Citation Nr: 18141392 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 15-35 263 DATE: October 10, 2018 ORDER The application to reopen a previously denied claim for service connection for bilateral carpal tunnel syndrome (CTS) is denied. Service connection for a right wrist disorder (other than CTS), to include a temporary total rating due to a period of convalescence, is denied. Service connection for tinnitus is denied. Service connection for hypertension is denied. Service connection for depressive disorder as secondary to the service-connected disabilities is granted. A rating in excess of 10 percent for right foot hallux valgus, status-post bunionectomy, is denied. A rating in excess of 10 percent for left foot hallux valgus, status-post bunionectomy, is denied. A rating in excess of 10 percent for scoliosis with degenerative changes of the lumbar spine is denied. A compensable rating for hemorrhoids is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for bilateral hammertoes (to include a temporary total rating due to a period of convalescence) as secondary to the service-connected disabilities is remanded. Entitlement to a rating in excess of 10 percent for residuals of a right 5th toe fracture, post-operative, with degenerative changes. Entitlement to a rating in excess of 60 percent for chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to a rating in excess of 10 percent for the right knee disability is remanded. Entitlement to a rating in excess of 10 percent for the left knee disability is remanded. Entitlement to a compensable rating for right great toenail, post-operative with anonychia, is remanded. Entitlement to a compensable rating of left great toenail, post-operative with partial anonychia, is remanded. Entitlement to an effective date prior to April 18, 2013, for the grant of a 60 percent rating for the COPD disability. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed August 2007 rating decision denied entitlement to service connection for bilateral CTS. 2. The evidence received since the final August 2007 rating decision is not new and material; it does not relate to an unestablished fact necessary to substantiate the claim for service connection for bilateral CTS. 3. The Veteran’s residuals of a right wrist fracture are not related to service, but were incurred as a result of a post-service injury. 4. As the right wrist disorder is not service connected, the associated convalescence period is not eligible for the temporary total rating for convalescence sought in this case. 5. The Veteran’s tinnitus and hypertension were first demonstrated years after service and are not etiologically related to any incident in service. 6. The weight of the evidence of record demonstrates that the Veteran’s diagnosed depressive disorder is caused by her service-connected disabilities. 7. The Veteran’s bilateral hallux valgus disability is not manifested by unique symptomatology. 8. The Veteran’s bunionectomy surgical scars are neither painful nor unstable. 9. The Veteran’s lumbar spine disability has not more nearly approximated 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. 10. The Veteran’s hemorrhoids have not been manifested by large or thrombotic hemorrhoids, which are irreducible with excessive redundant tissue, evidencing frequent recurrences. CONCLUSIONS OF LAW 1. The August 2007 rating decision, which denied the claims for service connection for right and left CTS, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). 2. The evidence received subsequent to the August 2007 rating decision is not new and material; the claim for service connection for bilateral CTS is not reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.156 (a) (2017). 3. The criteria for service connection for a right wrist disorder (other than CTS), to include a temporary total rating due to a period of convalescence, are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303. 3.304, 4.30 (2017). 4. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303. 3.307(a)(3), 3.309(a) (2017). 5. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303. 3.307(a)(3), 3.309(a) (2017). 6. The criteria for service connection for depressive disorder as secondary to the service-connected disabilities are met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.102, 3.310 (2017). 7. The criteria for a rating in excess of 10 percent for right foot hallux valgus, status-post bunionectomy, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5280 (2017). 8. The criteria for a rating in excess of 10 percent for left foot hallux valgus, status post bunionectomy, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes 5280 (2017). 9. The criteria for a compensable rating for a right foot bunionectomy scar are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). 10. The criteria for a compensable rating for a left foot bunionectomy scar are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). 11. The criteria for a rating in excess of 10 percent for scoliosis and degenerative changes of the lumbar spine are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5237, 5243 (2017). 12. The criteria for a compensable rating for hemorrhoids are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1980 to June 1993. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from the March 2013, February 2014, September 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran has raised the issue of unemployability during the pendency of the appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU claim has been added to the appeal as part and parcel of the increased rating claims on appeal. New and Material Evidence Claim -Laws and Analysis The Veteran was initially denied service connection for right and left CTS in an August 2007 rating decision because there was no indication that the Veteran’s disorder was incurred in service or was related to service. The Veteran was notified of the rating decision in September 2007, but did not appeal the decision. As such, the August 2007 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A claim will be reopened in the event that new and material evidence is presented. 38 U.S.C. § 5108. Because the August 2007 rating decision was the last final disallowance, the Board must review all of the evidence submitted since that rating decision to determine whether the Veteran’s claims for service connection should be reopened and re-adjudicated on a de novo basis. Evans v. Brown, 9 Vet. App. 273 (1996). If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Board shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. With regard to petitions to reopen previously and finally disallowed claims, the Board must conduct a two-part analysis. First, the Board must determine whether the evidence presented or secured since the prior final disallowance of the claim is “new and material.” Second, if the Board determines that the evidence is “new and material,” it must reopen the claim and evaluate the merits of the claim in view of all the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Section 3.156(a) provides as follows: A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing 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 of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a) (2017). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement. Id at 118. In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence received subsequent to the August 2007 rating decision includes various VA examinations unrelated to the Veteran’s CTS. The Veteran’s representative also submitted a written brief with additional medical evidence in June 2018; however, none of these submissions addressed the Veteran’s CTS. The remaining evidence of record, to include VA treatment records, does not address the etiology of the Veteran’s CTS disorder. Further, the Veteran has not submitted any lay statements in connection with her claim to reopen the claim for service connection for CTS. The Veteran’s ongoing VA treatment records are cumulative, not new, as they merely show that the Veteran continues to have CTS. The evidence is not material because the evidence could not reasonably substantiate the claim were it to be reopened as the evidence does not suggest any relationship between the Veteran’s CTS and her military service or to a service connected disability. The additional VA examinations and private medical opinions are new, but not material, as they do not address the Veteran’s CTS or indicate any link between CTS and service. In sum, none of the additional evidence, even when considered in combination with the other evidence of record, is new and material. Thus, this evidence does not relate to an unestablished fact necessary to substantiate this claim and does not raise a reasonable possibility of substantiating this claim. The prior denial is final, and the claim for service connection for bilateral CTS is not reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In the absence of new and material evidence, the benefit-of-the-doubt rule does not apply. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Only chronic diseases listed under 38 C.F.R. § 3.309 (a) (2017) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303 (b). Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical 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). Additionally, VA has identified certain chronic diseases for which medical nexus may be presumed if certain criteria are met; tinnitus and sensorineural hearing loss are considered to be such chronic diseases because they are “organic diseases of the nervous system.” 38 C.F.R. §§ 3.303 (a), (b), 3.309(a); see also Fountain v. McDonald, 27 Vet. App. 258 (2015), Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Accordingly, for the purposes of presumptive nexus, the third criterion requiring a nexus between the in-service, event, disease or injury and the claimed disability may be satisfied in one of two ways. First, the nexus element may be satisfied by evidence that the chronic disease at issue here manifested itself to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309. Or, alternatively, the Veteran may show entitlement to service connection by demonstrating a continuity of symptomology after discharge. 38 C.F.R. § 3.303(b); see generally Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility 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”). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382(1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner’s opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Right Wrist (other than CTS) The Veteran generally maintains that service connection for a right wrist disorder is warranted; however, she has not presented any evidence, lay or medical, as to why she believes her wrist disorder is related to service. Service treatment records are absent for any injury, diagnosis, or treatment for a right wrist disorder. In an April 1993 Report of Medical examination, a clinical evaluation at service separation of the Veteran’s upper extremities was normal and there was no indication of a right wrist disorder. The Veteran also did not report having right wrist symptoms in her April 1993 Report of Medical History, completed by the Veteran at service separation. Post-service VA treatment records show that the Veteran sustained an injury to the right wrist in 2012, more than 12 years after service separation. Specifically, March 2012 VA orthopedic notes show that the Veteran had fallen and injured her right wrist 10 days prior. Specifically, x-rays of the right wrist showed a distal radius and distal ulna styloid fracture. It was noted that the Veteran was in a splint and needed to stay immobilized for at least 1 month. Despite being treated for the right wrist fracture on numerous occasions, the Veteran did not report any previous right wrist injury or that she had experienced wrist symptoms during service. Additionally, there is no competent evidence of a nexus between the Veteran’s right wrist disorder and service. The only evidence of record supporting the contention that the Veteran’s wrist disorder is etiologically related to active service is the Veteran’s general, conclusory statements found in her claim for VA compensation benefits. However, the Veteran’s lay statements are not competent because the question of etiology is a complex medical question