Citation Nr: 1641361 Decision Date: 10/24/16 Archive Date: 11/08/16 DOCKET NO. 11-12 498 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for sinusitis. 2. Entitlement to a compensable evaluation for migraines. 3. Whether new and material evidence has been submitted to reopen a claim for service connection for sleep apnea (claimed as on a direct basis and as secondary to sinusitis) and, if so, whether the claim may be granted. 4. Entitlement to service connection for bilateral knee disability 5. Entitlement to service connection for low back disability 6. Entitlement to service connection for cervical spine disability 7. Entitlement to service connection for left arm disability, to include neurological disorder associated with cervical spine disability. 8. Entitlement to service connection for temporomandibular joint (TMJ) dysfunction. 9. Entitlement to a total disability evaluation based on individual unemployability due to service connected disability (TDIU). REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The Veteran served on active duty from June 1978 to September 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Offices (RO) in Cleveland, Ohio, and Atlanta, Georgia. The Board notes that the Montgomery RO prepared a Statement of the Case in some of the issues on appeal, but jurisdiction is now with the Atlanta RO. It is noted that the RO reopened the claim for service connection for sleep apnea in a February 2016 decision and then denied the claim on a de novo basis. See Statement of the Case (February 2016). Notwithstanding, the Board must determine on its own whether new and material evidence has been submitted to reopen a claim. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In May 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ) along with her spouse. A hearing transcript is associated with the record. The VLJ held the record open for 30 days following the hearing to permit the Veteran additional time to submit pertinent evidence in support of the appeal. See Hearing Transcript at 21. At the hearing, the Veteran waived consideration by the Agency of Original Jurisdiction (AOJ) of any additional evidence submitted in these matters. See Hearing Transcript at 29. Based on the Veteran's statements and sworn testimony concerning interference with employability and unemployment due to service-connected, the Board finds that entitlement to TDIU has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Although TDIU was denied by in a November 2002 unappealed rating decision, this was prior to current claims for increase and there is essentially a new claim for TDIU. Therefore, the issue of TDIU has been added to the issues in this appeal. The issues of entitlement to a compensable evaluation for migraines, service connection for sleep apnea (claimed as on a direct basis and as secondary to sinusitis), service connection for bilateral knee disability, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to AOJ. FINDINGS OF FACT 1. Sinusitis is not more nearly manifested by 3 or more incapacitating episodes per year requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment, or more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 2. Service connection for a sleep apnea was denied in an October 2013 unappealed rating decision; the evidence received since that decision is not cumulative or redundant of the evidence previously of record, relates to an unestablished fact necessary to substantiate the claim, and is sufficient to raise a reasonable possibility of substantiating the claim. 3. A low back disability was not incurred in or aggravated by service; arthritis of the lumbar spine is not shown within the initial post separation year; and competent evidence has not been presented linking any current low back disability to disease or injury incurred during service. 4. A cervical spine disability was not incurred in or aggravated by service; arthritis of the cervical spine is not shown within the initial post separation year; and competent evidence has not been presented linking any current cervical spine disability to disease or injury incurred during service. 5. Left arm disability, to include neurological disorder associated with cervical spine disability, was not incurred in or aggravated by service; and competent evidence has not been presented linking any current disability of the left arm to disease or injury incurred during service. 6. TMJ dysfunction is not shown at any time during this appeal period. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for sinusitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.97, Diagnostic Code 9513 (2015). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for sleep apnea. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 3. The criteria for service connection for low back disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 4. The criteria for service connection for cervical spine disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 5. The criteria for service connection for left arm disability, to include neurological disorder associated with cervical spine disability, are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 6. The criteria for service connection for TMJ are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by letters dated in December 2007 and November 2014. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the October 2014 sleep apnea claim, the Veteran completed her application for benefits under the Fully Developed Claim Program, which included all necessary notice with the application for benefits. See VA Form 21-526EZ; Veterans Benefits Administration (VBA) Fast Letter 12-25, The Fully Developed Claim Program, November 8, 2012. Notwithstanding, the RO supplemented this notice with a letter dated November 2014. VA also met its duty assist the Veteran. VA obtained the Veteran's service treatment records (STRs) along with all other relevant medical treatment records identified by the Veteran. The Veteran also provided supporting medical evidence. These records and evidence have been associated with the claims file. VA further afforded the Veteran appropriate VA medical examinations, which are adequate. The Board finds that the VA examination reports described the sinus disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also, Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). VA afforded the Veteran a hearing in this appeal before a Decision Review Officer at the RO and before the undersigned VLJ. It is noted that a VA examination of the Veteran's low back, neck, left arm and TMJ disorders was not obtained. The Board finds that a VA examination is not required in these matters as there is no indication in the record that a current disability is related to military service, as discussed in the decision below. 38 C.F.R. § 3.159. See also McClendon v. Nicholson, 20 Vet. App. 79 (2006); Duenas v. Principi, 18 Vet. App. 512 (2004). The Veteran has not identified any outstanding evidence that could be obtained to substantiate her claims; the Board is also unaware of any such evidence. II. Preliminary Matters Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). III. Claims for Increase Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained 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.A. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. Sinusitis The RO granted service connection for sinusitis with headaches in a January 1994 rating decision at the 10 percent disability level under 38 C.F.R. § 4.97, Diagnostic Code 6513. In 2007, VA received a claim for increase. Diagnostic Code 6513 provides that chronic maxillary sinusitis warrants a 10 percent evaluation where there are 1 or 2 incapacitating episodes per year of sinusitis requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment, or 3 to 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned where there are 3 or more incapacitating episodes per year of sinusitis requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment, or more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or when there is near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. The regulation defines an incapacitating episode as one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Code 6513. It is noted that the criteria for a higher evaluation are both conjunctive and disjunctive; in this regard, the criteria distinguishes between non-incapacitating episodes and incapacitating episodes. In the case of non-incapacitating episodes each criterion identified must be met to some extent at the very least. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). Both the 30 percent and 50 percent ratings under Diagnostic Code 6513 require headaches, pain "and" either purulent discharge "or" crusting. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an evaluation in excess of 10 percent for sinusitis. Neither the lay nor the medical evidence more nearly reflects 3 or more incapacitating episodes per year of sinusitis requiring prolonged (lasting 4 to 6 weeks) antibiotic treatment, or more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 38 C.F.R. § 4.7. The Veteran testified that she has symptoms of sinusitis that warrant a higher evaluation. At an August 2010 hearing, the Veteran reported worsened sinus problems treated with medication. She reported always having either headaches or drainage. She reported that she always has one or more symptoms and that she wakes up daily with headache. She reported treating her symptoms with acupuncture, nasal sprays, and "medication at least three times a week" along with use of an air purifier to help with her breathing. At her May 2016 hearing, the Veteran testified that she treated sinusitis with used nasal sprays and antibiotics and that she had nasal surgery. She reported symptoms of headache pain 3-4 times a week with purulent discharge, noting she had received antibiotics just this week and had used antibiotics at least 3 or more times a year. Hearing Transcript at 5-8. The Veteran's husband testified that his wife's symptoms appear to have worsened over the years-he has observed her symptoms of draining, and noisily trying to clear her air passages. Hearing Transcript at 9. Report of VA examination dated in December 2015 reflects a diagnosis for "Sinusitis, not active." History of sinusitis was noted, but the examiner indicated that there were currently no findings, signs or symptoms attributable to chronic sinusitis. The examiner indicated that the Veteran has not had "non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. The examiner indicated that the Veteran has not had incapacitating episodes over the past 12 months." It was noted that the Veteran had not had sinus surgery. X-ray results indicated "Negative paranasal sinus series;" nasal septum was at the midline. Laryngeal endoscopy was performed that showed interarytenoid edema; slightly erythematous; otherwise within normal limits. The examiner indicated that this condition did not impact the Veteran's ability to work. VA and private treatment records for the appeal period were reviewed. These reflect history of sinusitis. Notably, September 2007 private treatment note showed complaints of face pain and congestive headache; the impression was neck pain, memory loss, cephalgia-but no diagnosis was given for sinusitis. An April 2008 private treatment note shows that the Veteran presented with a sinus infection and sinus headache; she had symptoms of drainage, runny nose, and itchy sore throat. These records do not show incapacitating episodes or more than 6 non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Although VA treatment records reflect that, in September 2014, the Veteran underwent UPPP (uvulopalatoplasty) and turbinoplasty, these records further show that this surgery was due to breathing problems associated with obstructive sleep apnea. There is no indication that this surgery was performed due to sinusitis and VA treatment record dated 2013-14 show no treatment for sinusitis although the condition was noted on the Veteran's problem list and as a service-connected disability in these records. A July 2015 note reflect that the Veteran presented with complaint of "sinus headache" that was "moving into being a migraine." She reported sinus headache for 3 weeks, treated with over-the-counter medications. The examiner noted that she had not refilled "her Loratadine or Fluticasone for some time now (Nov and Feb)." The Veteran reported "sensitivity to light" and "that is how she can separate her sinus headache from migraines." The provider prescribed Azithromycin for a 5 day period along with refill of Loratadine and throat lozenges. A September 2015 exam of nose reflects patent nares, normal mucosa, and no obstructive lesion, polyps, or epistaxis. A December 2015 x-ray study of sinuses showed that the "paranasal sinuses are well aerated and clear" without mucosal thickening, air fluid levels or bony destructive changes. A February 2016 note shows chronic sinusitis with headaches, but no specific details. The Board has fully considered the Veteran's statements and testimony, along with the other lay evidence of record. To the extent that the Veteran suggested at her hearing that she had been bedridden from sinusitis, neither her statements, other lay evidence, or the medical evidence indicates that she had any incapacitating episodes during this appeal-that is, an episode of sinusitis that requires both bed rest and treatment by a physician. The Board accepts the Veteran's testimony in May 2016 that she had just that week been prescribed antibiotics for sinusitis. However, neither this evidence nor the medical evidence shows prolonged (lasting 4 to 6 weeks) antibiotic treatment in conjunction with 3 or more incapacitating episodes per year of sinusitis. The December 2015 VA sinus examination reflects that the Veteran's sinusitis is essentially non-active; that she has not had "incapacitating episodes" over the past 12 months; and that she has not had "non-incapacitating" episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. Additionally, the December 2015 x-ray series of the sinuses showed no abnormality. The Board accepts that the Veteran is competent to report that her disability is worse than evaluated. Layno, supra. The Board also finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor the medical evidence more nearly approximates the criteria for the next higher rating. The Board acknowledges the Veteran's consistent report of nagging headaches and waking in the morning with headache, which she reports are non-migraine type in nature. However, the presence of headache symptoms in the absence of the other rating criteria is insufficient to establish that her disability more nearly meets the criteria for the next higher rating. The Board has considered whether a higher or separate disability evaluation is available under any other potentially applicable provision of the rating schedule. However, neither a higher nor separate evaluation is warranted based on any other provision of the rating schedule. It is noted that the Veteran does not meet the schedular criteria for a higher rating under Diagnostic Code 6522 (Allergic or vasomotor rhinitis) as she does not have polyps. It is further noted that the Veteran has a separate rating for migraine headaches, which is addressed below. The Veteran's representative argued at the Board hearing that the Veteran's disability should be rated under the respiratory criteria for sleep apnea. However, the Board disagrees because, although both are disorders of the respiratory system and evaluated under 38 C.F.R. § 4.97, sinusitis involves different anatomy as recognized by the rating schedule itself, which distinguishes between ratings for "Diseases of the Nose and Throat" that includes sinusitis and "Restrictive Lung Diseases" that includes sleep apnea. Additionally, there is no medical indication of overlapping symptomatology to warrant a rating under the restrictive lung disease criteria for sinusitis-a disability of the nose and throat, not lungs. Accordingly, the claim is denied. As there is no distinct period where the disability more nearly met the criteria for a higher evaluation, a staged disability rating is not warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings). Also, as the evidence is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3; Gilbert, supra. Lastly, the Board finds that referral for extraschedular consideration is not warranted. Referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom., Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's sinus disorder are fully contemplated by the applicable rating criteria and consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. Referral for consideration of an extraschedular rating is therefore not warranted in this case. 38 C.F.R. § 3.321(b)(1). In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." In this case, the matter of entitlement to a TDIU has been remanded. The Federal Circuit in Johnson indicated that the TDIU provision only accounts for instances in which a veteran's combined disabilities establish total unemployability, i.e., a disability rating of 100 percent. Id. at 1366. On the other hand, 38 C.F.R. § 3.321(b)(1) performs a "gap-filling" function. Id. It accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented. Id. As the issue of TDIU has been remanded, the Board finds that consideration of § 3.321(b) as a "gap-filling" provision of would be premature. Therefore, further discussion of an extraschedular rating based on the collective impact of multiple disabilities is not warranted in at this time. IV. Claims to Reopen Service connection for a sleep apnea was denied in unappealed rating decision dated in an October 2013. Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c). The exception to this rule is 38 U.S.C.A. § 5108 , which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In this case, the RO denied the claim in October 2013 because there were no complaints or findings for sleep apnea in service and because there was no favorable medical evidence linking any current findings for sleep apnea to the Veteran's period of service. The Board finds that evidence received since that decision cures a prior evidentiary defect. Specifically, the Veteran submitted a medical opinion dated May 2016 from her VA treating physician for sleep apnea. It reflects the onset of obstructive sleep apnea in service based on "the patient's report and military records." For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510 (1992). The Board finds that the recent evidentiary submission is not cumulative or redundant of the evidence previously of record at the time of the October 2013 denial, relates to an unestablished fact necessary to substantiate the claim, and is sufficient to raise a reasonable possibility of substantiating the claim. Accordingly, the petition to reopen the claim is granted. V. Claims for Service Connection The Veteran seeks service connection for low back disability, cervical spine disability, left arm disability (to include neurological symptoms associated with cervical spine disability), and TMJ. Initially, the Board notes the Veteran does not assert that her claimed problems are a result of combat. Therefore, the provisions of 38 U.S.C.A. § 1154(b) are not for application in this matter. Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in- service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). However, the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis shall be considered to have been incurred in or aggravated by service although not otherwise established during the period of service if manifested to a compensable degree within one year following service in a period of war or following peacetime service on or after January 1, 1947. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). A. Low Back Disability The Veteran seeks service connection for low back disability. At her May 2016 Board hearing, the Veteran testified that "everyday training" to include rappelling and engineer-type activities caused her spine conditions. She further theorized that "an incident during childbirth" caused her lower back disorder. Transcript at 22-23. Specifically, she stated that the medical staff had "difficulty" administering an epidural during childbirth. She stated that her back symptoms began following the epidural. Hearing Transcript at 24. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against service connection for low back disability. A chronic low back disability is not shown in service and arthritis is not shown within the initial post separation year. Also, although the evidence shows disability of the lumbar spine diagnosed post service, this disability is not etiologically related to service. STRs show no chronic disability of the low back. In October 1979, the Veteran presented with complaints of abdominal and back pain, but no abnormal pathology of the spine was documented at this time. The Veteran presented for complaints of a late menstrual period with back pain in December 1988, but again no abnormal pathology of the spine was documented at this time. A July 1989 note shows complaints of frequent urination and lower back pain, but this was attributed to first trimester pregnancy. There were no findings for abnormal pathology of the lumbar spine. Moreover, report of separation examination dated in July 1992 reflects normal clinical evaluation of the spine and that the Veteran denied recurrent back pain on the history part of that examination. Soon after service discharge, the Veteran underwent a VA examination. Report of VA examination dated in March 1993 reflects no history of or complaints for chronic low back problems. Documented complaints of back symptoms are first shown in 1994. Specifically, private treatment notes dated in February 1994 reflect complaints of pain in the right neck, shoulder, arm and back for 2 days due to the Veteran's desk at work. A May 1994 follow-up exam noted that she felt better and had quit her job. A November 1995 note reflect complaints of crampy bloating pressure of the right lower quadrant to the back with an impression of rule out (uterine) fibroids and endometriosis. A March 1996 note shows complaints of backache for 2 weeks, increased with sitting and moving. A private treatment record dated in March 2002 reflects that the Veteran presented for a physical exam. The spine showed normal alignment and no deformity. Gait was normal and there were no complaints of chronic back problems. A June 2005 VA note shows complaints of low back and right side leg pain. A June 2005 VA note shows a diagnosis for low back pain, likely muscular, treated with Etolac. An October 2006 VA imaging study of the lumbar spine shows "question spondylolysis on the left at L5." A September 2006 VA treatment note shows a history of low back pain of several months. Clinical findings were negative for paraspinal tenderness. Straight leg raises were negative. No neurological (sensory or motor) deficits were found. The assessment was chronic low back pain. VA note dated in March 2007 reflects complaints of chronic neck and upper back pain and paresthesias in both upper extremities along with occasional low back pain radiating down the right lower extremity. An April 2008 private treatment note shows complaints of back pain along with pain of the shoulders, neck and legs; the impression was neck/back pain. VA notes dated in late 2011 show complaints of low back pain; a December 2011 x-ray study shows findings for lumbar spine degenerative changes (greatest at L5-S1). The physician commented that some of the low back arthritis "may account for your low back pain." The medical evidence shows no chronic low back disability in service or a current low back disability etiologically related to service. The Board accepts that the Veteran is competent to report her symptoms, the onset of those symptoms, and treatment. Layno, supra. See also Falzone v. Brown, 8 Vet.App. 398, 405 (1995). In this regard, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153 (a); 38 C.F.R. § 3.303 (a); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). To the extent that the Veteran reports continuity of symptoms dating from service, the Board finds that she is not credible in view of her denial of back problem on the July 1992 service separation examination coupled with the normal clinical evaluation. Also, the Board notes that arthritis is not shown within the initial post separation year and her diagnosis for arthritis has not been attributed by competent evidence to any event or injury in service. Additionally, the Board has considered the Veteran's theory that the current low back disability is etiologically related to her activities and/or injuries in service. The Board fully accepts that the Veteran engaged rigorous physical activities in service and that she fell at least on one occasion during her service. However, she is not competent to opine that her current disability is etiologically related to service as she lacks the requisite medical expertise and, unlike a broken leg, her disability shown many years after service is not susceptible to lay observation. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Likewise, although the Veteran theorizes that possibly the difficulties with administering a spinal epidural during childbirth in service caused her current low back disorder, she is not competent to provide an opinion in this regard because the etiology is not susceptible to lay observation. Also, the Board believes that her theory of causation from epidural is incongruous with the subsequent normal findings for the spine at service separation to include her denial of recurrent back pain at that time. The Board notes that whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. Because of the relative complexity of the particular question involved here and the inability to render a nexus opinion based on personal observation, the Board finds that a non-expert medical opinion has no probative value in this matter. The Board observes that the Veteran has not provided a favorable medical opinion in this matter although she was advised at her Board hearing that generally a claim for service connection requires medical evidence linking the claimed current disability to service. The Board assigns greater probative value to the STRs that essentially show no chronic low back disability and the July 1992 service separation examination that shows normal clinical evaluation of the spine along with the Veteran's denial of recurrent back pain. The Board finds that this evidence is more probative than the Veteran's unsubstantiated medical opinion many years later. STRs are highly probative as they reflect the Veteran's physical health during her active duty and at separation from active duty. This evidence is also probative because it was prepared by skilled, neutral, medical professionals. Although a low back disability is shown many years after service, competent evidence has not been presented linking this disability to disease or injury incurred in service. On balance, the weight of the evidence is against the claim. As the evidence of record is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, Gilbert, supra. Accordingly, the claim is denied. C. Cervical Spine Disability and Left Arm Disability The Veteran seeks service connection for cervical spine disability with left arm (neurological) involvement. At her August 2010 hearing, the Veteran reported onset of neck problems in service and noted that her duties required her to carry as much as 50 pounds on one side of her body and that the general duties put a lot of stress on her neck and back. She reported pain of the neck and spine since service. At her May 2016 Board hearing, the Veteran testified that "everyday training" to include rappelling and engineer-type activities caused her neck disorder. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against service connection for cervical spine disability and left arm disability. A chronic cervical spine (neck) disability is not shown in service and arthritis is not shown within the initial post separation year. Likewise, a chronic disability of the left arm to include neurological dysfunction is not shown in service, or soon after service. The current findings for cervical spine and left arm disabilities are not etiologically related to service, to include any events or incidents of service. STRs show no chronic disability of the cervical spine or left arm. A January 1986 note reflects complaints of headaches at the base of the neck during an exam for sinus problems. STRs reflect neck swelling associated with allergy problems. A June 1988 note reflects "swelling in neck x2 days" and an April 1989 note shows neck swollen with allergy problems and recurrent tonsillitis. An October 1990 note shows complaints of left scapular pain since childbirth, assessed as pinched nerve (neuralgia) of cervical spine. Naprosyn and physical therapy (heat and massage) were advised. Report of annual examination dated in January 1987 reflects normal clinical evaluation of the spine. Report of separation examination dated in July 1992 reflects normal clinical evaluation of the spine, upper extremities, and neurologic system. The Veteran reported no neck or left arm complaints when otherwise reporting symptoms to include swollen and painful joints involving the knees only. Soon after service discharge, the Veteran underwent a VA examination. Report of VA examination dated in March 1993 reflects no history of or complaints for chronic neck or left arm problems. Documented complaints of cervical spine and left arm are first shown many years after service. Private treatment records shows neck complaints in 2002, but these records show no abnormal pathology of the cervical spine or left arm. Private and VA treatment records dated since 2005 show complaints of neck pain and left arm involvement. A December 2005 note shows follow-up treatment for herniated disc of cervical spine. The impression was cervical radiculopathy and cervical discogenic disease. A December 2005 MRI showed canal stenosis and disc herniation. VA treatment records show x-ray findings in December 2005 for cervical spine spondylosis, some mild osteophytosis, and joint disease. A January 2006 VA treatment note shows complaints of neck pain and left upper extremity weakness. A January 2006 letter from a private physician shows an evaluation of the Veteran for cervical spine and arm complaints. By history, the Veteran had a long history of cervical neck pain and intermittent shoulder spasms as well as radicular type pain extending down the left with tenderness, paresthesias, and numbness. The assessment was early myelopathy. Imaging studies showed significant degenerative changes in the cervical spine and superimposed congenital narrowing of the canal that results in spinal canal narrowing in the cervical spine. VA CT scan of the neck dated in February 2006 reflects prominence of the posterior nasopharyngeal adenoids and hypertrophy of the palatine tonsils likely reactive post inflammatory; and multilevel spondylosis changes of the lower cervical spine. A March 2006 note shows a diagnosis for neck pain/spondylolithiasis. A September 2006 note reflects an assessment for chronic neck pain. A February 2006 VA treatment note reflects MRI findings for multilevel degenerative changes of cervical spine, assessed as multilevel cervical spondylosis with myelopathy. A March 2007 VA treatment note shows complaints of chronic neck and bilateral paresthesias of the upper extremities. Subsequently dated treatment records continued to show cervical spondylosis with myelopathy and cervical degenerative joint disease with pain management. The medical evidence shows no chronic cervical spine disability and/or left arm disability in service; also, the medical evidence shows no indication that the Veteran has a current cervical spine disability with left arm involvement etiologically related to service. The Board accepts that the Veteran is competent to report her symptoms, the onset of those symptoms, and treatment. Layno, supra. See also Falzone supra. However, her statements and testimony have limited probative value. To the extent that the Veteran reports continuity of symptoms dating from service, the Board finds that she is not credible because she expressed no complaints of cervical spine or left arm problems at service separation examination in July 1992 and clinical evaluation of the spine, upper extremities, and neurologic system was normal at that time. Therefore, her report of continuity of symptoms since service has diminished probative value. The Board has considered the Veteran's theory that the current cervical spine disability with left arm involvement is etiologically related to carrying heavy things in service. However, she is not competent to opine that her current disability is etiologically related to service, to include carrying heavy items, as she lacks the requisite medical expertise and her disabilities shown many years after service are not susceptible to lay observation. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Because of the relative complexity of the particular question involved here and the inability to render a nexus opinion based on personal observation, the Board finds that a non-expert medical opinion has no probative value in this matter. The Board observes that the Veteran has not provided a favorable medical opinion in this matter although she was advised at her Board hearing that generally a claim for service connection requires medical evidence linking the claimed current disability to service. The Board has considered a February 2016 letter from a VA physician. The letter reflects that the Veteran had been seen for chronic pain since October 2008 and she had "severe cervical spondylosis and spinal stenosis with cord compression and multiple levels of neuroforaminal stenosis." The Board finds that this letter has no probative value because the etiology of the Veteran's cervical spine disorder and left arm problems was not addressed. The Board assigns greater probative value to the STRs that essentially show no chronic cervical spine and/or left arm disability. The Board further assigned greater probative value to the July 1992 service separation examination, which shows normal clinical evaluation of the spine, upper extremities, and neurological system. This examination also reflects no neck or left arm complaints when otherwise reporting medical problems. The Board finds that this evidence is more probative than the Veteran's unsubstantiated medical opinion many years later. STRs are highly probative as they reflect the Veteran's physical health during her active duty and at separation from active duty. This evidence is also probative because it was prepared by skilled, neutral, medical professionals. Although disability of the cervical spine with left arm involvement is shown many years after service, competent evidence has not been presented linking these disabilities to disease or injury incurred in service. On balance, the weight of the evidence is against the claim. As the evidence of record is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, Gilbert, supra. Accordingly, the claim is denied. D. TMJ The Veteran seeks service connection for TMJ. Although a February 1991 STR shows a provisional diagnosis for "TMJ/MPD syndrome," an April 1991 STR reflects that history and exam do not reveal any real TMJ findings. STRs include a February 1992 notation of oral surgery for TMJ, but service separation examination dated in July 1992 shows no findings or complaints of TMJ disorder. VA received a claim for TMJ in September 2007, more than 20 years after service separation. Post service medical records reflect no findings or diagnosis of TMJ although a May 2012 VA treatment record shows that the Veteran had TMJ pain that had been diagnosed by a private dentist. At this time, the Veteran reported right side pain, use of "partials" and dental care through a private provider. She noted that she was advised to use a dental guard but cannot afford it. The Veteran testified in May 2016 that she was recently diagnosed with TMJ and had seen a dentist soon after service for TMJ symptoms. Hearing Transcript at 39. The VLJ held the record open for an additional 30 days so that the Veteran could submit supporting evidence in her appeal. However, the record shows that the medical evidence submitted by the Veteran did not include medical or dental findings showing that she has had a diagnosis for TMJ at any time during this appeal. Although the Veteran is competent to report her symptoms, such as grinding her teeth and TMJ pain, she is not competent to diagnose herself with TMJ dysfunction as she lacks the requisite medical expertise. Therefore, her report of having a current diagnosis for TMJ has no probative value. It is noted that VA's duty to assist in the development of a claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Veteran reported that she was diagnosed with TMJ disorder but she had not provided VA with the treatment notes showing this disorder although given the opportunity to do so. TMJ dysfunction is not shown at any time during this appeal period. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See 38 U.S.C.A. § 1110, 1131; Degmetich v. Brown, 104 F. 3d 1328 (1997). In the absence of proof of a present disability due to disease or injury, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Also, with regard to the Veteran's report of pain in the jaw joint, the Veteran is competent to report this symptom. Layno, supra. However, neither the lay nor the medical evidence shows any underlying abnormal pathology to account for his symptoms. Pain alone without a diagnosed or identifiable underlying malady or condition does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Accordingly, the claim is denied and there is no doubt to resolve. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, Gilbert, supra. ORDER An evaluation in excess of 10 percent for sinusitis is denied. The petition to reopen a claim for service connection for sleep apnea (claimed as on a direct basis and as secondary to sinusitis) is granted. Service connection for low back disability is denied. Service connection for cervical spine disability is denied. Service connection for left arm disability, to include neurological disorder associated with cervical spine disability, is denied. Service connection for TMJ dysfunction is denied. REMAND Headaches Service connection for headaches was established in an August 2002 rating decision at the noncompensable disability level. In September 2007, VA received a claim for increase. Report of VA examination dated in January 2008 reflects complaints of migraine described as throbbing frontal and occipital headaches associated with photophobia, nausea and vomiting on average of four times a week. The Veteran reported that each episode lasts for about 24 hours, but that she was able to go to work. She treated symptoms with Ibuprofen and rest. The Veteran testified before a Decision Review Officer in August 2010 that migraine headaches interferes with work; she noted that she was currently unemployed and had lost time from work previously due to headaches. She reported that she treated her symptoms with over-the-counter pain medication and acupuncture about every 6 weeks. The Veteran again testified at her May 2016 Board hearing that she was unable to work due to headaches. She differentiated between sinus headaches and migraine, indicating that migraine involved nausea and light sensitivity. She reported having had 1 to 2 emergency room (ER) visits in the past year. She reported that she treats her symptoms with acupuncture. She reported headache frequency as 3 times a week and seeing an acupuncturist every 6 weeks. Transcript 8-10. The Veteran's husband testified that the Veteran had headache with waking up in the morning for many years. Hearing Transcript at 41. Having carefully reviewed the record, the Board finds that the medical evidence, to include the last VA examination dated in January 2008, is inadequate as it does not described the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also, Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). Additionally, it appears that there are recent ER hospital records pertaining to the claimed disorder that should be obtained in order to fully evaluate the disability. 38 C.F.R. § 3.159. Therefore, remand is necessary. Sleep Apnea The Veteran seeks service connection for sleep apnea. In statements and sworn testimony, the Veteran and her husband reported that the Veteran had what they believe were symptoms of sleep apnea during her period of service as far back as 1985. In May 2016, the Veteran's husband testified that the Veteran snored heavily when they first married and over the years he noticed that she had night time breathing problems (i.e. she would stop breathing, need to be awakened, and gasped for air). Transcript 39-40. He noted that they were married while she served on active duty. STR dated in November 1989 (ENT consultation sheet) corroborates that the Veteran had chronic snoring in service. A May 2016 VA treatment note shows moderate obstructive sleep apnea and the Veteran was advised to use a CPAP machine. This note reflects that the Veteran reported symptoms were present since service and that she had "presented a record dating April 12, 1989 with documented loud snoring, headaches, and enlarged tonsils on exam to this provider." VA obtained a VA medical opinion in October 2013 indicating that sleep apnea was "not solely due to" service connected chronic sinusitis. The Veteran later submitted letter from her physician dated November 2014 and May 2016 in support of her claim. Having carefully reviewed the record, the Board finds that remand is necessary because the October 2013 VA medical opinion obtained in this matter is inadequate. The medical opinion does not address the Veteran's theory of onset of symptoms in service as evidence by symptom of snoring; and the medical opinion, while addressing secondary service connection, does not address whether sleep apnea is aggravated by service-connected sinusitis. Furthermore, the phrasing of the opinion does not adequately address the question of whether the Veteran's sleep apnea is as likely as not etiologically related to service or service-connected disability. It is noted that the November 2014 letter from Dr. R.E. reflects that "According to the patient, she had symptoms that can be attributed to Obstructive Sleep Apnea since she was in the military service. It is my impression that Obstructive Sleep Apnea is a [sic] least as likely as is not to be service-connected." The same physician provided a Disability Benefits Questionnaire dated in November 2014 showing that the Veteran had been diagnosed with obstructive sleep apnea by sleep study in April 2010. The May 2016 letter from the Veteran's VA treating physician for sleep apnea reflects the onset of obstructive sleep apnea in service based on "the patient's report and military records." The Board believes that the private medical evidence should be considered in a new VA medical opinion which addresses all theories advanced by the Veteran-that is, service connection on a direct basis (i.e. onset of symptoms in service) and secondary service connection (sleep apnea is proximately due to or caused by service-connected sinusitis). 38 C.F.R. §§ 3.303, 3.310. In this regard, the medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, the medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Bilateral Knee Disability The Veteran seeks service connection for disability of both the right and left knees. At an August 2010 DRO hearing, the Veteran reported that she was treated for her knees in service to include symptoms of swelling, and locking. She could not remember when she injured her knees but recalled training situations, falling once, and strenuous physical activities (i.e. crawling, rappelling, and running while wearing combat boots). She stated that she had fluid drained from her knee in service. She reported continuity of pain symptoms since service. At her May 2016 Board hearing, the Veteran testified that she was treated for knee pain in service and that she had injured her knees in service. She reported that activities in service caused knee injuries that included "propelling down" an obstacle course, running, and falling "at one time" into a ditch or ravine. Transcript at 14-15. She testified that she went to sick call in 1977 and 1992, but other occasions as well. She reported continuous post service treatment for the knees to include use of a brace and physical therapy. She stated that she was told by VA doctors that arthritis of her knees "could" be related to active duty and old injuries. Hearing Transcript at 17. STRs reflect knee complaints and treatment. A November 1978 note shows an impression for myalgia after the Veteran presented for complaints of pain of the legs, neck, eyes, and head-increased with running. Objectively, there was right knee swelling with edema, but good range of motion with some pain. Strength was good. The assessment was knee pain. Indocin was prescribed and x-ray planned. She was excused from physical training for days, with instructions to return to clinic in 30 days for follow-up. There are no follow-up treatment records. The Veteran presented in January 1985 (STR misdated January 1984) for complaints of right knee "discomfort" after she stepped in a pot hole 2 weeks earlier. She described pain that radiates down the calf and swelling of 4 days duration. She stated that the same knee has "slipped out of place." Objectively, there was right knee swelling, effusion, and warmth. Range of motion was decreased due to edema; there was no instability of the knee joint. X-ray was ordered. In January 1985, orthopedic consultation was requested-the provisional diagnosis was right knee effusion. A consultation record dated February 1985 shows that the Veteran had a right sprain after she slipped in a hole 2 weeks earlier, and that she had "injured it more severely in 1977." Objectively, there was small effusion, restricted range of motion, and no instability. X-ray was negative. The impression was sprain. An August 1982 note reflects that the Veteran presented with complaints of right knee pain for 2 months with swelling. She reported recurring symptoms but "no problem while running." She indicated that pain usually began after a run. In May 1985, the Veteran presented for complaints of right and left knee pain. A May 1985 orthopedic consultation sheet shows a provisional diagnosis of bilateral chondromalacia