Citation Nr: 22019944 Decision Date: 04/03/22 Archive Date: 04/03/22 DOCKET NO. 11-03 503 DATE: April 3, 2022 ORDER New and material evidence having been submitted, the claim of service connection for a right thigh disorder is reopened; the appeal is granted to this extent only. New and material evidence having been submitted, the claim of service connection for a right knee disorder is reopened; the appeal is granted to this extent only. New and material evidence having been submitted, the claim of service connection for a right ankle disorder is reopened; the appeal is granted to this extent only. New and material evidence having been submitted, the claim of service connection for a left ankle disorder is reopened; the appeal is granted to this extent only. Entitlement to a rating in excess of 40 percent for lumbar fact joint arthropathy, lumbar strain (lumbar spine disability) is denied. Prior to December 24, 2018, an initial 10 percent rating, but no higher, for right lower extremity radiculopathy is granted, subject to the laws and regulations governing the payment of monetary benefits. Since December 24, 2018, an initial rating in excess of 10 percent for right lower extremity radiculopathy is denied. For the entire period for which the rating for a lumbar spine disability is on appeal, an initial 10 percent rating, but no higher, for left lower extremity radiculopathy is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 30 percent for bilateral plantar fasciitis and Morton's metatarsalgia (bilateral foot disability) prior to August 1, 2019, and in excess of 50 percent thereafter, is denied. A separate 10 percent rating, but no higher, for Morton's metatarsalgia is granted; subject to the laws and regulations governing the payment of monetary benefits. REMANDED Service connection for a right thigh disorder is remanded. Service connection for a right knee disorder is remanded. Service connection for a right ankle disorder is remanded. Service connection for a left ankle disorder is remanded. Service connection for bilateral lower extremity neuropathy is remanded. Service connection for bilateral upper extremity neuropathy is remanded. Service connection for diabetes mellitus, to include as secondary to PTSD, sleep disorders, and/or a lumbar spine disability, is remanded. Service connection for a cervical spine disorder is remanded. Service connection for hypertension, to include as secondary to sleep apnea is remanded. Entitlement to a rating in excess of 10 percent for large gastroesophageal reflux disease (GERD) is remanded. Entitlement to total disability based on individual unemployability (TDIU) prior to December 20, 2014, is remanded. FINDINGS OF FACT 1. In a February 2008 rating decision, the regional office (RO) denied service connection for a right thigh disorder; the Veteran did not appeal that decision or submit new and material evidence within the year following notification of that decision. 2. Since the February 2008 rating decision, new evidence has been received to reopen a claim of service connection for a right thigh disorder. 3. In an August 2011 rating decision, the RO denied service connection for right knee, right ankle, and left ankle disorders; the Veteran did not appeal that decision or submit new and material evidence within the year following notification of that decision. 4. Since the August 2011 rating decision, new evidence has been received to reopen claims of service connection for right knee, right ankle, and left ankle disorders. 5. The Veteran's lumbar spine disability is not manifested by unfavorable ankylosis of the entire thoracolumbar spine or entire spine, or symptoms approximating unfavorable ankylosis of the entire thoracolumbar spine or entire spine, to include after repeated motion over time and during a flare-up. 6. The Veteran has mild right and left lower extremity radiculopathy related to his lumbar spine disability. 7. Prior to August 1, 2019, the Veteran's bilateral foot disability was productive of pain that limited standing and walking and Morton's metatarsalgia, but not symptoms indicative of pronounced bilateral flatfoot. 8. Since August 1, 2019, the Veteran's bilateral foot disability was productive of extreme tenderness of plantar surfaces of the feet without relief from orthotics and Morton's metatarsalgia. CONCLUSIONS OF LAW 1. The February 2008 RO decision, in which the Veteran's claim of service connection for a right thigh disorder was denied, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a right thigh disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The August 2011 RO decision, in which the Veteran's claims of service connection for right knee, right ankle, and left ankle disorders were denied, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 4. New and material evidence has been received to reopen claims of entitlement to service connection for right knee, right ankle, and left ankle disorders. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for a rating in excess of 40 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5242. 6. Prior to December 24, 2018, the criteria for an initial 10 percent rating, but no higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.120, 4.124a, DC 8520. 7. Since December 24, 2018, the criteria for an initial rating in excess of 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.120, 4.124a, DC 8520. 8. For the entire claims period on appeal, the criteria for an initial 10 percent rating, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.120, 4.124a, DC 8520. 9. The criteria for a rating in excess of 30 percent for bilateral foot disability prior to August 1, 2019, and in excess of 50 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5276. 10. The criteria for a separate 10 percent rating, but no higher, for Morton's metatarsalgia have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5279. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1989 to May 1990, from February 2003 to August 2004, and from September 2005 to November 2006. He is a recipient of the Combat Infantryman Badge. The claim of service connection for a cervical spine disorder is on appeal from an October 2008 rating decision. The claims of service connection for diabetes mellitus, hypertension, and right thigh disorders as well as the evaluation for bilateral plantar fasciitis are on appeal from a March 2010 rating decision. The remaining claims are on appeal from a June 2016 rating decision. In a June 2018 decision, the Board denied the Veteran's petitions to reopen claims of service connection for right thigh, right knee, right ankle, left ankle, right shoulder, and PTSD disorders as well as claims for higher ratings for a lumbar spine, bilateral foot, and GERD disabilities. The Board also reopened claims of service connection for bilateral lower extremity peripheral neuropathy and bilateral upper extremity peripheral neuropathy. Claims of service connection for bilateral lower extremity peripheral neuropathy, bilateral upper extremity peripheral neuropathy, a psychiatric disability other than PTSD, diabetes, a cervical spine disorder, and hypertension. The issue of entitlement to a rating in excess of 60 percent for a skin disability was also remanded pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). A statement of the case (SOC) was issued in November 2020, but the Veteran has not filed an appeal to the Board or opted into a review lane available under the Appeals Modernization Act. The Veteran appealed the Board's June 2018 decision to the United States Court of Appeals for Veterans Claims (Court). In May 2019, the Court granted a Joint Motion for Partial Remand, which vacated the Board's June 2018 decision to the extent that it denied petitions to reopen and higher ratings and remanded those claims to the Board. The claims remanded by the Court then returned to the Board. In November 2019, the Board granted the petition to reopen a claim of service connection for right shoulder disability and granted a 40 percent rating for the lumbar spine disability. The Board remanded the remaining claims as well as entitlement to a rating in excess of 40 percent for a lumbar spine disability. In a May 2020 rating decision, the RO granted service connection for right shoulder impingement syndrome, rated 20 percent disabling effective September 12, 2015. As this represents a full grant of the benefit sought, this claim is no longer on appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). With the issuance of a July 2021 rating decision, the RO effectuated the grant of the 40 percent rating for the lumbar spine disability. However, as this represents only a partial grant of the benefit sought, the issue of entitlement to a rating in excess of 40 percent for the lumbar spine disability remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). As for the service connection claims remanded by the Board in June 2018, those claims have now returned to the Board for further adjudication, except for the petition to reopen a claim of service connection for PTSD. In a January 2021 rating decision, the RO granted service connection for insomnia, unspecified, claimed as insomnia disorder, depressive disorder, and PTSD rated 30 percent disabling effective March 15, 2013. This was characterized as a full grant of the benefit sought, and the issue of service connection for PTSD was not included in the June 2021 supplemental SOC. Thus, the claim is not presently before the Board. The Board notes that, separate from the Veteran's peripheral neuropathy, right lower extremity radiculopathy was found on examination in August 2019 and left lower extremity radiculopathy was found on examination in June 2021. After the August 2019 VA examination, service connection was granted for right lower extremity radiculopathy rated 10 percent disabling effective December 24, 2018. The Board will consider ratings for right and left lower extremity radiculopathy as part and parcel of the lumbar spine disability rating. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (directing VA to rates separately objective neurological manifestations related to spine disabilities). The Veteran is in receipt of a 100 percent rating as of December 20, 2014. As discussed below, the claims period for the Veteran's foot disability rating begins June 29, 2009. There have been indications in the VA examinations of record that the Veteran's foot disability has affected his ability to work prior to December 20, 2014. Thus, the Board finds that entitlement to TDIU prior to December 20, 2014 has been raised as part and parcel of the increased rating claims on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). To summarize the dispositions in this decision, the Board will reopen claims of service connection for right thigh, right knee, right ankle, and left ankle disorders; deny higher ratings for the lumbar spine, right lower extremity radiculopathy, and bilateral foot disabilities; grant a 10 percent rating for left lower extremity radiculopathy; and remand the remainder of the claims before the Board, including reopened claims of service connection for right thigh, right knee, right ankle, and left ankle disorders. New and Material Evidence 1. Whether new and material evidence has been received to reopen a claim of service connection for a right thigh disorder By a February 2008 rating decision, a claim of service connection for a right thigh disorder was denied. The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in June 2009. No new evidence or notice of disagreement was received by VA within one year of the issuance of the February 2008 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for a right thigh disorder is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). The Veteran was afforded a VA examination of his thigh in October 2020, at which time he noted that a 2005 explosion happened near him. This is evidence of a potential in-service incident that could be related to service. Shade v, Shinseki, 24 Vet. App. 110 (2010) (noting that new and material evidence is not required as to each unproven element of a claim). In making this judgment, the Board presumes the credibility of the statement. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Thus, the claim of service connection for a right thigh disorder is reopened. 2. Whether new and material evidence has been received to reopen a claim of service connection for a right ankle disorder 3. Whether new and material evidence has been received to reopen a claim of service connection for a right knee disorder 4. Whether new and material evidence has been received to reopen a claim of service connection for a left ankle disorder By an August 2011 rating decision, claims of service connection for right knee, right ankle and left ankle disorders were denied. The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. A claim for the right knee was submitted to VA in March 2013 but withdrawn in December 2013 before any development or new information relevant to the right knee disorder was received. Rather, nothing substantive regarding the right knee, right ankle, and left ankle disorders was received until the present claims to reopen in December 2014 and October 2015. No new evidence or notice of disagreement was received by VA within one year of the issuance of the August 2011 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for right knee is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). The Veteran was afforded a VA examination of his right knee in August 2019. The diagnosis was noted as right knee strain. The Veteran reported that, during service, he did years of extensive running and rucking which he believed resulted in progressively worse right knee pain. As the new evidence points to a potential in-service incident which may be related to the Veteran's current right knee strain, the claim of service connection for a right knee disorder is reopened. The Board finds that new and material evidence has been submitted so that the previously denied claims of service connection for right ankle and left ankle are reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). In the August 2011 rating decision, the RO found that there was no treatment or diagnosis for ankle disorders in the available medical records. In May 2016, the Veteran underwent physical therapy for reported left leg pain at VA, as part of which he was given exercises that focused on stretching the ankles in dorsiflexion and plantar flexion. At the August 2019 VA examination for the right knee, the Veteran noted years of extensive running and rucking during service. There is some question as to whether these duties during service could be related to his right and left ankle disorders. See Shade, supra. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. For musculoskeletal disabilities, such as those to the lumbar spine and feet, there are additional criteria. Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion; a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The United States Court of Appeals for Veterans Claims (Court) has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. In Mitchell v. Shinseki, 25 Vet. App. 32 (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. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. 5. Entitlement to a rating in excess of 40 percent for lumbar spine disorder 6. Entitlement to an initial rating in excess of 10 percent for right lower extremity radiculopathy 7. Entitlement to an initial compensable rating for left lower extremity radiculopathy The Veteran claims that his 40 percent rating for a lumbar spine disability and 10 percent rating for his right lower extremity radiculopathy do not reflect the severity of his symptoms of his lumbar spine disorder. Spine disabilities are rated under 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The formula provides for: a 100 percent rating for unfavorable ankylosis of the entire spine; a 50 percent rating for unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent rating for forward flexion of the thoracolumbar spine 30 degrees or less; and a 20 percent rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or combined range of motion of the thoracolumbar spine not greater than 120 degrees or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. VA is to rate objective neurological manifestations of a spine disability separately under the appropriate diagnostic code. Id., Note (1). Unfavorable ankylosis is defined as a condition in which the entire thoracolumbar spine or entire spine is fixed in flexion or extension and ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id., Note (5). The Veteran's right and left lower extremity radiculopathies are rated under 38 C.F.R. § 4.124a, DC 8520. DC 8520 provides for a 10 percent rating for mild incomplete paralysis of the sciatic nerve in either lower extremity; a 20 percent rating for moderate incomplete paralysis of the sciatic nerve in either lower extremity, a 40 percent rating for moderately severe incomplete paralysis of the sciatic nerve in either lower extremity, a 60 percent rating for severe incomplete paralysis of the sciatic nerve with marked muscle atrophy in either lower extremity; and 80 percent for complete paralysis of the sciatic nerve described as the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. As noted above, the claim for a higher rating for the lumbar spine disability comes before the Board on appeal from a June 2016 rating decision which adjudicates a claim received by VA on October 30, 2015. Thus, the Board will consider the evidence of record beginning October 30, 2015, subject to any evidence of compensable worsening of the disability in the year prior to the date of claim. 38 C.F.R. § 3.400(o)(2). The Veteran was afforded a VA examination of his lumbar spine in May 2016. The Veteran reported flare-ups of pain with prolonged standing, sitting, and walking. Range of motion was to 35 degrees in forward flexion and to 15 degrees in extension, right and left lateral flexion, and right and left lateral rotation, without reduction on repetition. Range of motion contributed to functional loss in bending forward. There was no evidence of pain on weight-bearing. Tenderness was noted along the lumbar paravertebral muscle. The examiner failed to provide estimated range of motion with repeated use over time or during a flare-up, as estimates could not be done without resort to mere speculation because the examination was not conducted after repetitive use over time or during a flare-up. There was no ankylosis of the spine. Decreased sensation to light touch was noted in the foot/toes bilaterally, though the examiner stated that there was not radicular pain or any other signs or symptoms of radiculopathy. It was reported that the Veteran used a back brace for support occasionally. The examiner also noted that the Veteran should avoid heavy lifting. The Veteran was afforded another VA examination of his lumbar spine in August 2019. Diagnoses of degenerative arthritis of the spine and right leg radiculopathy were noted. Flare-ups of back pain for several days after strenuous load bearing activities were noted. The Veteran described functional loss as pain that can interfere with lifting, bending, and twisting. Range of motion in the lumbar spine was to 35 degrees in forward flexion, 15 degrees in extension and right lateral flexion, and 20 degrees in left lateral flexion and right and left lateral rotation, all without reduction on repetition. Passive range of motion could not be performed or was not medically appropriate. Loss of range of motion was reported to significantly interfere with routine activities such as getting dressed and getting in and out of a vehicle. Pain was noted as causing functional loss and noted on all range of motion as well as in weight-bearing. There was no pain in nonweight-bearing. Although additional pain was expected, no further reduction in range of motion was expected after repeated use overtime. During a flare-up, range of motion was estimated to 30 degrees in forward flexion, 10 degrees in extension and right lateral flexion, and 15 degrees in left lateral flexion and right and left lateral rotation, all without reduction on repetition. Additional factors contributing to disability were noted as disturbance of locomotion and interference with sitting and standing. There was no ankylosis. Decreased light touch sensation was found in the feet/toes. Mild paresthesias and numbness were noted in the right lower extremity. The examiner noted there was right lower extremity radiculopathy affecting the sciatic nerve. Most recently, the Veteran was afforded a VA examination of his lumbar spine in May 2021. Diagnoses of degenerative arthritis and bilateral radiculopathy were noted. Daily moderate flare-ups precipitated by prolonged sitting or standing, bending over, and lifting heavy objects were noted. The Veteran reported functional loss as decreased endurance to standing and walking. Range of motion was to 35 degrees in forward flexion, to 10 degrees in extension, and to 15 degrees in right and left lateral flexion and rotation, all without reduction on repetition. Pain was noted on all range of motion. Passive range of motion was not performed as it may cause the risk of further injury. Range of motion after repeated use over time was reported as to 15 degrees on forward flexion and to 5 degrees on extension and left and right lateral flexion and rotation. There was no ankylosis. There was decreased sensation to light touch bilaterally in the lower leg/ankle and foot/toes. The Veteran reported moderate constant pain and mild paresthesias/dysesthesias and numbness. The Veteran regularly used a brace for his back disability. The Board finds that a rating in excess of 40 percent for the Veteran's lumbar spine disability is not warranted. The Veteran is already in receipt of the highest available rating based on range of motion. No ankylosis has been reported at any examination. The Veteran's description of symptoms at each examination also do not describe symptoms that approximate unfavorable ankylosis. The May 2021 VA examiner did estimate range of motion during a flare-up and after repeated use over time as to 5 degrees in extension which may approximate ankylosis. However, VA defines the spine in a fixed position at 0 degrees as favorable ankylosis, and no additional disabling effects of ankylosis noted in Note (5) to the General Rating Formula for Injuries and Disease of the Spine have been noted. Finally, the Veteran's ratings for lower extremity radiculopathy contemplate the use of assistive devices. See Spellers v. Wilkie, 30 Vet. App. 211 (2018). The Veteran's symptoms such as pain on walking, standing, sitting, and lifting are contemplated by the rating assigned. 38 C.F.R. § 4.59. Thus, even when contemplating the Veteran's symptoms during a flare-up and after repetitive use over time, a rating in excess of 40 percent for a lumbar spine disability is not warranted. Prior to the period on appeal, the Veteran's lumbar spine disability was rated 20 percent disabling. As the May 2016 VA examination is the earliest ascertainable date on which the Veteran's lumbar spine disability was shown to be productive of more severe symptoms warranting a 40 percent rating, a 40 percent rating is not warranted prior to October 30, 2015, under 38 C.F.R. § 3.400(o)(2). See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). The Board does acknowledge that the May 2016 VA examination does not contain all of the findings required by Correia v. McDonald, 28 Vet. App. 158 (2016), or Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the findings of the subsequent examinations show a similar severity in the functional limitations associated with the disability, including range of motion, and are the best evidence available of the Veteran's functioning at the time of the May 2016 VA examination. Further, no evidence of unfavorable ankylosis, as required for a higher rating, have been noted. Therefore, a remand for a retrospective opinion is not warranted. 38 C.F.R. § 3.156(d). Likewise, a remand for testing for pain on passive motion or passive range of motion is not warranted, as it was feared that such testing may risk further injury. Id. The Board also finds that 10 percent ratings, but no higher, are warranted for the Veteran's right and left lower extremity radiculopathy. As early as the May 2016 VA examination, the Veteran was said to experience decreased sensation to light touch in the lower legs/ankles. This resulted in a formal diagnosis of right lower extremity radiculopathy at the August 2019 VA examination and left lower extremity radiculopathy at the May 2021 VA examination. However, the Veteran's symptoms have been limited to moderate constant pain, mild paresthesias/dysesthesias and numbness, and decreased sensation to light touch in the lower leg/ankles and feet/toes. These symptoms are primarily mild sensory disturbances without any evidence of organic changes. Thus, 10 percent ratings, but no higher, will be assigned bilaterally for the entire appeal period. In sum, a rating in excess of 40 percent for a lumbar spine disability is denied. Ratings of 10 percent, but no higher, for right and left lower radiculopathies are warranted for the entire period on appeal. 