Citation Nr: 18140196 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 14-34 715A DATE: October 2, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial 20 percent disability evaluation for low back strain, for the rating period prior to June 16, 2017, is granted. Entitlement to a disability evaluation in excess of 20 percent for low back strain is denied. Entitlement to an initial 10 percent disability evaluation for degenerative joint disease of the left knee, for the rating period prior to June 16, 2017, is granted. Entitlement to a disability evaluation in excess of 10 percent for degenerative joint disease of the left knee is denied. REMANDED Entitlement to service connection for a left wrist disorder is remanded. Entitlement to service connection for a right wrist disorder is remanded. Entitlement to service connection for a right knee disorder, including as secondary to service-connected disabilities is remanded. Entitlement to service connection for a disorder manifested by facial swelling and total body numbness and tingling is remanded. FINDINGS OF FACT 1. The Veteran does not have bilateral hearing loss disability for VA disability compensation purposes. 2. The Veteran’s low back strain is manifest by pain and spasm, without abnormal gait or spinal contour. Forward flexion is limited to 70 degrees; the Veteran does not experience incapacitating episodes, and no additional functional loss is present. 3. Degenerative joint disease of the left knee is manifested by painful motion; range of motion was full, with no effusion or locking, and no additional functional loss. CONCLUSIONS OF LAW 1. Bilateral hearing loss disability was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2018). 2. The criteria for an initial 20 percent disability evaluation for low back strain for the period prior to June 16, 2017, have been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 to 5243 (2018). 3. The criteria for a disability evaluation in excess of 20 percent for low back strain have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 to 5243 (2018). 4. The criteria for an initial 10 percent disability evaluation for degenerative joint disease of the left knee for the period prior to June 16, 2017, have been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 to 5243 (2018). 5. The criteria for a disability evaluation in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C. §§ 1155, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235 to 5243 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from April 2008 to April 2012. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran testified before the undersigned Veterans Law Judge at a May 2018 Board videoconference hearing. A copy of the transcript is associated with the claims file. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The VCAA requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). In this case, the agency of original jurisdiction (AOJ) issued notice letters to the Veteran. The letters explained the evidence necessary to substantiate the Veteran’s claims of entitlement to increased disability ratings; the letters also explained the legal criteria for entitlement to such benefits. The letters also informed him of his and VA’s respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of “relevant” records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be “necessary” to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran’s available service treatment records, reports of post-service treatment, and the Veteran’s own statements in support of his claims. The Veteran was afforded VA examinations responsive to the claims for increased disability evaluations and the claim for service connection. The Veteran was also afforded a VA examination responsive to the claim for service connection for bilateral hearing loss. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The opinions were conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The examination reports contain all the findings needed to assess the Veteran’s service-connected disabilities on appeal, including history and clinical evaluation. See 38 C.F.R. § 3.327(a) (2018); Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007). The claims file contains the Veteran’s available service treatment records, reports of post-service treatment, and the Veteran’s own statements in support of his claims. The Board has reviewed the Veteran’s statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran’s claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service—the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. For chronic diseases, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Entitlement to service connection for bilateral hearing loss At the outset, the Board notes that the Veteran does not allege, and the evidence does not show, that the Veteran was exposed to combat during service. As such, the provisions of 38 U.S.C. § 1154 are not applicable in this case. Nevertheless, the Board concedes that the Veteran had in-service noise exposure. See 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Despite the Veteran’s complaints of bilateral hearing loss, the post-service medical evidence reflects that the Veteran does not have hearing loss disability of either ear for VA disability benefits purposes at any time. She had a Maryland CNC speech recognition score of 96 percent in the right ear and 96 percent in the left ear at her February 2013 VA examination. Pure tone thresholds at the relevant frequencies were all less than 25 decibels. Similarly, her military and VA audiological evaluations show that the Veteran does not have sufficient hearing loss in either ear to meet the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered a disability by VA. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). The Board acknowledges the Veteran’s noise exposure during service and her assertions that this noise exposure caused her bilateral hearing loss. Nonetheless, the Board notes that, despite the Veteran’s complaints, the Veteran did not have auditory thresholds of 26 decibels or greater in at least three frequencies for either ear, or auditory threshold in excess of 40 decibels in either ear at any time. Clearly the Veteran is competent to report a decrease in hearing acuity. However, the results of the audiometric examination are controlling. For the foregoing reasons, the preponderance of the evidence is against the claim of service connection for bilateral hearing loss disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the service-connected disability on appeal has not materially changed and a uniform evaluation is warranted for the rating period on appeal. In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. 1. Entitlement to an initial compensable disability evaluation for low back strain prior to June 16, 2017 2. Entitlement to an increased disability evaluation for low back strain, rated as 10 percent disabling since June 16, 2017 The Veteran has been assigned an initial noncompensable disability rating for her low back strain for the rating period prior to June 16, 2017 and a 10 percent disability evaluation for the period since June 16, 2017, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (“general rating formula”). 38 C.F.R. § 4.71a, Diagnostic Code 5237-5242. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is to be assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237 for lumbosacral strain; Diagnostic Code 5242 for degenerative arthritis of the spine; and Diagnostic Code 5243 for intervertebral disc syndrome. After a review of all the evidence, the Board finds that the Veteran’s disability picture more nearly approximates the criteria for an initial 20 percent disability rating for the rating period on appeal. The Board notes that the Veteran’s February 2013 and June 2017 VA examinations and VA and private treatment records for the rating period on appeal do not reflect that the Veteran has intervertebral disc syndrome. Regardless, both VA examiners indicated that the Veteran does not have any incapacitating episodes as a result of her low back strain. Thus, even if intervertebral disc syndrome were present, it would not be compensable. At the February 2013 VA examination, the Veteran had forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees per side, and right and left lateral rotation to 30 degrees, respectively. More recently, at the June 2017 VA examination, the Veteran had forward flexion to 70 degrees, extension to 20 degrees, right and left lateral flexion to 30 degrees per side, and right and left lateral rotation to 30 degrees per side. Examination reports and treatment records indicate that the Veteran experienced decreased or abnormal range of motion, pain and tenderness to palpation, and muscle spasm, without abnormal gait and spinal contour. The VA examination reports and treatment records indicate that there was pain on motion, without guarding, weakness, or atrophy; strength and reflex testing was normal. There was no evidence of postural abnormalities or abnormalities of the musculature of the spine. Thus, applying the facts to the criteria set forth above, the Veteran is entitled to a 20 percent evaluation for her service-connected low back strain, for the entire rating period on appeal under the General Rating Formula for Diseases and Injuries of the Spine. The Board acknowledges that the Veteran’s low back strain disability was first shown to be sufficient to meet the rating criteria for a 20 percent disability rating at the June 2017 VA examination. However, the Board also acknowledges that the Veteran asserted throughout the appeal that her low back strain was continuing to worsen. As the Board is unable to ascertain an exact date as to when the Veteran became entitled to a compensable, 20 percent disability rating, given that no range of motion testing was performed for a large interval of time between the February 2013 and June 2017 VA examinations, the Veteran continued to assert worsening symptoms during that time frame, and fluctuations in her low back disability are possible, the Board finds that the equitable solution is to assume that the Veteran’s low back strain met the criteria for the entire rating period on appeal. To find that her hearing loss worsened on the date of the June 2017 VA examination is incongruous with the medical and lay evidence of record; it is highly unlikely that the Veteran’s low back strain had not worsened at some, unknown point, prior to that VA examination. The Board finds that the criteria for a disability rating of 40 percent have not been met or more nearly approximated for any part of the rating period on appeal. The evidence shows that the Veteran experiences forward flexion of the thoracolumbar spine which is better than 30 degrees. Here, the lay evidence has been considered; however, that evidence when accepted as correct does not establish that he is functionally limited to 30 degrees or less. She does not experience incontinence or bowel complaints as a result of her low back strain. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. To the extent that the Veteran claims that her pain upon motion is the equivalent of limited motion, the Board finds that the Veteran’s subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated limited reduced motion; the VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability, beyond which was reflected in the examination reports. See Mitchell v. Shinseki. Therefore, the lay and medical evidence demonstrates that the Veteran’s symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current 20 percent disability rating. As noted earlier, the Veteran’s low back strain has not been productive of incapacitating episodes for the rating period on appeal. The Veteran has not reported, and the evidence does not demonstrate, that the Veteran experiences incapacitating episodes requiring bed rest; the Veteran’s treatment records do not confirm that her treating physicians noted any incapacitating episodes or prescribed bed rest, and the Veteran’s February 2013 and June 2017 VA examination reports reflect that the Veteran has not experienced any incapacitating episodes requiring bed rest. With respect to a higher evaluation based on incapacitating episodes under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, the record does not show that the Veteran experiences incapacitating episodes requiring physician prescribed best rest having a total duration of at least 4 weeks during a 12 month period as contemplated by a higher evaluation. Review of the Veteran’s treatments record also do not reveal any periods of physician prescribed bed rest as a result of her low back strain. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, neurological evaluation of the Veteran’s extremities was normal, and there was no evidence of radiculopathy. As such, a separate evaluation for neurological deficits are not for consideration here. As such, the Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent for service-connected low back strain. 3. Entitlement to an initial compensable disability evaluation for degenerative joint disease of the left knee prior to June 16, 2017 4. Entitlement to an increased disability evaluation for degenerative joint disease of the left knee, rated as 10 percent disabling since June 16, 2017 The Veteran is currently rated for her degenerative joint disease of the left knee pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260. See 38 C.F.R. § 4.20. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2018). Diagnostic Code 5003 provides that degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, the Veteran has not reported experiencing any incapacitating exacerbations with regard to her left knee. The appropriate diagnostic codes for the knee joint are Diagnostic Codes 5260 and 5261, applicable to limitation of flexion and extension of the leg, respectively. Under Diagnostic Code 5260, limitation of flexion of a leg warrants a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating is warranted if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of a leg is noncompensable when extension is limited to 5 degrees, warrants a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. VA’s General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). In VAOGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA’s General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. The Board acknowledges that VA treatment records show that the Veteran has a history of knee instability; however, VA treatment records do not reflect any objective manifestations of instability; physical examinations were repeatedly negative for instability. Moreover, the February 2013 and June 2017 VA examination reports reflect that the Veteran does not experience instability of the left knee. As such, a separate evaluation for instability pursuant to Diagnostic Code 5257 is not warranted for the left knee in the present case. The Board finds that the weight of the evidence demonstrates that the symptoms of the Veteran’s service-connected degenerative joint disease of the left knee most closely approximate the criteria for the currently assigned 10 percent disability rating for the entire rating period on appeal. With regard to limitation of motion, the Veteran has not demonstrated that her left knee has compensable limitation of flexion or extension. The Board observes that the Veteran, at her February 2013 and June 2017 VA examinations, had flexion to 140 degrees. She also had full extension (0 degrees) in February 2013 and June 2017. A higher, 20 percent rating would require flexion of 45 degrees and extension of 15 degrees. In the absence of this level of limited motion, a higher rating based on limitation of motion is not warranted. Further, there is no evidence of ankylosis, recurrent effusion, or locking of the left knee at any time during the rating period on appeal. Thus, a higher rating based on Diagnostic Codes 5256, 5258, and 5259 is not warranted. Finally, with regard to functional loss, the Veteran’s current evaluation contemplates pathology productive of painful motion. The evaluation is consistent with the functional equivalent of limitation of flexion to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees (Diagnostic Code 5260) or extension to 15 degrees (Diagnostic Code 5261). The Board accepts the lay evidence that the Veteran experiences pain. Similarly, the Board accepts the evidence that she has limitation of flexion impacted by pain. However, such evidence does not establish that flexion is functionally limited to less than 45 degrees. Rather, the Veteran retains functional flexion to better than 45 degrees. The limitation due to pain is contemplated in the current evaluation that recognizes her painful motion. Although the Veteran has pain, such pain does not functionally limit flexion to less than 45 degrees or functionally limit extension. There is no indication that she has additional functional impairment, above and beyond the 10 percent level for degenerative joint disease of the left knee, which would support a higher rating. In this regard, the Board acknowledges that the VA examination reports reflect complaints of pain and weakness; however, there was no objective evidence of deformity or reduced muscle strength. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. Here, neither the medical nor lay evidence suggests that her limitation of motion approximated 30 degrees of flexion for the left knee. As a result, the 10 percent rating for degenerative joint disease of the left knee adequately compensates her for the extent of her pain during the applicable rating period. REASONS FOR REMAND 1. Entitlement to service connection for a left wrist disorder is remanded. 2. Entitlement to service connection for a right wrist disorder is remanded. 3. Entitlement to service connection for a right knee disorder, including as secondary to service-connected disabilities is remanded. 4. Entitlement to service connection for a disorder manifested by facial swelling and total body numbness and tingling is remanded. The Board notes that the Veteran asserts that she has bilateral wrist disorders, a right knee disorder, and a disorder manifested by facial swelling and total body numbness and tingling related to her service. The Board acknowledges that the Veteran was afforded VA examinations in connection with these claims for service connection in February 2013 and June 2017. However, the VA examiners failed to provide adequate etiology opinions. Specifically, the June 2017 VA examination report noted that the Veteran had been diagnosed with tendonitis of the wrists. However, the contemporaneous VA medical opinion shows a diagnosis of tenosynovitis of the wrists. It is unclear from a review of the reports which is the correct diagnosis. Likewise, the VA examiner found that the Veteran’s wrist disorder, however diagnosed, is less likely than not related to the Veteran’s service. Nevertheless, the Board finds that the VA examiner’s rationale is insufficient, as the VA examiner relied on the absence of wrist complaints during service, despite a report of complaints related to heavy lifting and repetitive activities in the Veteran’s service treatment records. The absence of evidence of a right and/or left wrist disorder at separation, or for several years thereafter, is not dispositive of whether the Veteran’s wrist disorder(s) is related to her military service, and cannot be relied upon in the absence of a rationale which addresses the Veteran’s contentions. See 38 C.F.R. § 3.303(d). Moreover, with regard to the Veteran’s claim of entitlement to service connection of a right knee disorder, the February 2013 and June 2017 VA examiners failed to address whether the Veteran’s right knee disorder was causally related to her service-connected low back strain and degenerative joint disease of the left knee. Additionally, the Board acknowledges that the Veteran was afforded a cranial nerves examination and multiple EMG tests and that no neurological disability was found. However, the Board notes that the Veteran’s service treatment records and a February 2013 VA examination report indicate that the Veteran has complained of facial swelling with associated numbness and tingling of the body. However, the VA examiner did not indicate whether the Veteran’s complaints were in any way related to the Veteran’s service-connected temporomandibular joint disease (TMJ). To this point, the VA examiner did not address whether the Veteran’s claimed disorder manifested by facial swelling and numbness of the body was part and parcel of the service-connected TMJ, or part of a separate, diagnosed disorder. Other than noting that evaluation of the Veteran’s cranial nerves did not yield a diagnosis, there was no mention of the claimed disorder manifested by facial swelling and numbness of the body whatsoever. As such, the Board finds that the Veteran should be afforded new VA examinations regarding the claims for service connection of a right knee disorder, right and left wrist disorders, and a disorder manifested by facial swelling and numbness and tingling of the body. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As such, the Board finds that the Veteran should be afforded a new VA examination regarding the claim for service connection of a right knee disorder. VA cannot exercise independent medical judgment in deciding an appeal; thus, a new medical opinion must be obtained. See Colvin v. Derwinski, 1 Vet. App. 171(1991).   The matters are REMANDED for the following action: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated her for the disabilities on appeal. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Veteran in accordance with 38 C.F.R. § 3.159. 2. After any additional records are associated with the claims file, the RO should schedule the Veteran for an appropriate examination to determine the nature and etiology of any right and left wrist disorders. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The VA examiner should identify all disabilities of the right and left wrist. The examiner should then render an opinion as to each identified disability, to include tendonitis and tenosynovitis, whether it is at least as likely as not (50 percent probability or more) that the identified disabilities of the right and left wrist are related to active service. The VA examiner must address the Veteran’s contentions that her wrist disorders had onset in service as a result of heavy and/or repetitive lifting and her contentions that she has experienced problems with her wrists since her service. The provider is advised that the Veteran is competent to report symptoms, including continuity of symptoms, treatment, and diagnoses and the examiner must take into account, along with the other evidence of record, the Veteran’s statements in formulating the requested opinions. A complete rationale, with specific reference to the relevant evidence of record, should accompany each opinion provided. 3. The RO should schedule the Veteran for an appropriate VA examination in order to determine the nature and etiology of any current disorder manifested by facial swelling and numbness and tingling of the body that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed disorder manifested by facial swelling and numbness and tingling of the body had onset during the Veteran’s active service or was caused by any event, illness, or injury during service. If the Veteran does not have a separate, diagnosed disorder manifested by facial swelling and numbness and tingling of the body, the VA examiner is asked to provide an opinion as to whether these complaints are symptoms of the Veteran’s service-connected TMJ. If so, the RO is requested to consider each in determining the appropriate disability rating for assignment for the Veteran’s service-connected TMJ. The provider is advised that the Veteran is competent to report symptoms, treatment, and diagnoses and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. A complete rationale, with specific reference to the relevant evidence of record, should accompany each opinion provided. 4. The Veteran should be afforded an appropriate VA examination to determine the nature and etiology of a right knee disorder, if any. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The VA examiner should identify all right knee disabilities. Then, for each identified right knee disability, render an opinion as to whether it is at least as likely as not (50 percent probability or more) that the identified disability was caused or aggravated by active service or her service-connected left knee and/or low back disabilities. The provider is advised that the Veteran is competent to report symptoms, including continuity of symptoms, treatment, and diagnoses and the examiner must take into account, along with the other evidence of record, the Veteran’s statements in formulating the requested opinions. A complete rationale, with specific reference to the relevant evidence of record, should accompany each opinion provided. (Continued on the next page)   5. After completing all indicated development, the RO should readjudicate the Veteran’s claims of entitlement to service connection for right and/or left wrist disorders, a right knee disorder, and a disorder manifested by facial swelling and numbness and tingling of the body. If any of the claims remain denied, the Veteran should be furnished with a supplemental statement of the case and afforded a reasonable opportunity for response. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel