Citation Nr: 22016278 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 10-29 881 DATE: March 21, 2022 ORDER Entitlement to an initial rating in excess of 20 percent for the appeal period prior to January 6, 2020 for a right elbow residuals of right arm shrapnel wound is denied. Entitlement to a rating of 50 percent for the appeal period beginning on January 6, 2020 for a right elbow residuals of right arm shrapnel wound is granted. Entitlement to an initial rating in excess of 20 percent diabetes mellitus type II is denied. Entitlement to a rating in excess of 10 percent for the appeal prior to October 2, 2020 for residuals of shell fragment wound, right median nerve is denied. Entitlement to a rating of 30 percent, but not higher, for the appeal period beginning on October 2, 2020 for residuals of shell fragment wound, right median nerve is granted. Entitlement to a rating of 30 percent, but not higher, for the appeal period prior to January 6, 2020 for residuals of shell fragment wound, right ulnar nerve is granted. Entitlement to a rating of 40 percent, but not higher, for the appeal period beginning on January 6, 2020 for residuals of shell fragment wound, right ulnar nerve is granted. REMANDED Entitlement to a compensable rating for bilateral pinguecula with corneal scars and dry eyes is remanded. Entitlement to service connection for a bilateral hip disorder is remanded. Entitlement to service connection for hypertension, to include as secondary to herbicide agent exposure in Vietnam or as secondary to service-connected posttraumatic stress disorder (PTSD) and diabetes mellitus type II, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to herbicide agent exposure in Vietnam or as secondary to service-connected posttraumatic stress disorder (PTSD) and diabetes mellitus type II, is remanded. Entitlement to a combined rating in excess of 90 percent prior to April 2, 2012, is remanded. FINDINGS OF FACT 1. The Veteran is right-hand dominant and his right upper extremity is his major extremity for rating purposes. 2. For the appeal period prior to January 6, 2020, the Veteran's right elbow residuals of right arm shrapnel wound manifested as painful joint motion with flexion limited to 70 degrees, at worst; it has not manifested with ankylosis, limitation of motion, flail joint, joint fracture, nonunion of the radius and ulna, nonunion of the radius, or impairment of supination and pronation. 3. For the appeal period beginning on January 6, 2020, the Veteran's right elbow residuals of right arm shrapnel wound manifested as painful joint motion with flexion limited to 40 degrees, at worst; it has not manifested with ankylosis, limitation of motion, flail joint, joint fracture, nonunion of the radius and ulna, nonunion of the radius, or impairment of supination and pronation. 4. Throughout the period on appeal, the Veteran's diabetes mellitus type II required the use of oral medication without the regulation of activities. 5. For the appeal period prior to October 2, 2020, the Veteran's residuals of shell fragment wound, right median nerve is manifested by, at worst, mild incomplete paralysis without moderate incomplete paralysis. 6. For the appeal period beginning on October 2, 2020, the Veteran's residuals of shell fragment wound, right median nerve is manifested by, at worst, moderate incomplete paralysis without severe incomplete paralysis. 7. For the appeal period prior to January 6, 2020, the Veteran's residuals of shell fragment wound, right ulnar nerve is manifested by, at worst, moderate incomplete paralysis without severe incomplete paralysis. 8. For the appeal period beginning on January 6, 2020, the Veteran's residuals of shell fragment wound, right ulnar nerve is manifested by, at worst, severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the appeal period prior to January 6, 2020 for right elbow residuals of a right arm shrapnel wound have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213. 2. The criteria for a 50 percent rating, but not higher, for the appeal period beginning on January 6, 2020 for right elbow residuals of a right arm shrapnel wound have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213. 3. The criteria for a rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.119, Diagnostic Code 7913. 4. The criteria for a rating in excess of 10 percent for the appeal period prior to October 2, 2020 for residuals of a shell fragment wound, right median nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8515. 5. The criteria for a rating of 30 percent, but not higher, for the appeal period beginning on October 2, 2020 for residuals of a shell fragment wound, right median nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8515. 6. The criteria for a rating of 30 percent, but not higher, for the appeal period prior to January 6, 2020 for residuals of a shell fragment wound, right ulnar nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8516. 7. The criteria for a rating of 40 percent, but not higher, for the appeal period beginning on January 6, 2020 for residuals of a shell fragment wound, right ulnar nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.123, 4.124a, Diagnostic Code 8516. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty April 1968 to August 1973, to include service in the Republic of Vietnam. The Veteran's awards and decorations for his service include a Purple Heart and a Vietnam Cross of Gallantry with Palm, among others. These matters come to the Board of Veterans' Appeals (Board) on appeal from August 2008, March 2009, April 2009, August 2010, October 2011, and May 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Huntington, West Virginia. This case was most recently before the Board in July 2019, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the matters were remanded to obtain outstanding private and VA treatment records and to conduct VA examinations to determine the nature and severity of his diabetes mellitus type II, right elbow condition and nerve conditions. Updated VA treatment records have been associated with the record and a November 2019 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain treatment records from his private medical sources. The Veteran submitted a completed Authorization to Disclose Information to VA (VA Form 21-4142) forms to allow VA to obtain private treatment records from Dr. A.C.. a urological clinic, Dr. H.V. and Dr. M.; the Board notes that the 21-4142 provided incomplete addresses for each of these providers. A January 2020 Report of Contact indicates that the Agency of Original Jurisdiction (AOJ) performed research and was unable to locate any contact information for the facility listed on the request for the urological clinic. A December 2019 Report of Contact indicates that the AOJ had contacted Dr. M.'s office and was informed that they were unable to locate any records for the Veteran. A December 2019 Report of Contact that the address for Dr. A.C. had been located and that record request had been faxed. A December 2019 Report of Contact indicates that research and been conducted and that the AOJ was unable to locate any contact information for Dr. H.V. A VA diabetes mellitus examination was conducted in January 2020, a VA elbow examination was conducted in January 2020 and a VA nerves examination was conducted in January 2020. The Board therefore finds that there has been substantial compliance with its previous remand with regards to the claims decided herein. The case has now been returned to the Board for appellate action. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (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. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation 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. The veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. 1. Right Elbow Residuals The Veteran asserts that he is entitled to a higher rating for his right elbow residuals as his symptoms are more severe than contemplated by the currently assigned rating. Specifically, the Veteran contends that he has limited use of his forearm and right hand and continuing nerve problems following right elbow surgery. See Correspondence, July 16, 2010. Additionally, the Veteran asserts that the VA examiner did not report nor measure his limited range of motion of his right arm, that he experiences pain, and that he has ankylosis. See e.g. Correspondence, October 19, 2010. Moreover, the Veteran reports he still has shrapnel in his right elbow, carpal tunnel in his right wrist, and an uncompensated scar; he also reported increased pain, neuropathy, numbness, tingling, and loss of use. See Correspondence, August 21, 2012. Initially, the Board notes that entitlement to a separate rating for scars of the right elbow were granted in a July 2021 rating decision, and assigned initial ratings, effective August 13, 2018 and November 12, 2008. To date, the Veteran has not expressed disagreement with either the rating and effective date assigned and are not currently on appeal. Therefore, the Board will not consider increased ratings for his right elbow scars. Additionally, the Board notes the Veteran's service-connected residuals of the shell fragment wound of the median and ulnar nerves are separately rated and separately on appeal. The Board will discuss the Veteran's claims for increased ratings for such disorders below. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Veteran's service-connected right elbow disorder is currently rated as 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5213. The Rating Schedule distinguishes between the major/dominant extremity and the minor/non-dominant extremity for rating purposes. 38 C.F.R. § 4.69. In this case, the record shows that the Veteran is presently left-handed. See e.g. VA examination report, May 1, 2012. However, as discussed below, the Veteran has reported he is naturally right-hand dominant but that he had trained himself to be able to use his left upper extremity as his dominant arm. Thus, resolving doubt in favor of the Veteran, his service-connected right elbow disability affects his major extremity, and will be rated accordingly. It should also be noted that portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021. However, these changes do not affect the pertinent diagnostic codes discussed below regarding the elbow and forearm. As a starting point, there has been no suggestion of ankylosis of the right elbow and in fact the Veteran was found to not have ankylosis of the right elbow at the various VA examinations. Consequently, Code 5205 pertaining to ankylosis is not applicable. Moreover, Code 5208, which is based on limitation of flexion and extension, does not provide for a rating greater than 20 percent and is therefore not applicable. Further, the Board finds that Codes 5209 to 5212 are not relevant to the instant analysis because there has been no objective medical finding of impairment of the flail joint, ulna, or radius. Limitation of flexion of the forearm (elbow) is rated 20 percent when limited to 90 degrees, 30 percent when limited to 70 degrees, 40 percent disabling when limited to 55 degrees, and a maximum of 50 percent when limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5206. Limitation of extension of the forearm is rated 20 percent when limited to 75 degrees, 30 percent when limited to 90 degrees, 40 percent when limited to 100 degrees and 50 percent when limited to 110 degrees. Under Code 5213 for impairment of supination and pronation of the major extremity, a maximum 30 percent rating is warranted for limitation of pronation with motion lost beyond middle of arc. For loss of (bone fusion), a 30 percent rating is warranted when the hand fixed in full pronation, and a maximum 40 percent rating is warranted when the hand fixed in supination or hyperpronation. 38 C.F.R. § 4.71a, Code 5213. 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."). For purposes of this decision, the normal motion of an elbow includes zero degrees of extension, 145 degrees of flexion, 80 degrees of forearm pronation, and 85 degrees of forearm supination. 38 C.F.R. § 4.71, Plate I. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). The Board notes that the Veteran's left elbow was undamaged throughout the period on appeal, and his range of motion measurements of the left elbow have consistently been shown to be within normal limits. Turning to the evidence, the Veteran was afforded a VA examination in May 2012. At that time, the examiner diagnosed shrapnel wound residuals of the right elbow. The Veteran reported a booby trap explosion injury, and treatment during active service. He reported loss of supination of the right forearm at that time. The Veteran reported he was left hand dominant. He denied flare-ups of the right elbow. Upon physical examination in May 2012, range of motion measurements of the right elbow were as follows: flexion was to 145 degrees or greater, without any objective evidence of painful motion; extension was to zero degrees, without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing, without any additional loss of range of motion after repetition. The Veteran was noy shown to have any functional loss and/or functional impairment of the right elbow and forearm. There was no localized tenderness or pain on palpation of the joints or soft tissues of the right elbow or forearm. Muscle strength testing showed active movement against some resistance in right elbow flexion and extension. He did not have ankylosis of the elbow. The Veteran was shown to have impairment of supination or pronation, however, the examiner failed to indicate which elbow and the nature of that impairment. However, the examiner did indicate that the Veteran had right supination from zero to 45 and right pronation from zero to 60. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's right elbow impacted his ability to work due to limited manual dexterity in the right arm and hand. The Veteran was afforded a VA examination in October 2017. At that time, the examiner diagnosed metallic foreign exostosis and degenerative joint disease of the right elbow. The Veteran reported current symptoms included weakness and decreased range of motion with respect to the right elbow; he denied pain or stiffness. The Veteran was left hand dominant. He denied flare-ups of the elbow. He reported functional loss or functional impairment of the right elbow described as inability to lift heavy objects. Upon physical examination in October 2017, range of motion measurements of the right elbow were as follows: flexion was from 5 to 100 degrees; extension was from 100 to 5 degrees; forearm supination was from zero to 35 degrees; and forearm pronation was from zero to 50 degrees. Range of motion itself did not contribute to a functional loss. There was no pain noted on examination. There was no evidence of pain with weight-bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing and was examined immediately after repetitive-use over time. The examiner found that it was unable to determine without resorting to mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repetitive-use over a period of time. Muscle strength testing was normal; there was no reduction in muscle strength. The Veteran did not have muscle atrophy. The Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive devices. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's right elbow did not impact his ability to work. The Veteran was afforded a VA examination in January 2020. At that time, the examiner diagnosed right elbow residuals of the right arm shrapnel wound, status post-surgery. The Veteran reported current symptoms included daily pain and stiffness, and that the right elbow disorder had worsened over the years. The Veteran was left hand dominant. The Veteran reported flare-ups of the right elbow that occurred every day, were severe, lasted hours, and were precipitated by daily activities. He reported flare-ups were alleviated by rest and pain medications. He reported functional loss or functional impairment that was described as daily activities and lifting. Upon physical examination in January 2020, range of motion measurements of the right elbow were as follows: flexion was from zero to 70 degrees; extension was from 70 to zero degrees; forearm supination was from zero to 20 degrees; and forearm pronation was from zero to 20 degrees. Range of motion itself did not contribute to a functional loss. Pain was noted on examination and caused a functional loss on all range of motion movements. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of pain with weight-bearing. There was no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing. There was additional loss of function or range of motion after three repetitions as follows: flexion was from zero to 60 degrees; extension was from 60 to zero degrees; forearm supination was from zero to 15 degrees; and forearm pronation was from zero to 15 degrees. Pain and lack of endurance were shown to cause this functional loss. The Veteran was not examined immediately after repetitive-use over time in January 2020; the examination was medically consistent with the Veteran's statements describing a functional loss with repetitive-use over time. Pain and lack of endurance were shown to significantly limit functional ability with repetitive-use over a period of time. The examiner was able to describe in terms of range of motion as follows: flexion was from zero to 50 degrees; extension was from 50 to zero degrees; forearm supination was from zero to 10 degrees; and forearm pronation was from zero to 10 degrees. The Veteran was not examined during a flare-up in January 2020; the examination was medically consistent with the Veteran's statements describing functional loss during a flare-up. Pain and lack of endurance were shown to significantly limit functional ability during flare-ups. The examiner was able to describe in terms of range of motion as follows: flexion was from zero to 40 degrees; extension was from 40 to zero degrees; forearm supination was from zero to 5 degrees; and forearm pronation was from zero to 5 degrees. Additional factors contributing to the disability included less movement than normal. In January 2020, muscle strength testing was normal; there was not a reduction in muscle strength. The Veteran did not have muscle atrophy. The Veteran did not have ankylosis. The Veteran was shown to have impairment of supination that was limited to 30 degrees or less on the right side. He had intermediate degrees of residual weakness, pain, or limitation of motion as a result of his right elbow shrapnel repair surgery. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's right elbow impacted his ability to work due to elbow pain, stiffness, limited range of motion, and difficulty with heavy lifting or repetitive motion. There was objective evidence of pain on passive range of motion and non-weight-bearing of the right elbow. The Veteran was afforded a VA examination in May 2021. At that time, the Veteran reported current symptoms of limited range of motion at the elbow joint, malunion of fracture segments, and that his condition had stayed the same since onset. He reported treatment included surgical correction. He denied flare-ups of the right forearm or elbow. The Veteran reported functional loss or functional impairment of the joint as loss of range of motion and painful range of motion. The examiner noted the Veteran reported painful motion on flexion and/or extension but that the complain of painful motion was not related to his service-connected right elbow disorder. The Veteran denied any complaints of painful motion on forearm supination and/or pronation. Upon physical examination in May 2021, range of motion measurements of the right elbow were as follows: flexion was to 120 degrees; extension was to zero degrees; forearm supination was to 45 degrees; and forearm pronation was to 80 degrees. The examiner noted the Veteran's range of motion was limited and resulted in difficulty with load carrying capacity and dexterity or precision. There was no evidence of pain. There was no objective evidence of crepitus. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive-use testing with at least three repetitions; there was not additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive-use over time in May 2021; and the procured evidence did not suggest that pain, fatigability, weakness, lack of endurance, or incoordination would significantly limit functional ability with repetitive-use over time. The Veteran was not examined during a flare-up; and the procured evidence did not suggest that pain, fatigability, weakness, lack of endurance, or incoordination would significantly limit functional ability during a flare-up. There were no additional factors contributing to the disability. The Veteran had muscle atrophy of the right elbow that was secondary to the muscle condition from the shrapnel wound; measurements showed approximately 7 centimeters of muscle atrophy distal to the elbow. Circumference measurements were as follows: normal side was 31 centimeters; atrophied side was 28 centimeters. There was no ankylosis. The Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. The Veteran had limited range of motion as a residual of his surgical repair. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's right elbow would impact his ability to work due to clearly negative impact of the use of the right elbow and arm; making strength, load-carrying capacity, precision, and dexterity suboptimal to the point where the contralateral extremity was preferred for work-related tasks. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his right elbow disorder. However, there is no indication from the treatment notes of record that the Veteran has reported right elbow disorder symptoms that are worse than those noted above. As noted above, range of motion testing was performed during VA examinations in May 2012, October 2017, January 2020, and May 2021. Range of motion testing during these examinations showed that the Veteran had range of motion to, at worst, flexion limited to 70 degrees at the October 2017 VA examination; extension to, at worst, 5 degrees at the October 2017 VA examination; and showed that after repetitive-use testing his right elbow range of motion was, at worst, limited to, at worst, 40 degrees of flexion during a flare-up, and 50 degrees with repetitive-use at the January 2020 VA examination; and full extension. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements other than that described above. See DeLuca v. Brown, supra. In this regard, the Veteran denied flare-ups of his right elbow at the May 2012, October 2017, and May 2021 VA examinations; he endorsed flare-ups at the January 2020 VA examination and the functional impact is described above. The January 2020 VA examiner noted that pain, weakness, and lack of endurance significantly limit functional ability with repeated use over a period of time, and functional ability could be described in terms of range of motion after repetitive use or with flareups of flexion to 40 degrees, full extension (to zero degrees), supination to 5 degrees, and pronation to 5 degrees. The Board acknowledges that the May 2012 and October 2017 VA examiners were not able to provide opinions regarding additional functional impairment during flare-ups or following repetition. However, the Board finds that all information required for rating purposes was provided. In this regard, the Board notes that the examiner clearly found that the Veteran specifically reported weakness and decreased range of motion of the right elbow, without stiffness nor pain. Moreover, the Veteran denied having flare-ups at those times. There is no other indication from the record, to include the Veteran's own statements, that he experiences additional decreased range of motion, weakness, or incoordination during flare-ups or following repeated use other than shown above. As the Veteran has not endorsed those symptoms, the Board finds the examinations of record to be adequate for rating purposes. See Correia v. McDonald, 28 Vet. App. 158 (2016); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Based on the foregoing, for the appeal period prior to January 6, 2020, the Board finds the evidence, to include the Veteran's reported symptoms as considered in the VA examination reports and treatment records, does not demonstrate symptoms that rise to the level as required for a higher rating under the diagnostic criteria. While the Veteran has essentially stated that he has pain in his elbow, he has not described a range of motion less than that found on examinations. In this regard, he reported that he experienced symptoms that included pain and weakness. The Veteran's statements do not show the requisite limitation of motion necessary for higher or separate ratings. Treatment records do not show greater limitations of motion than the above examination findings. Specifically, the Veteran was not shown to have range of motion that was limited to 90 degrees of flexion in the right elbow. Given the above, even when considering the impact of right elbow pain on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Based on the foregoing, for the appeal period beginning on January 6, 2020, the Board finds the evidence, to include the Veteran's reported symptoms as considered in the VA examination reports and treatment records demonstrate symptoms that rise to a higher 50 percent rating under the diagnostic criteria. In this regard, the Veteran's right elbow demonstrated flexion to 70 degrees, with full extension, and forearm supination and pronation to 20 degrees each. There was additional loss of range of motion following repetitive-use testing and with a flare-up, with range of motion measurements to flexion, at worst, 40 degrees during a flare-up and full extension. Accordingly, resolving all doubt in favor of the Veteran, he was shown to have range of motion of forearm flexion (elbow) that was limited to 45 degrees such that a maximum 50 percent rating is warranted beginning January 6, 2020. Given the above, even when considering the impact of right elbow pain on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5213. The Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to demonstrate ankylosis, limitation of motion, flail joint, joint fracture, nonunion of the radius and ulna, nonunion of the radius, or impairment of supination and pronation, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5205 through 5213 for his right forearm tendinopathy. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5205-5213. As noted above, a separate rating for a right elbow scar has already been awarded and is currently not on appeal; and such, will not be discussed further in this decision. The Board acknowledges the Veteran's statements that his right elbow residuals of right arm shrapnel wound are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for higher ratings have been met. Nevertheless, the Board acknowledges the statements of the Veteran that his right elbow residuals manifests in limited use of his forearm and right hand and continuing nerve problems following right elbow surgery. See Correspondence, July 16, 2010. Additionally, the Veteran asserts that the VA examiner did not report nor measure his limited range of motion of his right arm, experiences pain, and has ankylosis. See e.g. Correspondence, October 19, 2010. Moreover, the Veteran reports he still has shrapnel in his right elbow, carpal tunnel in his right wrist, and an uncompensated scar; he also reported increased pain, neuropathy, numbness, tingling, and loss of use. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his right elbow disorder. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. These arguments are therefore without merit. The Board has considered whether further staged rating under Hart v. Mansfield, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning further staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his representative has alleged that he is unable to secure and maintain substantially gainful employment. Moreover, the Veteran's current employment status is not clear from the record. As such, a Rice claim is not raised. Accordingly, the Board finds that the evidence is against the assignment of an initial rating higher than 20 percent prior to January 6, 2020, for right elbow residuals and to that extent the claim is denied; the Board finds that the evidence is for the assignment of a 50 percent rating beginning January 6, 2020 for right elbow residuals, and to that extent the claim is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Diabetes Mellitus The Veteran asserts that he is entitled to a higher rating for his diabetes mellitus because his symptoms are more severe than contemplated by the currently assigned rating. Specifically, the Veteran asserts that his diabetes mellitus symptoms include loss of sensation in his feet and legs, unexplained weight gain, erectile dysfunction, brittle and discolored toenails, toe pain, injections to treat his diabetes mellitus, and required medication. See e.g. Correspondence, September 25, 2009. Additionally, the Veteran contends that his diabetes mellitus requires a special diet, frequent urination, daily testing of blood sugar, obesity, onychomycosis, neuropathy, and eye problems. See e.g. Correspondence, August 21, 2012; see also Correspondence, May 17, 2019. The Veteran's diabetes mellitus, Type II, is rated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. Under Diagnostic Code 7913, a rating of 20 percent is warranted in circumstances requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. 38 C.F.R. § 4.119. A rating of 40 percent is warranted in circumstances requiring insulin, restricted diet, and regulation of activities. Id. A rating of 60 percent is warranted in circumstances requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. Id. Finally, a maximum schedular rating of 100 percent is warranted in circumstances requiring more than one daily injection of insulin, restricted diet, and regulation of activities (defined as avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Note (1) to Diagnostic Code 7913 states to evaluate compensable complications of diabetes separately, unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1. Note (2) states that when diabetes mellitus has been conclusively diagnosed, do not request a glucose tolerance test solely for rating purposes. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 2. The definition of "regulation of activities" in the criteria for a 100 percent rating, that is, "the avoidance of strenuous occupational and recreational activities," also applies to the "regulation of activities' criterion for a 40 or 60 percent rating under Diagnostic Code 7913. The criterion of "regulation of activities" requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 363-65 (2011). Turning to the evidence of record, the Veteran was afforded a VA examination in March 2008. At that time, the examiner diagnosed impaired glucose tolerance, with elevated fasting glucose. The Veteran's diabetes mellitus was stable and required oral medication for treatment. The Veteran did not have episodes of hypoglycemic reactions or ketoacidosis and was instructed to follow a restricted or special diet. The Veteran was not restricted in an ability to perform strenuous activities. The Veteran was afforded a VA examination in July 2008. At that time, the examiner noted the Veteran's diabetes was mild and had been treated with twice daily oral medication. The Veteran denied ketoacidosis and episodes or hypoglycemic reactions. The Veteran was following a low carbohydrate diet. He had never been on insulin injections. His activities were not restricted as a result of his diabetes. His ability to work was not impaired. He exercised by walking two miles a day. He denied any current symptoms or complaints; his neuropathy was unrelated to diabetes mellitus and related to other injuries. The examiner found there was no evidence of complications that could be related to his mild and recent diabetes without resort to mere speculation. The Veteran was afforded a VA examination in October 2017. At that time, the examiner diagnosed diabetes mellitus type II. The Veteran did not require regulation of activities as a part of medical management of diabetes mellitus. He visited his diabetic care provider for episodes of ketoacidosis and/or hypoglycemia less than two times per month. The Veteran had not had any episodes of ketoacidosis nor hypoglycemic reactions that required hospitalization in the past 12 months. The Veteran did not have any progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. The examiner found the Veteran did not have any recognized complications of diabetes mellitus. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's diabetes mellitus did not impact his ability to work. The Veteran was afforded a VA examination in January 2020. At that time, the examiner diagnosed diabetes mellitus type II that was managed with prescribed oral hypoglycemic agents. The Veteran did not require regulation of activities as a part of medical management of his diabetes mellitus. The Veteran visited his diabetic care provider for episodes of ketoacidosis and/or hypoglycemia less than two times per month. The Veteran had not had any episodes of ketoacidosis nor hypoglycemic reactions that required hospitalization in the past 12 months. The Veteran did not have any progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's diabetes mellitus did not impact his ability to work. The examiner remarked the Veteran's diabetes mellitus had gotten worse. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his diabetes mellitus. However, there is no indication from the treatment notes of record that the Veteran has reported diabetes mellitus symptoms that are worse than those noted in the various VA examination reports of record. Based on the foregoing, the Board finds no evidence which would support the assignment of an increased rating for the Veteran's diabetes mellitus. The clinical evidence does not establish, and the Veteran has not alleged, that his diabetes mellitus was not manifested by the necessity of regulation of activities for control. The Board observes that regulation of activities is defined within the Diagnostic Code 7913 as "avoidance of" strenuous occupational and recreational activities. The medical records are devoid of any limitation of strenuous activity during any portion of the period on appeal. During the March 2008, July 2008, October 2017, and January 2020 VA examinations, the examiners indicated that the Veteran did not require regulation of activities as part of his medical management of his diabetes mellitus. Notably, the Veteran was shown to exercise daily by walking two miles a day. See July 2008 VA treatment record. As such, a 40 percent rating under Diagnostic Code 7913 is not warranted. Therefore, as the evidence of record shows that the Veteran's diabetes mellitus has not required regulation of activities, the Board finds that it does not more closely approximate the rating criteria for a rating in excess of 20 percent under Diagnostic Code 7913. As the criteria for the next higher, 40 percent rating are not met, it follows that the criteria for an even higher rating (60 or 100 percent) likewise are not met. The Board acknowledges the Veteran's statements that his diabetes mellitus are more severe than evaluated, to include loss of sensation in his feet and legs, unexplained weight gain, erectile dysfunction, brittle and discolored toenails, toe pain, injections to treat his diabetes mellitus, required medication, special diet, frequent urination, daily testing of blood sugar, obesity, onychomycosis, neuropathy, and eye problems. The Veteran is competent to report his symptoms and has presented credible statements in this regard. See, e.g., Layno v. Brown, supra and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for higher ratings than assigned have been met. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board has considered whether a staged rating under Hart v. Mansfield, supra, is warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a further staged rating is not warranted. Further, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Accordingly, the Board finds that the evidence is against the claim for an initial rating in excess of 20 percent for diabetes mellitus, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Right Median and Ulnar Nerves Impairment The Veteran asserts that he is entitled to higher ratings for shell fragment wound residuals of the right median and ulnar nerves as his symptoms are more severe than contemplated by the currently assigned ratings. Specifically, the Veteran contends that he has had very limited use of his right hand since his combat injury sustained during active service, loss of sensation in half of his right hand, deterioration of the muscles in his right hand, loss of use of his fourth and pinky fingers in his right hand, limited grasping ability and strength, inability to rotate his hand, inability to grasp any object that weighs more than a few pounds, inability to use his hand to type or other daily activities, and that he believes his right hand is equivalent to having an amputated stump. See e.g. Correspondence, July 16, 2010. The Veteran contends that his right median and ulnar nerves warrant a 30 percent rating. Id. Moreover, the Veteran contends that his right hand is constantly numb and causes difficulty in using his right arm and hand. See e.g. Correspondence, March 9, 2012. Additionally, the Veteran reported sharp pain in his right hand and arm. Id; see also Correspondence, March 30, 2012. As noted above, the Board notes that entitlement to a separate rating for scars of the right elbow were granted in a July 2021 rating decision, and assigned initial disability ratings, effective August 13, 2018 and November 12, 2008. To date, the Veteran has not expressed disagreement with either the rating and effective date assigned and are not currently on appeal. Therefore, the Board will not consider increased ratings for his right elbow scars. Additionally, the Board notes the Veteran's service-connected right elbow residuals is separately rated and separately on appeal. The Board discussed the Veteran's claim for an increased rating for his right elbow disorder above. The Veteran's shell fragment wound residuals of the right median nerve is rated as 10 percent disabling prior to October 2, 2020, and 20 percent thereafter under 38 C.F.R. § 4.124a, Diagnostic Code 8515. His shell fragment wound residuals of the right ulnar nerve is rated as 10 percent disabling prior to April 2, 2012, 20 percent disabling from April 2, 2012 to January 6, 2020, and 30 percent thereafter under 38 C.F.R. § 4.124a, Diagnostic Code 8516. Disease of the peripheral nerves of the upper extremities are rated under 38 C.F.R. § 4.124a, Diagnostic Codes 8510 to 8719. As noted above, the Veteran's left side is his dominant side, and is thus considered the "major" extremity. However, the Veteran has reported that he is naturally right hand dominant but was able to train himself to use his left upper extremity for the majority of his daily tasks. Accordingly, resolving all doubt in favor of the Veteran, the Board considers his right side is his "major" side. Diagnostic Code 8515 contemplates paralysis of the median nerve. Pursuant to Diagnostic Code 8515, incomplete paralysis of the median nerve affecting the major extremity that is mild, moderate, and severe warrants ratings of 10, 30, and 50 percent, respectively. Compete paralysis of the median nerve of the major extremity warrants a 70 percent rating, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Neuritis and neuralgia of the ulnar nerve are evaluated according to the rating criteria in 38 C.F.R. § 4.124a, Diagnostic Code 8516, paralysis of the ulnar nerve. Under Diagnostic Code 8516, for the major arm, incomplete paralysis of the ulnar nerve affecting the major extremity that is mild, moderate, and severe warrants ratings of 10, 30, and 40 percent, respectively. Complete paralysis of the ulnar nerve warrants a 60 percent evaluation, with the griffin claw deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb flexion of wrist weakened. 38 C.F.R. § 4.124a. The Board notes that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Words such as "mild," "moderate," "severe," and "marked" are not defined in the VA Schedule for Rating Disabilities and the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 3 8 C.F.R. § 4.6. 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. Turning to the evidence, the Veteran was afforded a VA examination in May 2012 for muscle injuries. At that time, the examiner diagnosed shrapnel wound residuals of the right forearm. The Veteran reported loss of supination of the right forearm at that time. The examiner indicated the Veteran was left handed. In pertinent part, the examiner noted the Veteran had less than normal strength in right elbow flexion; less than normal strength in right elbow extension; no movement against gravity in right wrist flexion; and normal strength in the right shoulder. The Veteran did not have muscle atrophy. He denied the use of any assistive devices as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's muscle injuries would impact his ability to work due to weakness in his right hand and wrist. The Veteran was afforded a VA examination in May 2012 for peripheral nerve conditions. At that time, the examiner diagnosed neuropathy of the right median and ulnar nerves. The examiner indicated the Veteran was left handed. The Veteran reported he suffered decreased sensation of the fifth finger and half of the fourth finger, with decreased sensation along the lateral surface of the palm. The Veteran had his right ulnar nerve repaired in January 1970; the surgery was not successful. He reported current symptoms included persistent numbness of the fourth and fifth fingers of the right hand and lateral aspects of the right hand radiating to the right elbow. Symptoms attributable in May 2012 included mild paresthesias and/or dysesthesias of the right upper extremity, and moderate numbness of the right upper extremity. Muscle strength testing showed active movement against some resistance in elbow flexion; active movement against some resistance in elbow extension; active movement with gravity eliminated in wrist flexion; active movement against gravity in wrist extension; active movement with gravity eliminated in grip; and active movement against some resistance in pinch (thumb to index finger). He did not have muscle atrophy. Deep tendon reflexes were normal. Sensation testing for light touch showed absent sensation in the inner and outer forearm and hand/fingers. The Veteran did not have trophic changes attributable to peripheral neuropathy. Special tests were not indicated nor performed for median nerve evaluation The May 2012 VA examiner opined the Veteran's right median nerve impairment was manifested in mild incomplete paralysis; his ulnar nerve was manifested in moderate incomplete paralysis. The examiner noted additional pertinent physical findings included the Veteran's reports of continuing weakness in the right hand; difficulty gripping things; first three digits going numb, requiring shaking them out at night; and trouble holding onto glasses due to numbness. Electromyography (EMG) studies showed absent ulnar sensory potential; moderate prolongation of median sensory latency; moderate to severe prolongation of median distal motor latency; and ulnar motor slowing but to the same degree both above and below the elbow. The examiner noted the Veteran's right median and ulnar nerves would impact his ability to work due to weakness and limited manual dexterity of the right arm and hand. The Veteran was afforded a VA examination in October 2017 for muscle injuries. At that time, the Veteran reported weakness in his right hand, difficulty gripping, sensory loss, and reduced manual dexterity. The Veteran reported he was left hand dominant. The examiner noted the Veteran had injuries to Groups V (flexor muscles of the elbow, biceps, brachialis, brachioradialis), VI (extensor muscles of the elbow, triceps), VII (flexors of the wrist, fingers, and thumb), and VIII (extensors of the wrist, fingers, and thumb) on the right side. The examiner noted the Veteran's muscle injuries affected some impairment of muscle tonus and some loss of muscle substance. The Veteran was shown to have loss of power, weakness, lowered threshold of fatigue, and impairment of coordination that were consistent in muscle groups V-VIII. Muscle strength testing in October 2017 showed no movement against resistance in elbow flexion; less than normal strength in elbow extension; no movement against resistance in wrist flexion; and less than normal strength in wrist extension. The Veteran did not have muscle atrophy. The Veteran denied the use of any assistive devices as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's right median and ulnar nerves impacted his ability to work due to weakness in the right arm and hand with difficulty gripping, lifting, sensory loss, and reduced manual dexterity. The Veteran was afforded a VA examination in October 2017 for peripheral neuropathy. At that time, the examiner diagnosed neuropathy of the right medial and ulnar nerves. The Veteran reported persistent weakness in the right elbow and wrist extension, grip and numbness of the right third, fourth, and fifth fingers. The examiner indicated the Veteran was right handed. Symptoms attributable to his peripheral nerve conditions included mild intermittent pain, mild paresthesias and/or dysesthesias, and moderate numbness of the right upper extremity. Muscle strength testing showed active movement against some resistance in elbow flexion; active movement against gravity in elbow extension; active movement against some resistance in wrist flexion; active movement against gravity in wrist extension; active movement against some resistance in grip; and active movement against some resistance in pinch (thumb to index finger). The Veteran did not have muscle atrophy. Deep tendon reflexes were hypoactive in the biceps, triceps, and brachioradialis. Sensation testing for light touch was absent for the inner/outer forearm and hand/fingers. The Veteran did not have trophic changes attributable to his peripheral neuropathy. His gait was normal. Special tests were not indicated nor performed for median nerve evaluation. The examiner found the Veteran had mild incomplete paralysis of the median nerve and moderate incomplete paralysis of the ulnar nerve on the right side. The Veteran denied the use of assistive devices as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner noted the Veteran's right median and ulnar nerves impairment impacted his ability to work due to weakness in the right arm and hand with difficulty gripping, lifting, sensory loss, and reduced manual dexterity. The Veteran was afforded a VA examination in January 2020 for peripheral nerve conditions. At that time, the examiner diagnosed residuals of shell fragment wound, right ulnar nerve. The Veteran reported his condition had worsened over the years. The examiner indicated the Veteran was left handed. Symptoms attributable to his peripheral nerve conditions included severe constant pain, severe paresthesias and/or dysesthesias, and severe numbness in the right upper extremity. Muscle strength testing was normal. The Veteran did not have muscle atrophy. Reflex examination testing results were normal. Sensation testing showed decreased sensation for light touch in the inner and outer forearm and hand and fingers of the right arm. The Veteran did not have trophic changes attributable to peripheral neuropathy. The Veteran's gait was normal. The VA examiner noted the Veteran had severe incomplete paralysis of the right ulnar nerve. The Veteran endorsed the occasional use of a cane as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The VA examiner noted the Veteran's right arm did not impact his ability to work. The Veteran was afforded a VA examination in October 2020 for peripheral nerve conditions. At that time, the VA examiner diagnosed residual shell fragment wound of the right median nerve. The Veteran reported numbness that was constant in the right median nerve and right middle, ring, and small fingers since 1969. There was a moderate reduction in the sensation to touch and pinprick in those fingers on examination. The examiner indicated the Veteran was right handed. The Veteran had moderate paresthesias and/or dysesthesias of the right upper extremity. Muscle strength testing was normal. The Veteran did not have muscle atrophy. Reflex testing was normal. Sensation testing results showed decreased sensation for light touch in the right hand and fingers. The Veteran did not have trophic changes attributable to peripheral neuropathy. The Veteran's gait was normal. The VA examiner noted the Veteran had moderate incomplete paralysis of the right median nerve. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The VA examiner noted the Veteran's right arm did not impact his ability to work. The Veteran was afforded a VA examination in May 2021 for peripheral nerve conditions. At that time, the VA examiner diagnosed residuals of shell fragment wound, right ulnar nerve, residual scars, right elbow, right elbow residuals of right arm shrapnel wound, shell fragment wound, and right median nerve. The Veteran reported his conditions had stayed the same. He reported pain, paresthesias, and motor dysfunction of the nerves. Symptoms attributable to his peripheral nerve conditions included mild constant pain, mild intermittent pain, and severe numbness of the right upper extremity. Muscle strength testing demonstrated active movement against resistance in elbow flexion, elbow extension, wrist flexion, wrist extension, grip, and pinch (thumb to finger index) in the right upper extremity. The Veteran had right-sided forearm musculature atrophy that measured 28 centimeters on the atrophied side, and 31 centimeters on the normal side. Reflex examination testing results were normal. Sensory examination showed decreased sensation to light touch in the inner//outer forearm, and hand/fingers on the right upper extremity. The Veteran had trophic changes that demonstrated as display of loss of extremity hair and smooth/shiny skin consistent with trophic changes of peripheral neuropathy. The Veteran's gait was normal. Special tests were indicated and performed for median nerve conditions and results were as follows: positive for Phalen's sign, and positive for Tinel's sign. The VA examiner noted the Veteran had moderate incomplete paralysis of the right median nerve, and moderate incomplete paralysis of the right ulnar nerve. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The VA examiner noted the Veteran's right arm impacted his ability to work due to limited range of motion, dexterity, precision, and sensory changes that would encumber the use of the dominant extremity, making manipulations of objects or load-carrying difficult. In addition, the Veteran noted he was naturally right hand dominant but had trained himself to use his left arm for the majority of tasks. The Veteran was afforded a VA examination in May 2021 for muscle injuries. At that time, the VA examiner diagnosed right elbow residuals of right arm shrapnel wound status post-surgery (Group VII). The Veteran had a penetrating muscle injury that was a shrapnel wound from explosive device to the right upper extremity. The Veteran reported his condition had stayed the same. Current symptoms included weakness; incoordination; and associated sensory deficits. He had surgical savage and correction with nerve repair. Upon physical examination, the Veteran had ragged, depressed and adherent scars indicating wide damage to muscle groups in the missile track; some impairment of muscle tonus; some loss of muscle substance; visible or measurable atrophy; consistent loss of power; consistent weakness; consistent lowered threshold of fatigue; consistent fatigue and/or pain; and consistent impairment of coordination. Muscle strength testing showed less than normal strength in wrist flexion of the right side. The Veteran had forearm muscle atrophy that measured as 28 centimeters of the atrophied side and 31 centimeters of the normal side. The Veteran denied the use of assistive devices as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. Electrodiagnostic tests were conducted and demonstrated absent ulnar sensory potential; moderate prolongation of median sensory latency; moderate to severe prolongation of median distal motor latency; ulnar motor slowing but to the same degree both above and below the elbow; and the findings were indicative of moderately severe degree of carpal tunnel syndrome and ulnar neuropathy without entrapment. The VA examiner noted the Veteran's right arm would impact his ability to work due to an inability to maintain a reasonably expected work pace and reasonably expected precision that was clearly impacted by the deficits in the arm strength, dexterity, and fine motor control. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his shell fragment wound residuals of right median and ulnar nerve peripheral neuropathy. However, there is no indication from the treatment notes of record that the Veteran has reported peripheral neuropathy symptoms of the right upper extremity, namely ulnar and median nerve peripheral neuropathy, that are worse than those noted in the various VA examination reports of record. I. Analysis Right Median Nerve Based on the foregoing, for the appeal period prior to October 2, 2020, the evidence shows that the Veteran's right median nerve manifested in, at worst, mild incomplete paralysis of the right median nerve. In this regard, the May 2012 and October 2017 VA examinations, the VA examiners noted the Veteran had mild incomplete paralysis of the right median nerve. In addition, the VA examiners noted the Veteran's reports of continuing weakness in the right hand, difficulty gripping things, that the first three digits going numb, requiring shaking them out at night and trouble holding onto glasses due to numbness. The clinical evidence does not establish, and the Veteran has not alleged, that his right median nerve manifested in moderate incomplete paralysis of the right median nerve prior to October 2, 2020 to warrant a higher 30 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8515. As such, a higher 30 percent rating prior to October 2, 2020 under Diagnostic Code 8515 is not warranted. Id. Based on the foregoing, for the appeal period beginning on October 2, 2020, the evidence shows that the Veteran's right median nerve manifested in, at worst, moderate incomplete paralysis of the right median nerve. In this regard, the October 2020 and May 2021 VA examinations, the VA examiners noted the Veteran had moderate incomplete paralysis of the right median nerve. In addition, the VA examiners noted the decreased sensation to touch and pinprick, decreased sensation for light touch, and some decreased muscle strength on examination. The clinical evidence does not establish, and the Veteran has not alleged, that his right median nerve manifested in severe incomplete paralysis of the right median nerve beginning October 2, 2020 to warrant a higher 50 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8515. As such, a 30 percent rating, but not higher beginning October 2, 2020 under Diagnostic Code 8515 is warranted. Id. II. Analysis Right Ulnar Nerve Based on the foregoing, for the appeal prior to January 6, 2020, the evidence shows that the Veteran's right ulnar nerve manifested in, at worst, moderate incomplete paralysis of the right median nerve. In this regard, the May 2012, October 2017, and January 2020 VA examinations, the VA examiners noted the Veteran had moderate incomplete paralysis of the right ulnar nerve. In addition, the VA examiners noted the Veteran's reports of continuing weakness in the right hand, difficulty gripping things, that his first three digits going numb, requiring shaking them out at night and that he had trouble holding onto glasses due to numbness. The clinical evidence does not establish, and the Veteran has not alleged, that his right ulnar nerve manifested in severe incomplete paralysis of the right median nerve prior to January 6, 2020 to warrant a higher 40 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8515. As such, a 30 percent rating, but not higher, prior to January 6, 2020 under Diagnostic Code 8516 is warranted. Id. Based on the foregoing, for the appeal period beginning on January 6, 2020, the evidence shows that the Veteran's right ulnar nerve manifested in, at worst, severe incomplete paralysis of the right median nerve. In this regard, at the January 2020 VA examination, the VA examiner noted the Veteran had severe incomplete paralysis of the right ulnar nerve. In addition, the VA examiners noted severe constant pain, paresthesias and/or dysesthesias, and numbness of the right upper extremity due to his right ulnar nerve impairment. As such, a schedular maximum 40 percent rating, beginning January 6, 2020 under Diagnostic Code 8516 is warranted. Id. Finally, the Board has considered whether a right rating based on the loss of use of the right hand is warranted. Special monthly compensation is payable to a veteran for anatomical loss or loss of use of a hand. 38 U.S.C. § 1114(k). Loss of use of a hand will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. 38 C.F.R. §§ 3.350(a)(2), 4.63. While the Veteran's VA examinations and treating records indicate that he had some limitation of function of the right hand, such limitations do not show that no effective function remained other than that which would be equally well served by amputation with use of a suitable prosthetic appliance. As noted above, strength, dexterity and fine motor control were negatively impacted which renders the manipulation of objects or load-carrying difficult. However, the Veteran retained some limited function with his right hand. For instance, reported that he could not lift anything weighing more than a few pounds with that hand. See July 2010 statement. Therefore, special monthly compensation based upon the loss of use of the right hand is not warranted. III. Conclusion Right Median and Ulnar Nerves The Board has reviewed other Diagnostic Codes pertaining to upper extremity neurological disabilities under 38 C.F.R. § 4.124a. As the evidence is clear that the rated disabilities stem from median and ulnar nerve impairments Diagnostic Codes 8515 and 8516 are the appropriate provision under which to rate the Veteran's disabilities. The Board has considered whether further staged rating under Hart v. Mansfield, supra, is warranted, however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning further staged rating is not warranted. Further, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. As noted above, a separate rating for a right elbow scar has already been awarded and is currently not on appeal; and such, will not be discussed further in this decision. The Board acknowledges the Veteran's statements that his right median and ulnar nerve impairment are more severe than evaluated. Specifically, the Board notes the Veteran's complaints of very limited use of his right hand since his combat injury sustained during active service, loss of sensation in half of his right hand, deterioration of the muscles in his right hand, loss of use of his fourth and pinky fingers in his right hand, limited grasping ability and strength, inability to rotate his hand, inability to grasp any object that weighs more than a few points, inability to use his hand to type or other daily activities, and that he believes his right hand is equivalent to having an amputated stump. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for higher ratings than that assigned above have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his median and ulnar nerves. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. These arguments are therefore without merit. Additionally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his representative has alleged that he is unable to secure and maintain substantially gainful employment. Moreover, the Veteran's current employment status is not clear from the record. As such, a Rice claim is not raised. Accordingly, the Board finds that the evidence is against the assignment of a 10 percent rating prior to October 2, 2020 for right median nerve impairment, and to that extent the claim is denied. The Board finds that the evidence is for the assignment of a 30 percent rating, but not higher, beginning October 2, 2020 for right ulnar nerve impairment; for the assignment of a 30 percent rating, but not higher, prior to January 6, 2020 for right ulnar nerve impairment; and for the assignment of a 40 percent rating, but not higher, beginning January 6, 2020, for right ulnar nerve impairment, and to that extent the claims are granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Increased Rating Bilateral Pinguecula The Veteran seeks entitlement to a compensable rating for his bilateral pinguecula. Specifically, the Veteran contends that his eye symptoms include pain; extreme light sensitivity; constant tearing and trying to flush out debris; requiring surgery; irritation; reddening; pain; and required medication for treatment. See e.g. Correspondence, May 17, 2019. As noted above, the claim was most recently before the Board in July 2019 when it was remanded to the AOJ for further development. Specifically, the July 2019 Board remand directed the AOJ to schedule the Veteran for a VA examination to determine the current nature and severity of his bilateral pinguecula. In this regard, the July 2019 Board remand noted that the Veteran's most recent eye examination was from November 2017 and was considered too remote in time to address the current severity and manifestations of his bilateral pinguecula. The Veteran was afforded the directed VA examination in January 2020. At that time, the examiner diagnosed bilateral pinguecula, and opined that such were due to ultraviolet exposure and less likely than not caused by his service. Additionally, the examiner noted the Veteran had bilateral corneal scars, that were at least as likely as not related to service but were small and visually insignificant. The January 2020 VA examiner conducted an eye examination to determine the Veteran's visual acuity, visual field acuity, and the like. The Board notes that the Veteran's bilateral pinguecula are evaluated under 38 C.F.R. § 4.79, Diagnostic Code 6037, which instructs adjudicators to evaluate pinguecula based on disfigurement, using the criteria set forth in 38 C.F.R. § 4.118, Diagnostic Code 7800. This diagnostic code enumerates eight characteristics of disfigurement, six of which include some reference to the size or total area of the scar(s) under consideration. The Board acknowledges that pinguecula may not be considered "scarring" in the medical sense of the term; however, VA regulations treat them as such for the purpose of evaluating the severity of the disability. Therefore, the sizes of the Veteran's bilateral pingueculas are information that is necessary to properly adjudicate his claims. Consequently, as the VA examinations conducted to date address only visual impairment, the Board finds that a remand is necessary in order to afford the Veteran a VA examination evaluating his bilateral pinguecula based on scarring. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See D'Aries, 22 Vet. App. at 105; see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As such, remand is again required to afford the Veteran additional VA examination that complies with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. at 268, 271 (1998). Service Connection Claims Bilateral Hip Disorder, Hypertension, and Erectile Dysfunction The Veteran seeks entitlement to service connection for a bilateral hip disorder, hypertension, and erectile dysfunction. Specifically, with regard to bilateral hip disorder, the Veteran contends that such disorders are as a result of the physical rigors of his service, to include combat and related injuries, and such symptoms manifested during active service and have continued since. See e.g. Notice of Disagreement, January 18, 2011. Specifically, with regard to his hypertension and erectile dysfunction, the Veteran contends that such disorders are as a result of his service in the Republic of Vietnam, to include exposure to herbicide agents, and is secondary to his service-connected PTSD and diabetes mellitus. See e.g. Correspondence, December 12, 2019; see also e.g. Correspondence, December 1, 2011. As noted above, the claims were most recently before the Board in July 2019 when they were remanded to the AOJ for further development. Specifically, the July 2019 Board remand directed the RO to obtain private treatment records from the 1970s to 1998, and to afford the Veteran additional VA examination to obtain etiology opinions as to his hypertension and erectile dysfunction. Additional VA examination was not requested for the Veteran's claimed bilateral hip disorder. The Veteran was afforded the directed VA examination for hypertension in January 2020 and for erectile dysfunction December 2020. The Veteran had been previously afforded a VA examination for his claimed bilateral hip disorder in October 2017. The July 2019 Board remand noted that the Veteran disputed the accuracy of the information documented and indicated he had been mostly under private care. Unfortunately, a new VA examination for the Veteran's bilateral hip disorder was not directed by the July 2019 Board, and therefore, additional VA examination was not afforded with respect to his bilateral hips. The October 2017 VA examiner opined, in pertinent part, that the Veteran's bilateral hip degenerative joint disease was not related to the events that occurred during his military service, nor secondary to his lumbar arthritis. The examiner noted that the Veteran was not diagnosed with a chronic bilateral hip condition in the military service, and that there was no history of a shell fragment wound to either hip; the examiner further noted that the Veteran's bilateral hip degenerative joint disease developed 32 years after separation from active service. Additionally, the examiner noted that there is not a consensus of evidence in medical literature or in the medical community that supported a causal or aggravating relationship between lumbar arthritis and bilateral hip degenerative joint disease. The January 2020 VA examiner opined that the Veteran' hypertension was less likely than not the Veteran's hypertension was secondary to or aggravated beyond its natural progression by his PTSD. In this regard, the examiner noted that hypertension commonly has multiple contributing factors and causes, and tends to be multifactorial in nature, to include genetic, environmental, and life factors. The examiner further noted there was no direct pathophysiologic link between PTSD causing or aggravating hypertension, and there was no direct causal relationship between PTSD and hypertension. Additionally, the January 2020 VA examiner opined that hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, the examiner noted that there were no medical records showing a diagnosis or treatment for hypertension during active service or a year after his service in 1973. The December 2020 VA examiner opined the Veteran's erectile dysfunction was less likely than not proximately due to or the result of his diabetes mellitus. In this regard, the examiner noted the Veteran's reports that he developed erectile dysfunction in 1977 which is many years before his diagnosis 2008 of diabetes mellitus. Additionally, the examiner noted the Veteran's erectile dysfunction was medically recognized in 2002. Therefore, the December 2020 VA examiner concluded that his erectile dysfunction was a condition that preexisted the diabetes mellitus and would therefore be as due to other reasons than his diabetes mellitus. Moreover, with the contention that his erectile dysfunction is secondary to PTSD, the examiner noted that while his PTSD may have had some influence on his erectile dysfunction, the Veteran had other non-PTSD related factors such as, age, obesity and hypertension, that would have made it more likely than the erectile dysfunction arose from those risk factors. Moreover, the examiner opined his erectile dysfunction is less likely than not aggravated beyond its natural progression by his PTSD and diabetes mellitus. In this regard, the examiner noted the Veteran's erectile dysfunction was brought to the attention of the VA facility in 2002, managed conservatively with oral medications, had not required surgical interventions, and is what one would expect with erectile dysfunction. Therefore, the December 2020 VA examiner found there was no evidence of aggravation with erectile dysfunction as due to PTSD or diabetes mellitus. The Board finds the October 2017, January 2020, and December 2020 VA medical opinions inadequate to decide the claims. In this regard, the VA medical opinions failed to provide adequate rationale for the conclusions reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In addition, the VA examiners failed to adequately address the Veteran's lay statements and contentions that his symptoms began during active service and have continued since, are as due to his combat exposure during his service in the Republic of Vietnam and are as due to herbicide agent exposure during his service in the Republic of Vietnam. Moreover, with regard to hypertension, the Board notes that that hypertension is not a disability that is presumptively related to herbicide exposure. 38 C.F.R. § 3.309(e). However, a recent determination from the National Academy of Sciences upgraded hypertension to the "sufficient" category from "limited or suggestive," indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and herbicide exposure. Given these deficiencies, the Board is unable to find that substantial compliance with the prior remand has been achieved. See also Dyment v. West, supra. As such, remand is again required to afford the Veteran additional VA examinations that complies with the Board's prior remand directives. See Stegall v. West, supra. Combined Rating Regarding the issue of entitlement to a combined rating in excess of 90 percent prior to April 2, 2012, the Board notes that the issue is inextricably intertwined with the claims remanded herein. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Hence, a determination on the claim for the issue of entitlement to a combined rating in excess of 90 percent should be deferred pending final dispositions of the claims of entitlement to service connection for a bilateral hip disorder, hypertension, and erectile dysfunction. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate examiner to determine the current severity of his service-connected bilateral pinguecula based on scarring/disfigurement. The record, to include a copy of this Remand, should be provided to the examiner and all indicated tests should be conducted. The examiner should describe the nature and severity of the manifestations of the Veteran's bilateral pinguecula, to include any resulting functional impairment. In this regard, the examiner should identify the types of scarring/disfigurement caused by the pinguecula, to include a measurement of the approximate size of each pinguecula, as well as individual and combined total areas for the pingueculas in both eyes. In this regard, the Board notes that while pinguecula may not be considered "scarring" or "disfigurement" in the medical sense of the terms, VA regulations treat them as such for the purpose of evaluating and rating the severity of the disability. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Following the receipt of outstanding records, schedule the Veteran for VA examination to determine the nature and etiology of his bilateral hip disorder. The need for further in-person physical examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) Is it at least as likely as not (50 percent or greater probability) that such bilateral hip disorder had its initial onset in service or is otherwise etiologically related to the Veteran's active service, to include combat in the Republic of Vietnam? (B) Is it at least as likely as not (50 percent or greater probability) that such bilateral hip disorder is caused by or permanently aggravated by his service-connected lumbar arthritis? The examiner must address the lay statements of the Veteran that his hip symptoms began during active service, to include pain, and have continued since. The examiner is reminded that the absence of diagnosis and treatment for a disorder during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Following the receipt of outstanding records, schedule the Veteran for VA examination to determine the nature and etiology of his hypertension. The need for further in-person examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) Is it at least as likely as not (50 percent or greater probability) that such hypertension had its initial onset in service or is otherwise etiologically related to the Veteran's active service, to include combat and/or herbicide exposure in the Republic of Vietnam? (B) Is it at least as likely as not (50 percent or greater probability) that such hypertension was caused by or permanently aggravated by his service-connected PTSD and/or diabetes mellitus? The examiner should discuss the significance, if any, of the Veteran's herbicide agent exposure during active service and the recent determination by the National Academy of Sciences upgrading the relationship between hypertension to herbicide exposure to "sufficient." The examiner is reminded that the absence of diagnosis and treatment for a disorder during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Following the receipt of outstanding records, schedule the Veteran for VA examination to determine the nature and etiology of his erectile dysfunction. The need for further in-person examination is left to the discretion of the examiner. After reviewing the record, considering the lay evidence, and any recommended testing, the examiner should address the following: (A) Is it at least as likely as not (50 percent or greater probability) that such erectile dysfunction had its initial onset in service or is otherwise etiologically related to the Veteran's active service, to include combat and/or herbicide exposure in the Republic of Vietnam? (B) Is it at least as likely as not (50 percent or greater probability) that such erectile dysfunction was caused by or permanently aggravated by his service-connected PTSD and/or diabetes mellitus? The examiner is reminded that the absence of diagnosis and treatment for a disorder during service cannot be the sole basis for finding that the claimed disorder is not etiologically related to active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.