Citation Nr: 22015487 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 20-06 268 DATE: March 17, 2022 ORDER Entitlement to a compensable rating for costochondritis is denied. Entitlement to a rating in excess of 40 percent for a lumbar spine disability is denied. Entitlement to a rating in excess of 10 percent for radiculopathy of the left lower extremity is denied. Entitlement to a rating in excess of 20 percent for a cervical spine disability is denied. Entitlement to a rating in excess of 20 percent for radiculopathy of the left upper extremity is denied. REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a liver disability is remanded. Entitlement to a compensable rating for ingrown toenails is remanded. FINDINGS OF FACT 1. Costochondritis is manifested by muscle pain, but has not resulted in injury or impairment to the muscle mass. 2. A lumbar spine disability has not resulted in ankylosis of the spine. 3. Left lower extremity radiculopathy has been manifested by no more than mild incomplete paralysis of the sciatic nerve. 4. A cervical spine disability has not resulted in forward flexion of the cervical spine to 15 degrees or less or ankylosis. 5. Left upper extremity radiculopathy has been manifested by no more than mild incomplete paralysis of the radicular nerve. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for costochondritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.20, 4.21, 4.40, 4.56, 4.73, Diagnostic Code 5399-5297. 2. The criteria for a rating in excess of 40 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5242. 3. The criteria for a rating in excess of 10 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Code 8520. 4. The criteria for a rating in excess of 20 percent for a cervical spine disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Code 5242. 5. The criteria for a rating in excess of 20 percent for left upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.124a, Diagnostic Code 8510. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1999 to April 2004. In April 2021, the Board denied the issues of entitlement to service connection for a right knee disability, allergic rhinitis, and a liver disability, and for an increased rating for ingrown toenails. Those denials were appealed to the Court of Appeals for Veterans Claims, and after an October 2021 Joint Motion for Remand, were remanded to the Board for further adjudication . In April 2021, the Board also remanded the issues of entitlement to service connection for obstructive sleep apnea (OSA), and sinusitis, and claims for increased rating for costochondritis, a lumbar spine disability, and a cervical spine disability. Those claims are now before the Board. In April 2021, the Board denied an increased rating for radiculopathy of the right lower extremity, and that denial was not appealed to the Court, therefore that issue is no longer before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified. However, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Rating Schedule 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. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 1. Entitlement to a compensable rating for costochondritis is denied. The Veteran's costochondritis is rated by analogy under Diagnostic Code 5299-5297. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. That hyphenated diagnostic code indicates that the disability was rated under the criteria for removal of ribs. Costochondritis may be rated as a musculoskeletal disability under 38 C.F.R. § 4.71a, or alternatively as a muscle disability under 38 C.F.R. § 4.73. Diagnostic Code 5297, under which the Veteran is currently rated, states that removal of one rib or resection of two or more ribs without regeneration warrants a 10 percent disability rating. A 20 percent rating requires removal of two ribs. A 30 percent rating requires removal of three or four ribs. A 40 percent rating requires removal of five or six ribs. A 50 percent rating requires removal of more than six ribs. 38 C.F.R. § 4.71a, Diagnostic Code 5297. The Veteran could also be rated by analogy as an injury to Muscle Group XXI, the muscles of respiration of the thoracic muscle group. Under Diagnostic Code 5321, a slight injury warrants a 0 percent rating. A moderate injury warrants a 10 percent rating. A moderately severe or severe injury warrants a 20 percent rating. 38 C.F.R. § 4.73, Diagnostic Code 5321. Muscle group damage is categorized as mild, moderate, moderately severe, and/or severe, and evaluated accordingly. 38 C.F.R. § 4.56. Disability of a muscle group is based on impaired joint motion and its ability to perform its full work. Principal symptoms are weakness, fatigability, coordination, swelling, deformity, and atrophy. The principal factors are impairment of delicate coordination, strength of scar bound muscles, and lowering of fatigue threshold. Skin scars are incidental and negligible but allow for envisaging the whole track of the missile, including any bony or nerve involvement. It is the deep intra-and inter-muscular scarring that is disabling. Through-and-through or other wounds of the deep structure almost invariably cause scarring so that muscles pull against other muscles causing incoordination and loss of strength. Prolonged exertion brings about fatigue and pain, thus interfering with function. 38 C.F.R. §§ 4.47-4.51, 4.54. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56 (c). The Board has carefully reviewed the evidence of record and finds that the evidence weighs against the claim for a compensable rating for costochondritis. Specifically, and as shown on July 2021 VA examination, while the Veteran experiences constant pain in the costochondral junction, no functional impairment was demonstrated on examination. Physical examination showed no impairment to the muscular system or musculoskeletal system. On November 2019 VA examination, the Veteran reported ongoing left chest wall pain that felt deep inside the tendon. He stated that he could not push up or lift weight. However, physical examination of the chest muscles and bone structure was within normal limits. The same was true on August 2016 VA examination. At that time, the Veteran reported chest pain. However, there was no tenderness on palpation of the chest or evidence on x-ray of any deformity. In this case, the Board finds that a compensable rating is not warranted. The VA examinations were negative for any indication of a muscle disability. The VA treatment records are also negative indication of a muscle disability. The evidence of record indicates that the Veteran's costochondritis manifests with no significant functional impairment. The VA examiners noted the Veteran's reports of sharp pain in the chest area, but those were not found to adversely affect the Veteran's functional ability. The Veteran has experienced frequent sharp pain in the chest, but the chest pain had no radiations and was not accompanied by any other symptoms or systemic manifestations. The Veteran has had no rib surgery, and intermittent chest muscle pain is no more severe than a slight muscle injury, which is noncompensable. 38 C.F.R. § 4.56 (d)(1). The Board finds that a compensable initial rating is not warranted for costochondritis. The Board notes that because there is no evidence of impairment to a joint in this situation, and therefore 38 C.F.R. § 4.59 does not provide for a minimum compensable rating. In so concluding, the Board again has considered the Veteran's reports of chest wall pain and that he cannot push or lift due to his costochondritis. However, because of the normal examinations of the chest wall consistently throughout the appeal period, the Board assigns less probative weight to those statements. While the Veteran is credible to report those symptoms, these reports are not consistent with the multiple VA examinations that have been obtained. The examinations do not show functional impairment due to costochondritis, and contradict the Veteran's assertions. Accordingly, the Board finds that the weight of the competent and credible evidence is against a finding that a higher rating is warranted. The Board finds that there is no reasonable doubt to resolve in favor of the Veteran and the evidence does not more nearly approximate the criteria for a higher rating. Accordingly, the claim for a compensable rating for costochondritis must be denied. 2. Entitlement to a rating in excess of 40 percent for a lumbar spine disability is denied. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. Those amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." 85 Fed. Reg. 230 (Nov 30, 2020). Under the new criteria regulation, the criteria pertaining to rating disabilities of the spine were not changed. However, the new regulation that became effective February 7, 2021, specified that Diagnostic Code 5243 is only to be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. The amendments are not relevant to the present claim as the Veteran has not claimed, and the evidence does not suggest, that he has experienced incapacitating episodes which required physician prescribed bed rest. Therefore, the amended rating criteria are not applicable and will not be discussed further. Disabilities of the spine are rated under the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in a higher rating. 38 C.F.R. § 4.71a, General Rating Formula for Rating Diseases and Injuries of the Spine, Diagnostic Codes 5235-5243. Under the General Rating Formula, with or without symptoms such as pain, to include whether it radiates, stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 30 percent rating is warranted when forward flexion of the cervical spine is 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is warranted when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A maximum 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a, General Rating Formula for Rating Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the thoracolumbar spine is 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. 38 C.F.R. § 4.71a. In this case, the Board finds that a rating higher than 40 percent for a lumbar spine disability is not warranted at any time during the appeal period. At no time has the lumbar spine disability resulted in ankylosis of the spine, or symptoms equivalent to ankylosis. The most recent VA examination in July 2021 found that the Veteran was able to forward flex the spine to 30 degrees. The examiner found no indication of further limitation of motion on repetitive testing. The examiner found no additional functional loss on repetitive testing that would warrant a higher rating in this instance. The examiner found no procurable evidence to demonstrate additional functional loss on repetitive movement or flare-ups. Therefore, because there was no indication of a more severe disability due to repetitive movement or flare-up, the examiner did not provide further estimated range of motion loss. The examiner made that determination after interviewing the Veteran and conducting thorough testing. The examiner solicited details from the Veteran during this examination, but found that no further limitation of motion need be estimated based on the examination responses. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The same is the case for the remaining evidence of record, as an August 2016 VA examination found forward flexion was much greater, to 70 degrees. There was no evidence of additional functional loss on repetitive testing or flare-up that would warrant a higher rating. Based upon the above, the Board finds that a rating higher than 40 percent for a lumbar spine disability is not warranted. Accordingly, the Board finds that the weight of the competent and credible evidence is against a finding that a higher rating is warranted. The Board finds that there is no reasonable doubt to resolve in favor of the Veteran and the evidence does not more nearly approximate the criteria for a higher rating. Accordingly, the claim for a higher rating for a lumbar spine disability must be denied. 3. Entitlement to a rating in excess of 10 percent for radiculopathy of the left lower extremity is denied. Next, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Disability from neurological disabilities is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the sciatic nerve, is rated 80 percent and contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 10 percent rating is warranted for mild incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Code 8620 refers to neuritis of the sciatic nerve, and Diagnostic Code 8720 refers to neuralgia of the sciatic nerve, and use the same rating criteria. The issue of a higher rating for radiculopathy of the right lower extremity was decided by an unappealed Board decision issued in April 2021. That issue is no longer on appeal. With regard to the left lower extremity, the Board finds that a rating higher than 10 percent is not warranted. Specifically, the Veteran's left lower extremity symptoms have been primarily subjective in nature, with reports of symptoms such as pain and tingling in the left leg. However, on clinical testing, sensation, muscle strength, and motor reflexes have been shown to be within normal limits. On July 2021 VA examination, no abnormal neurological symptoms were shown. On November 2019 VA examination, the Veteran reported severe left leg pain. However, clinical testing showed normal neurological findings. In October 2018, the Veteran reported sharp shooting pains in his leg. However, clinical testing showed mild neurological symptoms. Thus, the 10 percent rating currently assigned accounts for the more subjective symptoms. Absent more severe clinical findings, a rating higher than 10 percent cannot be assigned. The Board finds that the involvement in only sensory, without any findings that would warrant elevation of the moderate level. The Board has considered and given weight to the Veteran's reports of more severe symptoms in his left lower extremity. The Veteran is competent to report these symptoms, as they are observable. However, the Board ultimately places less weight on these statements when finding that a higher rating is not warranted because they lack consistency when reviewing the multiple VA examinations of record demonstrating no more than mild neurological deficit. The Board finds that the VA examinations in this case outweigh the Veteran's statements with regard to whether a higher rating is warranted. The Board finds that examiner opinions more persuasive because of their training and the testing conducted. Accordingly, the Board finds that the weight of the competent and credible evidence is against a finding that a higher rating is warranted. The Board finds that there is no reasonable doubt to resolve in favor of the Veteran and the evidence does not more nearly approximate the criteria for a higher rating. Accordingly, the claim for a higher rating for a left lower extremity radiculopathy must be denied. 4. Entitlement to a rating in excess of 20 percent for a cervical spine disability is denied. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A maximum rating in this case of 30 percent is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Under the new rating criteria, Diagnostic Code 5243, which contemplates intervertebral disc syndrome, with which the Veteran has been diagnosed, should be rated either under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The next highest 40 percent rating under Diagnostic Code 5423 is warranted when there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. After a review of the evidence, the Board finds that a rating higher than 20 percent for a cervical spine disability is not warranted. On August 2021 VA examination, the Veteran reported chronic neck pain. He denied weakness or numbness in the hands. Forward flexion of the cervical spine was to 30 degrees. Passive range of motion was not performed because it was thought to exacerbate the condition. There was evidence of pain on active motion. There was no additional loss of motion on three repetitions. With repeated use, there was no evidence of additional limitation of motion. The procured evidence did not suggest additional functional loss on flare-up, therefore further estimated loss of range of motion findings were not indicated. The examiner made that determination after interviewing the Veteran and conducting thorough testing. The examiner solicited details from the Veteran during this examination, but found that no further limitation of motion need be estimated based on the examination responses. Those findings and evidence do not meet the criteria for a rating in excess of 20 percent for the Veteran's cervical spine disability. The remainder of the evidence also does not demonstrate symptoms warranting an increased rating. On August 2016 VA examination, forward flexion of the cervical spine was to 45 degrees. The Veteran had functional loss in that he could not lift items or twist due to pain. Repetitive testing did not result in further limitation of motion. Considering the evidence, the Board finds that for a rating in excess of 20 percent for a cervical spine disability, even when considering functional loss, does not meet the criteria for a higher rating. The evidence does not show forward flexion of the cervical spine to 15 degrees or less or, favorable ankylosis of the cervical spine. Additionally, the Veteran was noted on VA examination to not require bedrest prescribed by a physician for his cervical spine disability. Therefore, a higher rating under Diagnostic Code 5243 is also not warranted. Accordingly, the Board finds that the weight of the competent and credible evidence is against a finding that a higher rating is warranted. The Board finds that there is no reasonable doubt to resolve in favor of the Veteran and the evidence does not more nearly approximate the criteria for a higher rating. Accordingly, the claim for a higher rating for a cervical spine disability must be denied. 5. Entitlement to a rating in excess of 20 percent for radiculopathy of the left upper extremity is denied. Diagnostic Code 8510 provides ratings for paralysis of the upper radicular group of nerves (fifth and sixth cervicals). Diagnostic Code 8510 provides that mild incomplete paralysis is rated 20 percent on the major side and 20 percent on the minor side. Moderate incomplete paralysis is rated 40 percent on the major side and 30 percent on the minor side. Severe incomplete paralysis is rated 50 percent on the major side and 40 percent on the minor side. Complete paralysis of the upper radicular group, with all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected, is rated 70 percent on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a. After considering the evidence of record, the Board finds that a rating higher than 20 percent for the left upper extremity radiculopathy is not warranted. On July 2021 VA examination, there were no signs of neurological abnormality. On November 2019 VA examination, physical examination resulted in a finding of mild incomplete paralysis of the left upper extremity. On August 2016 VA examination, neurological testing was normal. Therefore, based upon the evidence, and a review of the remaining treatment records of record, the Board finds that a rating higher than 20 percent for mild incomplete paralysis of the left upper neurological system is not warranted. The Board finds that moderate incomplete paralysis is not shown. The evidence shows mild symptoms that are sensory only, and have not been found on some examination. The Board finds that condition is not of the severity that would warrant elevation to a finding of moderate symptomatology. The Board finds that the VA examinations are the most persuasive evidence of record because of the training of the examiners and the testing conducted. Accordingly, the Board finds that the weight of the competent and credible evidence is against a finding that a higher rating is warranted. The Board finds that there is no reasonable doubt to resolve in favor of the Veteran and the evidence does not more nearly approximate the criteria for a higher rating. Accordingly, the claim for a higher rating for a left upper extremity radiculopathy must be denied. REASONS FOR REMAND 1. Entitlement to service connection for OSA is remanded. 2. Entitlement to service connection for a right knee disability is remanded. A remand for a VA examination and opinion is necessary for the claim for service connection for sleep apnea. In July 2021, a VA examiner opined that the Veteran's OSA was less likely than not related to a service-connected panic disorder with major depressive disorder and anxiety. However, the examiner did not provide a rationale for that opinion. That is necessary, as the examiner stated that the Veteran's OSA was related to poor diet and obesity. That opinion does not adequately address the question as to whether the Veteran's obesity served as an intermediary step between the service-connected disabilities, particularly a psychiatric disability and lumbar and cervical spine disabilities, and OSA. If OSA is due to obesity, the question remains as to whether his service-connected disabilities caused his obesity. Thus, remand is necessary for further examination. For the claim for service connection for a right knee disability, as directed by the October 2021 Joint Motion for Remand, a VA opinion should be obtained as to whether the Veteran's obesity served as an intermediary step between the service-connected disabilities, particularly a psychiatric disability and lumbar and cervical spine disabilities, and a right knee disability. 3. Entitlement to service connection for sinusitis is remanded. 4. Entitlement to service connection for allergic rhinitis is remanded. The Board finds that clarification is still needed with regard to claimed sinusitis. As noted in the April 2021 Board remand, the Veteran's VA treatment records contain several records documenting sinusitis, to include in July 2018, August 2018, and May 2019, when the Veteran was noted to have chronic sinusitis. The August 2021 VA examiner, upon finding that the Veteran did not have chronic sinusitis, did not discuss those records, and in fact stated that there were no records of chronic sinusitis. That is an inaccurate statement regarding the factual background. On remand, these records should be discussed. If it is found that the has a chronic sinusitis disability, the date of onset must also be provided, because of the the presumption outlined in 38 C.F.R. § 3.320 for Persian Gulf veterans. The Board finds that clarification is needed with regard to claimed allergic rhinitis. As directed by the October 2021 Joint Motion for Remand, the October 2018 VA examination is inadequate because it did not offer an opinion as to the etiology and pathophysiology of rhinitis in relation to service in the Persian Gulf. Stewart v. Wilkie, 30 Vet. App. 383 (2018). In that regard, an illness is a medically unexplained chronic multisymptom illness (MUCMI) where either the etiology or pathophysiology of the illness is inconclusive. Conversely, an illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Stewart v. Wilkie, 30 Vet. App. 383 (2018). Thus, when an examiner opines whether a MUCMI exists, the examiner must address both the etiology and pathophysiology of the claimed illness, and the opinion is inadequate if it does not do so. The Board notes that here, too, the date of onset of rhinitis should be confirmed on VA examination to determine whether entitlement to service connection on a presumptive basis is warranted. 5. Entitlement to service connection for a liver disability is remanded. As directed by the October 2021 Joint Motion for Remand, for the Veteran's liver disability, while the examiner stated that there was a clear diagnosis and etiology, a pathophysiology was not noted. Therefore, additional VA examination or opinion is necessary on remand. 6. Entitlement to a compensable rating for ingrown toenails is remanded. As directed by the October 2021 Joint Motion for Remand, clarification is necessary to determine whether the Veteran's use of topical therapy to treat ingrown toenails amounts to systemic therapy for the purposes of Diagnostic Code 7806. Burton v. Wilkie, 30 Vet. App. 286 (2018). Therefore, clarification is needed on remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of sleep apnea. The examiner must review the claims file and should note that review in the report. Any indicated studies should be performed, and all findings should be reported in detail. (a.). Opine whether it is at least as likely as not that sleep apnea is related to service or any event, injury, or disease during service. (b.) Opine whether it is at least as likely as not that sleep apnea is due to or the result of the service-connected disabilities. (c.) Opine whether it is at least as likely as not that sleep apnea has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities. (d.) Opine whether it is at least as likely as not that the service-connected disabilities, to include a psychiatric disability, flat foot, lumbar and cervical spine disabilities with radiculopathy, and migraine headaches, caused the Veteran's obesity. If so, opine whether it is at least as likely as not that obesity served as an intermediary step to the development of his OSA. The examiner should discuss whether the Veteran's poor diet stated to be the cause of his obesity is related to any of his service-connected disabilities, specifically a psychiatric disability. 2. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of a right knee disability. The examiner must review the claims file and should note that review in the report. Any indicated studies should be performed, and all findings should be reported in detail. (a.) Opine whether it is at least as likely as not that any right knee disability is related to service or any event, injury, or disease during service. (b.) Opine whether it is at least as likely as not that any right knee disability is due to or the result of the service-connected disabilities or any gait disturbance due to the service-connected disabilities. (c.) Opine whether it is at least as likely as not that any right knee disability has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities, or any gait disturbance due to the service-connected disabilities. (d.) Opine whether it is at least as likely as not that the service-connected disabilities, to include a psychiatric disability, flat foot, lumbar and cervical spine disabilities with radiculopathy, and migraine headaches, caused the Veteran's obesity. If so, opine whether it is at least as likely as not that obesity served as an intermediary step to the development of any right knee disability. The examiner should discuss whether the Veteran's poor diet stated to be the cause of his obesity is related to any of his service-connected disabilities, specifically a psychiatric disability. 3. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of his sinusitis. The examiner must review the claims file and should note that review in the report. Any indicated studies should be performed, and all findings should be reported in detail. (a.) State whether a diagnosis of sinusitis is warranted and reconcile that finding with the other evidence of record, to include records in July 2018, August 2018, and May 2019, when the Veteran was noted to have chronic sinusitis. Explain the basis for that opinion. Opine as to the date of onset of chronic sinusitis, with reference to the evidence of record. Consider the lay statements of the Veteran in making that determination. (b.) Opine whether it is at least as likely as not that sinusitis is related to service or any event, injury, or disease during service, to specifically include environment exposures in the Persian Gulf area during service. (c.) Opine whether it is at least as likely as not that sinusitis is due to or the result of the service-connected disabilities. (d.) Opine whether it is at least as likely as not that sinusitis has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities. 4. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of rhinitis. The examiner must review the claims file and should note that review in the report. Any indicated studies should be performed, and all findings should be reported in detail. (a.) State whether a diagnosis of rhinitis is warranted and reconcile that finding with the other evidence of record. Explain the basis for that opinion. Opine as to the date of onset of rhinitis, with reference to the evidence of record. Consider the lay statements of the Veteran in making that determination. (b.) Opine whether it is at least as likely as not that rhinitis is related to service or any event, injury, or disease during service, to specifically include environment exposures in the Persian Gulf area during service. (c.) Opine whether it is at least as likely as not that rhinitis is due to or the result of the service-connected disabilities. (d.) Opine whether it is at least as likely as not that rhinitis has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities. (e.) State whether the etiology of the Veteran's rhinitis is completely or partially understood, and explain that opinion. (f.) State whether the pathophysiology of the Veteran's rhinitis is completely or partially understood, and explain that opinion. 5. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of any liver disability. The examiner must review the claims file and should note that review in the report. Any indicated studies should be performed, and all findings should be reported in detail. (a.) Diagnose all liver disabilities found or shown in the records during the pendency of the claim. (b.) Opine whether it is at least as likely as not that any liver disability is related to service or any event, injury, or disease during service, to specifically include environment exposures in the Persian Gulf area during service. (c.) Opine whether it is at least as likely as not that any liver disability is due to or the result of the service-connected disabilities. (d.) Opine whether it is at least as likely as not that any liver disability has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities. (e.) State whether the etiology of the Veteran's liver disability is completely or partially understood, and explain that opinion. (f.) State whether the pathophysiology of the Veteran's liver disability is completely or partially understood, and explain that opinion. 6. Schedule the Veteran for an examination to determine the current severity of an ingrown toenail disability. The examiner must review the claims file and should note that review in the report. Clarify whether the Veteran's use of topical medication for the disability constitutes systemic therapy such as corticosteroids or other immunosuppressive drugs at any time since 2016. Explain why or why not. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals R. Erdheim, Attorney for the Board Department of Veterans Affairs 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.