Citation Nr: 22018796 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 15-12 741 DATE: March 30, 2022 ORDER Entitlement to an initial 10 percent rating for right ankle scar residuals is granted. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) residuals is denied. REMANDED Entitlement to service connection for a heart disability, to include non-ischemic cardiomyopathy with LV dysfunction, is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to a rating in excess of 10 percent for right wrist flexor tendonitis is remanded. Entitlement to a rating in excess of 10 percent for left wrist flexor tendonitis is remanded. Entitlement to a rating in excess of 10 percent prior to June 18, 2021, and in excess of 20 percent for cervical spine spondylosis on and after June 18, 2021, is remanded. Entitlement to an initial rating in excess of 10 percent for thoracolumbar spine degenerative disc disease is remanded. Entitlement to a rating in excess of 10 percent for right ankle and fibula arthritis with open reduction and internal fixation residuals is remanded. Entitlement to an initial rating in excess of 20 percent for right upper extremity radiculopathy is remanded. Entitlement to an initial rating in excess of 20 percent for left upper extremity radiculopathy is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The right ankle scar residuals have been shown to be manifested by no more than two well healed, stable, and non-tender surgical scars of the medial and lateral aspect of the right ankle measuring 13 centimeters by.3 centimeters and 9 centimeters by.3 centimeter; involvement of a total combined area of 6.6 centimeters; pain due to rubbing of footwear, clothing, and sheets against the scars; and no underlying tissue damage. 2. PTSD with TBI residuals has been shown to be productive of no more than occupational and social impairment with reduced reliability and productivity due to depression; anxiety; chronic sleep impairment; nightmares; irritability; mild memory loss; mildly impaired judgment; a flattened affect; disturbances of motivation and mood; and inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent rating, and no higher, for right ankle scar residuals have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7802, 7804. 2. The criteria for an initial rating in excess of 50 percent for PTSD with TBI residuals have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.124a, 4.130, Diagnostic Codes 8045,9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active service from July 1972 to July 1976 and from November 1976 to December 1992. The Veteran appeared at an April 2016 videoconference hearing before a Veterans Law Judge. The hearing transcript is of record. In January 2018, the Veteran was notified that the Veterans Law Judge who conducted the April 2016 hearing had left the Board of Veterans' Appeals (Board), and he had the right to another hearing before a different Veterans Law Judge. The Veteran did not respond to the Board's notice. INCREASED RATINGS Disability ratings are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. RIGHT ANKLE SCARS The Veteran contends a compensable rating is warranted for the service-connected right ankle scars. In 2018, the Secretary of the Department of Veterans Affairs (VA) amended the provisions of the Rating Schedule applicable to skin disabilities including scars. Claims pending prior to the August 2018 effective date will be considered under both old and new rating criteria, and whichever criteria are more favorable to the Veteran are to be applied. 38 C.F.R. § 4.118. Prior to August 13, 2018, scars that were not related to burns; did not involve the head, face, or neck; and were superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm) or greater warranted a 10 percent rating. A superficial scar was one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2018). Prior to and after August 13, 2018, a 10 percent rating was warranted where there are one or two scars that are unstable or painful. A 20 percent rating requires that there are three or four unstable or painful scars. A 30 percent rating requires that there are five or more scars that are unstable or painful warrants. 38 C.F.R. § 4.118, Diagnostic Code 7804. Prior to and after August 13, 2018, other scars (including linear scars), and other effects of scars not considered in a rating provided under Diagnostic Codes 7800 to 7804 are to be rated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. On and after August 13, 2018, a 10 percent rating is warranted for burn scars or scars due to other causes which do not involve the head face or neck and not associated with underlying soft tissue damage where the scar covers an area or areas of 144 square inches (929 sq. cm) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802. The report of an October 2012 VA ankle examination states that the Veteran exhibited a scar over the medial aspect of the right ankle which measured 8 centimeters by .2 centimeters and a scar over the lateral aspect of the right ankle which measured 8.5 centimeters by .1 centimeters. The examiner related that the scars involved a total area is not greater than 39 square centimeters and were not painful or unstable. At the April 2016 Board hearing, the Veteran testified that the right ankle scars were painful if boots, high top shoes, clothing, or sheets rubbed against them. The report of a June 2021 VA scar examination states that the Veteran exhibited two well healed, stable, and non-tender surgical scars of the medial and lateral aspect of the right ankle which measured 13 centimeters by .3 centimeters and 9 centimeters by .3 centimeters, respectively; involvement of a total combined area of 6.6 centimeters; and no underlying tissue damage. The examiner found that the Veteran's scars do not impact his ability to work. VA clinical documentation notes complaints of right ankle pain and discomfort partially related to the right ankle scars. Based on the evidence of record, the Board finds that the evidence is against finding that an increased rating in excess of 10 percent is warranted. The Veteran's right ankle scars are a residual of in-service surgery. The right ankle scar residuals have been shown to be manifested by no more than two well healed, stable, and non-tender surgical scars of the medial and lateral aspect of the right ankle measuring 13 centimeters by.3 centimeters and 9 centimeters by.3 centimeter; involvement of a total combined area of 6.6 centimeters; pain due to rubbing of footwear, clothing, and sheets against the scars; and no underlying tissue damage. Such findings merit at least a 10 percent rating under Diagnostic Code 7804. In the absence of a finding of the presence of more than two scars; an unstable scar; or involvement of an area or areas of 144 square inches (929 sq. cm) or greater, the Board finds that a rating in excess of 20 percent under Diagnostic Code 7804 and/or a separate rating under Diagnostic Code 7802 are not warranted. Therefore, an initial 10 percent rating, and no higher, for right ankle scar residuals is granted. PTSD with TBI Residuals The Veteran contends that an initial rating in excess of 50 percent for PTSD with TBI residuals is warranted. A 50 percent rating is warranted for PTSD which is productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8045 address the three main areas of dysfunction that may result from TBI residuals and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headaches or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. The rater is to evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." The rater is to evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. The rater is to assign a 100- percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the rater shall assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, the rater shall assign a 70 percent rating if 3 is the highest level of evaluation for any facet. 38 C.F.R. § 4.124a, DC 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a co-morbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013) the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The report of an August 2011 VA psychiatric examination states that the Veteran reported current symptoms of depressed mood, anxiety, mild memory loss, flattened affect, disturbances of motivation and mood, and an inability to establish and maintain effective relationships. He was diagnosed with PTSD and TBI residuals. The examiner found occupational and social impairment with occasional deceases in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with normal routine behavior, self-care and conversation was noted. The examiner noted that it is not possible to differentiate the symptoms and associated occupational and social impairment arising from the PTSD and TBI residuals. The Veteran reported going "blank" in conversations and that his speech became garbled at times. Psychological test results noted on Cognitive Difficulties Scales administered in June 2011 a "sometimes" difficulty with attention and concentration, orientation and memory and domestic activities. The examiner noted that symptoms of decreased attention and concentration and occasional forgetfulness are symptoms that overlap and coexist with PTSD. The examiner noted the Veteran is capable of managing his financial affairs. The report of a June 2012 VA neuropsychological examination notes that the Veteran reported "going blank" in conversations and his speech became garbled at times. The Veteran reported a decline in his memory. The evaluation noted normal range functioning across most the of Veteran's neurobehavioral domains and deficits that could represent the effects of very mild cerebral impairment but were nonspecific with regard to etiology. The examiner noted potential areas of difficulty might involve verbal ideational fluency, planning ability and retrieval of auditory-verbal information from recent memory. The report of an October 2012 VA TBI examination conveys that the Veteran reported recent events of speech/thought disturbances. He was diagnosed with TBI residuals including post-traumatic migraines and vertigo. A February 2013 VA psychiatry evaluation notes that the Veteran reported ongoing symptoms of hyperarousal, avoidance, fair energy, appetite, and concentration. The Veteran was observed to be oriented times three. On mental status examination, the Veteran exhibited clear and coherent speech, organized and linear thought process, fair insight and judgment, and no perceptual disturbances and no suicidal and homicidal ideations. The report of a February 2013 VA examination notes that the identified decreased attention and concentration were most likely caused by anxiety symptoms associated with the diagnosed PTSD. Assessment of facets of TBI related cognitive impairment noted a complaint of mild memory loss, with occasional difficulty recalling information. Judgement was noted to be mildly impaired, as the Veteran reports some difficulty in making decisions and at times, he loses his train of thought. Social interaction was noted to be occasionally inappropriate, attributed to the Veteran's irritability. As to orientation, the Veteran was noted to occasionally be disoriented to one of the four aspects of person, place, time, and situation citing episodes of speech and thought arrest. Motor activity was normal. Visual spatial orientation was mildly impaired at times, the Veteran reporting getting lost in both familiar and unfamiliar surroundings. Subjective symptoms were noted that do not interfere with work, instrumental activities of daily living, work, family, or other close relationships. One or more neurobehavioral effects, specifically irritability, was noted that does not interfere with workplace or social interactions. As to communication, comprehension or expression is occasionally impaired, in that the Veteran reports occasional episodes of speech and thought arrest. Consciousness was normal. TBI residuals were noted to be headaches and dizziness/vertigo. Neuropsychological testing conducted in June 2012 noted normal range of functioning across most of the examiner's measured neurobehavioral domains with circumscribed deficits of unclear etiology, possibly representing very mild cerebral impairment. The examiner noted the TBI residuals impacted the Veteran's ability to work. A December 2013 VA psychiatry note conveys that the Veteran was observed to be oriented times three and well-groomed. On mental status examination, the Veteran exhibited a stable mood with fair motivation, energy, and concentration; clear and coherent speech; an organized and linear though process; fair insight and judgment; and no suicidal and homicidal ideation. At the April 2016 Board hearing, the Veteran testified that the PTSD symptoms included nightmares, recurrent sleep difficulties, depression, guilt, irritability, and isolating behaviors. The PTSD impacted his employment with the Department of Defense and necessitated his early retirement. A June 2016 VA psychiatry outpatient treatment record states that the Veteran reported increased feelings of depression; reduced anxiety; and difficulty falling asleep. The Veteran was observed to be neatly dressed and oriented times three. On mental status examination, the Veteran exhibited a subdued and tense mood; intact memory; and no signs or symptoms of psychotic thinking. In a January 2020 VA mental health note the Veteran reported that his mood has been good, and he experiences nightmares several times per week. The Veteran reported he enjoys studying the Bible and is helping his father who is living with him. A mental status examination noted the Veteran presented in casual and appropriate attrite, with normal speech, neutral affect, linear, logical and goal directed thought process and concentration. The Veteran denied hallucinations and denied suicidal and or homicidal ideations. His insight and judgment were good. The report of a June 2020 VA PTSD examination states that the Veteran was diagnosed with PTSD and TBI residuals. The examiner noted that it was not possible to differentiate the symptoms attributable to PTSD and the TBI residuals. The Veteran was observed to be oriented in all spheres. On mental status examination, the Veteran exhibited an affect and mood appropriate to the situation; logical thought processes; clear speech; intact memory functions; and no suicidal or homicidal ideation. The examiner commented that the PTSD and TBI residuals were productive of occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The report of a July 2021 VA TBI examination indicates that the Veteran was diagnosed with TBI residuals. Assessment of facets of TBI related cognitive impairment and subjective symptoms of TBI noted no complaints of impairment of memory, attention, concentration, or executive functions. Judgment was normal. Social interaction is routinely appropriate. As to orientation the Veteran is always oriented to person, time, place, and situation. Motor activity and visual spatial orientation was normal. No neurobehavioral effects were noted. As to communication the Veteran is able to communicate by spoken and written language. Consciousness was normal. No subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to TBI were noted. The examiner was unable to delineate nor separate out the PTSD and TBI symptoms. The service connected PTSD with TBI residuals has been shown to be productive of no more than occupational and social impairment with reduced reliability and productivity due to depression; anxiety; chronic sleep impairment; nightmares; irritability; mild memory loss; mildly impaired judgment; a flattened affect; disturbances of motivation and mood; and inability to establish and maintain effective relationships. During the period on appeal, the Veteran reported symptoms including depression, anxiety, sleep impairment, nightmares, irritability, mild memory loss, mildly impaired judgment, flattened affect, disturbances of motivation and mood and inability to establish and maintain effective relationships at times. Such symptomatology does not establish a level of disability contemplated by a rating in excess of 50 percent. Some of the reported symptomology approximates the listed criteria for an evaluation in excess of 50 percent. The Board finds that the Veteran's occupational and social impairment has not been shown to encompass the disability needed to support the assignment of a 70 percent rating. It has not been characterized by occupational and social impairment with deficiencies in most areas. Indeed, the Veteran has consistently reported completing activities of daily living, with assistance at times; regularly attending his VA appointments; completing projects around the house; and taking care of family members. Taking a holistic analysis of the signs and symptoms of the service connected PTSD with TBI residuals, the Board finds that the occupational and social impairment caused by these symptoms has not risen to the level of an increased 70 percent rating. Therefore, the Board concludes that an initial rating in excess of 50 percent for PTSD with TBI residuals is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability, to include non ischemic cardiomyopathy with LV dysfunction, is remanded The Veteran contends that service connection is warranted for a heart disability as the service connected disabilities either caused or aggravated the diagnosed non ischemic cardiomyopathy with LV dysfunction. He asserts that the service connected disabilities render him unable to engage in regular physical exercise and activity leading to his current heart disability. Service connection may be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for PTSD with TBI residuals, right upper extremity radiculopathy, left upper extremity radiculopathy, cervical spine spondylosis, right ankle arthritis, tinnitus with benign paroxysmal positional vertigo, esophagal reflux, left and right wrist tendonitis, thoracolumbar spine degenerative disc disease, right ear hearing loss, irritable bowel syndrome and right ankle scars. The report of a June 2021 VA heart examination states that the examiner concluded that it is less likely than not that the diagnosed heart disability is proximately due to or the result of service connected thoracolumbar spine, wrist, and right ankle disability. The physician assistant noted that the Veteran's current heart disability "is a separate entity entirely" from the service connected musculoskeletal disabilities. The examiner did not address whether the diagnosed heart disability was related to the service-connected PTSD with TBI residuals and whether the diagnosed heart disability had been aggravated by the service connected thoracolumbar spine, right ankle, right wrist, and left wrist disabilities. In light of such deficiencies, the Board finds that the June 2021 VA examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA heart evaluation is needed. 2. Entitlement to service connection for diabetes mellitus is remanded. The Veteran contends that service connection is warranted for diabetes mellitus as the service connected disabilities either caused or aggravated the diabetes mellitus. He asserts that the service connected disabilities render him unable to engage in regular physical exercise and activity leading to his current diabetes mellitus. The report of a June 2021 VA diabetes examination conveys that the examiner concluded that it is less likely than not that the diagnosed diabetes mellitus was incurred in or caused by any claimed in-service injury, event, or illness. The physician assistant noted that there is "no objective evidence that shows a plausible relationship between the Veteran's current diagnosis of diabetes mellitus and his military service" and no relationship between the diagnosed diabetes mellitus and the service connected musculoskeletal disabilities. The examiner did not address whether the diagnosed diabetes mellitus was aggravated by the thoracolumbar, right ankle, right wrist, and left wrist disabilities. In light of such deficiencies, the Board finds that the June 2021 VA evaluation is of limited probative value. 3. Entitlement to increased ratings in excess of 10 percent for right wrist flexor tendonitis and left wrist flexor tendonitis is remanded. The report of a June 2021 wrist examination conducted for VA states that the Veteran indicated pain and decreased range of motion affecting his ability to lift, carry or grip with decreased manual dexterity, and avoidance of activity. On examination, of the right wrist the Veteran exhibited range of motion of dorsiflexion to 70 degrees, palmar flexion to 60 degrees, ulnar deviation to 30 degrees and radial deviation to 20 degrees. On examination, of the left wrist the Veteran exhibited range of motion of dorsiflexion to 70 degrees, palmar flexion to 55 degrees, ulnar deviation to 35 degrees and radial deviation to 20 degrees. Painful range of motion with dorsiflexion, palmar flexion, ulnar deviation, and radial deviation was noted bilaterally. The physician assistant did not indicate the degree at which the Veteran experienced pain on motion of the right and left wrist. In light of such deficiency, the Board finds that the functional loss associated with the service-connected right and left wrist disabilities is unclear and the examination report is of limited probative value. As such the Board finds that further right and left wrist evaluation is needed. Clinical documentation dated after October 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 4. Entitlement to a rating in excess of 10 percent prior to June 18, 2021, and in excess of 20 percent for cervical spine spondylosis on and after June 18, 2021, is remanded. The report of a June 2021 cervical spine examination conducted for VA states that the Veteran indicated a worsening of his daily neck pain and symptomology, and pain affecting his ability to turn his head. On examination, of the cervical spine, the Veteran exhibited range of motion of forward flexion to 30 degrees, extension to 20 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees and right and left lateral rotation to 65 degrees. The physician assistant did not indicate the degree at which the Veteran experienced pain on range of motion of the neck. Given such deficiency, the Board finds that the functional loss associated with the service-connected neck disability is unclear and the examination report is of limited probative value. As such the Board finds that further neck evaluation is needed. 5. Entitlement to an initial rating in excess of 10 percent for thoracolumbar spine degenerative disc disease is remanded. The report of a June 2021 back examination conducted for VA states that the Veteran indicated pain which affects his ability to lift, carry, walk, run, bend, twist and sit or stand for long periods. On examination of the back the Veteran exhibited range of motion of forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees and right and left lateral rotation with painful motion. The physician assistant did not indicate the degree at which the Veteran experienced pain on motion of the back. Given such deficiency, the Board finds that the functional loss associated with the Veteran's service-connected back disability is unclear and the examination report is of limited probative value. As such the Board finds that further back evaluation is needed. 6. Entitlement to a rating in excess of 10 percent for right ankle and fibula arthritis with open reduction and internal fixation residuals is remanded. The report of a June 2021 ankle examination conducted for the VA states that the Veteran indicated pain and decreased range of motion affecting his ability to walk long distances and difficulty bending, kneeling, or squatting due to increased pain. On examination, of the right ankle the Veteran exhibited range of motion of plantar flexion to 25 degrees and dorsiflexion to 5 degrees. The physician assistant did not indicate the degree at which the Veteran experienced pain on motion of the right ankle. In light of such deficiency, the Board finds that the functional loss associated with the service-connected right ankle disability is unclear and the examination report is of limited probative value. As such the Board finds that further right ankle evaluation is needed. 7. Entitlement to both initial ratings in excess of 20 percent for right upper extremity radiculopathy and left upper extremity radiculopathy and a TDIU is remanded. The issues of both initial ratings in excess of 20 percent for right upper extremity radiculopathy and left upper extremity radiculopathy and a TDIU are inextricably intertwined with issue of an increased rating for his cervical spine disability being remanded and must also be remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who treated him for any heart and diabetic disability and the service connected cervical spine, thoracolumbar spine, wrist, right ankle, and upper extremity disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA clinical documentation not already of record, including treatment records dated after October 2021. 3. Schedule the Veteran for a VA heart examination conducted by a medical doctor to assist in determining the nature and etiology of any identified heart disability. The examiner must review the record and should note that review in the reports. A rationale for all opinions should be provided. The examiner should: (a) Identify all heart disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified heart disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified heart disability is due to or the result of the service connected disabilities. (d) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified heart disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the service-connected disabilities. 4. Schedule the Veteran for a VA diabetes mellitus examination conducted by a medical doctor to assist in determining the nature and etiology of the diagnosed diabetes mellitus. The examiner must review the record and should note that review in the reports. A rationale for all opinions should be provided. The examiner should: (a) Identify all diabetic disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed diabetes mellitus had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed diabetes mellitus is due to or the result of the service connected disabilities. (d) Opine whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed diabetes mellitus has been aggravated (increased in severity beyond the natural progression of the disorder) by the service-connected P disabilities. 5. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected wrist disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight-bearing and nonweight-bearing and passive and active motion of the right and left wrist. The examiner should specifically indicate the degree at which the Veteran experiences pain on motion of the wrists. (b) State whether there is any additional loss of function of the wrists due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. 6. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected cervical spine and thoracolumbar disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the spine. The examiner should specifically indicate the degree at which the Veteran experiences pain on motion of the spine. The examiner should state whether there is any additional loss of spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate whether, and to what extent, the Veteran experiences functional loss of the spine due to pain or any other symptoms during flare-ups or with repeated use. (c) State whether or not any incapacitating episodes due to the lumbar spine disability have been shown, and if so, the frequency and duration. (d) State whether any ankylosis of the spine is shown. 7. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected wrist disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight-bearing and nonweight-bearing and passive and active motion of the right and left wrist. The examiner should specifically indicate the degree at which the Veteran experiences pain on motion of the wrists. (b) State whether there is any additional loss of function of the wrists due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. 8. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature and severity of the right ankle disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight-bearing and nonweight-bearing and passive and active motion of the right ankle. The examiner should specifically indicate the degree at which the Veteran experiences pain on motion of the right ankle. (b) State whether there is any additional loss of function of the right ankle, due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.