veteran's right knee disability was manifested by no worse than 110 degrees flexion and normal extension, to include during flare-ups and repeated use over time. 4. For the appeal period prior to April 14, 2014, the Veteran had a torn meniscus in the right knee manifested by frequent episodes of joint pain and effusion. 5. The Veteran underwent a meniscotomy in the right knee on April 14, 2014; he continued to have residual symptoms in the right knee. 6. The Veteran has already been awarded a 100 percent temporary total rating for residuals of his partial right knee replacement surgery from June 26, 2019 to September 30, 2019. 7. Following the Veteran's partial right knee replacement, his right knee disability more nearly approximated chronic residuals consisting of severe painful motion. 8. Throughout the appeal period, the Veteran has had severe head tics. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic bronchitis are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. For the appeal period prior to June 26, 2019, the criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome with osteoarthritis with painful limitation of motion are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261. 3. For the appeal period prior to April 14, 2014, the criteria for a separate 20 percent rating for a torn meniscus in the right knee are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a , Diagnostic Code 5258. 4. For the appeal period from April 14, 2014 to September 30, 2019, the criteria for a separate 10 percent rating for residuals of a right knee meniscectomy are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5259. 5. For the appeal period beginning October 1, 2019 to June 26, 2020, the criteria for a 100 percent temporary total rating for a partial right knee replacement are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.71a, Diagnostic Code 5055. 6. For the appeal period beginning June 27, 2020, the criteria for a 60 percent rating, but no higher, for residuals of a partial right knee replacement are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.71a, Diagnostic Code 5055. 7. The criteria for a rating of 30 percent for a neurological tic (claimed as hiccups and muscular twitching) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.20, 4.120, 4.124a, Diagnostic Code 8103. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2014, June 2014, and July 2015 rating decisions. The issues on appeal were previously remanded by the Board for further development in December 2018. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) (2020) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Chronic Bronchitis The Veteran asserts that he first experienced episodes of bronchitis in service. He contends that this condition has been recurring since service separation. Initially, the Board finds that the Veteran has been diagnosed with chronic bronchitis. See October 2019 VA respiratory examination report. Next, service records show that the Veteran was treated for upper respiratory tract infections and bronchitis in August 1984, July 1988, and September 1988. Private treatment records dated in July 1995 indicate that the Veteran had been treated since August 1992 (only 6 months following service separation). It was specifically noted that the Veteran had been treated for bronchitis along with other conditions, including chest pain, cough, and a rash. A March 1993 record shows that the Veteran was again diagnosed with bronchitis. VA treatment records show continued diagnoses and treatment for recurring bronchitis in April 2011 and December 2011. An April 2017 VA treatment record reflects that the Veteran was again treated for bronchitis and reported having 6-7 episodes of bronchitis per year. VA obtained a medical opinion in November 2019. At that time, the examiner opined that the Veteran's chronic bronchitis was not related to service. In this regard, the examiner stated that the Veteran's bronchitis had resolved without residuals. However, the examiner did not discuss post-service treatment records which continued to show recurring episodes of bronchitis. As such, this opinion is afforded little probative weight. For these reasons, and given the Veteran's treatment and diagnosis of bronchitis in service and recurring episodes since service, the Board finds that the evidence is at least in equipoise as to whether the Veteran's bronchitis first manifested in service. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's chronic bronchitis was incurred in service. The appeal is therefore granted. Rating for Right Knee DisabilityLaws and Analysis Disability evaluations 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 his 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. 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). 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 Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to Diagnostic Code 5003, 5010, and 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, Diagnostic Code 5010, instructed the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under the revised criteria, Diagnostic Code 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under both the earlier and revised rating criteria, degenerative arthritis is rated under Diagnostic Code 5003. Under this code, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As it pertains to recurrent subluxation or instability of the knee, and as noted above, revisions to Diagnostic Code 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76457 (Feb 7, 2021). Because these changes took effect during the pendency of the Veteran's appeal, both the former and revised criteria will be considered in evaluating the Veteran's service-connected right knee disability. However, application of the new criteria prior to the effective date of the amended regulation is not allowed. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Green v. Brown, 10 Vet. App. 111, 116-119 (1997); see also 38 U.S.C. § 5110 (g). Prior to February 7, 2021, instability of the knee was rated under Diagnostic Code 5257, which provided ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee, which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As it pertains to patellar instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See DC 5257 (Effective February 7, 2021). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis can also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). VA's General Counsel has subsequently held that separate ratings can also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Appeal Period Prior to June 26, 2019 Prior to June 26, 2019 (i. e., the date of the Veteran's partial knee replacement surgery), the Veteran was in receipt of a 10 percent rating for right knee patellofemoral syndrome and osteoarthritis with painful limitation of motion. In other words, the Veteran has already been afforded a 10 percent rating for painful motion of the right knee for the appeal period prior to June 26, 2019. Because the Veteran's range of knee motion in flexion, to include during repetitive use testing, has been no worse than 110 degrees in the right knee prior to June 26, 2019 (see June 2014 VA knee examination report), a rating higher than 10 percent is not warranted under DC 5260. Further, as noted in the 2014 VA knee examination report, the Veteran was been able to fully extend the knee; as such, a separate compensable rating under Diagnostic Code 5261 is also not warranted. For these reasons, a rating in excess of 10 percent for the right knee under Diagnostic Code 5010-5260 is not warranted, nor is a separate rating for limited extension of the right knee under DC 5010-5261. The Board recognizes the Veteran's reports of continued knee pain and stiffness. The Board considered this knee pain, as well as any additional limitations of motion due to pain (including difficulty with prolonged sitting and standing). However, even considering additional limitation of motion or function of the knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), the evidence still does not show that the right knee disability (prior to June 26, 2019) more nearly approximates the criteria for higher ratings. Repetitive-use testing during the 2014 VA examination showed no significant decreased range of motion in right knee (flexion was reduced from 120 degrees to 110 degrees). As such, even considering the Veteran's complaints of pain and flare-ups, the Board finds that the severity of the Veteran's right knee disability does not more nearly approximate a higher rating. Regarding instability, the Board notes that the Veteran has not reported, and the objective medical evidence of record does not demonstrate lateral instability in the right knee. A September 2012 VA treatment record shows that the Veteran denied any locking or instability in the knee. The 2014 VA examiner also conducted stability testing and found no lateral instability in the right knee. As such, a higher or separate rating under DC 5257 is not warranted. Moreover, there is no evidence of any knee ankylosis, or malunion of the tibia and fibula to support higher or separate ratings under DCs 5256 or 5262 for the appeal period prior to June 26, 2019. Next, the evidence shows that the Veteran had a torn meniscus prior to April 2014. The meniscal tear was surgically repaired on April 14, 2014. Therefore, the Board finds that, prior to April 14, 2014, the Veteran is entitled to a separate 20 percent rating for a torn meniscus with residual pain and effusion. See June 2014 VA examination report. See Diagnostic Code 5258. The Board next finds that for the appeal period from April 14, 2014 (date of meniscotomy) to June 26, 2019 (date of partial right knee replacement surgery), the Veteran is entitled to a 10 percent rating for residuals of a meniscotomy (see Diagnostic Code 5259). This is the maximum assignable under Diagnostic Code 5259 for post-operative cartilage removal. In sum, the Board finds that, for the appeal period prior to June 26, 2019, a rating in excess of 10 percent for right knee patellofemoral syndrome with osteoarthritis with painful limitation of motion is not warranted. For the appeal period prior to April 14, 2014, a separate 20 percent rating for a torn meniscus in the right knee is granted. For the appeal period from April 14, 2014 to September 30, 2019, a separate 10 percent rating for residuals of a right knee meniscectomy is warranted. Appeal Period Beginning June 26, 2019 The Veteran underwent a partial right knee replacement on June 26, 2019. The Agency of Original Jurisdiction (AOJ) awarded the Veteran a temporary total rating from June 26, 2019 to September 30, 2019 (approximately three months). However, the Board finds that the Veteran is entitled to a 100 percent rating for a full one-year period following the surgery pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5055. Under 38 C.F.R. § 4.71a, Diagnostic Code 5055 (under the rating criteria effective prior to February 7, 2021), replacement of either knee joint warranted a 100 percent evaluation for a one-year period following implantation of the prosthesis. Thereafter, a minimum rating is 30 percent warranted and a 60 percent evaluation is warranted if there are chronic residuals consisting of severely painful motion or severe weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability will be rated by analogy to Diagnostic Codes 5256, 5261 or 5262. The provisions of Diagnostic Code 5055 are applicable to partial knee replacements. Hudgens v. McDonald, 823 F.3d 630 (Fed. Cir. 2016). The Veteran is therefore entitled to a 100 percent rating for a partial right knee replacement for the full 12-month regulatory period under Diagnostic Code 5055. The Veteran has been granted a 100 percent rating for a portion of the period but is entitled to an additional period of 100 percent rating from October 1, 2019 to June 26, 2020. Next, the Board finds that the Veteran's right knee disability more nearly approximates a 60 percent rating following the one-year temporary total rating periodi. e., beginning June 27, 2020 In this regard, during an October 2019 VA knee examination, the Veteran reported an inability to fully flex or extend the right knee. He also indicated that, during flare-ups or in cold weather, he experienced additional loss of motion and stiffness. Upon range of motion testing and in consideration of the Veteran's pain during flare-ups, the examiner noted that right knee flexion would be restricted to only 30 degrees. Muscle strength testing was also slightly decreased in the right knee. The examiner did not specifically indicate the severity of the Veteran's residuals following his partial knee replacement, but it was noted that the Veteran had pain and stiffness. The Veteran was also noted to regularly use a cane to assist with ambulation. The Veteran's right knee disability also limited his ability to stand, walk, and climb stairs. The residual surgical scar was not painful or unstable. Based on this evidence, the Board finds that the Veteran's right knee condition warrants a 60 percent disability rating under Diagnostic Code 5055 for the period beginning June 26, 2020. As noted above, VA promulgated a final rule amending the regulations governing the rating musculoskeletal disabilities, including the knees, while the Veteran's claim was pending. 85 Fed. Reg. 76,453 (Nov. 30, 2020) (eff. Feb. 7, 2021). The Board must evaluate the Veteran's claim under both sets of schedular criteria beginning on the effective date of the amendment, applying the most beneficial to the Veteran. See Kuzma, 341 F.3d 1328 (Fed. Cir. 2003). The Board has considered the applicable post-amendment Diagnostic Codes and finds that the pre-amendment regulations are more advantageous. As discussed above, the Board has assigned a 60 percent rating under Diagnostic Code 5055 for the residuals of the Veteran's partial knee replacement. Note (3) of the amended rating criteria for Prosthetic Implants and Resurfacing explicitly limits the application of Diagnostic Code 5055 to total knee replacements. Therefore, under the amended rating criteria the Veteran's right knee would instead be evaluated under the other Diagnostic Codes applicable to the knee. The maximum single rating available under the post-amendment regulation is 60 percent under Diagnostic Code 5256, which is assigned for extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. There is no medical or lay evidence indicating the Veteran's right knee has worsened to the point of ankylosis. Further, the rating assigned under the pre-amendment Diagnostic Code 5055 is equal to the highest rating available to the Veteran under the post-amendment Diagnostic Codes. Neurological Tic (claimed as hiccups and muscular twitching) The Veteran is currently in receipt of a 10 percent rating for neurological tics impacting his head and neck. The Veteran's disability is rated by analogy as a compulsive tic under 38 C.F.R. § 4.124a, Diagnostic Code 8103. A mild tic is rated at 0 percent, a moderate tic is rated at 10 percent, and a severe tic is rated at 30 percent. The Note to Diagnostic Code 8103 directs the Board to assign a disability rating depending upon the frequency, severity, and muscle groups involved. The Board acknowledges that the words "mild," "moderate and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. In a May 2015 VA examination, the Veteran complained of eye twitching and hiccuping, which he could not control. The Veteran's tics were noted to have not respond ot medical treatment. VA treatment records include a March 2017 note where the Veteran was seen for facial spasms and vocal tics. During an October 2019 VA examination report, it was indicated that the Veteran had tics (of unknown etiology) impacting his head, throat, and mouth. Tics occurred approximately 40 times a minute. The examiner also indicated that the Veteran had fatigue due to his tics, which would impact his stamina in any type of job. The Veteran also submitted a statement in August 2020. At that time, he indicated that he had over 100 tics per minute. After reviewing the evidence of record, the Board finds that the service-connected tic disability is most analogous to a severe tic. The Veteran has competently reported having 40 to 100 tics per minute on a daily basis. The tics have been found to cause the Veteran to become fatigues, ultimately impacting his ability to function in a work environment. Therefore, the Board finds that the service-connected tics warrant a 30 percent rating. REASONS FOR REMAND Sinusitis Pursuant to the Board's decision herein, the Veteran is now service connected for chronic bronchitis. The Veteran maintains that his sinus condition may be related (i. e., caused or aggravated) to his now service-connected bronchitis disability. Medical records show that, during episodes of bronchitis, the Veteran has also been diagnosed with sinus infections. See e. g., April 4, 2011 VA treatment note. As such, an opinion should be obtained regarding whether the Veteran's sinusitis is secondary to the now service-connected bronchitis disability. The matter is REMANDED for the following actions: 1. Obtain a VA medical opinion regarding the Veteran's sinusitis disorder. The examiner must review all pertinent documents in the record. The examiner should provide the following: (a.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sinusitis is either caused or aggravated by his now service-connected chronic bronchitis disability. **Please note that for secondary service connection, "aggravation" need not be permanent in nature. See Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019). The examiner must provide separate findings and rationales relating to causation and aggravation. All opinions should be accompanied by a clear rationale. 2. Then, readjudicate the claim on appeal. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Casadei, 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.