8. Entitlement to a rating in excess of 30 percent for bilateral foot disorder prior to August 1, 2019, and in excess of 50 percent thereafter The Veteran claims that his current 30 percent and 50 percent ratings for his bilateral foot disorder, described as bilateral plantar fasciitis with Morton metatarsalgia, do not reflect the severity of his symptoms. Pes planus is rated under 38 C.F.R. § 4.71a, DC 5276. DC 5276 provides for a 50 percent rating for bilateral pes planus that is pronounced with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances and a 30 percent rating for severe bilateral pes planus with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. 38 C.F.R. § 4.71a, DC 5276. Under 38 C.F.R. § 4.71a, DC 5279, a 10 percent rating is provided for metatarsalgia, anterior (Morton's disease), unilateral, or bilateral. 38 C.F.R. § 4.71a, DC 5279. As noted above, the claim for a higher rating for the lumbar spine disability comes before the Board on appeal from a March 2010 rating decision which adjudicates a claim received by VA on June 29, 2009. Thus, the Board will consider the evidence of record beginning June 29, 2009, subject to any worsening evidence in the year prior to the date of claim. 38 C.F.R. § 3.400(o)(2). The Veteran was first afforded a VA examination in conjunction with the current claim in August 2009. The Veteran experienced pain, stiffness, weakness, and lack of endurance in the plantar area bilaterally. He was able to stand for 15-30 minutes but unable to walk more than a few yards. The Veteran used shoe inserts, but they did not provide much relief. In both feet, there was painful motion in stretching and flexion of the plantar fascia, tenderness at the metatarsal area and foot arch to calcaneal area, and weakness due to pain. The Veteran was afforded another VA examination of his feet in March 2012, at which time diagnoses of bilateral metatarsalgia and plantar fasciitis were noted. The Veteran reported pain at the anterior foot pad which limited standing position tolerance. There was no further discussion of the Veteran's symptoms. The Veteran was afforded another VA examination of his feet in March 2015. He reported continued pain to the heels and plantar area radiating to the anterior foot. Pain was worst with the first steps and then gradually decreased. During a flare-up, he would have to sit for 15-20 minutes before continuing to stand and walk. He was unable to ascend stairs and slopes during flare-ups. The Veteran noted that flare-ups would require frequent breaks during his workday to sit and rest. The examiner noted that the disability was of a moderate nature which chronically compromised weight-bearing. The Veteran also reported having shoe inserts. The Veteran was afforded another VA examination of his feet in August 2019. The Veteran noted sharp pain in the arch of the foot when he would first wake up and after prolonged weight-bearing, which would interfere with running, walking, and standing. The Veteran also had shoe inserts. There was pain accentuated on manipulation of each foot, which was noted as extreme tenderness of the plantar surfaces of the feet. Prior to August 1, 2019, a rating in excess of 30 percent under DC 5276 for the Veteran's bilateral foot disability is not warranted. At this time, the Veteran's plantar fasciitis was manifested by pain in the feet that increased with use and required breaks at work to sit for 15-20 minutes before he could begin standing or walking again. Though the Veteran did not experience relief from orthotics, symptoms noted in the definition of pronounced flatfoot were not found on examination. Prior to the beginning of the appeal period, the Veteran's bilateral foot disability was rated at 10 percent disabling. There is no discernable date within a year prior to June 29, 2009, on which the Veteran's foot disability became more severe such that a 30 percent rating was warranted. Rather, the August 2009 examination is the earliest ascertainable evidence of increase in severity. See Swain, supra. From August 1, 2019, a rating in excess of 50 percent under DC 5276 is not warranted. The 50 percent rating is the highest schedular rating under DC 5276, and the Veteran has not noted any symptoms not contemplated by DC 5276 or which are contemplated another rating for the feet related to this disability. Only upon examination on August 1, 2019, was extreme tenderness of the plantar surfaces of the feet found. Though the Veteran had noted pain prior to August 1, 2019, his reported pain was described as pain on manipulation and use, as contemplated by the 30 percent criteria. Thus, a rating in excess of 30 percent under DC 5276 is not warranted prior to August 1, 2019. See Swain, supra. A separate 10 percent rating is also warranted for Morton's metatarsalgia for the entire claims period. The VA examinations of record disclose a diagnosis of Morton's metatarsalgia. The rating schedule provides for a 10 percent rating under DC 5279 for Morton's metatarsalgia. While the Veteran's plantar fasciitis is rated by analogy as flatfoot, VA cannot rate the Veteran's Morton's metatarsalgia by analogy. Rather, the separate 10 percent rating must be afforded. Copeland v. McDonald, 27 Vet. App. 333, 336-337 (2015) ("Where, however, a condition is listed in the schedule, rating by analogy is not appropriate. In other words, '[a]n analogous rating. . . may be assigned only where the service-connected condition is unlisted.'") (emphasis in original); Suttman v. Brown, 5 Vet. App. 127, 134 (1993) ("An analogous rating thus may be assigned only where the service-connected condition is unlisted."); see also Scott v. Wilkie, 920 F.3d 1375, 1379-80 (2019) (vacating a decision in which the Board failed to consider the applicability of DC 5284 for the Veteran's unlisted conditions and based its analysis solely under DC 5276 without any factual finding that the two conditions constituted one disability properly rated under DC 5276). In sum, the Board is granting a separate 10 percent rating for Morton's metatarsalgia under DC 5279, but higher ratings under DC 5276 are denied. REASONS FOR REMAND 1. Service connection for a right thigh disorder is remanded. A remand is necessary for a new medical opinion to determine the etiology of the Veteran's right thigh disorder. Specifically, the Veteran was afforded a September 2020 VA examination of his right thigh, at which time he reported a 2005 incident which caused injury to his right thigh. The examiner opined that the Veteran's right thigh disorder did not onset within a year after separation from service (2004), was not caused or aggravated by the Veteran's lumbar spine disability, and there was no chronicity or continuity of care for the right thigh during or after active duty. The Board finds that the September 2020 medical opinion is inadequate to decide the claim. First, the examiner stated that the Veteran's right thigh condition did not onset within a year after separation from service, which the examiner noted as being in 2004. This implies that the examiner did not consider the Veteran's report of an injury as a result of an explosion in 2005 or the final period of active duty from September 2005 to November 2006. Second, the Board notes that the Veteran began pursuing a previous claim of service connection for a right thigh disorder in February 2007, implying that symptoms may have onset just a few months after service. Third, there is note of a right hamstring strain in the December 2007 VA examination report. Finally, no substantive rationale was given for any opinion provided, including the inquiries addressing secondary service connection. Therefore, a remand is necessary to obtain a new medical opinion as to the etiology of the Veteran's right thigh disorder. In contemplating the need for a remand, the Board has considered whether service connection should be granted based on the available record. However, the September 2020 VA examination report does not contain enough details for the Board to make a definitive credibility determination as to the Veteran's report of a right thigh injury due to an explosion, especially in light of the absence of reports of a right thigh disorder in the October 2006 post-deployment assessment. Further, the details of the 2005 incident also do not indicate whether the explosion was combat-related. 38 C.F.R. § 3.304(d). 2. Service connection for a right knee disorder is remanded. A remand is necessary to obtain an addendum medical opinion to determine the etiology of the Veteran's right knee disorder. The Veteran was afforded a VA examination of his right knee in August 2019. At that time, the examiner opined that the Veteran's right knee disorder was less likely than not secondary to his lumbar spine disability. Rather, the right knee disorder was caused by chronic weight bearing. This medical opinion is inadequate to decide the claim. First, the medical opinion does not consider the Veteran's report at the August 2019 VA examination of years of extensive running and rucking during service which warrants consideration of service connection on a direct basis. Further, the examiner appears to have not addressed the aggravation prong of secondary service connection. See El Amin v. Shinseki, 26 Vet. App. 136 (2013). Finally, the examiner did not explain why chronic weight bearing led to the conclusion that the Veteran's right knee disorder was not related to service. Thus, a remand to obtain a new medical opinion as to the etiology of the Veteran's right knee disorder is necessary. 3. Service connection for a right ankle disorder is remanded. 4. Service connection for a left ankle disorder is remanded. A remand is necessary to afford the Veteran a VA examination and to obtain medical opinions as to the etiologies of his right and left ankle disorders. VA is to afford veterans an examination where there is an indication that a currently diagnosed disorder (or symptoms thereof) may be related to an incident or injury during service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran has received treatment from VA for right and left ankle disorders. Notably, the June 2011 VA examination report reveals a slight decrease in range of motion of the right ankle in plantar flexion. In May 2016, the Veteran underwent physical therapy for reported left leg pain at VA, at which time he was given exercises that focused on stretching the ankles in dorsiflexion and plantar flexion. At the August 2019 VA examination for the right knee, the Veteran noted years of extensive running and rucking during service. There is some question as to whether these duties during service could be related to his right and left ankle disorders. Therefore, a remand is necessary to afford the Veteran a VA examination of his ankle and to obtain a medical opinion as to the etiology of his ankle disorders. 5. Service connection for bilateral lower extremity neuropathy is remanded. 6. Service connection for bilateral upper extremity neuropathy is remanded. A remand is necessary to obtain an addendum medical opinion regarding the nature and etiology of the Veteran's bilateral lower and upper extremity peripheral neuropathy. In August 2019, a medical opinion regarding the etiology of the Veteran's peripheral neuropathy was obtained. The examiner opined that peripheral neuropathy was related to the Veteran's diabetes and not in any way related to the structural degeneration of the bones in the spine. Regarding the lower extremities, as a result of this decision, the Veteran is service-connected for right and left lower extremity radiculopathy. However, it remains unclear whether and to what extent the Veteran's lower extremity radiculopathy is separate and distinct from any symptoms of peripheral neuropathy. If the symptoms are not differentiable, then the Veteran is already in receipt of compensation for his claimed peripheral neuropathy symptoms. See Mittleider v. West, 11 Vet. App. 181 (1998). An addendum medical opinion is also needed to address whether lower and upper extremity peripheral neuropathy was aggravated by the Veteran's lumbar spine disability. El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Further, the examiner does not appear to have addressed direct service connection in the August 2019 medical opinion. Finally, given that the August 2019 medical opinion stated that peripheral neuropathy was part of the diabetic process, the claims of service connection for bilateral lower and upper extremity peripheral neuropathy are intertwined with the claim of service connection for diabetes, which the Board also remands herein for further development. Harris v. Derwinski, 1 Vet. App. 180, 183 (noting that issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Therefore, a remand is necessary to obtain a medical opinion as to the etiology of the Veteran's bilateral lower extremity radiculopathy and for the intertwined claim for service connection for diabetes to be adjudicated. 7. Service connection for diabetes mellitus, to include as secondary to PTSD, sleep disorders, and/or a lumbar spine disability is remanded. Another remand of the claim for service connection for diabetes is required to obtain new medical opinions as to the etiology of the Veteran's diabetes. In June 2018, the Board ordered that a medical opinion be obtained addressing direct service connection and whether diabetes was caused by or aggravated by sleep apnea, a condition for which service connection had recently been awarded. The Veteran was afforded a VA examination of his diabetes in September 2020. The examiner opined that there was no current diagnosis. Further, the examiner stated that any disorder was less likely than not related to service or was caused by or aggravated by sleep apnea as there was no record to support diabetes directly arising from service or as secondary to sleep apnea. The September 2020 opinion is problematic in several respects. First, a diagnosis of diabetes was noted on examination in April 2015. Thus, there is a diagnosed disorder for purposes of the present claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Second, the examiner did not provide a sufficient rationale for the medical opinions provided. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that lack of documented findings alone is not an adequate basis for a negative opinion). Therefore, another remand of the Veteran's claim for service connection for diabetes is necessary to comply with the directives of the Board's June 2018 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Finally, the Veteran has also recently been service connected for insomnia related to his claimed psychological disorders. Therefore, a medical opinion as to secondary service connection is needed to address these disorders as well. 8. Service connection for a cervical spine disorder is remanded. 9. Service connection for hypertension, to include as secondary to sleep apnea is remanded. Another remand of the claims for service connection for a cervical spine disorder and hypertension is necessary to obtain new medical opinions. In June 2018, the Board remanded these claims to afford the Veteran a VA examination and to obtain the necessary medical opinions. The Veteran was afforded VA examinations of his hypertension and cervical spine in September 2020. The medical opinions for direct service connection are based solely on the lack of documentation of treatment during service. As noted above, this is an inadequate rationale. See Dalton, supra. This is especially concerning for the Veteran's cervical spine disorder as a December 2007 x-ray has been noted as showing cervical lordosis with an impression of mild spondylosis. A medical opinion as to secondary service connection was also requested for hypertension. The examiner provided an adequate opinion addressing the causation prong of secondary service connection, noting that hypertension can cause sleep apnea, but that the causation does not work the other way. However, no medical opinion was provided as to the aggravation prong of secondary service connection. Thus, a remand is also needed for an addendum opinion to address whether the Veteran's hypertension was aggravated by sleep apnea. El Amin, supra. 10. Entitlement to a rating in excess of 10 percent for large GERD is remanded. A remand is necessary to obtain a medical opinion as to the severity of the Veteran's GERD in the absence of the ameliorative effects of medication during the claims period. GERD is rated pursuant to 38 C.F.R. § 4.114 DC 7346 as analogous to "hiatal hernia." The rating criteria do not contemplate the ameliorative effects of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (holding that, where rating criteria says nothing about medication, the condition is to be evaluated as if without medication). The Veteran has been afforded three VA examinations of his GERD during the appeal period, in May 2016, August 2019, and May 2021. At each time, it was noted that he was taking one or more medication to control his GERD. The Veteran has noted significant symptoms related to GERD at each VA examination. At the May 2016 VA examination, symptoms of infrequent episodes of epigastric distress, pyrosis, reflux, and regurgitation were noted as well as sleep disturbance caused by esophageal reflux of less than one day 4 or more times per year. At the August 2019 VA examination, symptoms were noted as pyrosis, reflux, regurgitation, substernal pain, and sleep disturbance caused by esophageal reflux. At the May 2021 VA examination, it was noted that the Veteran had persistently recurrent epigastric distress manifesting as dyspepsia, pyrosis, reflux, regurgitation, nausea, vomiting, shoulder pain, and sleep disturbance. Though these symptoms are significant, there has not yet been an attempt to obtain a medical expert's opinion regarding the severity of the Veteran's GERD in the absence of medication. Therefore, a remand to obtain this retrospective opinion is necessary. 11. Entitlement to TDIU prior to December 20, 2014, is remanded. As the Board is remanding entitlement to service connection for several disorders which, if granted, could affect the overall disability picture prior to December 20, 2014, as well as the Veteran's combined rating, the Board finds that the issue of entitlement to TDIU prior to December 20, 2014, is inextricably intertwined with the claims remanded herein. Thus, the Board must remand this claim as well. Harris, supra. As the claim for TDIU is being remanded, information regarding the Veteran's employment history and educational background should be obtained. The matters are REMANDED for the following actions: 1. Request that the Veteran provide information regarding his employment history prior to December 20, 2014, as well as his educational background. 2. Obtain a new medical opinion regarding the etiology of the Veteran's right thigh disorder. It is left to the examiner's discretion whether to conduct a new examination. Specifically, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran's right thigh disorder is related to any incident of active service, to include a 2005 explosion. (B) It is at least as likely as not that the Veteran's right thigh disorder was caused or aggravated (made worse) by his lumbar spine disability. A complete rationale should be provided for any opinion rendered. The opinion must address both the causation and aggravation prongs of service connection. As to direct service connection, please note that the Veteran first pursued service connection for a right thigh disorder in February 2007, shortly after separating from service. Also note the diagnosis of a right hamstring strain at the December 2007 VA examination, the reported 2005 explosion at a September 2020 VA examination, and any other pertinent evidence of record, including the October 2006 post-deployment assessments and other STRs of record. 3. Obtain a new medical opinion regarding the etiology of the Veteran's right knee disorder. It is left to the examiner's discretion whether to conduct a new examination. Specifically, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran's right knee disorder is related to any incident of service, to include years of extensive running and rucking during service. (B) It is at least as likely as not that the Veteran's right knee disorder was caused or aggravated (made worse) by his lumbar spine disability. A complete rationale should be provided for any opinion rendered. The opinion must address both the causation and aggravation prongs of service connection. 4. Afford the Veteran a VA examination to determine the etiology of the Veteran's right and left ankle disorders. After the examination, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran's right ankle disorder is related to any incident of service, to include years of running and rucking during service. (B) It is at least as likely as not that the Veteran's left ankle disorder is related to any incident of service, to include years of running and rucking during service. A complete rationale should be provided for any opinion rendered. 5. Obtain a new medical opinion regarding the etiology of the Veteran's bilateral lower and upper extremity peripheral neuropathy. It is left to the examiner's discretion whether to conduct a new examination. Specifically, the examiner should opine as to whether: (A) The Veteran's bilateral lower extremity peripheral neuropathy is distinguishable from his bilateral lower extremity radiculopathy. (B) It is at least as likely as not that the Veteran's bilateral lower extremity peripheral neuropathy is related to any incident of service. (C) It is at least as likely as not that the Veteran's bilateral lower extremity peripheral neuropathy was aggravated (made worse) by his lumbar spine disability. (D) It is at least as likely as not that the Veteran's upper extremity bilateral peripheral neuropathy is related to any incident of service. (E) It is at least as likely as not that the Veteran's bilateral upper extremity peripheral neuropathy was aggravated (made worse) by his lumbar spine disability. A complete rationale should be provided for any opinion rendered. 6. Obtain a new medical opinion as to the etiology of the Veteran's diabetes. Specifically, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran's diabetes is related to any incident of service. (B) It is at least as likely as not that the Veteran's diabetes was caused or aggravated (made worse) by his service-connected insomnia and/or sleep apnea disorders. A complete rationale should be provided for any opinion rendered. Please note that for the purposes of the service connection claim on appeal, the Veteran has a diagnosis of diabetes. See also April 2015 VA Diabetes examination. 7. Obtain a new medical opinion regarding the etiology of the Veteran's cervical spine disorder. Specifically, the examiner should opine as to whether: It is at least as likely as not that the Veteran's cervical spine disorder is related to any incident of service. A complete rationale should be provided for any opinion rendered. Please note that x-ray results from December 2007 show cervical lordosis with an impression of mild spondylosis. 8. Obtain an addendum medical opinion regarding the etiology of the Veteran's hypertension. Specifically, the examiner should opine as to whether: (A) It is at least as likely as not that the Veteran's hypertension is related to any incident of service. (B) It is at least as likely as not that the Veteran's hypertension was aggravated (made worse) by his service-connected sleep apnea. A complete rationale should be provided for any opinion rendered. Please note that the September 2020 VA examiner provided an adequate medical opinion as to the causation prong of secondary service connection, but the aggravation prong of secondary service connection must still be addressed. 9. Obtain an opinion regarding the severity of the Veteran's GERD symptoms in the absence of the ameliorative effects of medication during the entire appeal period (from October 2015 to present). (Continued on the next page) A complete rationale should be provided for any opinion rendered. The examiner should consider the Veteran's medication history and report of symptoms at the May 2016, August 2019, and May 2021 VA examinations. CLAIRE M. DAVIDOSKI Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. George 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.