and, as a layperson, the Veteran is not competent to provide an opinion relating it to service. An opinion of etiology would require knowledge of the complexities of the musculoskeletal system and would involve objective clinical testing and expertise that the Veteran is not competent to perform. The medical evidence that has been obtained weighs against the Veteran’s claim—in that it shows the occurrence of a post-service right wrist injury, which resulted in a period of convalescence. Further, as noted above, there is no in-service injury; therefore, any medical opinion sought by VA would be speculative. For these reasons, the Board finds that the weight of the lay and medical evidence shows that the right wrist disorder was not incurred in service, and is not otherwise related to service. As the Veteran has not presented competent evidence showing that her right wrist disorder is related to service, the claim must be denied. The preponderance of the evidence is against the claim, and the benefit-of-the doubt standard of proof does not apply. 38 U.S.C. § 5107 (b) (2017). Service connection for a right wrist disorder is denied. The Veteran also seeks a temporary total rating based on convalescence for the right wrist injury. The threshold legal requirement for establishing entitlement to a temporary total rating under 38 C.F.R. §§ 4.29 and 4.30 is that the surgery must have been for a service-connected disability. However, as indicated above, the Board is denying the Veteran’s claim for service connection for a right wrist disorder; therefore, service connection has not been awarded for a disability of the right wrist. Accordingly, the treatment in question was not for a service-connected disability and, therefore, the threshold requirement for benefits under §§ 4.29 and 4.30 are not met. Absent specific argument from the Veteran or her representative, the Board is unable to identify any basis upon which this claim may be granted. In Sabonis v. Brown, 6 Vet. App. 426, 430 (1994), the Court held that where the law is dispositive, the claim should be denied because of lack of legal entitlement under the law. Accordingly, the appeal in this matter must be denied. Tinnitus The Veteran contends that her tinnitus is related to in-service noise exposure. The Veteran’s DD Form 214 shows that she worked as a computer programmer/analyst, which the Board finds does not necessarily reflect exposure to noise or acoustic trauma. Nonetheless, the Veteran was also noted to have received a sharpshooter marksmanship badge (rifle M-16). As such, the Board finds it likely that the Veteran was exposed to at least some loud weapon noises during service. Next, the Board finds that the Veteran has currently diagnosed tinnitus. In an August 2014 VA audiological examination, the Veteran reported tinnitus, bilaterally, a condition capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran’s assertion of tinnitus is competent evidence, and the Board has no reason to doubt the credibility of such assertion. The Board finds that the Veteran’s tinnitus was not chronic in service. Service treatment records are absent for any complaints of tinnitus. In an April 1993 Report of Medical examination completed at service separation, clinical evaluation of the Veteran’s ears was normal and there was no indication of tinnitus noted. The Veteran also did not report having tinnitus in her April 1993 Report of Medical History, completed by the Veteran at service separation. For these reasons, the Board finds that symptoms of tinnitus were not chronic in service. Further, the evidence demonstrates that symptoms of tinnitus did not manifest within one year of service separation. Post-service VA treatment records include a March 2005 note where the Veteran denied having hearing changes or tinnitus. The remaining VA treatment records are absent for any complaints of tinnitus. Instead, the first evidence of the disorder is the June 2014 claim for VA compensation benefits, filed more than 20 years after service separation. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). For these reasons, the Veteran is not entitled to presumptive service connection under 38 C.F.R. § 3.307 (a)(3). Regarding whether presumptive service connection may be granted on the basis of continuity of symptomatology in conjunction with 38 C.F.R. § 3.303 (b), there is no evidence of continuous symptoms pertaining to tinnitus since service separation. Although now, pursuant to her 2014 claim for VA compensation benefits, the Veteran maintains that she had tinnitus as a result of service, the objective evidence shows that the Veteran never reported any problems consistent with tinnitus until many years after service separation. As such, the Board finds that the Veteran’s recent statements regarding continuous symptoms of tinnitus since service are not credible as they are inconsistent with the medical evidence of record. For these reasons, the presumptive service connection is not warranted on the basis of continuity of symptomatology in conjunction with 38 C.F.R. § 3.303 (b). Concerning direct service connection, for the reasons that will be set forth below, the Board finds that the Veteran’s tinnitus is not related to service. The Veteran was afforded a VA audiological examination in August 2014. At that time, the Veteran reported having tinnitus that had occurred for over one year or more. The examiner then opined that the Veteran’s tinnitus was not related to service. In this regard, the examiner indicated that, although the Veteran had a change in hearing in the right ear during service, she did not provide a history of excessive noise exposure due to her job duties or an event that occurred that could cause tinnitus. It was noted that the Veteran worked as computer analyst in service and also discharged weapons without the use of hearing protection. However, the Veteran did not require a hearing conservation program in service. The Board finds the August 2014 VA medical opinion to be probative as to whether the Veteran’s currently diagnosed tinnitus is related to service. The examiner reviewed and discussed the medical evidence and the Veteran’s history in detail. Further, the medical opinion was supported by a well-reasoned rationale, which was consistent with the medical evidence of record. See Prejean, 13 Vet. App. at 448-9; Hernandez-Toyens, 11 Vet. App. at 382. The Board s also considered the Veteran’s statements regarding her belief that she has tinnitus that is related to service. However, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the etiology of the medically complex disorder of tinnitus. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Tinnitus is a medically complex process because of its multiple possible etiologies. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). For these reasons, and based on the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence is against a finding of relationship between the Veteran’s tinnitus and service. The Board finds that a preponderance of the evidence is against the claim for service connection for tinnitus, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Hypertension The Veteran generally maintains that service connection for hypertension is warranted; however, she has not presented any evidence, lay or medical, as to why she believes her hypertension is related to service. Hypertension refers to persistently high arterial blood pressure. For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2017). This provision also states that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. In this case, post-service VA medical records confirm a diagnosis and treatment for benign essential hypertension. See e.g., January 2018 VA primary care note. However, the Board finds that no vascular injury, disease, or chronic symptoms of hypertension occurred during service or were manifested during service. The Veteran’s service treatment records show no symptoms, treatment, or diagnoses referable to hypertension. In an April 1993 Report of Medical Examination, completed upon service separation, the Veteran’s blood pressure reading was 110/80; there was no diagnosis of hypertension. The Veteran also denied having high or low blood pressure in the April 1993 Report of Medical History. Thus, the Board finds that the most probative evidence of record weighs against the existence of any hypertensive disease in service. The first suggestion of hypertension is not shown until decades later in 2013, where VA treatment records indicated a diagnosis of hypertension and that the Veteran had been recently prescribed hydrochlorothiazide. See Maxson, 230 F.3d 1330. Accordingly, symptoms of hypertension were not continuous since service, the Veteran’s hypertension did not manifest to a compensable degree during the first post-service year, and the evidence does not otherwise show manifestations of hypertension to a degree of ten percent within one year of service separation. Accordingly, there is no basis for presumptive service connection. 38 C.F.R. §§ 3.307, 3.309. Additionally, there is no competent evidence of a nexus between the Veteran’s hypertension and service. The Veteran has not submitted any lay or medical evidence that demonstrates any link between her hypertension and service. The only evidence of record supporting the contention that the Veteran’s hypertension is etiologically related to active service is the Veteran’s general, conclusory statements found in her claim for VA compensation benefits. However, the Veteran’s lay statements are not competent because the question of etiology is a complex medical question and, as a layperson, the Veteran is not competent to provide an opinion relating it to service. Such a diagnosis requires blood pressure readings which are not found within the record during or immediately following his service period. Additionally, an opinion of etiology would require knowledge of the complexities of the cardiovascular-renal system, the various causes of unobservable hypertension, and would involve objective clinical testing and expertise that the Veteran is not competent to perform. Further, as noted above, there is no in-service injury; therefore, any medical opinion sought by VA would be speculative. The lay statements of record attributing the Veteran’s hypertension to service are further outweighed by the lay and medical evidence of record showing no hypertension, diagnosis, or treatment for decades since service separation. For these reasons, the Board finds that the weight of the lay and medical evidence shows that the hypertension was not incurred in service, and is not otherwise related to service. As the Veteran has not presented competent evidence showing that her hypertension is related to service, the claim must be denied. The preponderance of the evidence is against the claim, and the benefit-of-the doubt standard of proof does not apply. 38 U.S.C. § 5107 (b) (2017). Service connection for hypertension is denied. Depressive Disorder The Veteran maintains that she has a psychiatric disorder that is secondary to her service-connected disabilities. Initially, the Board notes that the Veteran has been awarded service connection for COPD, residuals of a right toe fracture, degenerative disease of the thoracolumbar spine, bilateral knee chondromalacia, bilateral hallux valgus, hemorrhoids, post-operative bilateral ingrown toenails, and scars associated with bilateral bunionectomies. The evidence includes a private medical opinion and corresponding disability benefits questionnaire from Dr. H. H. G., dated in May 2018. At that time, Veteran was diagnosed with DSM 5 depressive disorder with anxious fear “caused by medial conditions.” It was further noted that, prior to service, the Veteran had no social or relationship issues. Instead, the Veteran related her depression to her medical issues, which had resulted in social and relationship issues, social anxiety and irritability, communication problems, isolation, intimacy issues, and avoidance of social interactions, to include in a work setting. The Veteran also reported that she stopped working in 2008 due to physical and mental issues. Dr. H. H. G. indicated that she had performed a clinical interview and examination of the Veteran. The claims file and lay statements from the Veteran’s family were also reviewed. Specifically, Dr. H. H. G. referenced VA medical records, which demonstrated complaints of depression and stress due to an inability to work as a result of pain in her back and knees. Complaints of sleep impairment were also noted due to pain. Dr. H. H. G. indicated that the Veteran’s service-connected hemorrhoids flared up several times a year, which resulted in an inability for the Veteran to sit longer than 30 minutes. The Veteran was also service-connected for COPD, which limited her ability to walk. In conclusion, and based on the evidence of record, to include VA treatment records, buddy statements, and a clinical examining of the Veteran, Dr. H. H. G. opined that the Veteran’s depressive disorder was caused by the service-connected COPD, hemorrhoids, and orthopedic disabilities (including spine and knees). The Board finds the medical opinion from Dr. H. H. G. to be highly probative as to whether the Veteran’s currently diagnosed depressive disorder is related to her service-connected disabilities. Dr. H. H. G., a licensed psychologist, reviewed and discussed the medical evidence and the Veteran’s history in detail. Further, the medical opinion was supported by a well-reasoned rationale, which was consistent with the medical evidence of record. See Prejean, 13 Vet. App. at 448-9; Hernandez-Toyens, 11 Vet. App. at 382. The Board has reviewed the remaining evidence of record and finds that there are no other medical opinions that are contradictory to Dr. H. H. G.’s findings. As such, the Board finds that the Veteran’s depressive disorder is secondary to her service-connected disabilities. Accordingly, and resolving all reasonable doubt in the Veteran’s favor, the Board finds that service connection for depressive disorder is warranted on a secondary basis. See 38 C.F.R. §§ 3.102, 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Disability Ratings Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2017). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. § 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2017). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2017). Right and Left Foot Hallux Valgus Disability with Scars The Veteran is assigned 10 percent ratings for the right and left hallux valgus disabilities, status-post bunionectomy under Diagnostic Code 5280. Noncompensable evaluations are assigned for the right and left bunionectomy scars under Diagnostic Code 7804. A 10 percent rating is the maximum rating allowed under Diagnostic Code 5280. Therefore, the Veteran has been in receipt of the maximum schedular rating for his bilateral hallux valgus throughout the appeal period. See 38 C.F.R. § 4.71a, DC 5280. The Veteran has not contended and the record otherwise does not show that increase rating for his bilateral hallux valgus should be considered on extraschedular basis. Furthermore, the Board does not find that the Veteran’s bilateral hallux valgus would be more appropriately rated under a different diagnostic code as the currently applied code directly contemplates the Veteran’s disabilities. See Copeland v. McDonald, 27 Vet. App. 333, 337-38 (2015) (holding that, as a matter of law, DC 5284 does not apply to the eight other foot conditions specifically listed in § 4.71a, and so listed conditions could not be rated by analogy under that DC). Thus, a rating higher than 10 percent for hallux valgus on each foot is denied. Regarding the Veteran’s bilateral bunionectomy scars, the Board finds that compensable ratings are not warranted because none of the scars have been found to be symptomatic. The Veteran’s scars have been rated under Diagnostic Code 7804 for scars, including linear scars. Under Diagnostic 7804, one or two scars that are unstable or painful warrant a 10 percent rating. The evidence includes the November 2013 VA foot examination report. At that time, the examiner noted that the Veteran did not have any residual signs or symptoms due to the bilateral bunionectomy procedures. The examiner also specifically indicated that the Veteran’s scars were neither painful nor unstable and did not have a total area equal to or greater than 39 square centimeters. The remaining evidence of record does not show that the Veteran’s right and left foot bunionectomy scars are symptomatic. As such, compensable ratings for the scars are not warranted. Lumbar Spine The Veteran is currently in receipt of a 10 percent rating for scoliosis and degenerative changes of the lumbar spine throughout the entire rating period on appeal. The Veteran’s lumbar spine disability has been rated under Diagnostic Code 5237 for lumbosacral strain and 5242 for degenerative arthritis of the spine. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula)). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), unfavorable or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003). The General Rating Formula provides a 10 percent rating 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 rating is 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 rating is assigned forward flexion of the thoracolumbar spine 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. The Notes following the General Rating Formula 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, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 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 thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. DC 5243 provides that IVDS is to be rated either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The IVDS Formula provides a 10 percent rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) to DC 5243 provides that, for purposes of ratings under DC 5243, an incapacitating episode is 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. 38 C.F.R. § 4.71a. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The Veteran was afforded a VA spine examination in November 2013. At that time, the examiner diagnosed lumbosacral strain, degenerative disc disease, and degenerative scoliosis. During the evaluation, the Veteran reported that her low back pain made it difficult to complete daily living tasks, such as getting dressed and household chores. The Veteran further indicated that she experienced flare-ups on a daily basis and stated that she had pain on the date of examination in the lower portion of her back. Upon range of motion testing, flexion was limited to 90 degrees, extension was to 30 degrees, and bilateral lateral flexion and rotation were to 30 degrees. Repetitive use testing did not additionally limit motion. The Veteran was also noted to have a normal gait and normal spinal contour. A sensory examination was normal and the Veteran was not found to have radiculopathy. The examiner also indicated that the Veteran did not have IVDS. VA treatment records include a June 2016 VA primary care note where the Veteran reported that her back pain was “status quo.” The Veteran denied any radiation of pain, lateralizing weakness, or sensory disturbance. There were no bladder or bowel control issues noted. Examination of the low back showed diffused paralumbar tenderness. Straight leg raise was negative. Upon review of all the evidence of record, lay and medical, the Board finds that the criteria for a rating in excess of 10 percent has not been met for the rating period on appeal. Specifically, forward flexion of the thoracolumbar spine was limited to, at worst, 90 degrees and the combined range of motion of the thoracolumbar spine in the November 2013 VA examination discussed above was greater than 120 degrees. There is also no objective evidence of muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour or ankylosis. There is also no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination. See 38 C.F.R. §§ 4. 40 and 4.45 and DeLuca, 8 Vet. App. at 206-7. Despite experiencing a flare-up during the November 2013 examination, the Veteran was able to perform repetitive use testing with no additional loss of motion. The Board finds that the limitation of motion and functional loss due to pain is contemplated in the 10 percent rating assigned. Based on the objective medical evidence of record, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination, and the Board finds that the assignment of additional disability pursuant to 38 C.F.R. §§ 4.40 and 4.45 is not warranted. The Board further finds that a higher rating is not warranted under Diagnostic Code 5243 for incapacitating episodes associated with intervertebral disc syndrome. There is no indication in the medical evidence of record indicating that the Veteran had been prescribed bedrest by a physician due to her back disability. Thus, the Board finds that a disability evaluation in excess of 10 percent for the lumbar spine disability is not applicable under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. In summary, the Board finds that the preponderance of the evidence is against the assignment of a disability evaluation in excess of 10 percent for the lumbar spine disability. Hemorrhoids The Veteran is assigned a noncompensable disability rating pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336, which is assigned for mild or moderate hemorrhoids. A 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, Diagnostic Code 7336. The evidence includes a VA examination in November 2013. During the evaluation, the Veteran reported using suppositories, Tucks pads, and Colace. The examiner indicated that the Veteran had “mild” and “occasional” hemorrhoids. Upon physical examination, the Veteran had small or moderate external hemorrhoids. VA treatment records note that the Veteran continues to have “external hemorrhoids without mention of complication.” Based on a review of the Veteran’s medical records and examinations, the Board finds that the Veteran is not entitled to a compensable rating under Diagnostic Code 7336. For the period on appeal, the Veteran’s hemorrhoid symptoms more nearly approximate “mild” or “moderate” symptoms. The Veteran has not provided a lay description of her hemorrhoids during the appeal period. There is simply no probative evidence describing the severity of the Veteran’s hemorrhoids to support a compensable rating. Neither the medical evidence nor the Veteran’s lay statements indicate that the Veteran’s hemorrhoids are currently, or ever were, large or thrombotic, irreducible, with excessive redundant tissue, with anal fissure, or with persistent bleeding with secondary anemia. Therefore, the evidence does not show that the Veteran’s hemorrhoids more nearly approximate the criteria corresponding to a compensable rating pursuant to Diagnostic Code 7336. 38 C.F.R. §§ 4.7, 4.114. Accordingly, a compensable rating for service-connected hemorrhoids is not warranted. REASONS FOR REMAND Headaches The Veteran generally maintains that service connection for headaches is warranted. Initially, the Board finds that the Veteran has a current diagnosis of tension headaches. In this regard, the Board finds that a tension headache is a disorder associated with symptoms capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran’s assertion of headaches is competent evidence, and the Board has no reason to doubt the credibility of such assertion. See also July 2017 VA treatment record (noting complaints of tension headaches). Next, the Board finds that service treatment records reflect various complaints of headaches in service. Specifically, in an April 1987 emergency care note, the Veteran reported that her apartment was broken into and that she was a “mess.” At that time, the Veteran complained of headache, tiredness, and crying spells. A diagnosis was not provided. In an October 1990 Report of Medical History, the Veteran complained of headaches. At that time, the examiner indicated that the Veteran had frequent headaches and had been referred for an eye examination. It was further indicated that corrective lenses had reduced the occurrence of headaches. A corresponding October 1990 Report of Medical Examination indicated that the Veteran had a refractive error. In March 1992, the Veteran complained of severe headaches around the eyes and it was noted that the Veteran worked on computers and read often, causing eye strain. The Veteran was diagnosed with an astigmatism. The Veteran has not been afforded a VA examination regarding her headache disorder. As such, given the Veteran’s current diagnosis of tension headaches and an indication that she experienced headaches in service, the Board finds that a VA examination and medical opinion is warranted to assist in determining the etiology of the Veteran’s disorder. Hammertoes The Veteran was afforded a VA foot examination in November 2013, where a diagnosis of bilateral hammertoes was confirmed. In a January 2014 VA medical opinion, the examiner opined that the Veteran’s hammertoes were not proximately due to or the result of the service-connected foot disabilities (including hallux valgus, bilateral ingrown toenails, and a post-operative fracture of the right 5th toe). In support of this opinion, the examiner stated that a review of the medial literature did not reveal that the Veteran’s service-connected foot disabilities “cause” hammertoes. However, the examiner subsequently stated that hammertoes was a deformity of the proximal interphalangeal joint “caused by either foot wear or secondary medical conditions.” Moreover, the examiner stated that hallux valgus was often found in conjunction with hammertoe deformities, but did not cause hammertoes. The Board finds the January 2014 VA medical opinion inadequate. In this regard, the examiner failed to address the theory of aggravation. Moreover, despite noting that hammertoes were often caused by either foot wear or secondary to a medical condition, the examiner did not indicate which medical conditions were noted to cause hammertoes. This is especially problematic since the Veteran has been diagnosed with three different foot disabilities and is also service-connected for knee and spine disabilities. The Veteran also underwent surgery (arthoplasty) on the 2nd toe of the left foot in September 2017 due to his hammertoes. For these reasons, the Board finds that a new examination and medical opinion is required. Residuals of a Right 5th Toe Fracture The Veteran has been assigned a 10 percent rating for residuals of a right 5th toe fracture disability, post-operative, with degenerative changes. This rating has been appropriately assigned under Diagnostic Code 5284 for foot injures. Diagnostic Code 5284 may be applied to foot disorders other than those for which specific diagnostic criteria are otherwise set forth in the Rating Schedule. Under this diagnostic code, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries, and a 30 percent rating is assigned for severe foot injuries. Diagnostic Code 5284 also allows for the assignment of a 40 percent rating for loss of use of the foot. The Veteran was afforded a VA foot examination in November 2013; however, the examiner did not complete the section of the report titled “foot injuries and other conditions,” which would appear to properly address the rating criteria under Diagnostic Code 5284. The examiner also did not otherwise address the Veteran’s residual right toe fracture disability, to include the current severity of the disability. For these reasons, and given that a new examination is being requested for the Veteran’s hammertoes, the Veteran’s claim for a higher rating for the right toe fracture disability is remanded. COPD The Veteran maintains that her COPD disability is more severe than what is contemplated by the currently assigned 60 percent rating. The Veteran’s COPD is rated under 38 C.F.R. § 4.97, Diagnostic Code 6604, and assigned a 60 percent evaluation for the entire rating period on appeal. Under Diagnostic Code 6604, a 60 percent rating is warranted when the FEV-1 is 40 to 55 percent predicted, or; FEV-1/FVC is 40 to 55 percent, or; DLCO (SB) is 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg (with cardiorespiratory limit). A 100 percent rating is warranted for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg in oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.96, Diagnostic Code 6604. For evaluation purposes, the post-bronchodilator results are used unless they are poorer than the pre-bronchodilator results. 38 C.F.R. § 4.96, Note 5. If a maximum exercise capacity test is not of record, the COPD is to be rated based on alternative criteria. 38 C.F.R. § 4.96 (d)(1)(i). The Veteran was afforded a VA respiratory examination report in November 2013. At that time, PFTs results showed post-bronchodilator FEV-1 at 45 percent predicted, FVC at 77 percent predicted, FEV-1/FVC of 47 percent predicted. Pre-bronchodilator results were worse than post-bronchodilator results. The examiner further noted that the FEV-1/FVC percentage results most accurately reflected the Veteran’s current pulmonary function. DLCO results were not noted. VA treatment records include PFTs dated in March 2014. At that time, post-bronchodilator FEV-1 at 47 percent predicted, FVC at 72 percent predicted, FEV-1/FVC of 64 percent predicted. Pre-bronchodilator results were worse than post-bronchodilator results. DLCO results included only pre-bronchodilator test, which was 39 percent predicted. According to April 2016 VA PFTs, the Veteran was noted to have pre-bronchodilator FEV-1 at 37 percent predicted, FVC at 57 percent predicted, FEV-1/FVC of 64 percent predicted. DLCO was 20 percent predicted. Notably, the VA physician indicated that post-bronchodilator testing could not be conducted as the Veteran had used her inhaler prior to the appointment. The Board finds that a new VA respiratory examination is required as the current PFT results currently of record are inadequate for rating purposes. In this regard, the November 2013 VA examination did not report DLCO results. The March 2014 PFT results did not include post-bronchodilator DLCO results. Moreover, the most recent April 206 PFT results did not conform to 38 C.F.R. § 4.96, Note 5, as only pre-bronchodilator testing was performed. Accordingly, a new examination is warranted to assist in determining the current severity of the Veteran’s COPD disability. Effective Date of 60 percent Rating for COPD In the February 2014 rating decision, the RO granted a 60 percent rating for COPD effective April 18, 2013. In September 2014, the Veteran filed a notice of disagreement (NOD) with both the rating and effective date assigned for the COPD disability. Despite the Veteran’s timely filed NOD, no further action has been completed by the RO regarding the claim for an earlier effective date for the grant of a 60 percent rating for COPD. Accordingly, a Statement of the Case must be sent to the Veteran on this issue. See Manlincon v. West, 12 Vet. App. 238 (1999). Right and Left Knee Disabilities The Veteran maintains that her bilateral knee disability is more severe than what is contemplated by the currently assigned 10 percent ratings. In a November 2013 VA knee examination, the Veteran was diagnosed with bilateral knee strain, patellofemoral pain syndrome, and chondromalacia. During the evaluation, the Veteran reported flare-ups during the day and at night. She reported taking steroid injection and indicated that she used knee braces. Range of motion testing showed bilateral knee flexion to 140 degrees and normal extension. Although pain was noted on range of motion testing, the examiner did not indicate at what degree the pain began. Repetitive use testing did not additionally limit motion and did not contribute to functional loss. Muscle strength testing was normal. There was no ankylosis of either knee, instability, or recurrent subluxation. The Veteran also did not have any meniscal condition in either knee. In a June 2015 VA primary care note, the Veteran reported “worsening bilateral knee pain” right greater than left. She indicated that her pain was an 8 out of 10, with 10 being the most severe. The pain was noted to increase with walking. The VA physician indicated that the right knee was swollen and painful. In a July 2015 VA treatment record, a physical examination of the Veteran’s knees showed no edema. On the right, there was no tenderness and the knee was not swollen or warm. There was some tenderness laterally and crepitus sensation. The left knee was the same, but with less tenderness. The Veteran continued to receive steroid injections in both knees. Range of motion testing was not conducted. The Board finds that a new VA knee examination is required. In this regard, the Board notes that the November 2013 VA examiner indicated that there was pain on range of motion testing of both knees; however, the examiner did not indicate where pain began. See VAOPGCPREC 9-98 (recognizing the motion effectively ends where pain begins). Moreover, subsequent to the 2013 VA examination report, VA treatment records indicate that the Veteran’s bilateral knee disabilities have worsened. See 38 C.F.R. § 3.327 (a) (re-examinations are generally required if evidence indicates that there has been a material change in a disability or that the current rating may be incorrect). For these reasons, a new VA knee examination is therefore necessary. Ingrown Toenails The Veteran has been assigned noncompensable ratings for his right and left ingrown toenail disabilities. Notably, the Veteran’s right great toenail is post-operative with anonychia (absence of nail). The left great toenail is also post-operative with only partial anonychia. The Board notes that there is no diagnostic code specifically applicable to ingrown toenails. The RO has rated the Veteran’s ingrown toenails by analogy under Diagnostic Code 7813-7824. Diagnostic Code 7824 contemplates disease of keratinization and Diagnostic Code 7813 contemplates dermatophytosis (nail fungus). Neither of these codes appear to yield a compensable rating for the Veteran. Because the Veteran is service connected for ingrown toenails, which affects not just the nail but the tissue surrounding the nail, the Board finds that Diagnostic Code 7804 for painful scars is also applicable. The Veteran was afforded a VA skin examination in November 2013; however, upon review, the Board finds that the examination is inadequate. In this regard, the Board finds that clarification is needed as to whether the Veteran has active ingrown nails. Notably, the Veteran’s anonychia appears to suggest that the Veteran no longer has a nail on the right great toe and only has a partial nail on the left. It would be reasonable to assume that if the nail was removed, the Veteran would no longer have ingrown nails; however, the examiner indicated that the Veteran’s disability impaired her physical activities due to “chronic ingrown toenails.” As such, the Board finds that a new VA examination is required to clarify the nature of the disabilities and their respective severity. TDIU The Veteran is seeking entitlement to a TDIU based on her service-connected disabilities, which now include depressive disorder. As such, the TDIU claim is inextricably intertwined with the Board’s grant of service connection for depressive disorder and the pending assignment of its corresponding rating percentage by the AOJ. Additionally, the issue of a TDIU is also intertwined with the claims being remanded herein. Consideration of the TDIU must therefore be deferred. The matters are REMANDED for the following actions: 1. Obtain updated VA treatment records from March 2018 to the present and associate them with the electronic claims file. 2. Schedule the Veteran for an appropriate VA examination to assist in determining the etiology of his headache disorder. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. Then, the examiner is asked to provide an opinion as to the following: (a.) Is it at least as likely as not (50 percent or more probability) that the Veteran’s headache disorder was incurred in service or is otherwise related to service? (Note: the examiner should note that service treatment records reflect complaints and treatment for headaches). (b.) All opinions are to be accompanied by a rationale consistent with the evidence of record. 3. Schedule the Veteran for a VA foot examination to assist in determining the etiology of his bilateral hammertoes and the severity of his residuals of a right 5th toe fracture. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. Then, the examiner is asked to provide an opinion as to the following: (a.) Regarding the Veteran’s hammertoes, the examiner should state whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s bilateral hammertoes are either caused or aggravated by the service-connected disabilities (to include the service-connected foot, spine, and/or knee disabilities). If aggravation is found, to the extent possible, the examiner should identify the baseline level of severity of the disability prior to the onset of aggravation (b.) