Citation Nr: 22005233 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 10-07 909 DATE: February 1, 2022 ORDER Service connection for bunions, bilateral little toes is denied. Service connection for a neck disability is denied. An earlier effective date of July 20, 2007 for the increased 20 percent disability rating for service connected degenerative arthritis of the lumbosacral spine with intervertebral disc syndrome (lumbosacral disability), is granted. An effective date of April 24, 2009 for the award of an increased 40 percent disability rating for service connected lumbosacral disability is granted. A disability rating in excess of 20 percent prior to April 24, 2009 and in excess of 40 percent thereafter for service-connected lumbosacral disability is denied. An increased disability rating for service connected left hip strain is granted, with one 10 percent evaluation for painful limited motion (flexion) and a separate 10 percent evaluation on the basis of limited adduction of the thigh granted throughout the relevant appeal period. REMANDED Entitlement to service connection for bilateral eye condition, to include glaucoma, periorbital swelling, and meibomian gland dysfunction/dry eye syndrome is remanded. Entitlement to an increased rating for right lower extremity peripheral neuropathy and radiculopathy, currently with a noncompensable evaluation prior to May 8, 2019 and a 20 percent evaluation thereafter is remanded. Entitlement to a separate evaluation for left lower extremity radiculopathy is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that bunions of the bilateral little toes began during active service, or are otherwise related to an in-service injury or disease. 2. The evidence of record persuasively weighs against finding that the Veteran's neck disability began during active service, or is otherwise related to an in-service injury or disease. 3. The evidence of record demonstrates that as of July 20, 2007, less than one year prior to the Veteran submitting his claim for an increased rating, the Veteran's lumbosacral spine disability had worsened and manifested in muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. 4. Prior to April 24, 2009, the Veteran's lumbosacral spine disability manifested in pain, stiffness, muscle spasms, and limited range of motion, but not forward flexion of the thoracolumbar spine limited to 30 degrees or less or ankylosis. 5. Resolving all doubt in the Veteran's favor, from April 24, 2009, his lumbosacral spine disability manifested in symptoms consistent with forward flexion of the thoracolumbar spine 30 degrees or less, but not unfavorable ankylosis of the entire thoracolumbar spine. 6. The Veteran's left hip disability has manifested in pain and stiffness, but has not manifested in flexion limited to 30 degrees or less, extension limited to 5 degrees or less, or abduction lost beyond 10 degrees. CONCLUSIONS OF LAW 1. The criteria for service connection for bunions of the bilateral little toes are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a neck disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an effective date of July 20, 2007 for the award of the increased 20 percent disability rating for service connected lumbosacral disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.71a, DC 5242. 4. The criteria for an effective date of April 24, 2009 for the award of an increased 40 percent disability rating for service connected lumbosacral disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.71a, DC 5242. 5. The criteria for a disability rating in excess of 20 percent prior to April 24, 2009 and in excess of 40 percent thereafter for service connected lumbosacral disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.71a, DC 5242. 6. The criteria for an award of two 10 percent evaluations for service-connected left hip strain, on the basis of limited flexion and limited adduction and rotation have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.71a, DC 5251-5253. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1976 to February 1998. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs Regional Office (RO). In January 2021, the Veteran presented testimony on all of the issues here on appeal at a virtual Board hearing held before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. These matters were previously remanded by the Board for additional development in June 2017, May 2018, and June 2021. They have since been returned to the Board for further appellate review. The Veteran submitted VA Form 10182s: Decision Review Request: Board Appeal (Notice of Disagreement) that were received by VA in June 2021 and August 2021 disagreeing with June 2021 rating decisions denying an increased rating for posttraumatic stress disorder (PTSD) with major depressive disorder and a service connection for sleep apnea and compensation under 38 USC 1151 for adenocarcinoma prostate cancer. Those appeals will be subject to separate Board decisions under the modernized review system, also known as the Appeals Modernization Act (AMA). Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for bunions, bilateral little toes is denied. The Veteran asserts that he suffers from bunions on his bilateral little toes related to running and marching in boots during physical training in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of Tailor's bunions on the bilateral little toes, the evidence of record persuasively weighs against finding that the Veteran's current diagnosis began during service or is otherwise related to an in-service injury, event, or disease. The Veteran was provided with a VA examination of his feet in May 2019, at which time he was diagnosed with Tailor's bunion of the little toes. The Veteran reported developing the bunions during his military service due to running in jump boots in the 1970s until 1983, after which the military issued tennis shoes for running and physical training. He indicated that he was not sure if he was seen for his feet in service, but stated that his little toes continued to hurt him even with tennis shoes. He stated that he never followed up with podiatry, but that his toe bunions hurt with walking and that he trims them with razor blades once a month and uses over the counter gel pads to cushion his feet in his shoes. The May 2019 examiner provided an opinion that the Veteran's bunion condition was less likely than not incurred in or caused by his claimed in-service injury. She reasoned that the Veteran's service treatment records and post-military treatment records are silent for any contention relating to his bunions, and that per medical literature, including the internet information provided by the Veteran, the wearing of tight-fitting shoes may lead to bunions with symptoms of pain, swelling and redness arising during the wearing of the ill-fitting footwear, but not after the passage of several years. She made specific note that the Veteran's October 1997 retirement physical was silent for any foot contentions and the Veteran checked the box indicating no foot problems. She further cited to medical literature indicating that Tailor's bunion is easily diagnosed because the protrusion is visually apparent. The examiner's opinion is found to be probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes that at the June 2021 hearing, the Veteran testified that he went to the doctor in service for his feet, but they never did anything and just gave him some pain medicine. He also reported that post-service, he has told his doctor about having to shave off his calluses but that she has never scheduled him to have this done in-office. While the Veteran is competent to report symptoms of foot pain since service and his personal observations about calluses on his toes, the Board finds the probative value of these statements to be limited by their inconsistency with other evidence of record. The Veteran VA treatment records and private treatment records do not reflect any complaints or treatment for a foot or bunion condition. Additionally, with regard to the Veteran's service treatment records, he affirmatively denied experiencing foot trouble on Reports of Medical history in December 1991 and at the time of his retirement physical in October 1997. Further, the record includes reports of periodic medical examinations conducted throughout his more than twenty years of service which all note the Veteran's feet to be normal upon clinical evaluation. When the Veteran was seen on isolated incidents in February 1975 for a "twisted right foot" incurred while "playing ball" and in March 1987 for a swollen left foot with tenderness at the head of the 5th metatarsal with assessment of strain, no mention was made as to the presence of any bunions or toe abnormalities. As per the medical opinion provided by the VA examiner that Tailor's bunions are easily diagnosed because the protrusion is visually apparent, the Board finds that were such a condition present during the examinations of his feet in service, such would likely have been noted. The Veteran believes his bilateral Tailor's bunions are related to in-service injury from wearing ill-fitting boots. However, the Veteran in this case has not been shown to have the medical training or credentials to make such a determination concerning the etiology of a condition that the evidence demonstrates arose many years following his separation from service. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the opinion provided by the VA examiner. The most probative evidence is found to weigh against a finding that the Veteran's current bilateral Tailor's bunions of the little toes arose during or are otherwise related to his military service. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for Tailor's bunions of the little toes is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for a neck disability is denied. The Veteran asserts that he suffers from a neck disability, to include cervical strain, that he believes is related to carrying rucksacks during long road marches in service. At the January 2021 hearing, he testified that he noticed neck pain in service, more on the right than the left, and still has problems post-service. While the Veteran's service treatment records include extensive documentation of low back and knee pain, the only notation concerning a neck complaint is from May 1986 where the Veteran reported left neck pain without injury, and was found to have left trapezius muscle pain/tenderness. At the time of his October 1997 retirement physical examination, the Veteran did not report any complaints concerning his neck or spine. The Board concludes that, while the Veteran has a current diagnosis of cervical strain, the evidence of record persuasively weighs against finding that the Veteran's current diagnosis began during service or is otherwise related to an in-service injury, event, or disease. Pursuant to the Board's remand directives, the Veteran was provided with a VA examination pertaining to his cervical spine in August 2021. At that time, the examiner found that the Veteran had a current diagnosis of cervical strain, and noted the Veteran's report that he experienced an onset of symptoms during service due to having to do marches with a backpack, and has experienced neck pain since that time. The examiner stated an opinion that the Veteran's current neck pain is less likely than not related to an in-service event, reasoning that there are no records of ongoing care to the Veteran's neck or longitudinal history or evidence of ongoing neck pain. She remarked that there was one notation in the service treatment records of muscle pain over the trapezius area but no mention of neck pain at the separation examination or at a later examination in May 2010, when he also had a normal neck examination. The Board acknowledges that the examiner's notations of the dates of the service treatment records documenting trapezius pain and the retirement examination are inaccurate in terms of the years listed, but does not find such mistake to significantly impact the overall conclusion stated. The examiner found it noteworthy that the Veteran had a single instance in service where he complained of trapezius pain followed by no complaint of neck symptoms at the time of separation from service. While the Veteran is competent to report on his personally-experienced symptoms, the Board finds the credibility of his assertions of experiencing neck pain since service to be lessened by the fact that despite documentation of his reports of chronic low back and knee pain during service, there is no such mention of recurring or constant neck pain in the service treatment records. Additionally, while the claims file includes physical therapy records from Fox Army Medical hospital showing care for the low back and knee in the years following service, such records do not reflect complaints or treatment for the neck, other than a notation of a telephone call in June 2000 noting that the Veteran was admitted to the hospital for his chest, stomach, leg, and neck following a car wreck. VA and private treatment records associated with the file thereafter either are silent for complaints of neck pain or note that the neck was normal upon a review of systems until a May 2019 SportsMed note indicates that the Veteran was seeing a doctor, T.E., for his cervical spine. The Veteran has been given several opportunities to submit private treatment records and/or identify private treatment records that he wishes for VA to obtain on his behalf, including following the most recent Board remand, but he has not done so for these particular records concerning treatment for his cervical spine. The Veteran may truly believe that his current neck disorder is related to marches during service while carrying a heavy backpack. However, the Veteran has not been shown to have either the medical education or training necessary to provide a competent opinion on the etiology of his current disorder, particularly given the occurrence of an apparent intervening injury involving an automobile accident since service. Therefore, the most probative evidence of record is found to weigh against a finding that the current neck disability arose during or is otherwise related to service. As the evidence is persuasively against the claim, there is no doubt to resolve in the Veteran's favor. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. An award of service connection for a neck disability is denied. Increased Rating Claims Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that 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). Lumbosacral Spine 3. An earlier effective date of July 20, 2007 for the increased 20 percent disability rating for service-connected degenerative arthritis of the lumbosacral spine with intervertebral disc syndrome (lumbosacral disability) is granted. 4. An effective date of April 24, 2009 for the award of a 40 percent disability rating for service-connected lumbosacral disability is granted. 5. A disability rating in excess of 20 percent prior to April 24, 2009 and in excess of 40 percent thereafter for service-connected lumbosacral disability is denied. The Veteran is seeking an increased rating for his lumbosacral disability. He filed a claim for increase in September 2007, at which time he was in receipt of a 10 percent evaluation for the disability. In the April 2008 rating decision on appeal, the RO increased the evaluation to 20 percent, effective from September 6, 2007. The Veteran appealed the rating and in an August 2020 rating decision, during the pendency of the appeal, the RO granted a 40 percent evaluation effective from May 8, 2019. The Veteran's lumbosacral disability has been assigned a disability rating under DC 5242 of 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as "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." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. Effective February 7, 2021, the DCs pertaining to the lumbar spine were amended. For purposes of this decision, the applicable rating criteria for those DCs did not materially change. See 85 Fed. Reg. 76453 (Nov. 30, 2020, as corrected). In considering the evidence of record, the Board finds that the increased 20 percent disability rating granted by the RO in the appealed decision may be granted from an earlier effective date of July 20, 2007. The record includes a private physical therapy note from that date documenting the Veteran's report of increased back pain over the last month, and observing abnormal muscle tone and muscle spasm with decreased lumbar lordosis. As this represents a worsening of the Veteran's service-connected low back disability within the one-year period prior to his filing the claim for an increased rating in September 2007, it may serve as the effective date for the award of the increased evaluation. See 38 C.F.R. § 3.400(o)(2). While a June 2007 Fox Army hospital treatment record noted lumbar spasms of the paraspinal muscles on the right side, the spine was noted to exhibit a normal appearance. Thus, July 20, 2007 represents the earliest date that it is factually ascertainable from the record that the Veteran's low back disability manifested in muscle spasms severe enough to result in an abnormal spinal contour. Muscle spasms not resulting in abnormal spinal contour or abnormal gait is contemplated by a 10 percent disability rating under the General Rating Formula for Diseases and Injuries of the Spine and there is no evidence demonstrating that forward flexion of the thoracolumbar spine was limited to 60 degrees or less or combined range of motion of the thoracolumbar spine was limited to 120 degrees or less. The Veteran was provided with VA examination of his lumbosacral spine disability in February 2008. He reported low back and hip pain of an 8/10 severity, and stated that certain movements make it worse. He reported almost daily flareups, and stated that over the prior year, he was incapacitated for two days when he was unable to drive at all. He reported being able to walk half a mile and climb a few steps without difficulty, and reported that he can sit a while but has to get up and move around or becomes stiff. On physical examination, he demonstrated forward flexion of the thoracolumbar spine from 0-80 degrees, extension from 0-5 degrees, and bilateral lateral flexion and rotation from 0-15 degrees. Muscle spasms were evident with rotation. Private evaluation notes from February 2008 document that the Veteran was able to flex about 60 degrees at the waist and extend 15 degrees with pain more on flexion than extension. Lumbar spine films showed grade I spondylolisthesis at L4 on L5 and moderate degenerative disc disease. In considering the record, the Board finds that the weight of the evidence is persuasively against the assignment of a rating in excess of 20 percent for the lumbosacral spine disability prior to April 24, 2009. The Veteran's symptoms of muscle spasms and limited motion of the thoracolumbar spine to 60 degrees or less are specifically contemplated by the 20 percent criteria. Even when considering the Veteran's lay reports of additional symptoms & functional loss, the degree of additional limitation reflected by his statements is not found to result in symptoms more nearly approximated by the 40 percent criteria, which contemplates forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The Board acknowledges the Veteran's report at the February 2008 VA examination of almost daily flareups, and notes that no opinion has been provided as to the expected further degree of limited motion during such flareups. However, considering the passage of almost 14 years since that examination, the Board finds it highly unlikely that further remand in an attempt to obtain a retrospective opinion as to the additional range of motion lost during such flareups would result in an opinion that is anything more than speculative, and would only further delay adjudication of this matter. When considered in the context of the Veteran's report that he was able to walk half a mile without difficulty and description of severe symptoms rendering him unable to drive for only two during the prior year, the Board does not interpret his report as describing flareups of such duration or severity as would render his overall functional impairment more appropriately reflected by the 40 percent criteria. Resolving all doubt in the Veteran's favor, the Board finds that the increased 40 percent evaluation for the lumbosacral disability is warranted from an earlier effective date of April 24, 2009, rather than the May 2019 effective date currently assigned. A private treatment record from April 2009 documents that the Veteran described continued stiffness of his back, and was observed with range of flexion limited to 40 degrees. A plan was stated to perform injections following MRI, and to begin physical therapy with decompression post injections, with additional medication prescribed for severe pain. An August 2009 followup appointment record documented his reports that his back is very stiff when going from a sitting to standing position, particularly difficult in the morning and after sitting in a chair in the office. It was noted that on physical examination, he had very limited mobility in his lumbar spine because of guarding, and that he reported increased symptoms with extension and rotation at very few degrees of movement. MRI was reviewed and showed degenerative disc disease with a herniated nucleus pulposus lateralizing to the right. A series of injections was ordered, and the records indicate that he returned for lumbar and sacroiliac injections on a number of subsequent occasions. While flexion of the thoracolumbar spine limited to 40 degrees falls within the degrees of functional limitation contemplated by the 20 percent criteria (forward flexion of the thoracolumbar spine limited to greater than 30 degrees but not greater than 60 degrees), this objective evidence of additional limited motion demonstrating a worsening of the condition, in addition to the Veteran's descriptions of significant pain and stiffness in transitioning from sitting to standing, need for injections of pain medication in his spine, and observed significant guarding resulting in "very limited mobility in his lumbar spine" is found to describe an overall level of impairment comparable to that contemplated by the 40 percent criteria. While the Board is resolving all doubt in the Veteran's favor in finding that a 40 percent evaluation is warranted for his lumbosacral disability from April 24, 2009, the Board finds that the weight of the evidence is persuasively against an award of a rating in excess of 40 percent. At the March 2016 VA hip examination, the Veteran reported that he cannot bend over due to combined low back and hip pain. It was noted that at that time, he had walked three blocks to get to the clinic. The Veteran was provided with a VA examination of his back in May 2019, at which he reported regularly using a low back brace and cane, and stated that he cannot pick up things from the floor and that it is hard to bend due to pain. He reported that he experienced flare-ups lasting for 3-5 minutes if he moves wrong or gets out of bed fast. At that examination, he demonstrated forward flexion from 0-31 degrees. Pain was noted on examination and was noted to cause functional loss. At the January 2021 Board hearing, the Veteran reported that his low back pain sometimes gets to the point that he cannot do anything other than sit around and wait for the pain to ease from medications. He stated that he cannot pick up anything that is very heavy. The 40 percent criteria under the General Rating Formula contemplate disability resulting in forward flexion of the thoracolumbar spine limited to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Examination of the Veteran has never demonstrated that he suffers from ankylosis of the spine, and his lay descriptions do not describe a level of disability functionally comparable to unfavorable ankylosis as defined in the regulations. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence does not demonstrate that he has had any incapacitating episodes requiring bedrest prescribed by a physician, let alone having a total duration of at least 4 weeks over any 12-month period of the appeal. A higher rating under these provisions is therefore inapplicable. See 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. The Board notes that consideration of the availability of a higher rating based on the separate evaluation of any associated objective neurologic abnormalities per Note (1) to the General Rating Formula, including an increased rating for service-connected right lower extremity radiculopathy and a potential separate evaluation for left lower extremity radiculopathy is being addressed in the remand portion of this document, below. The evidence of record does not otherwise indicate the presence of other potentially neurologic abnormalities, such as bowel or bladder impairment. Left Hip 6. An increased disability rating for service connected left hip strain is granted, with one 10 percent evaluation for painful limited motion (flexion) and a separate 10 percent evaluation on the basis of limited adduction and rotation of the thigh granted throughout the relevant appeal period. The Veteran is seeking a higher rating for his left hip strain. He was originally granted service connection for left hip strain in a December 2011 rating decision, which assigned a 10 percent disability rating for painful motion of the hip with range of motion of the thigh limited to a noncompensable degree under DC 5251 (extension). The Veteran filed a supplemental claim for an increased evaluation for the left hip in January 2016. The RO continued the 10 percent disability rating for left hip strain in the March 2016 rating decision here on appeal. In a June 2020 rating decision, the RO decreased the rating for left hip strain based on limited extension to a noncompensable evaluation effective January 15, 2020, but instead assigned a 10 percent evaluation for left hip strain on the basis of limitation of adduction of the thigh effective from that same date. The Veteran has thus been in receipt of one 10 percent evaluation for his service-connected left hip disability throughout the relevant appeal period. In relevant part, limited motion of the thigh is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5250 to 5255. Under DC 5251, extension of the thigh limited to 5 degrees warrants a 10 percent rating. Under Diagnostic Code 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. Under Diagnostic Code 5253, impairment of the thigh limiting rotation such that one cannot toe-out more than 15 degrees with the affected leg or limitation of adduction such that the legs cannot be crossed warrants a 10 percent evaluation while limitation of abduction with motion lost beyond 10 degrees warrants a 20 percent evaluation. The Veteran was scheduled for a VA examination of his left hip in March 2016. At that time, the Veteran reported complaints of stiffness and pain in the left hip and low back with prolonged walking or standing. He reported that he can walk 200 yards before having to stop due to pain. He reported being unable to climb more than 1-3 stairs due to pain, and being unable to bend over due to a combination of low back and hip pain. The examination report indicates that the examiner was unable to test range of motion because the Veteran reported having to walk 3 blocks to the clinic and being in severe pain. It was noted that the Veteran was unable to flex the hip sufficiently to assess and that he could not perform the rest of the range of motion measurements due to pain. The Veteran's hip was noted as painful to light palpation anywhere in the lateral or posterior aspect. There was no reduction in muscle strength or ankylosis found. The Veteran was provided with an additional VA examination of his hips in January 2020. He reported experiencing worsening bilateral hip pain since his last examination in 2016, and use of antalgesic gel to the affected joints daily, as needed. The examination report indicates that the Veteran did not report flare-ups of the hip condition and notes that pain, weakness, fatigability, and incoordination do not significantly impact functional ability with repeated use over a period of time. On physical examination, range of motion of the left hip was measured from 0-90 degrees flexion, 0-15 degrees extension, 0-30 degrees abduction, 0-15 degrees adduction, 0-40 degrees external rotation, and 0-30 degrees internal rotation. It was noted that adduction was limited such that he could not cross his legs, and that pain was noted on all movements and causes functional loss. The Veteran was able to perform three repetitions of motion without additional limitation of motion. The examiner found that the Veteran's hip condition(s) had impacted his ability to perform occupational tasks, noting that due to right hip strain with limited flexion and extension as well as left hip strain, the Veteran reported difficulty sitting, standing, walking, and lifting. The examiner noted that the Veteran was a retired VA claims assistant and would have lost 0-1 week's work time over the last 12 months from his hip disabilities. The Board notes that at this examination, the Veteran indicated that he had undergone right hip injection 8 months prior with little to no relief, and reported that his right hip was worse than his left. He reported being unable to sleep on his right side, and to have difficulty with walking, standing, sitting, load bearing, and exercise. Additionally, range of motion of the right hip was demonstrated to be significantly more limited than the left (with documented range of motion of the right hip of 0-20 degrees flexion, 0-10 degrees extension, 0-15 degrees abduction, 0-15 degrees adduction, 0-15 degrees external rotation, and 0-15 degrees internal rotation. The Veteran was also noted to regularly use a cane as an assistive device due to his right hip strain with limitation of flexion and extension of the right hip. In considering the evidence of record, and when resolving doubt in the Veteran's favor, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's service-connected left hip disability warrants a rating in excess of the single 10 percent evaluation currently assigned throughout the relevant appeal period. Specifically, an award of a 10 percent disability rating under DC 5252 for painful flexion and a separate 10 percent disability rating under DC 5253 for limitation of adduction and rotation is found warranted. Two separate 10 percent evaluations may be assigned here under separate diagnostic codes without impermissible pyramiding, as the Veteran's condition has been observed to limit his ability to adduct the thigh to the point he cannot cross his legs, and the hip pain he experiences on prolonged use is being considered in the context of finding that his functional ability to flex the thigh is comparable to flexion limited to 45 degrees. The Board finds, however, that the evidence of record persuasively weighs against the award of a rating in excess of two 10 percent ratings for the left hip disability at any point during the relevant appeal period. While consideration has been given to the fact that range of motion testing was unable to be performed at the time of the March 2016 examination due to pain, it is noted that such was observed immediately following the Veteran's having reportedly walked three blocks, thus demonstrating an ability to use the hip, and no functional ankylosis. Additionally, at that time, the record reflects that the Veteran continued to drive and work full-time in a sedentary job. The Board notes that the January 2020 VA examiner indicated that sitting and driving require at least 50-60 degrees of hip flexion. It is unfortunate that additional examination was not conducted sooner-in-time to the March 2016 examination as might provide additional evidence of range of motion measurements of the left hip/thigh historically, but as it stands, there is no evidence available demonstrating left hip flexion limited to 30 degrees, 20 degrees, or 10 degrees at any point during the relevant appeal period. Private treatment records obtained pursuant to the Board's remand directives did not demonstrate continuing evaluation or document range of motion measurements for the left hip during the relevant appeal period, and there is no indication that additional attempts to further develop the record might result in the discovery of such evidence. Rather, private medical records from slightly before and during the year prior to the Veteran's request for an increased rating note that internal rotation was limited by tenderness and pain, and indicate that he was provided with anesthetic hip injections. There is no mention of limited flexion or extension. Additionally, on the one instance when range of motion testing was conducted, at the January 2020 VA examination, the Veteran was shown to retain the ability to flex the left thigh to 90 degrees and extend it to 15 degrees. Considering the Veteran's statement at that time, that his hip symptoms had worsened since the 2016 examination, it is reasonable to conclude that he retained a similar if not greater degree of flexion and extension at that earlier time. Therefore, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation is not found to result in symptoms more nearly approximating flexion limited to 30 degrees or less, limited abduction of the thigh with motion lost beyond 10 degrees, or extension limited to 5 degrees. The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, as the evidence does not demonstrate ankylosis of the hip, flail joint of the hip, or impairment of the femur, DCs 5250, 5254, and 5255 are not for application. In conclusion, the Board finds that the evidence of record supports an award of two separate 10 percent evaluations for the left hip disability under Diagnostic Codes 5252 and 5253, but persuasively weighs against assignment of separate or higher ratings. As the evidence of record persuasively weighs against an additional and/or higher award, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). As a final matter, the Board has considered whether the issue of entitlement to a TDIU has been raised in connection with the Veteran's claims for increased disability ratings for his lumbosacral and left hip disabilities. The United States Court of Appeals for Veterans Claims (Court) has held that entitlement to a TDIU may be considered part and parcel of an increased rating claim where a claimant or the evidence reasonably raises the possibility that the relevant disability causes or contributes to a claimant's unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In the present case, the evidence demonstrates that the Veteran completed four years of college with a Bachelor of Science degree and worked as a Veterans Service Representative with VA for approximately 15 years before retiring in 2017. The Veteran filed an application for a TDIU in June 2021, on which he asserted that his PTSD with anxiety and depression prevents him from securing and following any substantially gainful occupation. There has been no assertion, and the record does not otherwise reasonably raise the possibility that the Veteran's lumbosacral and/or left hip disabilities caused or contribute to his claimed unemployability. In so finding, the Board recognizes the finding of the January 2020 VA examiner that the Veteran's hip disabilities impact his ability to perform certain occupational tasks, and that due to right hip strain with limited flexion and extension as well as left hip strain, the Veteran reported difficulty with sitting, standing, walking, and lifting. However, by the Veteran's subjective reports and objective range of motion testing performed at the time of the examination, the right hip impairment was shown to be significantly worse than the left, and the Board concludes it is therefore most likely responsible for the functional impairment relating to his ability to perform occupational tasks. Therefore, the claim for a TDIU is found to be separate from the present appeal seeking increased ratings for service-connected lumbosacral and left hip disabilities, and is not found to be before the Board in the present appeal. REASONS FOR REMAND While the Board regrets any additional delay, further development is found warranted with regard to the below issues, in keeping with due process. 1. Entitlement to service connection for bilateral eye condition, to include glaucoma, periorbital swelling, and meibomian gland dysfunction/dry eye syndrome is remanded. In the June 2021 remand, the Board instructed that a supplemental medical opinion was needed in part because it was unclear whether prior medical opinions had considered evidence of meibomian dysfunction in September 2006. A supplemental opinion was provided in October 2021. While the "evidence comments" with the report indicates consideration of the September 2006 and November 2006 ophthalmology clinical records pertaining to meibomian gland disease, the rationale provided in the opinion itself is that the Veteran's dry eye syndrome is less likely than not related to service because the symptoms did not start until 17 years following service (approximately 2015) and is due to meibomian gland dysfunction (MGD). While the opinion states a conclusion that MGD is not the result of previous chalazion events which have resolved and no longer are present in either eye, there is no explanation as to the typical course of MGD or whether later recurrences of symptoms could be considered part of a single long-term dysfunction (e.g. the likelihood that eyelid symptoms of blepharitis and chalazion represent symptoms of MGD and whether the current dry eyes/MGD is a continuation of an eye disorder arising during service). On remand, additional opinion and medical explanation is needed to inform the Board's lay adjudication of this matter. 2. Entitlement to an increased rating for right lower extremity peripheral neuropathy and radiculopathy, currently with a noncompensable evaluation prior to May 8, 2019 and a 20 percent evaluation thereafter is remanded. As noted in a prior Board remand, a claim seeking a higher disability rating for a spine disability is also considered to include a claim for assignment of separate and/or higher evaluations for associated neurological abnormalities. See General Rating Formula for Diseases and Injuries of the Spine, Note (1). In the Board's June 2021 Remand, it was noted that at the May 2019 VA examination of the spine, the examiner made a selection that the Veteran's right lower extremity sciatic involvment was moderate, out of options for mild, moderate, and severe, whereas the rating schedule's criteria for evaluating levels of sciatic nerve involvement contemplate mild, moderate, moderately severe, or severe incomplete paralysis. The remand directed that an addendum opinion be obtained to clarify the severity of the Veteran's radiculopathy, with a rationale explaining what sort of symptoms/manifestations the clinician would expect to be present for the next higher-level of severity. Rather than obtaining an addendum opinion clarifying the level of sciatic nerve involvement present at the time of the May 2019 examination, the Veteran was provided with an additional examination in August 2021 to assess the current severity and manifestations of the Veteran's right lower extremity radiculopathy. The examination report from August 2021 reflects fewer objective manifestations than did the May 2019 examination, and the examiner opined that this reflected mild incomplete paralysis of the sciatic nerve, because there was no objective findings such as motor deficit, sensory loss, or diminished reflexes. Unfortunately, this does not address the inadequacy identified by the Board in the May 2019 examination, and a supplemental or addendum opinion is needed. 3. Entitlement to a separate evaluation for left lower extremity radiculopathy is remanded. Upon further review of the file, the Board additionally notes that during the relevant appeal period, private medical records at times mention radiation of back pain down the left side (see November 2013 SportsMed treatment note documenting report of constant left side pain radiating down to leg and below the calf, MRI showing paracentral disc protrusion on the left with moderate spinal stenosis, and recommendation for epidural injection on the left) and include notations of abnormal objective findings affecting the left lower extremity (see July 2007 private physical therapy note with positive SLR test on the left and decreased muscle strength bilaterally; March 2008 SportsMed record noting positive bilateral SLR tests and abnormal reflexes at the bilateral knees and abnormal strength tone; April 2009 SportsMed record noting positive bilateral SLR tests and diminished deep tendon reflexes at the bilateral knees and ankles). On remand, a retrospective medical opinion is found needed to address whether such findings reflect the presence of left lower extremity neurological abnormality associated with the Veteran's lumbosacral disability. The matters are REMANDED for the following action: 1. Return the claims file to the optometrist who performed the October 2021 eye examination, or if unavailable to another suitably qualified medical professional, for an addendum opinion concerning the etiology of the Veteran's meibomian gland dysfunction. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's meibomian gland dysfunction arose during or is otherwise related to his active service. A clear rationale must be provided for any and all conclusions stated. The examiner is specifically asked to address the likelihood that eyelid symptoms noted in the Veteran's service treatment records (dermatological abnormality on lower right eyelid by nose in June 1986 and trace blepharitis on both lower lids in March 1997) represent early manifestations of MGD which continued on an intermittent basis after service. An explanation of the typical course of MGD and whether later recurrences of symptoms could be considered part of a single long-term dysfunction process would be of significant help to the lay adjudicator in understanding the disease process. 2. Refer the claims file to a suitably qualified medical professional for a retrospective medical opinion concerning the presence and severity of any right and left lower extremity sciatic radicular symptoms associated with the Veteran's lumbosacral disability during the relevant appeal period (July 2007 to present). The clinician is asked to state an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's lumbosacral disability manifested in left lower extremity sciatic radiculopathy at any point during the relevant appeal period. The Board notes that during the relevant appeal period, private medical records at times mention radiation of back pain down the left side (see November 2013 SportsMed treatment note documenting report of constant left side pain radiating down to leg and below the calf, MRI showing paracentral disc protrusion on the left with moderate spinal stenosis, and recommendation for epidural injection on the left) and include notations of abnormal objective findings affecting the left lower extremity (see July 2007 private physical therapy note with positive SLR test on the left and decreased muscle strength bilaterally; March 2008 SportsMed record noting positive bilateral SLR tests and abnormal reflexes at the bilateral knees and abnormal strength tone; April 2009 SportsMed record noting positive bilateral SLR tests and diminished deep tendon reflexes at the bilateral knees and ankles). For any left or right lower extremity sciatic radiculopathy present at any point during the relevant appeal period, the clinician is asked to indicate whether the Veteran's radiculopathy can best be characterized as mild, moderate, moderately severe, or severe. In particular, the clinician's attention is directed to the objective findings documented at the May 2019 VA examination of the low back as well as abnormal muscle strength and reflex testing noted in private SportsMed treatment records. If it is the clinician's opinion that the Veteran experienced distinct periods of time during which the radiculopathy changed in severity, they should so state. A clear rationale should be provided for any conclusion stated. If possible, the examiner should indicate what sort or extent of symptoms/manifestations they would expect to see for the next-higher level of severity. If an opinion cannot be rendered without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. After completing remand directives 1 and 2, review the opinions provided to ensure they are fully compliant with these remand directives. Obtain addendum opinion(s) as necessary. 4. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the Veteran's claims for entitlement to service connection for bilateral eye condition, to include glaucoma, periorbital swelling, and meibomian gland dysfunction/dry eye syndrome, entitlement to an increased rating for right lower extremity peripheral neuropathy and radiculopathy, currently with a noncompensable evaluation prior to May 8, 2019 and a 20 percent evaluation thereafter is remanded, and entitlement to a separate compensable evaluation for left lower extremity radiculopathy. If any of the appeals remain denied, issue the Veteran a supplemental statement of the case and allow him an opportunity to respond before returning the appeal to the Board, if in order. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, 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.