Citation Nr: 22005351 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 15-30 201 DATE: February 1, 2022 ORDER Entitlement to service connection for bilateral radiculopathy of the upper extremities is denied. Entitlement to service connection for bilateral radiculopathy of the lower extremities is denied. Entitlement to service connection for a bilateral hip disability is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to an initial 30 percent rating for posttraumatic stress disorder (PTSD) prior to October 27, 2020 is granted. Entitlement to an initial rating in excess of 10 percent for right ankle strain is denied. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to a rating in excess of 10 percent for residual fibromatosis, right foot, prior to April 13, 2015, and a rating in excess of 10 percent for residual fibromatosis, left foot, prior to April 13, 2015, now rated as 50 percent disabling as combined bilateral plantar fasciitis/fibromatosis, is remanded. Entitlement to an initial compensable rating prior to April 13, 2015 and in excess of 10 percent thereafter for scars is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran has had bilateral radiculopathy of the upper extremities at any time during or approximate to the pendency of the claim. 2. The evidence of record persuasively weighs against finding that the Veteran has had bilateral radiculopathy of the lower extremities at any time during or approximate to the pendency of the claim. 3. The Veteran's bilateral hip disability is not secondary to service-connected disabilities and is not otherwise related to an in-service injury or disease. 4. The Veteran's left shoulder disability is not secondary to service-connected disabilities and is not otherwise related to an in-service injury or disease. 5. The severity, frequency, and duration of the Veteran's PTSD symptoms more closely approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but no higher, prior to October 27, 2020. 6. The Veteran's right ankle strain is productive of "moderate" limitation of motion (dorsiflexion and plantar flexion), when considering pain and other factors of functional loss. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral radiculopathy of the upper extremities are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for bilateral radiculopathy of the lower extremities are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 3. The criteria for service connection for a bilateral hip disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a left shoulder disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to an initial rating of 30 percent but no higher prior to October 27, 2020 for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 6. The criteria for entitlement to an initial rating in excess of 10 percent for right ankle strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1973 to February 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The appeal was previously before the Board in August 2018, when it was decided in part and remanded in part. In a September 2021 rating decision, the RO awarded an increased 100 percent evaluation for the Veteran's PTSD effective October 27, 2020. As the Veteran is in receipt of the highest schedular rating from October 27, 2020, entitlement to an increased rating for PTSD from this date is moot. However, as the 10 percent rating assigned prior to October 27, 2020 is less than the maximum benefit allowed under VA law and regulations, the claim for an increased rating prior to October 27, 2020 remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). SERVICE CONNECTION 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). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for bilateral radiculopathy of the upper extremities 2. Entitlement to service connection for bilateral radiculopathy of the lower extremities Issues 1-2: The Veteran contends he has bilateral radiculopathy of the upper and lower extremities that is related to service, to include to service-connected disabilities. See June 2012 Veteran's statement. 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, or that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of bilateral radiculopathy of the upper and lower extremities and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In making this determination, the Board has considered the case of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. On July 2012 VA examination, the Veteran reported weakness in his hands and cramp-like sensations in his feet, and he denied numbness, "electric sensation," and radicular symptoms in his extremities. Nerve testing was normal, and no diagnosis was made at that time. The examiner noted there was no clinical evidence of upper and lower extremity radiculopathy and/or peripheral neuropathy. On September 2012 VA examination, the Veteran did not have radicular pain or other signs or symptoms of radiculopathy. The November 2020 VA examiner evaluated the Veteran and also determined that he did not have radicular pain or other signs or symptoms of radiculopathy in any of his extremities. Further, despite consistent treatment for many years, VA treatment records do not contain a diagnosis of bilateral radiculopathy of the upper or lower extremities. Muscle strength, reflex, and sensory testing were all normal. The Board acknowledges that the Veteran submitted a November 2020 private medical opinion that reported the Veteran had diagnoses of peripheral neuropathy of the upper and lower extremities. However, it is unclear whether the doctor examined the Veteran, and the opinion simply listed the diagnoses and did not provide medical support in the way of diagnostic testing; therefore, the Board does not find it probative. While the Veteran believes he has a current diagnosis of bilateral radiculopathy of the upper and lower extremities, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The Board finds that the evidence of record, as well the VA examination reports, is of more probative and persuasive value than the Veteran's contention and the private medical statement. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the preponderance of the evidence weighs against a finding that he has bilateral radiculopathy of the upper and lower extremities. As the preponderance of the evidence is against the claims, the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a bilateral hip disability The Veteran contends his hip bilateral disability is related to service, or, alternatively, due to his service-connected disabilities. See June 2012 Veteran's statement. 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, or that is proximately due to or the result of or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of bilateral iliopsoas tendonitis, and evidence shows that he complained of hip pain during service, the preponderance of the evidence weighs against finding that the Veteran's bilateral iliopsoas tendonitis began during service or are otherwise related to an in-service injury, event, or disease, or that it is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A review of the Veteran's service records document one complaint of hip pain. See April 1978 STRs. VA treatment records show the Veteran was not diagnosed with a hip disability until his June 2021 VA examination. On June 2021 VA examination, the examiner opined that bilateral iliopsoas tendonitis were less likely than not incurred in or caused by service, to include his complaint of hip pain. In this regard, the examiner noted the Veteran's complaint during service resolved without complication, and that there was no evidence in his service treatment records of treatment, medical followup, or signs or symptoms of iliopsoas tendonitis. The examiner further noted that none of the Veteran's examinations during service noted hip disability, and that his hip disability dated to more recent years. Further, the June 2021 VA examiner opined that the Veteran's bilateral iliopsoas tendonitis was less likely than not proximately due to, the result of, or aggravated by service-connected disabilities. The rationale was that medical literature did not support an etiological link between iliopsoas tendonitis and the Veteran's service-connected disabilities, and that the disabilities have different pathophysiological or biomechanical processes from iliopsoas tendonitis. The examiner's opinions are probative because they are based on an accurate medical history and provide explanations that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges that the Veteran submitted a November 2020 private medical opinion that stated the Veteran has "severe musculoskeletal diseases" that "are more probable than not secondary to his military performance." This opinion does not specifically address the Veteran's bilateral hip disability. However, the opinion is conclusory and does not provide any rationale, nor is it clear whether the doctor examiner the Veteran or his medical records; therefore, the Board does not find it probative. After reviewing all the pertinent evidence of record, the Board finds that the preponderance of the evidence is against the claim for service connection for a bilateral hip disability. The only adequate medical opinions to address the medical relationship, if any, between the Veteran's bilateral hip disability and active service and his bilateral hip disability and service-connected disabilities weigh against the claim. The June 2021 VA opinions considered all the evidence of record and opined that the Veteran's bilateral hip disability was not related to service, nor was it proximately due to, the result of, or aggravated by service-connected disabilities. The Board finds that the opinions constitute probative evidence on the medical nexus question, based on a review of the Veteran's documented medical history, assertions, and physical examination. The opinions provided clear rationale based on accurate discussions of the evidence of record, to include consideration of in-service complaints of pain, as well as the Veteran's lay opinion. Prejean v. West, 13 Vet. App. 444 (2000). The Board also notes that the Veteran can attest to that which he is competent to observe, such as symptoms of pain, but he is not competent to provide a medical diagnosis of a bilateral hip disability or relate any symptoms to service or service-connected disabilities. The Board acknowledges that the Veteran is competent to give evidence about what he experienced. Layno v. Brown, 6 Vet. App. 465 (1994). However, competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). While the Veteran attributes his bilateral hip disability to service or service-connected disabilities, it does not necessarily follow that there is a relationship between a current hip disability and service, or between a current hip disability and service-connected disabilities. The Board finds that the contemporaneous in-service evidence of record, as well the June 2021 VA opinions, are of more probative and persuasive value than the Veteran's contention and the private statement. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the preponderance of the evidence weighs against finding that a bilateral hip disability is related to active service, and that it is proximately due to, the result of, or aggravated by service-connected disabilities. As the preponderance of the evidence is against the claim for service connection for a bilateral hip disability, the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a left shoulder disability The Veteran contends his left shoulder disability is related to service, or, alternatively, due to his service-connected disabilities. See June 2012 Veteran's statement. 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, or that is proximately due to or the result of or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of left shoulder tendonitis/impingement syndrome status post arthroscopy, the preponderance of the evidence weighs against finding that the Veteran's left shoulder disability began during service or is otherwise related to an in-service injury, event, or disease, or that it is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A review of the Veteran's service records reflect a complaint of a shoulder sprain, but it is unclear which shoulder was affected. See April 1975 STRs. VA treatment records show the Veteran was not diagnosed with a left shoulder disability until February 2018, so decades after his separation from service. See VA treatment records. While the Veteran is competent to report having experienced symptoms of left shoulder pain since service, he is not competent to provide a diagnosis in this case or determine that any symptoms were manifestations of his current left shoulder disability. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). On February 2019 VA examination, the examiner noted left shoulder tendonitis/impingement syndrome status post arthroscopy, but did not provide an etiological opinion. One June 2021 VA examination, the examiner opined that a left shoulder disability was less likely than not incurred in or caused by service, to include the notation of shoulder injury in service. In this regard, the examiner noted the Veteran's service treatment records are silent for left shoulder tendonitis/impingement syndrome during service, and that there is no clinical evidence of treatment, medical followup, or signs or symptoms of his current left shoulder disability during service. The examiner noted the Veteran's left shoulder disability dated to recent years. Further, the June 2021 VA examiner opined that the Veteran's left shoulder disability was less likely than not proximately due to, the result of, or aggravated by service-connected disabilities. The rationale was that medical literature did not support an etiological link between left shoulder tendonitis/impingement syndrome and the Veteran's service-connected disabilities, and that the disabilities have different pathophysiological or biomechanical processes from left shoulder tendonitis/impingement syndrome. The examiner's opinions are probative because they are based on an accurate medical history and provide explanations that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes the Veteran submitted a November 2020 private medical opinion that stated the Veteran has "severe musculoskeletal diseases" that "are more probable than not secondary to his military performance." This opinion fails to specifically address the Veteran's left shoulder. However, the opinion is conclusory and does not provide a supporting rationale, nor does it indicate whether the doctor examiner the Veteran or reviewed his medical records; therefore, the Board finds it lacks probative value. After reviewing all the pertinent evidence of record, the Board finds that the preponderance of the evidence is against the claim for service connection for a left shoulder disability. The only adequate medical opinions to address the medical relationship, if any, between the Veteran's left shoulder disability and active service and his left shoulder disability and service-connected disabilities weigh against the claim. The June 2021 VA opinions considered all the evidence of record and opined that the Veteran's left shoulder disability was not related to service, nor was it proximately due to, the result of, or aggravated by service-connected disabilities. The Board finds that the opinions constitute probative evidence on the medical nexus question, based on a review of the Veteran's documented medical history, assertions, and physical examination. The opinions provided clear rationale based on accurate discussions of the evidence of record, to include consideration of in-service complaints of pain, as well as the Veteran's lay opinion. Prejean v. West, 13 Vet. App. 444 (2000). The Board also notes that the Veteran can attest to that which he is competent to observe, such as symptoms of pain, but he is not competent to provide a medical diagnosis of a left shoulder disability or relate any symptoms to service or service-connected disabilities. The Board acknowledges that the Veteran is competent to give evidence about what he experienced. Layno v. Brown, 6 Vet. App. 465 (1994). However, competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). While the Veteran attributes his left shoulder disability to service or service-connected disabilities, it does not necessarily follow that there is a relationship between a current left shoulder disability and service, or between a current left shoulder disability and service-connected disabilities. The Board finds that the contemporaneous in-service evidence of record, as well the June 2021 VA opinions, are of more probative and persuasive value than the Veteran's contention and the private opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board finds that the preponderance of the evidence weighs against finding that a left shoulder disability is related to active service, and that it is proximately due to, the result of, or aggravated by service-connected disabilities. As the preponderance of the evidence is against the claim for service connection for a left shoulder disability, the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned specific diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), the U.S. Court of Appeals for Veterans Claims (Court) distinguished appeals involving a Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Accordingly, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection, and consideration of the appropriateness of "staged ratings" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) or, as here, additional staged ratings, is required. 5. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder prior to October 27, 2020 The Veteran contends a higher rating is warranted for his service-connected PTSD, rated as 10 percent disabling prior to October 27, 2020. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating higher than 10 percent prior to October 27, 2020. The Board concludes that the Veteran's symptoms approximated the symptoms associated with a 30 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 30 percent rating, and no higher, prior to October 27, 2020. In relevant part, the General Rating Formula for Mental Disorders provides the following: A 0 percent rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress cause occupational and social impairment, or for symptoms controlled by continuous medication. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. On November 2010 VA examination, the Veteran denied current mental health treatment, but reported symptoms of insomnia, irritability, nightmares, disturbing dreams, reliving military life in his dreams, and fatigue in the mornings. He stated the symptoms occurred almost daily for the past three years and were severe. The examiner noted the condition was chronic and stable. The examination report stated the Veteran's social relations were "fine," and that he worked daily and had been at the same job for more than 20 years. He also helped with household chores and went on outings with his family. However, the examination report also stated that the Veteran was not taking care of his medical conditions. On an April 2015 VA Disability Benefits Questionnaire (DBQ), the examiner noted the Veteran's PTSD was in full remission. The examiner indicated that a mental condition had been formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran reported occasional mild sleep difficulties that resolved with herbal tea, but denied any mental health treatment or other symptoms. On an October 2020 VA DBQ, the examiner opined the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in understanding complex commands, disturbances of motivation and mood, impaired impulse control, spatial disorientation, and disorientation to time or place. The examination report also notes that the Veteran visual hallucinations in the form of seeing dark shadows for the past 10 years. The examiner noted that the Veteran's symptoms had worsened. This examination was the basis for the Veteran's increased rating to 100 percent for his PTSD, effective October 27, 2020. Here, on review of the record, the Board finds that the disability picture presented by the Veteran's PTSD prior to October 27, 2020 is more accurately reflected by a 30 percent rating. In this regard, the Board notes that the October 2010 VA examination reflected that the Veteran reported some PTSD symptoms, including sleep impairment. VA outpatient treatment reports show that the Veteran's mental health symptoms prior to October 27, 2020 were described as manageable and tolerable, but he also reported flashbacks, nightmares, depression, and irritability. See, e.g., June 2010 and July 2013 VA treatment records. While the Veteran's reported symptoms are not all directly listed in the 30 percent rating in the General Rating Formula for Mental Disorders, the Board makes a finding of fact that these symptoms are analogous to the 30 percent rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board finds the preponderance of the evidence of record supports a 30 percent rating for his PTSD prior to October 27, 2020. The Board further finds that the preponderance weighs against a rating in excess of 30 percent prior to October 27, 2020. In this regard, the Board notes that the overall record does not show that the Veteran had flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships, or other symptoms reflective of a higher 50 percent rating. The Veteran reported typical, supportive familial relationships during this time, and had long-term employment at a stable, full-time job. The Board has considered the level of impairment contemplated by the various levels delineated in the rating schedule and found that the evidence indicates that the overall level of disability prior to October 27, 2020 most nearly approximates a 30 percent rating. The Board has considered the lay and medical evidence of the occupational and social impairment caused by all symptoms of the disability. The Board finds that the Veteran's impairment prior to October 27, 2020 is contemplated by a 30 percent rating when considering the frequency, severity, and duration of these symptoms. 6. Entitlement to an initial rating in excess of 10 percent for right ankle strain The Veteran contends a higher rating is warranted for his service-connected right ankle strain, currently rated as 10-percent disabling. 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). The Veteran has been assigned a 10 percent rating for his right ankle under Diagnostic Code (DC) 5271. This code provides for a 10-percent rating for moderate limited motion, and a maximum 20 percent rating for marked limited motion. 38 C.F.R. § 4.71a. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a , at Plate II. The words "moderate" and "marked" are not defined, and VA must evaluate all evidence to arrive at an equitable and just decision. See 38 C.F.R. §§ 4.2, 4.6. On September 2012 VA examination, the Veteran reported mild right ankle pain. He had plantar flexion to 45 degrees or greater, with objective evidence of painful motion beginning at 40 degrees, and dorsiflexion to 20 degrees or greater, with objective evidence of painful motion beginning at 15 degrees. After repetitive-use testing, he had plantar flexion to 45 degrees or greater and dorsiflexion to 20 degrees or greater. Functional loss in the form of interference with sitting, standing, and weight-bearing was noted. On April 2015 VA examination, the Veteran reported his right ankle pain had increased recently. He stated he experienced flare-ups and functional impairment upon prolonged ambulation and standing. Range of motion testing showed plantar flexion to 35 degrees and dorsiflexion to 15 degrees, with pain with weightbearing and localized tenderness to the lateral aspect of the right ankle. The examiner noted that ankle instability was suspected. On November 2020 VA examination, the Veteran reported ankle pain treated with over-the-counter pain medication as needed. He also reported flareups occurring once per week and lasting less than an hour, as well as functional impairment in the form of poor tolerance for prolonged ambulation or standing activities. Range of motion testing showed dorsiflexion to 20 degrees and plantar flexion to 40 degrees, with pain noted. He was able to perform repetitive-use testing with no additional loss of function or range of motion. The examiner noted that during a flareup, dorsiflexion was limited to 15 degrees and plantar flexion to 35 degrees. There was also objective evidence of mild localized tenderness or pain on palpation at the lateral aspect of the ankle. No joint instability or other symptoms were noted. The examiner specifically noted there was no objective evidence of right ankle pain when non-weightbearing, and passive range of motion results were the same as for active range of motion. After a review of the record, including the Veteran's outpatient medical records, the Board finds the overall probative evidence of record shows right ankle ranges of motion are generally approaching full, such that he demonstrates at most a "moderate", not "marked" limitation of motion under DC 5271. At its worst, there was right ankle dorsiflexion to 15 out of 20 degrees and plantar flexion to 35 out of 45 degrees. Taken as a whole, and even with consideration of the pain the Veteran experiences, the findings more closely approximate moderate limitation of motion without additional compensable functional loss. See 38 C.F.R. §§ 4.40, 4.45, 4.49; DeLuca v. Brown, 8 Vet. App. 202 (1995). For instance, none of the VA examiners noted the Veteran had swelling or weakened movement. Thus, a higher initial rating of 20 percent under DC 5271 is not shown at any stage of the appeal. The Board has considered other Diagnostic Codes, but a rating in excess of 10 percent is also not warranted under the rating criteria of other applicable Diagnostic Codes. The record shows that the Veteran does not have ankylosis of the right ankle (DC 5270), ankylosis of the subastragalar or tarsal joint (DC 5272), malunion (DC 5273), astragalectomy (DC 5274), or impairment of the tibia or fibula (DC 5262). The Board has considered the level of impairment contemplated by the various levels delineated in the rating schedule and found that the evidence indicates that the overall level of disability most nearly approximates the current 10 percent rating. The Board has considered the lay and medical evidence functional impairment caused by all symptoms of the disability. The Board finds that the Veteran's impairment is contemplated by the current 10 percent rating. REASONS FOR REMAND 1. Entitlement to service connection for a back disability is remanded. The Veteran contends his back disability is related to service, or, alternatively, due to service-connected disabilities. See June 2012 Veteran's statement. The Board cannot make a fully-informed decision on this issue, because no VA examiner has opined whether the Veteran's back disability, currently diagnosed as arthritis of the lumbar spine, is secondary to his service-connected disabilities. In this regard, the Board notes the November 2020 VA examiner opined that the Veteran's arthritis of the lumbar spine is less likely than not proximately due to, the result of, or aggravated by service-connected right ankle strain and residual bilateral fibromatosis plantar region. However, the Veteran has a number of other service-connected disabilities that were not addressed. Therefore, an addendum opinion is needed to fully address the Veteran's contention that his low back disability is due to his service-connected disabilities. 2. Entitlement to a rating in excess of 10 percent for residual fibromatosis, right foot, prior to April 13, 2015, and a rating in excess of 10 percent for residual fibromatosis, left foot, prior to April 13, 2015, now rated as 50 percent disabling as combined bilateral plantar fasciitis/fibromatosis is remanded. 3. Entitlement to an initial compensable rating prior to April 13, 2015 and in excess of 10 percent thereafter for scars is remanded. Issues 2-3: The Veteran seeks higher ratings for his service-connected bilateral plantar fasciitis/fibromatosis and scars associated with residuals fibromatosis plantar region and surgery left foot. Initially, the Board notes that the Veteran's right and left foot disabilities were previously rated separately as 10 percent disabling for residual fibromatosis, right foot, prior to April 13, 2015 and 10 percent disabling for residual fibromatosis, left foot, prior to April 13, 2015. Effective April 13, 2015, the Veteran's ratings for his right and left foot residual fibromatosis were combined, resulting in a single 50 percent rating for bilateral plantar fasciitis/fibromatosis. A review of the record reveals that current VA examinations are needed in order to accurately assess the severity of the Veteran's disabilities in question. The Board notes that the Veteran's last VA examination for these disabilities was conducted in April 2015, nearly seven ago. VA's duty to assist includes the conduct of a thorough and comprehensive medical examination. Green v. Derwinski, 1 Vet. App. 121, 214 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). This includes providing a new medical examination when the available evidence is too old for an adequate evaluation of the current condition. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month-old exam was too remote in time to adequately support the decision in an appeal for an increased rating). Accordingly, more contemporaneous VA examinations are required to provide current pictures of the Veteran's service-connected bilateral plantar fasciitis/fibromatosis and associated scars. 38 C.F.R. §§ 3.326, 3.327. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from July 2021 to the present. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's back disability is at least as likely as not proximately due to or aggravated, i.e., worsened beyond its natural progression, by, his service-connected disabilities. The examiner should comment on each of the Veteran's service-connected disabilities and provide a complete rationale for all opinions expressed. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral plantar fasciitis/fibromatosis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected scars associated with residuals fibromatosis plantar region and surgery left foot. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (Continued on the next page) 5. Then readjudicate the issues on appeal. If the claims are not granted to the Veteran's satisfaction, send the Veteran a statement of the case and allow the appropriate time for response. R.R. WATKINS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dean, 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.