Citation Nr: 22066324 Decision Date: 11/29/22 Archive Date: 11/29/22 DOCKET NO. 01-01 647 DATE: November 29, 2022 ORDER Entitlement to a separate 10 percent rating, but no higher, for bowel incontinence since June 3, 1998 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to separate 10 percent rating, but no higher, for right foot degenerative joint disease since April 6, 1998 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to separate 10 percent rating, but no higher, for left foot degenerative joint disease since April 6, 1998 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a compensable rating for bilateral pes planus with pes cavus, hammer toes and hallux valgus from April 6, 1998 to August 1, 2012, is denied. Entitlement to a rating in excess of 20 percent for bilateral pes planus with pes cavus, hammer toes and hallux valgus from August 2, 2012 to March 30, 2021 is denied. Entitlement to a rating in excess of 30 percent for bilateral pes planus with pes cavus, hammer toes and hallux valgus since March 30, 2021 is denied. Entitlement to a rating in excess of 30 percent for residuals of a left ankle fracture, status-post surgical fusion with traumatic arthritis is denied. Entitlement to a 20 percent rating, but no higher, for a left ankle scar from April 6, 1998 to June 30, 2018 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a 100 percent rating based on convalescence under 38 C.F.R. § 4.30 for a left ankle scar from July 1, 2018 to October 9, 2018 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a 20 percent rating, but no higher, for left ankle scar from October 10, 2018 to August 2, 2022 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a compensable rating for a left ankle scar since August 3, 2022 is denied. Entitlement to a compensable rating for a low back scar is denied. REMANDED Entitlement to service connection for type II diabetes mellitus is remanded. Entitlement to service connection for an eye disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for right upper extremity radiculopathy is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to ratings in excess of 50 percent prior to March 30, 2021 and 70 percent since March 30, 2021 for PTSD with depression and insomnia is remanded. Entitlement to a rating in excess of 30 percent for left wrist arthritis status-post fracture since April 12, 2016 is remanded. Entitlement to a rating in excess of 40 percent for degenerative arthritis of the spine prior to June 25, 2018 and from October 11, 2018 to January 16, 2019 is remanded. Entitlement to an effective date prior to June 3, 1998 for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Since June 3, 1998, the Veteran's bowel incontinence was manifested by constant slight, or occasional moderate leakage, but not by occasional involuntary bowel movements necessitating the wearing of a pad. 2. Since April 6, 1998, the Veteran's right foot degenerative joint disease was manifested by non-compensable limitation of motion. 3. Since April 6, 1998, the Veteran's left foot degenerative joint disease was manifested by non-compensable limitation of motion. 4. From April 6, 1998 to August 1, 2012, the Veteran's bilateral pes planus with pes cavus, hammer toes and hallux valgus was not manifested by acquired bilateral pes cavus with the great toe dorsiflexed, with some limitation at the ankle, and definite tenderness under the metatarsal heads. 5. From August 2, 2012 to March 30, 2021 the Veteran's bilateral pes planus with pes cavus, hammer toes and hallux valgus was not manifested by bilateral disability when there is severe disability, characterized by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 6. Since March 30, 2021 the Veteran's bilateral pes planus with pes cavus, hammer toes and hallux valgus was not manifested by 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. 7. The Veteran's left ankle fracture, status-post surgical fusion with traumatic arthritis is not manifested by ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. 8. From April 6, 1998 to June 30, 2018 the Veteran's left ankle scar was painful and unstable, but was not deep and did not cover an area of 144 square inches (929 square centimeters (cm)) or larger. 9. From July 1, 2018 to October 9, 2018 the Veteran had surgery for a left ankle scar necessitating continued convalescence, with severe postoperative residuals such as incompletely healed surgical wounds, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited). 10. From October 10, 2018 to August 2, 2022 the Veteran's left ankle scar was painful and unstable, but was not deep and did not cover an area of 929 square cm or larger. 11. Since August 3, 2022 the Veteran's left ankle scar was not painful, unstable, or deep and did not cover an area of 929 square cm or larger. 12. The Veteran's low back scar is not painful, unstable, or deep and did not cover an area of 929 square cm or larger. CONCLUSIONS OF LAW 1. The criteria for entitlement to a separate 10 percent rating, but no higher, for bowel incontinence since June 3, 1998 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.114, Diagnostic Code (DC) 7332. 2. The criteria for entitlement to a separate 10 percent rating, but no higher, for right foot degenerative joint disease since April 6, 1998 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5003. 3. The criteria for entitlement to entitlement to a separate 10 percent rating for left foot degenerative joint disease since April 6, 1998 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5003. 4. The criteria for entitlement to a compensable rating for bilateral pes planus with pes cavus, hammer toes and hallux valgus from April 6, 1998 to August 1, 2012, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5276-5284. 5. The criteria for entitlement to a rating in excess of 20 percent for bilateral pes planus with pes cavus, hammer toes and hallux valgus from August 2, 2012 to March 30, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5276-5284. 6. The criteria for entitlement to a rating in excess of 30 percent for bilateral pes planus with pes cavus, hammer toes and hallux valgus since March 30, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5276-5284. 7. The criteria for entitlement to a rating in excess of 30 percent for residuals of a left ankle fracture, status-post surgical fusion with traumatic arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5270. 8. The criteria for entitlement to a 20 percent rating, but no higher, for left ankle scar from April 6, 1998 to June 30, 2018 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.118, DCs 7801-7805. 9. The criteria for entitlement to a 100 percent rating based on convalescence under 38 C.F.R. § 4.30 for a left ankle scar from July 1, 2018 to October 9, 2018 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.30. 10. The criteria for entitlement to a 20 percent rating, but no higher, for a left ankle scar from October 10, 2018 to August 2, 2022 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.118, DCs 7801-7805. 11. The criteria for entitlement to a compensable rating for a left ankle scar since August 3, 2022 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.118, DCs 7801-7805. 12. The criteria for entitlement to a compensable rating for a low back scar are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.118, DCs 7801-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1980 to September 1983 and from September 1990 to June 1991, including service in Southwest Asia from November 1990 to May 1991. These matters are before the Board of Veterans' Appeals (Board) on appeal of October 2008, July 2009, July 2011, June 2012, December 2016, November 2017, rating decisions of a Department of Veterans Affairs (VA) Regional Office. This case was previously before the Board in May 2012, May 2018, March 2021 and July 2022. In March 2021, the Board, in pertinent part, denied entitlement to ratings in excess of 40 percent for degenerative arthritis of the spine prior to June 25, 2018 and from October 11, 2018 to January 16, 2019 and in excess of 30 percent for left ankle fracture, status-post surgical fusion with traumatic arthritis. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2022 Order, the Court granted a Joint Motion for Remand (JMR) of the Veteran and the Secretary of Veterans Affairs (the Parties) to vacate and remand the portion of the Board's March 2021 decision that denied those claims. In July 2022 the Board remanded the appeals for further development. The issues have now been returned to the Board, together with the claims remanded by the March 2021 Board decision. In her October 2022 brief, the representative generally asserted that the VA examinations of record are inadequate and that relevant treatment records may be outstanding. An examination "is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994)); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The representative has not provided any specific argument as to why she believes that the specific VA examinations relevant to the increased rating claims decided herein are inadequate. With regard to each of the claims decided below, the Board finds that the most recent VA examinations of record are adequate for adjudication purposes as they fully address all findings relevant to the rating criteria in these appeals and are based on consideration of the relevant history. Additionally, the July 2022 foot examination and August 2022 ankle examination adequately discuss any additional functional loss during flare-ups and after repetitive use over time, in full compliance with Sharp v. Shulkin, 29 Vet. App. 26 (2017). Additionally, those examinations fully comply with the terms of the March 2021 and July 2022 Board remands. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the VA examinations are adequate for adjudication of the issues decided herein. With regard to outstanding records, VA's duty to assist includes aiding the claimant in the procurement of relevant records to include VA treatment records and sufficiently identified, private records. See 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (c). In her October 2022 brief, the representative stated that "the Veteran receives ongoing, relevant medical care from previously identified medical providers. To the extent the VA has not collected all ongoing medical reports, the VA has committed remandable error." VA treatment records were last obtained in September 2022, and there is no specific indication that relevant VA treatment records are outstanding. The Veteran has also received care from numerous private providers throughout the course of this appeal. As neither the Veteran nor the representative have identified any specific provider from whom relevant medical records are outstanding, VA's duty to assist is not triggered by the general reference to "previously identified medical providers." The United States Court of Appeals for Veterans Claims has held, "[t]he duty to assist in the development and adjudication of a claim is not a one-way street." Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). "If a [claimant] wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). See also Olson v. Principi, 3 Vet. App. 480, 483 (1992). As no relevant, outstanding treatment records have been sufficiently identified to trigger VA's duty to assist, no duty to assist error exists to delay the Board's adjudication of these issues. Neither the Veteran nor representative has raised any issues with the duty to notify or duty to assist other than those contentions addressed in this decision. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). The Board has recharacterized the appeal for service connection for right-side numbness as right upper extremity radiculopathy. In this regard, the Veteran has been awarded service connection for right lower extremity radiculopathy which contemplates the claimed right-side numbness of the right lower extremity. The Veteran's remaining right-side numbness was attributed to right upper extremity radiculopathy by the June 2022 cervical spine examiner. Therefore, the issue on appeal has been recharacterized accordingly. Increased Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). Nevertheless, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods within the period on appeal. Where there is a question as to which of the 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. If the positive and negative evidence is in approximate balance, the claimant receives the benefit of the doubt. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 1. Entitlement to a separate 10 percent rating for bowel incontinence is granted. Entitlement to service connection for urinary/bowel incontinence was granted by a May 2012 Board decision on a direct basis. The June 2012 rating decision, in implementing the Board's decision, granted service connection for urinary incontinence, effective June 3, 1998, but did not address bowel incontinence. The Veteran appealed from the assigned initial rating for urinary incontinence, and in March 2021 the Board interpreted the appeal for a higher rating for urinary incontinence to include the issue of entitlement to a separate rating for bowel incontinence as part of the appeal for a higher rating for urinary incontinence. Impairment of sphincter control of the rectum and anus is rated under 38 C.F.R. § 4.114, DC 7332. Under that DC 7332, a noncompensable disability rating is assigned where impairment of sphincter control is healed or slight, without leakage. A 10 percent disability rating is warranted when there is constant slight, or occasional moderate leakage. A 30 percent disability rating is assigned where there are occasional involuntary bowel movements necessitating the wearing of a pad. 38 C.F.R. § 4.114. In a June 1998 statement the Veteran reported incidents where he lost control of his bodily functions and had to change his clothes. He stated that he sometimes lost control of his bodily functions at night while sleeping. At his February 2002 Board hearing, the Veteran reported that he had experienced bowel incontinence ever since service. On VA examination in July 2003, the Veteran was reported to experience incontinence of urine, but there was no requirement for absorbent materials. There was no discussion of bowel incontinence. In December 2005 the Veteran again stated that at times he had difficulty controlling his bowels and could not make it to the bathroom. In an April 2008 statement, the Veteran reported bowel incontinence, particularly caused by coughing or sneezing. On VA examination in September 2008 the Veteran reported leakage of "slight amounts" of stool one or two days out of three, not requiring a pad. On VA examination in May 2011 the examiner stated that the Veteran reported "fecal leakage at times but no real incontinence" and "no absorbent material is used." An April 2016 VA anus and rectum examination contained no reference to bowel incontinence. On VA examination in April 2021 the Veteran reported two to three instances per month where a small amount of stool would come out in his underwear. He did not report use of absorbency pads. This evidence persuasively demonstrates that the Veteran's bowel incontinence is manifested by constant slight, or occasional moderate leakage since June 3, 1998. However, the evidence weighs persuasively against finding that the Veteran's bowel incontinence necessitated the use of absorbent pads. On the contrary, the evidence of record specifically documents no use of absorbent material to control bowel incontinence at any time during the period on appeal. Based on the foregoing, the Board finds that the competent and credible evidence persuasively weighs in favor of finding that a 10 percent rating, but no higher, for bowel incontinence since June 3, 1998, is warranted. The claim is granted in part. 2-6. Entitlement to separate 10 percent ratings for right and left foot degenerative joint disease since April 6, 1998 is granted; a compensable rating for bilateral pes planus with pes cavus, hammer toes and hallux valgus from April 6, 1998 to August 1, 2012, is denied; a rating in excess of 20 percent from August 2, 2012 to March 29, 2021 is denied; and a rating in excess of 30 percent since March 30, 2021 is denied. The Veteran contends that his pes cavus is more severely disabling than represented by the currently assigned noncompensable rating prior to August 2, 2012, 20 percent rating from August 2, 2012 to March 30, 2021, and 30 percent rating since March 30, 2021. In April 2021, a VA examiner diagnosed bilateral pes planus with bilateral fifth metatarsal calluses, hammer toes, and hallux valgus with degenerative joint disease, in addition to the already service-connected pes cavus and opined that these additional foot diagnoses were secondary to bilateral pes planus. Based on these findings, in an August 2022 rating decision, The AOJ recharacterized the Veteran's bilateral pes cavus disability as pes planus with pes cavus, hammer toes and hallux valgus with degenerative joint disease, both feet, and right first metatarsophalangeal joint. As these additional foot disabilities have been found to be related to the bilateral pes cavus, the Board will consider whether higher or separate ratings are warranted based on the associated diagnostic codes. Under 38 C.F.R. § 4.71a, DC 5003, degenerative arthritis is to be rated based on limitation of motion. However, where the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. Under DC 5276 for pes planus, a noncompensable rating is warranted where symptoms are mild and relieved by a built-up shoe or arch support. A 30 percent rating is warranted for bilateral severe disability, characterized by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A maximum 50 percent rating requires 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. See 38 C.F.R. § 4.71a. "Pronounced" is defined as a degree greater than "severe" under DC 5276. Prokarym v. McDonald, 27 Vet. App. 307, 311 (2015). "Extreme" means existing in very high degree. See Merriam-Webster, https://www.merriam-webster.com/dictionary/extreme. "Severe" means "of a great degree" or "serious." See Merriam-Webster's Collegiate Dictionary, 1140 (11th ed. 2003). "Marked" is defined as "clearly defined and evident, noticeable." See Webster's New World Dictionary, Third College Edition (2008) at 686. "Moderate" is defined as "of average or medium quality, amount, scope, range, etc." See Webster's New World Dictionary, Third College Edition (2008) at 721. But the Court held that a "severe" disability under DC 5276 (pes planus) is not equivalent to a "severe" disability under DC 5284 (other foot injury) that is, what is classified as "severe" can be dependent on the diagnostic code used. See Breniser v. Shinseki, 25 Vet. App. 64, 76-77 (2011). Under DC 5278, a 10 percent rating is warranted for acquired bilateral pes cavus where the great toe is dorsiflexed, with some limitation at the ankle, and definite tenderness under the metatarsal heads. A 30 percent rating is warranted for acquired bilateral pes cavus with all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads. A 50 percent rating is warranted for acquired bilateral pes cavus when there is marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity. The criteria under DC 5278 are conjunctive, not disjunctive. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive in a statutory provision meant that all of the conditions listed in the provision must be met); cf Johnson v. Brown, 7 Vet. App. 9 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). See also Tatum v. Shinseki, 23 Vet. App. 152 (2009) (holding that 38 C.F.R. § 4.7 is not applicable when the ratings criteria are successive and not variable). Under DC 5280, a maximum 10 percent rating is warranted for severe unilateral hallux valgus if equivalent to amputation of great toe. A maximum 10 percent rating is warranted for unilateral hallux valgus, operated with resection of metatarsal head. 38 C.F.R. § 4.71a, DC 5280. Hammer toes are rated under DC 5282, with a 0 percent rating for hammer toe in a single toe and a maximum 10 percent rating for "all toes, unilateral without claw foot." The rule against pyramiding provides that evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. See C.F.R. § 4.14. In June 1998, the Veteran reported his feet were always sore and tender with constant swelling. A March 2002 statement from a private physician, Dr. B.T., reported that the Veteran suffered from chronic bilateral foot pain, and now required use of a walking cane. Two VA examinations were conducted in June 2003 pertaining to the feet. The Veteran reported symptoms of persistent burning and weakness in his feet. The examiner stated that the Veteran had "a mild arch" which he "would not consider ... to be a pes cavus" and there was some loss of range of motion in both feet on examination. X-rays showed mild degenerative changes in the right metatarsophalangeal joint and left intertarsal and metatarsophalangeal joints. The examiner stated that "most of his disability is due to burning in both of his feet" and that "the burning symptoms are primarily due to a long-standing lumbar radiculopathy." However, "the constant walking on the lateral border of his foot has aggravated the local plantar nerves which already are functioning abnormally due to the long-standing radiculopathy." In April 2004 the Veteran stated that standing for long periods caused his feet to become swollen and achy. On VA examination on April 12, 2016, the examiner diagnosed bilateral pes cavus and left foot degenerative arthritis. The examiner stated that the Veteran reported pain in the outside edge of his foot intermittently with use and proportional to the duration of weight-bearing. Examination of the left foot revealed pain over callosities on the plantar surfaces. There was less movement than normal, and the Veteran was noted to regularly use a cane for ambulation for multiple musculoskeletal conditions including his painful callouses. On VA examination in March 2021, the examiner diagnosed bilateral pes cavus, hammer toes, pes planus with bilateral fifth metatarsal callus formation, and hallux valgus with degenerative joint disease. The examiner stated pes cavus was bilateral, but right more so than the left when in non-weightbearing. The examiner found a "flexible pes planus" where the arch was fallen when standing but returns when the foot is lifted off the ground. The left pes planus was more prominent than the right. The examiner noted complaints of recurring pain in the forefoot and arch of feet, right worse than left due to pes cavus, and the Veteran could not distribute his weight evenly on the right foot because he could not put it flat on the ground. There were no flare-ups of the foot conditions. Symptoms of pes planus were bilateral foot pain, accentuated on use, but no pain on manipulation. There was no indication of swelling on use, but there were characteristic calluses bilaterally. The Veteran used bilateral arch supports but remained symptomatic. There was no extreme tenderness, but there was decreased longitudinal arch height of both feet. There was no objective evidence of marked deformity of either foot or marked pronation of either foot. The weight-bearing line was not over or medial to the great toe and there was no inward bowing of the Achilles' tendon, hindfoot valgus, with lateral deviation of the heel of one or both feet. There was no marked inward displacement or severe spasm of the Achilles' tendon on manipulation. There were hammer toes of the second, third and fourth toes bilaterally, which were reportedly asymptomatic. There were no symptoms of hallux valgus or history of surgery for hallux valgus. The symptoms of pes cavus were a varus deformity of the right foot, which was "not marked meaning it is not more than moderate but less than extreme. It is mild." There was bilateral recurring pain in the forefoot and arch of feet, right worse than left, which was precipitated by prolonged standing or walking. There Veteran stated that he could not distribute weight evenly on the right foot because he could not put it flat on the found. With regard to the mild degenerative changes of the first metatarsophalangeal joint, the condition was described as mild bilaterally. Generally, there was disturbance of locomotion, interference with standing, and pain bilaterally due to the foot conditions. The examiner noted that the Veteran reported his foot pain differed based on the day, with some days being able to walk or stand for 10 minutes and other days being able to walk for longer before having to stop. In addressing flare-ups, the examiner stated that the Veteran's symptoms of pain were precipitated by standing or walking for certain periods of time, requiring him to rest. The examiner stated that the primary foot complaints in recent years were related to the calluses which were of "moderate" severity. On VA examination in July 2022, the examiner diagnosed bilateral pes cavus, calluses, right degenerative first metatarsophalangeal joint, and a small plantar heel spur on the right foot. With regard to pes cavus, the symptoms were a definite tenderness under the metatarsal heads, shortened plantar fascia, and some limitation of dorsiflexion at ankle. The examiner noted additional disabilities of right metatarsal arthritis, right heal spur, swollen right metatarsal joint, tenderness under right heel and bilateral feet calluses, collectively described as mild bilaterally, moderate on the right and moderately severe bilaterally. There was disturbance of locomotion, interference with standing and pain in both feet. The Veteran was noted to make occasional use of a wheelchair, regular use of a cane and regular use of arch supports due to the bilateral foot conditions. Based on the foregoing evidence, for the period since April 6, 1998 the evidence is in approximate balance as to whether separate 10 percent ratings are warranted based on degenerative arthritis of the feet with noncompensable limitation of motion. In this regard, the evidence through the period on appeal reveals symptoms of swelling, pain on motion and loss of range of motion of the feet. The June 2003 VA examiner specifically attributed burning pain to lower extremity radiculopathy, however, swelling, pain on motion and loss of range of motion was not entirely contemplated by the ratings for lower extremity radiculopathy. There is no compensable rating provided for loss of range of motion of the feet. Accordingly, separate 10 percent ratings are for application under DC 5003, effective since April 6, 1998. A higher rating under DC 5003 is not warranted at any time in the absence of incapacitating exacerbations which are not shown in this case. Even if such findings were shown, the assignment of two separate 10 percent ratings is more favorable than a single 20 percent rating after the calculation of the applicable bilateral factor. During the period from April 6, 1998 to August 1, 2012, the Veteran is in receipt of a noncompensable rating for pes planus with pes cavus, hammer toes and hallux valgus with degenerative joint disease both feet. Therefore, no pyramiding results from the assignment of separate 10 percent rating under DC 5003 during this period. However, no higher or separate rating is warranted. Pertinent to DC 5278, limitation of motion of the great toe is contemplated by the separate 10 percent ratings under DC 5003 and limitation of left ankle motion is contemplated by the separate rating for the left ankle fracture residuals. There is also no evidence of all toes tending to dorsiflexion as required for a higher 30 percent rating during this period. All toes were not hammer toes (DC 5282). There is no evidence of actual pes planus (DC 5276), hallux valgus (DC 5280), malunion or nonunion of tarsal nor metatarsal bones (DC 5283), or other foot injuries not contemplated by the assigned ratings (DC 5284) during this period. While pes planus and hallux valgus are service-connected, they are not demonstrated by the record during this period. Accordingly, no higher or additional rating is warranted for the period from April 6, 1998 to August 1, 2012. For the period from August 2, 2012 to March 29, 2021, the Veteran is in receipt of a 20 percent rating based on pes planus with pes cavus, hammer toes and hallux valgus with degenerative joint disease both feet. The December 2016 rating decision which assigned the 20 percent rating states that the rating was assigned based on the single symptom of very painful callosities. That rating thus contemplates symptoms such as pain on standing and walking, but does not contemplate limitation of foot motion, pain on motion or swelling. Thus, no pyramiding results from the assignment of separate 10 percent ratings under DC 5003 during this period. However, during this period, no higher or separate rating is warranted. Pertinent to DC 5278, there is no evidence of all toes tending to dorsiflexion as required for a higher 30 percent rating during this period. Additionally, while there were very painful callosities, there was not marked contraction of the plantar fascia with dropped forefoot. While there was varus deformity, it was not "marked" in that it was mild. Additionally, there is again no evidence of actual pes planus (DC 5276), hallux valgus (DC 5280), malunion or nonunion of tarsal nor metatarsal bones (DC 5283), or other foot injuries not contemplated by the assigned ratings (DC 5284). Accordingly, no higher or separate rating is warranted for the period from August 2, 2012 to March 29, 2021. For the period since March 30, 2021, the Veteran is in receipt of a 30 percent rating under DC 5276 based on pes planus with pes cavus, hammer toes and hallux valgus with degenerative joint disease both feet. The August 2022 rating decision stated that the rating was assigned based on characteristic callosities, pain on use of the feet and pain accentuated on use of the feet with symptoms not improved by orthopedic shoes or appliances. As that rating does not contemplate limitation of motion, pain on motion or swelling, no pyramiding results from the assignment of separate 10 percent ratings under DC 5003 during this period. However, during this period, no higher or separate rating is warranted. Pertinent to DC 5276, there is no evidence of marked pronation, or marked inward displacement and severe spasms of the tendo achilles on manipulation. Pertinent to DC 5278, limitation of motion of the great toe is contemplated by the separate 10 percent ratings assigned herein, and limitation of ankle motion is contemplated by the separate rating for the left ankle fracture residuals. Hallux valgus was not manifested by resection of the metatarsal head, or equivalent to amputation of the great toe for purposes of DC 5280. There is no evidence of malunion or nonunion of tarsal nor metatarsal bones (DC 5283). With regard to other foot injuries, the Board acknowledges that the July 2022 VA foot examiner identified additional foot conditions related to the service-connected foot disability including right metatarsal arthritis, a right heel spur, swollen right metatarsal joint, tenderness under the right heel and bilateral foot calluses. As discussed above, right metatarsal arthritis and swelling are contemplated by the assigned separate 10 percent ratings. Calluses, right heel spur and resulting right heel tenderness are contemplated by the assigned 30 percent rating under DC 5276 which contemplates pain on use of the feet (i.e. standing, walking) as well as characteristic callosities. While the examiner characterized the other foot injuries as "moderately severe," the 30 percent rating combined with the separate 10 percent ratings assigned herein are more favorable to the Veteran than separate 20 percent ratings under DC 5284. Accordingly, no higher or additional rating is warranted for the period since March 30, 2021. As for functional loss due to pain and other factors set forth in 38 C.F.R. §§ 4.40 and 4.45, the Board is sympathetic to the Veteran's reports of pain. In assigning separate 10 percent ratings under DC 5003, the Veteran is in receipt of the highest available rating for limitation of motion of the feet, and therefore, functional loss due to pain, to include during flare-ups or after repetitive use, is fully contemplated in the criteria used to evaluate the disability; hence, pain and tenderness alone do not provide an additional basis for any higher rating. See 38 C.F.R. § 4.71a, DC 5276-5282; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). There is no evidence of any specific additional functional limitation due to pain, to include during flare-ups or after repetitive use, which would approximate the criteria for a higher rating during this period. While the Veteran has required the use of a cane, arch supports and occasional use of a wheelchair, the Veteran has generally been able to stand and walk on his feet, and his functional limitations are not shown to be so disabling as to approximate a level of functioning so diminished that amputation with prosthesis would equally serve the Veteran. On the contrary, the evidence of record consistently demonstrates that the Veteran retains the use of his feet, being able to walk for at least five minutes before resting. Therefore, loss of use of the feet for VA compensation purposes is not demonstrated. Based on the foregoing, the Board finds that the evidence is at least in approximate balance as to whether separate 10 percent ratings for right and left foot degenerative joint disease since April 6, 1998 are warranted. However, a compensable for bilateral pes planus with pes cavus, hammer toes and hallux valgus from April 6, 1998 to August 1, 2012, and ratings in excess of 20 percent from August 2, 2012 to March 29, 2021 and 30 percent since March 30, 2021 are denied. The claims are granted in part. 7-11. Entitlement to a rating in excess of 30 percent for residuals of left ankle fracture is denied; a 20 percent rating for a left ankle scar from April 6, 1998 to June 30, 2018 is granted, a 100 percent rating based on convalescence under 38 C.F.R. § 4.30 from July 1, 2018 to October 9, 2018 is granted; entitlement to a separate 20 percent rating from October 10, 2018 to August 2, 2022 is granted; and a compensable rating since August 3, 2022 is denied. The Veteran contends that his residuals of left ankle fracture are more severely disabling than contemplated by the currently assigned 30 percent rating. In its March 2021, the Board granted entitlement to a 30 percent rating for residuals of left ankle fracture from April 6, 1998 to August 2, 2012, but denied a rating in excess of 30 percent since April 6, 1998. In the February 2022 JMR the parties agreed that the Board erred by failing to consider whether a separate rating was warranted based on the Veteran's chronic open wound of the left ankle. The Board remanded for additional development of that issue in July 2022. In a September 2022 rating decision, the AOJ assigned a separate noncompensable rating for a left ankle scar, status-post skin graft, effective August 2, 2012. As the rating for the left ankle scar is part of the appeal for a higher rating for the left ankle fracture residuals, the Board has jurisdiction to review the rating for that disability since April 6, 1998. Under DC 5270, a 30 percent evaluation is warranted for ankylosis in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees, and a 40 percent rating is warranted for ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, DCs 5270, 5271. The normal range of motion of the ankles is 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Additionally, DC 7801 provides ratings for burn or other scars (not on the head, face, or neck) that are deep and nonlinear. Deep and nonlinear scars involving an area or areas of at least 6 square inches (39 square cm) but less than 12 square inches (77 square cm) are rated 10 percent. 38 C.F.R. § 4.118. Note (1) specifies that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under DC 7802, burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear warrant a rating of 10 percent for area or areas of 144 square inches (929 square cm) or greater. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under DC 7804, unstable or painful scars warrant a rating of 10 percent for one or two scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under DC 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC, when applicable. 38 C.F.R. § 4.118. DC 7805, for other scars (including linear scars) and other effects of scars evaluated under DC 7800, 7801, 7802, and 7804, provides for evaluation of disabling effects not considered in a rating provided under DC 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118. A total disability rating of 100 percent will be assigned if treatment of a service-connected disability resulted in surgery necessitating: (1) at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30 (a)(1), (2), (3). Extensions of one, two or three months beyond the initial three months may be granted; extensions of one or more months up to six months beyond the initial six months period may be granted upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.30 (b)(1). A post-service injury to the left ankle has been attributed to the Veteran's service-connected back disability. He underwent left ankle open reduction and internal fusion (ORIF) with primary fusion of the tibiotalar joint surgery in June 1996, following the post-service injury. An April 1998 VA treatment record noted a non-healing left lateral incision of the left ankle. A VA treatment record of January 1999 noted "rigid painless fusion" upon examination of the left ankle. There was a residual five-millimeter open wound. In December 1999 the Veteran stated that the left ankle wound was still open and had not healed. He reported aching in the ankle "from time to time" with quivering of the tissue and muscles and some drainage. A June 2003 VA examination report for the feet noted that there was no subtalar or ankle motion and that the left ankle was fused in the neutral position in a sagittal plane. In a December 2005 statement the Veteran reported an ongoing open wound of the left ankle for which he needed to change the dressing every two days and attended wound care appointments to ensure no infection occurred. He reported that the wound ached from time to time. In November 2007, the notation in a VA treatment record was again that the left ankle was "fused without motion." There was skin breakdown to the left ankle exposing screw heads in the ankle. The Veteran reported no infection of the ankle for the last 5 years, but related oozing and drainage from the site. There was an ulcer over one screw which had still not healed but was not getting worse. The Veteran was recommended to have the hardware removed but declined. An April 2016 VA examination report for the ankles found that the left ankle was surgically fixed (ankylotic) in a 90-degree, functionally neutral position. There was no range of motion for dorsiflexion or plantar flexion ("0 degrees to 0 degrees"). A VA skin examination conducted at that time noted left ankle superficial ulceration measuring about 3 cm by 1 cm (3 square cm) "with both fixation screws exposed." The Veteran stated this had been present for multiple years, but that hardware removal had not been strongly advocated so long as the area remained clean and cared-for. He reported changing the dressing daily and keeping close watch for any infection. On June 25, 2018 the Veteran was involved in a motor vehicle accident. While hospitalized for his injuries, he developed an infection in the left ankle wound and in July 2018, the Veteran underwent removal of the left ankle hardware and skin graft to the wound. Following surgery, the Veteran required the use of crutches. On October 9, 2018, a VA treatment record noted a small ulceration of the skin of the left ankle measuring 1 cm by 1 cm (1 square cm). The Veteran was walking again. Upon VA examination of the ankles in July 2020, it was noted that the Veteran had "pinning" in his left ankle and could plantar flex and dorsiflex only his toes on the left. Full plantar flexion and dorsiflexion were not able to be performed on the left ankle. The examiner noted that, given the pinning and prior surgical intervention on the left ankle, the Veteran was completely unable to plantar flex or dorsiflex the left ankle, which was "fixed." The "degrees" found for ankylosis in plantar flexion and in dorsiflexion were 0. There was no abduction, inversion, or eversion deformity concerning left ankle ankylosis. On VA examination of the ankles in August 2022, the examiner reported left ankle ankylosis at 0 degrees of plantar and dorsiflexion. There were no left ankle flare-ups and no additional loss of function or range of motion after repetitive use. A VA scar examination conducted at that time revealed one left ankle scar which was not painful or unstable and measured 25 cm by 4 cm (100 square cm), and was not associated with underlying tissue damage. There was no other limitation of function due to the left ankle scar. This evidence weighs persuasively against finding that the criteria for a higher, 40 percent rating are approximated, because the left ankle was not ankylosed in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. On the contrary, the evidence of record persuasively demonstrates that the left ankle was fused at the zero-degree position throughout the period on appeal. Based on the foregoing, the competent and credible evidence is neither evenly nor approximately balanced as to whether a rating in excess of 30 percent for left ankle fracture residuals is warranted. With regard to the left ankle scar, the evidence is at least in approximate balance as to whether, from April 6, 1998 to June 30, 2018, the Veteran's left ankle scar was painful and unstable. In this regard, the left ankle open wound most nearly approximates an unstable scar, and the Veteran reported aching in the wound "from time to time." This evidence warrants a 20 percent rating. However, the evidence weighs persuasively against finding that the left ankle scar was deep, covered an area of 144 square inches (929 square cm) or greater, or was manifested by any additional functional impairment. In this regard, the evidence demonstrates no underlying soft tissue damage associated with the left ankle scar, and the only other functional impairment indicated by the record are concerns regarding prevention of infection, including avoiding unsanitary working environments and regularly changing dressings. The Board finds that these functional impairments are contemplated by the rating for an unstable scar, as risk of infection is presumed to be a concern wherever there is frequent loss of the covering of the skin. Accordingly, a 20 percent rating, but no higher, from April 6, 1998 to June 30, 2018 is warranted. For the period from July 1, 2018 to October 9, 2018, a 100 percent rating is warranted based on convalescence under 38 C.F.R. § 4.30. During that period, the Veteran was hospitalized or convalescing due to injuries resulting from the June 2018 motor vehicle accident to include the resulting left ankle wound infection. The record demonstrates use of crutches and incompletely healed surgical wounds until October 9, 2018. Therefore, a 100 percent rating is warranted for that period. For the period from October 10, 2018 to August 2, 2022, continuation of the prior 20 percent rating is warranted. Notably, even following the skin graft procedure, on October 9, 2018, a VA treatment record noted a small ulceration of the skin of the left ankle measuring 1 cm by 1 cm (1 square cm). As the Veteran was not provided a VA examination to reevaluate the severity of the left ankle scar until August 3, 2022, the Board will presume that the pre-surgery left ankle scar symptoms continued. However, the evidence weighs persuasively against finding that the left ankle scar was deep, covered an area of 144 square inches (929 square cm) or greater, or was manifested by any additional functional impairment. In this regard, as prior to the skin graft, the evidence demonstrates no underlying soft tissue damage associated with the left ankle scar. Accordingly, a 20 percent rating, but no higher, from October 1, 2018 to August 2, 2022 is warranted. For the period since August 3, 2022, a compensable rating for the left ankle scar is not warranted. In this regard, at the August 3, 2022 VA examination, the left ankle scar was not deep, painful or unstable and did not constitute an area of 929 square cm or more. This evidence indicates that at the time of the August 3, 2022 VA examination, the left ankle scar symptoms resolved. Based on the foregoing, the Board finds that the competent and credible evidence is at least in approximate balance as to whether a 20 percent rating for a left ankle scar was warranted from April 6, 1998 to June 30, 2018 and from October 10, 2018 to August 2, 2022 and whether a 100 percent rating based on convalescence under 38 C.F.R. § 4.30 was warranted from July 1, 2018 to October 9, 2018. However, the evidence persuasively weighs against finding that the criteria are met for a rating in excess of 30 percent for the left ankle fracture residuals or a compensable rating for the left ankle scar since August 3, 2022. The claim is granted in part. 12. Entitlement to a compensable rating for a low back scar is denied. The issue of entitlement to increased ratings for degenerative arthritis of the spine prior to January 17, 2019 are before the Board, and are further addressed in the remand section below. During the course of this appeal, in a September 2022 rating decision, the AOJ awarded a separate noncompensable rating for a low back scar, as secondary to the service-connected disability of degenerative arthritis of the spine, effective since June 25, 2018. As part of the appeal for an increased rating for degenerative arthritis of the spine, the Board will address the issue of entitlement to a compensable rating for a low back scar prior to January 17, 2019. As the period since January 17, 2019 regarding the degenerative arthritis of the spine is not before the Board, the Board will also not address that period with regard to the low back scar. The Veteran's low back scar is a result of surgical lumbar fixation performed on June 25, 2018. The scar was evaluated on VA examination in January 2019. At that time, the examiner reported one lower lumbar scar which measured 3 cm by .5 cm (1.5 square cm). It was not painful or unstable. Based on the foregoing, the Board finds that the competent and credible evidence is neither evenly nor approximately balanced as to whether a compensable rating for a low back scar is warranted. Rather, the evidence persuasively weighs against finding that a low back scar was painful, unstable or measured 39 square cm or greater. The benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b), Lynch, 21 F.4th 776. The claim is denied. REASONS FOR REMAND 13. Entitlement to service connection for type II diabetes mellitus is remanded. In March 2021 the Board remanded the issue of entitlement to service connection for type II diabetes mellitus to obtain a medical opinion addressing the nature and etiology of that condition, to specifically include consideration of the medical article submitted by the Veteran pertaining to the secondary theory of entitlement, Weisberg, et al, Nonpsychiatric Illness among Primary Care Patients with Trauma Histories and Posttraumatic Stress Disorder. In April 2021 a VA examiner opined against a secondary etiology of diabetes but failed to discuss the medical articles submitted by the Veteran as directed by the March 2021 Boar remand. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 14. Entitlement to service connection for an eye disorder is remanded. The prior Board remand requested a secondary service connection opinion. The Veteran was provided a VA examination to address the nature and etiology of his claimed eye disorders in September 2021. The examiner opined that an eye disorder was unlikely caused or aggravated by a service-connected disorder on the basis that the eye disorders were unrelated to a reported in-service immersion heater explosion. As this rationale pertains to the primary theory of service connection rather than the secondary theory, (i.e., whether the eye disorder was caused or aggravated by another service-connected disorder), it is inadequate. Another remand is required. The only service-connected disability raised as a possibly causing or aggravating an eye disorder are the Veteran's service-connected headaches. Specifically, the Veteran has described blurred vision during headaches. No other specific service-connected disability has been identified by the Veteran or representative as a possible basis for secondary service connection and none is raised by the record. Therefore, the Board will limit its remand instruction to the only theory raised by the Veteran and the record. Robinson v. Peake, 21 Vet. App. 545, 552-56 (2008) (concluding "that the Board is not required sua sponte to raise and reject 'all possible' theories of entitlement in order to render a valid opinion" and "commits error only in failing to discuss a theory of entitlement that was raised either by the appellant or by the evidence of record"), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (stating that "[w]here a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). 15. Entitlement to service connection for a left knee disorder is remanded. The Veteran was provided with a VA examination to consider the nature and etiology of his claimed left knee disorder in April 2021. The examiner opined against a direct or secondary etiology of the diagnosed knee disorder. In addressing the direct etiology, the examiner noted "no overwhelming evidence in support of a chronic knee condition in the years immediately following service." However, service connection does not require "overwhelming evidence" but only an approximate balance of the evidence. Therefore, the April 2021 examiner applied an inapplicable evidentiary standard. With regard to the secondary theory, the examiner provided one rationale addressing both theories of causation and aggravation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are independent concepts and should have separate findings and rationales). With regard to direct causation, the examiner provided no rationale beyond the conclusory statement that he "found no objective evidence to support a causal relationship between the left knee and any of his service-connected conditions or a disorder for which service connection is sought." For these reasons, remand is required to obtain a new medical opinion. 16. Entitlement to service connection for a neck disorder is remanded. The Veteran contends that his claimed neck disorder was incurred in service or is secondary to all of his other service-connected conditions. A medical opinion was obtained addressing this issue in June 2022. Thereafter, the AOJ revised the Veteran's service-connected foot conditions to include pes planus, hammer toes, hallux valgus and degenerative joint disease. Remand of this issues is required to obtain a medical opinion addressing secondary entitlement to include consideration of all service-connected disabilities. 17. Entitlement to service connection for right upper extremity radiculopathy is remanded. An October 2021 VA examiner declined to provide a medical opinion regarding the etiology of any right-side numbness, on the basis that the examiner concluded that the records demonstrated no right-side neuropathy apart from the already service-connected right lower extremity radiculopathy. However, a June 2022 cervical spine examination identified a right upper extremity upper radicular group nerve involvement. Remand is required to obtain a medical opinion addressing the etiology of that disorder. 18. Entitlement to ratings in excess of 50 percent prior to March 30, 2021 and 70 percent since March 30, 2021 for PTSD with depression and insomnia is remanded. In its March 2021 decision, the Board granted an earlier effective date of March 18, 2004, for PTSD with depression and insomnia. Prior to this grant, the effective date of service connection for this disability was March 22, 2004 and PTSD had been rated 50 percent disabling for the entire period. The initial rating for this disability was also on appeal. The Board remanded the issue of entitlement to a rating higher than 50 percent, explaining the basis of the remand as being for the sole purpose of obtaining an opinion that discussed medical literature submitted by the Veteran in October 2007 and October 2010. However, in the remand directives a full examination was requested and he was asked to "give consideration to... Medical literature cited or provided by the Veteran, to include the filings of October 2007, October 2010, and December 2016 in relation to PTSD, depression, and insomnia, as applicable to the current severity of the service-connected psychiatric disability." An examination was provided on March 30, 2021, resulting in a subsequent partial grant of a staged higher rating of 70 percent from March 30, 2021. Unfortunately, the March 2021 VA examiner did not discuss the specific evidence as requested in the remand directives. A narrow addendum opinion is required to correct this. Stegall, 11 Vet. App. at 271. 19. Entitlement to a rating in excess of 30 percent for left wrist arthritis status-post fracture since April 12, 2016 is remanded. In its March 2021 remand, the Board directed that the Veteran be provided a VA examination to ascertain the current severity of his left wrist arthritis status-post fracture. The examiner was to specifically discuss the Veteran's account of the severity, frequency and duration of left wrist flare-ups and the degree of functional loss during flare-ups with repeated use over time, to include the Veteran's statement in the April 2016 VA examination report that he loses 75 to 100 percent of the use of his left wrist during flare-ups. The March 2021 VA examination failed to discuss this evidence. Therefore, another remand is required. Stegall, 11 Vet. App. at 271. 20. Entitlement to a rating in excess of 40 percent for degenerative arthritis of the spine prior to June 25, 2018 and from October 11, 2018 to January 16, 2019 is remanded. In its July 2022 remand, the Board directed that the Veteran was to be provided a VA examination to ascertain the current severity of his degenerative arthritis of the spine. The examiner was to specifically address additional functional loss during flare-ups. The August 2022 VA examiner found no current report of flare-ups and provided no further discussion of the functional impact of flare-ups. However, the October 2008, October 2010 and April 2016 VA examinations which are relevant to the period on appeal do report flare-ups. Therefore, remand is required to obtain a medical opinion addressing the functional impact of flare-ups as directed by the July 2022 remand instructions. Stegall, 11 Vet. App. at 271. 21. Entitlement to an effective date prior to June 3, 1998 for the award of a TDIU is remanded. The issue of entitlement to an effective date prior to June 3, 1998 for the award of a TDIU is inextricably intertwined with the other service connection issues remanded herein. Harris, 1 Vet. App. at 183. Remand of this issues is required pending adjudication of the issues of entitlement to service connection for type II diabetes mellitus, an eye disorder, left knee disorder, right upper extremity radiculopathy and a neck disorder. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the etiology of type II diabetes mellitus. In-person examination is not required unless deemed necessary by the examiner. In the reasoning for the opinions, the examiner must discuss the medical article submitted by the Veteran on March 18, 2004, Weisberg, et al, Nonpsychiatric Illness among Primary Care Patients with Trauma Histories and Posttraumatic Stress Disorder. a. Is type II diabetes mellitus proximately caused by service-connected PTSD with depression and insomnia? b. Is type II diabetes mellitus aggravated beyond its natural progression by service-connected PTSD with depression and insomnia? An explanation of the medical reasoning for each opinion must be provided. Causation and aggravation opinions must have separate and distinct rationales. 2. Obtain an addendum opinion from an appropriate clinician to addressing secondary service connection for an eye disorder, to include dry eye syndrome, pinguecula, arcus senilis and cataracts. In-person examination is not required unless deemed necessary by the examiner. The examiner must answer the following questions: a. For each eye disorder, is it proximately caused by the Veteran's service-connected headaches? Why or why not? b. For each eye disorder, is it aggravated beyond its natural progression by the Veteran's service-connected headaches? Why or why not? An explanation of the medical reasoning for each opinion must be provided. Causation and aggravation opinions must have separate and distinct rationales. 3. Obtain an addendum opinion from an appropriate clinician to determine the etiology of a left knee disorder to include degenerative joint disease. In-person examination is not required unless deemed necessary by the examiner. The examiner must answer the following questions: a. For each left knee disorder, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to an in-service injury or illness, to include the June 18, 1982 left knee injury? b. For each left knee disorder, is it proximately caused by any service-connected disability? c. For each left knee disorder, is it aggravated beyond its natural progression by any service-connected disability? An explanation of the medical reasoning for each opinion must be provided. Causation and aggravation opinions must have separate and distinct rationales. 4. Obtain an addendum opinion from an appropriate clinician to determine the etiology of a neck disorder to include degenerative arthritis, degenerative disc disease, and intervertebral disc syndrome. In-person examination is not required unless deemed necessary by the examiner. The examiner must answer the following questions: a. For each neck disorder, is it proximately caused by pes planus, hammer toes, hallux valgus and/or degenerative joint disease? b. For each neck disorder, is it aggravated beyond its natural progression by pes planus, hammer toes, hallux valgus and/or degenerative joint disease? An explanation of the medical reasoning for each opinion must be provided. Causation and aggravation opinions must have separate and distinct rationales. 5. Obtain an addendum opinion from an appropriate clinician to determine the etiology of right upper extremity radiculopathy. In-person examination is not required unless deemed necessary by the examiner. The examiner must consider the June 2022 cervical spine examination identified a right upper extremity upper radicular group nerve involvement in answering the following questions: a. Is right upper extremity radiculopathy related to an in-service injury or illness, to include any hazardous exposure in service? b. Is right upper extremity radiculopathy a manifestation of an undiagnosed illness or a medically unexplained, chronic multi-symptom illness? c. Is right upper extremity radiculopathy proximately caused by any service-connected disability? d. Is right upper extremity radiculopathy aggravated beyond its natural progression by any service-connected disability? An explanation of the medical reasoning for each opinion must be provided. Causation and aggravation opinions must have separate and distinct rationales. 6. Request an addendum opinion from the clinical psychologist who provided the March 2021 VA psychiatric examination. (If he is unavailable, request the opinion from an appropriate provider.) The examiner is asked to review the diagnoses of PTSD, depression and alcohol dependence made by the VA examination report for PTSD in May 2011 and medical literature cited or provided by the Veteran to include filings of October 2007, October 2010 and December 2016 in relation to PTSD, depression and insomnia. Based on review of this evidence, please answer the following questions: a. Does this evidence support a finding that the Veteran's PTSD with insomnia and depression resulted in occupational and social impairment with deficiencies in most areas (such as work, school, family relations, judgment, thinking and/or mood) prior to March 30, 2021? Why or why not? b. If the answer to (a.) is yes, can you identify when the disability resulted in this level of impairment? 7. Obtain an addendum opinion from an appropriate clinician to explicitly discuss the Veteran's statement in the April 2016 VA examination report that he loses 75 to 100 percent of the use of his left wrist during flare-ups. Based on review of the record and lay evidence, provide an opinion estimating the severity of the Veteran's left wrist disability and any additional degree of limited motion caused by functional loss during a flare-up or after repeated use over time. If the clinician cannot provide the above-requested opinion regarding flare-ups without resorting to speculation, he or she should state whether all procurable medical evidence has been considered, to specifically include the Veteran's description as to the severity, frequency, and duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner's medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). 8. Obtain an addendum opinion from an appropriate clinician to determine the severity of degenerative arthritis of the spine from April 6, 1998 to June 25, 2018 and from October 11, 2018 to January 16, 2019. In-person examination is not required unless deemed necessary by the examiner. The examiner must answer the following question: At any time from April 6, 1998 to June 24, 2018 and from October 11, 2018 to January 16, 2019, did the Veteran's degenerative arthritis of the spine result in functional loss approximating unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine, to include during a flare-up or after repeated use over time? (Continued on the next page) If the clinician cannot provide the above-requested opinion regarding flare-ups without resorting to speculation, he or she should state whether all procurable medical evidence has been considered, to specifically include the Veteran's description as to the severity, frequency, and duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner's medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bametzreider, Paul J. 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.