Citation Nr: 22012264 Decision Date: 03/03/22 Archive Date: 03/03/22 DOCKET NO. 12-19 215 DATE: March 3, 2022 ORDER Entitlement to service connection for bilateral pes planus is granted. A rating in excess of 10 percent prior to November 2, 2017 for a tear of the ulnar collateral ligament (UCL) of the right thumb (other than neurological impairment) is denied. REMANDED Entitlement to service connection for a bilateral foot disability, including plantar fasciitis but not including pes planus, is remanded. Entitlement to service connection for low back disorder, to include as secondary to service-connected bilateral Achilles tendonitis and gastrocnemius strain, is remanded. Entitlement to service connection for deviated septum with enlarged inferior turbinates is remanded. Entitlement to service connection for congenital nevus is remanded. Entitlement to a separate disability rating for injuries to Muscle Groups VII and VIII is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's pes planus, which existed prior to service, increased in severity during service. 2. For the entire rating period, the Veteran's service-connected tear of the UCL of the right thumb has not been manifested by a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for pes planus based on aggravation of a pre-existing condition are met. 38 U.S.C. §§ 1153, 5107; 38 C.F.R. §§ 3.102, 3.306. 2. The criteria for entitlement to a rating in excess of 10 percent for a tear of the UCL of the right thumb (other than neurological impairment) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5228, 4.73, Diagnostic Code 5309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Marine Corps on inactive duty for training from August 2001 to November 2002 and on active duty from January 2003 to July 2003, and July 2004 to January 2006. In the July 2012 VA Form 9, the Veteran requested a Board hearing. In May 2016, the Veteran was notified by letter that he was scheduled for the hearing in July 2016. The May 2016 notice was sent to the most recent address of record at that time. The Veteran failed to appear for the July 2016 hearing and, as of this date, no response has been received by the Veteran. Accordingly, his request for a hearing is considered withdrawn. 38 C.F.R. § 20.704(d). In October 2016, the Board remanded these issues of entitlement to service connection for low back disorder, pes planus, carpal tunnel syndrome (CTS) of the right hand, congenital nevus, and a deviated septum; and entitlement to a rating in excess of 10 percent for a tear of the UCL of the right thumb for additional evidentiary development. The issue of entitlement to service connection for right median nerve neuropathy (previously claimed as CTS of the right hand) was granted in a March 2017 VA rating decision, which represents a full grant of the benefits sought so it is no longer on appeal before the Board. In September 2018, the Board remanded these issues of entitlement to service connection for low back disorder, pes planus, congenital nevus, and a deviated septum; and entitlement to a rating in excess of 10 percent for a tear of the UCL of the right thumb for additional evidentiary development. In April 2021, the Board remanded the issues of entitlement to service connection for low back disorder, pes planus, congenital nevus, and a deviated septum; entitlement to a rating in excess of 10 percent for a tear of the UCL of the right thumb; and entitlement to a TDIU for additional evidentiary development. The case has been returned to the Board for further appellate review. There was substantial compliance with the October 2016, September 2018, and April 2021 remand directives for the issue on appeal discussed below on the merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, outstanding VA treatment records and the Veteran's Social Security Administration (SSA) were obtained and associated with the record, and the Veteran was provided VA examinations for muscle injuries in November 2016 and November 2017 and for hand and finger conditions in November 2016 and November 2017. These examination reports, collectively, are adequate as they are based on examination and review of the history and sufficient information was provided to allow the Board to render an informed determination. The issue was also readjudicated in July 2017, January 2020, and July 2021 supplemental statements of the case (SSOCs). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with regards to the issue discussed below on the merits. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Entitlement to service connection for bilateral pes planus is granted. The Veteran served on initial active duty for training in the Marines from August 2001 to November 2002, listed as "IADT" on his DD Form 2014. This is a period of active duty for training (ACDUTRA). In a June 2007 rating decision, the AOJ granted service connection for left achilles tendonitis based upon medical evidence during this period of ACDTURA. Therefore, he has "veteran" status for this period of ACDUTRA. He is therefore entitled to the presumption of aggravation if applicable. Hill v. McDonald, 28 Vet. App. 243, 252 (2016). The Veteran's October 2000 report of medical examination for enlistment, mild asymptomatic pes planus was noted. If a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service incurrence for that disorder, but he may bring a claim for service-connected aggravation of that disorder. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). In that case, the provisions of 38 U.S.C. § 1153 and 38 C.F.R. § 3.306 apply. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). Service connection is warranted if the preexisting disorder was aggravated by a veteran's active service. A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). The threshold question in this case is whether the pre-existing pes planus increased in severity during service. After his enlistment, a May 2002 STR noted "symptomatic" pes planus. Subsequent STRs, noted complaints of symptomatic pes planus. There is no clear and unmistakable evidence that this was due to the natural progression of the disease. Service connection based upon aggravation of a pre-existing disability is granted. Id. Entitlement to a rating in excess of 10 percent for a tear of the UCL of the right thumb (other than neurological impairment) 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 separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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 reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected tear of the UCL of the right thumb in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. On March 27, 2009, the Veteran's request for a higher rating for his service-connected right thumb disability was obtained and associated with the record. In the November 2009 VA rating decision on appeal, the AOJ recharacterized the service-connected disability as a tear of the UCL of the right thumb and assigned a 10 percent disability rating effective for the entire rating period from March 27, 2009. See 38 C.F.R. § 4.73, Diagnostic Code 5309. Since the 10 percent disability rating is not the maximum rating available during the appeal period, the issue has been characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). The Board considers whether a rating in excess of 10 percent for a tear of the UCL of the right thumb (other than neurological impairment) is warranted at any time since or within one year prior to the date of claim on March 27, 2009. Diagnostic Criteria The Veteran's service-connected tear of the UCL of the right thumb is currently rated under Diagnostic Code 5309. Diagnostic Code 5309 provides for a disability of Muscle Group IX. 38 C.F.R. § 4.73. The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc., and is to be rated on limitation of motion, minimum 10 percent. Id. Diagnostic Code 5228 denotes limitation of motion of the thumb. 38 C.F.R. § 4.71a. The next-higher and maximum rating of 20 percent rating is warranted for a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. 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."). Although the portion of the rating schedule that addresses muscle injuries and the musculoskeletal system were revised effective February 7, 2021, Diagnostic Codes 5309 and 5228 were not changed. Evidence and Analysis Review of the evidentiary record since March 27, 2008 documents the following symptomatology for the Veteran's right thumb disability. In June 2008, the Veteran underwent a VA examination of the right thumb. The Veteran reported localized pain elicited by physical activity, characterized the pain as crushing, squeezing, burning, aching, oppressing, sharp, sticking, and cramping, problem with job of turning bolts, and cannot use thumb after an activity that causes fatigue. Upon range of motion testing, the Veteran demonstrated right thumb MP flexion to 60 degrees and IP flexion to 60 degrees, additional limited right thumb function after repetitive use due to pain only and by 0 degrees. Clinical findings also revealed the right thumb is bulkier at the proximal phalanx than the left thumb with pain on palpation and motion and right hand x-ray results were within normal limits. The VA examiner summarized that range of motion findings of the right thumb as normal with pain on abduction. In an October 2008 correspondence, the Veteran reported that his right thumb in-service injury has been a great impediment to his life, but did not specify any further. In June 2009, the Veteran underwent a VA examination of the right thumb. The Veteran reported pain in the web space of his right thumb and around the thumb which occurs constantly, the pain travels up the forearm, pain is elicited by physical activity, unable to grip things normally, he had to learn how to write differently, and he characterized the pain as squeezing, aching, sharp, sticking, and cramping. Following the clinical evaluation, he demonstrated a gap of 0 centimeters between the right thumb pad and the fingers, with the thumb attempting to oppose the fingers, right thumb MP flexion to 50 degrees and IP flexion to 50 degrees, as well as additional limited function after repetitive use by 10 degrees due to pain, fatigue, weakness, lack of endurance, incoordination, and pain. In January 2014 (following the Veteran's surgery on the right thumb in 2011), the Veteran underwent a VA examination for hand and finger conditions. The Veteran reported current symptoms of pain, stiffness, difficulty with fine motor function, and increased pain with overuse. Following the clinical evaluation, he demonstrated no limitation of motion or evidence of painful motion for any fingers or thumb, no additional limitation of motion or functional loss after repetitive-use testing, and no additional limitation of functional ability of the hand during flare-ups or repeated use over time due to pain, weakness, fatigability, and/or incoordination. There were also no findings of tenderness or pain to palpation or ankylosis. The VA examiner affirmed the Veteran's current diagnosis as tear of the UCL of the right thumb status/pos repair with tendon graft. In November 2016, the Veteran underwent VA examinations for muscle injuries and for hand and finger conditions. The VA examiner noted the Veteran's tear of the UCL was surgically resolved and post-surgical residuals of the right hand included scars and a distal median nerve neuropathy. Clinical findings of the right thumb also revealed no gap between the thumb pad and the fingers of the right hand, limited flexion of MCP to 95 degrees, limited flexion of IP to 80 degrees, and full extension to MCP and IP to 0 degrees. The VA examiner further noted the examination is nether medically consistent or inconsistent with the Veteran's statement describing functional loss with during flare up, and marked "no" for any limited functional ability with flare ups. There were also no findings of pain on examination, additional functional loss or range of motion after three repetitions, nor limited functional ability with repeated use over a period of time, or muscle atrophy or ankylosis of the right hand. In November 2017, the Veteran underwent VA examinations for muscle injuries and for hand and finger conditions. The VA examiner noted injury to Muscle Groups VII (flexion of wrist and fingers), VIII (extension of wrist, fingers and thumb), and IX (intrinsic muscles of the hand assist in delicate manipulative movements) of the right forearm or hand. The Veteran reported current symptoms of thumb pain and limited motion and denied flare-ups and functional loss or impairment. Clinical findings of the right thumb revealed a gap between the thumb pad and the fingers of the right hand measured at 3 centimeters, limited flexion of MCP to 80 degrees, limited flexion of IP to 70 degrees, and full extension to MCP and IP to 0 degrees. He demonstrated pain on opposition with thumb, localized tenderness or pain on palpation, pain on passive range of motion testing, and pain with non-weight bearing. There were also no findings of muscle atrophy or ankylosis of the right hand, no functional loss due to pain or after three repetition, and no abnormalities of the opposing joint (left thumb). In a November 2019 statement, the Veteran reported his right thumb usually locks up and is near impossible bend, and attributes such symptomatology to the developing arthritis in his right hand. Review of private treatment records, particularly dated in November 2019 and December 2019, shows the Veteran's reports of right thumb pain and locking and clinical findings of tenderness, ability to oppose the tip of thumb to tip of ring finger, good thumb IP range of motion (not documented in terms of degrees with no obvious tigering. In January 2020, the Veteran underwent a VA examination for hand and finger conditions. The Veteran reported current symptoms of pain, locking, weakness, stiffness, change of color of hand randomly, shooting pains, numbness, loss of sensation, partial loss of function, paresthesia, and extreme weakness in thumb strength. He stated that he had flare ups that could last for hours and were severe and occurred multiple times per day. Clinical findings of the right thumb revealed a gap between the thumb pad and the fingers of the right hand measured at 3 centimeters, limited flexion of MCP to 10 degrees, limited flexion of IP to 5 degrees, and full extension to MCP and IP to 0 degrees. He demonstrated right hand pain on finger flexion and extension, moderate localized tenderness or pain on palpation, pain on passive range of motion testing, and pain with non-weight bearing. The VA examiner noted the examination medically consistent with the Veteran's statement describing functional loss during flare ups and explained that he was unable to determine wither pain, weakness, fatigability or incoordination significantly limited ability with flare ups. He explained that the Veteran could not reliably determine and demonstrate range of motion loss during a flare up, and that medical records did not identify previous flare ups where there was loss of range of motion. The examiner concluded that general medical knowledge of the Veteran's disability is not sufficient to reasonably estimated range of motion for each plane as there was "great variability" between veterans with a similar disability. There were also no findings of muscle atrophy or ankylosis of the right hand, no functional loss due to pain or after three repetition, and no abnormalities of the opposing joint (left thumb). Review of VA treatment records shows the Veteran's report in June 2008 of right thumb chronic pain and occasional limited range of motion with possible trigger finger, but clinical findings revealed no limited range of motion of the right thumb. In July 2008, the Veteran reported progressive stiffness and loss of dexterity in the right thumb, but clinical findings of the right hand revealed full range of motion, stable thumb but mildly tender along the UCL, negative CMC grind, mildly positive tunnels over median nerve (carpal tunnel), paresthesias with median nerve compression, and assessment of signs/symptoms consistent with early CTS. Examination of the right hand in August 2008 also revealed full range of motion, stable thumb but mildly tender along UCL, negative CMC grind, stable thumb joint, and distally neurovascularly intact. September 2008 MRI results of the right thumb revealed high-grade partial tear of the UCL with only thin residual attachment of the base of the proximal phalanx of the thumb. The Veteran reported constant ache and stabbing right thumb pain in October 2008. In April 2011, the Veteran continued to report right thumb pain and clinical findings revealed tenderness at the MCP joint, pain on stressing the UCL but does not open much (no measured in terms of inches or centimeters), and pain on active and passive motion of MCP joint. In July 2011, the Veteran continued to report right thumb pain and clinical findings revealed tenderness at the MCP joint, pain on stressing the UCL radial excursion to 22 degrees, and pain on active and passive motion of MCP joint. In October 2011, the Veteran underwent a right thumb UCL repair with tendon graft and pain was controlled at a follow up session in November 2011. In December 2011, the Veteran reported discomfort and throbbing in the right hand, including the thumb. February 2015 report of pain in right thumb. Clinical findings in July 2019 document range of motion reduced of the right thumb (but not measured) Additionally, a September 2010 statement by C. B. A. from the Atlanta VA Medical Center (VAMC) noted the Veteran "retains a level of permanent disability for his [right] hand which causes inability to perform functions and extended periods of time to perform other tasks including typing, writing and grasping/manipulating with this hand." The Board considers the Veteran's reported history of symptomatology related to the service-connected tear of the UCL of the right thumb. He is competent to report pain and difficulty with use because this requires only personal knowledge as it comes through one's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not, when viewed in conjunction with the medical evidence, establish additional functional loss to the degree that would warrant a 20 percent rating the service-connected right thumb disability based upon limitation of motion. In this case, competent evidence concerning the nature and extent of the Veteran's right thumb has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). After review of the evidence discussed above, the Board finds the Veteran's right thumb disability has not been manifested by a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. In fact, he demonstrated, at worst, a gap of 3 centimeters as noted in the November 2017 and January 2020 VA examination reports. As a result, the next-higher and maximum rating of 20 percent for service-connected tear of the UCL of the right thumb is not warranted at any time during the appeal period based on limitation of motion. See 38 C.F.R. §§ 4.71a, Diagnostic Code 5228, 4.73, Diagnostic Code 5309. The Board has also considered the possibility of staged ratings and finds that the proper ratings for tear of the UCL of the right thumb have been in effect for appropriate periods on appeal. Accordingly, additional staged ratings are inapplicable. See Hart v. Mansfield, 21 Vet. App. 505 (2007). REASONS FOR REMAND 1. Entitlement to service connection for a bilateral foot disorder, other than pes planus In the March 2009 VA Form 21-526, the Veteran requested service connection for bilateral foot pain and he noted that the Navy issued orthotic inserts in October 2005. Since separation from active service, the January 2016 VA examination for foot conditions notes a diagnosis of symptomatic plantar fasciitis. In the November 2009 VA rating decision on appeal, the AOJ recharacterized this claim on appeal as service connection for pes planus. Nevertheless, in light of the evidence of record and the Veteran's contentions, the Board has recharacterized the Veteran's claim bilateral foot pain more broadly to a bilateral foot disorder, in order to clarify the nature of the benefit sought and ensure complete consideration of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). The January 2016 VA examiner failed to address a nexus between the additional current diagnosis during the appeal period of bilateral plantar fasciitis. As a result, an additional VA medical opinion is needed to properly adjudicate this claim on appeal on a direct basis. When VA undertakes to provide a VA examination and/or opinion, it must ensure that the examination and/or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for low back disorder, to include as secondary to service-connected bilateral Achilles tendonitis and gastrocnemius strain In the March 2009 VA Form 21-526, the Veteran requested service connection for chronic lower back pain with spasms and peripheral neuropathy and herniated disk/lower back due to constantly being thrown and high velocity hits to the ground during combat training, running, and lifting heavy loads and equipment, including weights to go on planes on a drill weekend. An October 2019 private treatment record also shows the Veteran reported the onset of back pain in 2001. In August 2019, the Veteran underwent a VA examination for back (thoracolumbar spine) conditions. The VA examiner rendered a diagnosis of degenerative arthritis of the spine and provided a VA medical opinion on a direct basis; however, the rationale provided was based solely on the absence of documented chronicity and continuity of care for many years after separation from service, thus is inadequate. See Barr, 21 Vet. App. at 312. As such, the Board finds that an additional VA medical opinion that considers the lay statements is needed to clarify the etiology of the Veteran's low back disorder. Additionally, review of the November 2006 VA examination report shows reported pain from bilateral Achilles to lower back and the June 2008 VA examination report shows reported pain from bilateral Achilles to back and back pain occurs with leg pain. The issues of service connection for left Achilles tendonitis with partial tear and gastrocnemius strain and for right Achilles tendonitis and gastrocnemius strain were granted in the June 2007 VA rating decision. As such, the Board finds that a VA medical opinion on a secondary basis to his service-connected bilateral Achilles tendonitis and gastrocnemius strain is needed to clarify the etiology of the Veteran's low back disorder. 3. Entitlement to service connection for deviated septum with enlarged inferior turbinates In the March 2009 VA Form 21-526, the Veteran requested service connection for deviated septum due to repeated blows during combat training and being hit with a helmet during active service. Since separation from active service, review of VA treatment records shows clinical findings of chronic nasal congestion with septal deviation and bilateral enlarged inflamed turbinates in July 2009. In November 2016, the Veteran underwent a VA examination for sinusitis/rhinitis and other conditions of the nose, throat, larynx and pharynx. While the VA examiner concluded there were no clinical findings of pathology to render a diagnosis, the VA examiner failed to address a nexus between the diagnosis during the appeal period of chronic nasal congestion with septal deviation and bilateral enlarged inflamed turbinates and lay assertions of an in-service occurrence in the November 2016 VA medical opinion. As a result, an additional VA medical opinion is needed to properly adjudicate this claim on appeal on a direct basis. See Barr, 21 Vet. App. at 312. The Board emphasizes that it is not determining whether or not the Veteran's statement that he had repeated blows during combat training and was hit with a helmet during active service is credible at this time, as the additional development set forth in the directives below could impact that determination. 4. Entitlement to service connection for congenital nevus In the March 2009 VA Form 21-526, the Veteran requested service connection for dermatitis due to rashes after attending bootcamp and service connection for neoplasm back due to removal of skin after repeated sunburns while "ccing" vans and during combat training outdoors. In the November 2009 VA rating decision on appeal, the AOJ recharacterized this claim on appeal as service connection for congenital nevus. In October 2016, while the Board denied the issue of service connection for dermatitis, the Board remanded the issue of service connection for congenital nevus and it remains on appeal before the Board. In November 2016, the Veteran underwent a VA examination for skin diseases. Following the clinical evaluation, the VA examiner rendered a diagnosis of benign congenital nevi and marked in the VA medical opinion that the claimed condition, which clearly and unmistakably existed prior to service was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. As specified in the October 2016 Board remand directives, the VA examiner was asked to initially "indicate whether the Veteran's nevi represent[s] a congenital defect or are part of a disease." Review of the November 2016 VA examination report and medical opinion does not show that initial indication was made by the VA examiner. The Veteran is entitled to substantial compliance with the Board's remand directives. See Stegall, 11 Vet. App. at 271. If the Board proceeds with final disposition of an appeal and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Id. Because there has not been substantial compliance with the October 2016 remand directives, another remand is necessary. The Board stresses the importance of carefully following the directives of this remand in order to allow for a final resolution of this issue. 5. Entitlement to a separate disability rating for injuries to Muscle Groups VII and VIII is remanded. As previously noted, the November 2017 VA examiner also marked involvement of Muscle Groups VII and VIII when examining the Veteran's right hand. Diagnostic Code 5307 provides for a disability of Muscle Group VII. 38 C.F.R. § 4.73. The function of these muscles are as follows: flexion of wrist and fingers. Muscles arising from internal condyle of humerus: Flexors of the carpus and long flexors of fingers and thumb; pronator. For the dominant extremity, the next-higher rating of 30 percent is warranted for moderately severe injury; and a 40 percent rating, maximum available, is warranted for severe injury. Id. Diagnostic Code 5308 provides for a disability of Muscle Group VIII. 38 C.F.R. § 4.73. The function of these muscles are as follows: extension of wrist, fingers, and thumb; abduction of thumb. Muscles arising mainly from external condyle of humerus: Extensors of carpus, fingers, and thumb; supinator. For the dominant extremity, the next-higher rating of 20 percent is warranted for moderately severe injury; and a 30 percent rating, maximum available, is warranted for severe injury. Id. The November 2017 VA examiner also noted the Veteran's injury to his gastrocnemius in Muscle Group XI, which addresses the foot, ankle, and calf. The examiner attributed many symptoms specifically to the gastrocnemius muscle injury. When answering the question, "Does the Veteran's muscle injury(ies) affect muscle substance or function?" the examiner found that there was some impairment of muscle tonus and that tests of endurance or coordinated movements compared with the corresponding muscles of the uninjured side indicate "severe impairment of function." However, the examiner did not clarify whether they were referring to the Muscle Group XI (foot, ankle, and calf) injury, or Muscle Groups VII and VIII which contemplate the thumb. Clarification is needed for the Board to determine the symptoms of the Veteran's right thumb disability as related to Muscle Groups VII and VIII. An examiner should state whether the answers to the question are for Muscle Groups VII and VIII. 6. Entitlement to a TDIU While the Board remands the issue of entitlement to service connection for a low back disorder for additional evidentiary development, as discussed above, that decision may impact this claim for TDIU. As such, these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Provide the Veteran's claims file to an appropriate clinician to provide an opinion regarding the Veteran's claim for a bilateral foot disorder. The examiner must opine as to whether the Veteran's diagnosis of bilateral plantar fascitis (even if resolved since January 2016 VA examination) began during active service or is related to an incident of service. Note - It is not sufficient to provide an opinion that the Veteran's eye disability is not directly related to an incident of service solely based on the absence of documented treatment, chronicity, or diagnosis for many years after separation from service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide the Veteran's claims file to an appropriate clinician to provide an opinion regarding the Veteran's claim for low back disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination (physical or telehealth) is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: In the March 2009 VA Form 21-526, the Veteran reported constantly being thrown and high velocity hits to the ground during combat training, running, and lifting heavy loads and equipment, including weights to go on planes on a drill weekend. An October 2019 private treatment record also shows the Veteran reported the onset of back pain in 2001. The November 2006 and June 2008 VA examination reports shows reported pain from bilateral Achilles to lower back and reported back pain occurs with leg pain. The examiner must opine as to the following: (a.) Whether the Veteran's degenerative arthritis of the spine began during active service, is related to an incident of service, or began within one year after discharge from active service, to include consideration of job duties as an aviation technician and physical training during service. (b.) Whether the Veteran's degenerative arthritis of the spine was proximately due to or the result of his service-connected bilateral Achilles tendonitis and gastrocnemius strain. (c.) Whether the Veteran's degenerative arthritis of the spine was aggravated beyond its natural progression by his service-connected bilateral Achilles tendonitis and gastrocnemius strain. Note - It is not sufficient to provide an opinion that the Veteran's eye disability is not directly related to an incident of service solely based on the absence of documented treatment, chronicity, or diagnosis for many years after separation from service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Provide the Veteran's claims file to an appropriate clinician to provide an opinion regarding the Veteran's claim for deviated septum. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination (physical or telehealth) is only required if deemed necessary by the examiner. For the purposes of this remand only, and for the limited purpose of conducting the examination and providing a medical opinion, the examiner should assume that the Veteran's lay assertion of repeated blows during combat training and being hit with a helmet during active service (as noted in the March 2009 VA Form 21-526) is true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case. The examiner must opine as to whether the Veteran's diagnosis of chronic nasal congestion with septal deviation and bilateral enlarged inflamed turbinates (even if resolved since July 2009 VA treatment session) began during active service or is related to an incident of service. Note - It is not sufficient to provide an opinion that the Veteran's chronic nasal congestion with septal deviation and bilateral enlarged inflamed turbinates is not directly related to an incident of service solely based on the absence of documented treatment, chronicity, or diagnosis for many years after separation from service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Provide the Veteran's claims file to an appropriate clinician to provide an opinion regarding the Veteran's congenital nevus. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination (physical or telehealth) is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: Pre-service treatment records show the existence of nevi, at least one excised Service treatment records show additional nevi, one excised Post-service treatment records show additional nevi, some changing in appearance In the March 2009 VA Form 21-526, the Veteran reported neoplasm on his back due to removal of skin after repeated sunburns while "ccing" vans and during combat training outdoors The examiner must opine as to the following: (a.) Whether the Veteran's congenital nevi is a congenital defect, congenital disease, or neither. Note - A defect is defined as a structural or inherent abnormality or condition which is more or less stationary in nature. A disease is any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. (b.) If the Veteran's congenital nevi is a congenital defect, whether it was subject to a superimposed disease or injury during his period of active service that resulted in additional disability. (c.) If the Veteran's congenital nevi is a congenital disease, presume it existed prior to service (as noted at the time of entry to service in October 2000), and address whether (i) it increased in severity during service or (ii) was aggravated beyond its natural progression by his period of service. If the pre-existing congenital nevi is found to have been aggravated beyond its natural progression by the Veteran's period of service, whether any such increase was clearly and unmistakably (obviously, manifestly, or undebatable) due to the natural progress of the disease. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 5. Schedule the Veteran for an examination to determine whether his right thumb disability manifests as injuries to Muscle Groups VII and VIII. In forming the opinion, the examiner must address the findings in the November 2017 VA examination report showing injuries to Muscle Groups VII and VIII, and clarify whether the answers to the question "Does the Veteran's muscle injury(ies) affect muscle substance or function?" are for Muscle Groups VII and VIII of the right arm as opposed to his gastrocnemius muscle in his leg. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. All pertinent symptomatology and findings must be reported in detail. 6. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 7. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Carter, 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.