patellae, rule out "IDK" (internal knee derangement). A May 1985 arthrogram showed normal right knee with intact menisci and cruciate ligaments, and no meniscal tear. A June 1985 note reflects follow-up for right knee. There were normal menisci and cruciates. She was given a knee brace for "severe activities." An August 1986 note shows complaints of right knee pain and swelling of 2 weeks duration with history of injury 9 years earlier. The assessment was chondromalacia patella; Tylenol, heat, and elevation were advised. A February 1982 consultation sheet shows that the Veteran had a history of right calf pain and bilateral chondromalacia patella, and that she had been seen for treatment of possible peroneal entrapment. STRs further include reports of examinations dated in 1987 and 1992. Report of annual examination dated in January 1987 reflects normal clinical evaluation of the lower extremities with the notation of history of bilateral chondromalacia patella. Report of separation examination dated in July 1992 reflects normal clinical evaluation of the lower extremities. The Veteran provided a history of "Trick" or locked knee. Report of VA examination dated in March 1993 reflects no history of or complaints for knee problems. A private treatment record dated March 2002 reflects that the Veteran presented for a physical exam. Examination of the lower extremities shows normal range of motion and strength. There was no joint enlargement or tenderness. Gait was normal and there were no complaints of chronic knee problems. VA treatment records include a July 2005 x-ray that showed right knee mild tricompartmental osteoarthritis; small to moderate size suprapatellar effusion; and no obvious acute fracture or dislocation. After careful review of the evidence, the Board finds that remand for a VA examination is necessary to decide the claim. The record shows documented knee complaints in service along with findings for bilateral chondromalacia patella. The record further shows competent and credible complaints for bilateral knee symptoms since service along with medical findings for right knee arthritis. A VA examination and medical opinion is necessary to ascertain whether it is as likely as not that the Veteran has a disability of the right and/or left knee that was first manifested in service, or is otherwise etiologically related to the in-service complaints, findings, or events. The Board notes that the Veteran argues that her current bilateral knee symptoms are the same as those experienced in service and continuously since service. The Board further notes that she believes that she has a current bilateral knee disability related to injury and strenuous physical activities in service. Accordingly, remand for a VA examination and opinion is necessary to decide this appeal. 38 C.F.R. § 3.159 (c). See McClendon v. Nicholson, 20 Vet. App. 79 (2006); Duenas v. Principi, 18 Vet. App. 512 (2004) (a VA examination and/or opinion is warranted when there is an indication in the record that a current disability is related to military service; the threshold for an indication is low). TDIU The claim for TDIU is inextricably intertwined with the claim for increase for migraines and the results of the requested VA examination of that disorder; therefore, consideration TDIU must be deferred pending resolution of the claim for increase claim for migraines. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Additionally, the RO should consider whether VA examinations are necessary for all service connected disorders to ascertain the effect of symptoms associated therewith on the Veteran's ability to perform the mental and physical acts required for employment. 38 C.F.R. § 4.16; see also, Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994) (TDIU may not be denied without producing evidence, as distinguished from mere conjecture, that the Veteran's disability does not prevent him/her from performing work that would produce sufficient income to be other than marginal). Accordingly, the case is REMANDED for the following action: 1. All updated treatment records should be obtained and associated with the claims file to include the hospital emergency room treatment records pertaining to headache treatment reference by the Veteran at her May 2016 Board hearing. All attempts to obtain private medical records, such as the emergency room treatment reports, should be documented. If any records cannot be obtained, the RO should notify the Veteran and provide her an opportunity to obtain those records. 2. The Veteran should be scheduled for a VA examination for her service-connected migraine headache disability using the appropriate Disability Benefits Questionnaire. The examiner should clearly identify all symptoms, to include their severity, frequency and duration. The examiner should indicate the impact of headache symptoms and treatment on the Veteran's ability to perform the mental and physical acts requirement for employment. The claims filed must be reviewed and the review must be noted in the report of examination. 3. The Veteran should be scheduled for a VA examination of her knees to ascertain whether it is as likely as not (50 percent or greater probability) that the Veteran has a disability of the right and/or left knee that was first manifested in service, or is otherwise etiologically related to service to include the Veteran's in-service complaints and the findings for bilateral chondromalacia patella. The claims filed must be reviewed and the review must be noted in the report of examination. A detailed medical history should be obtained. The examiner should address the Veteran's theory that her current knee disability is related to in-service injury and/or strenuous physical activities in service. The examiner should accept the Veteran's history of injury, activities, symptoms, and treatment as truthful unless otherwise demonstrated by the record; the examiner must explain the basis for any history rejected. A complete rationale for the medical opinion is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. The RO should identify and complete any other development deemed necessary (i.e. whether additional VA examinations are necessary to ascertain the effect of symptoms associated with service-connected disorders on the Veteran's ability to perform the mental and physical acts required for employment). 5. The AOJ should readjudicate the claims. If the benefits sought are not granted, the Veteran and her representative should be furnished a Supplemental Statement of the Case and given the requisite opportunity to respond before the case is returned to the Board. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs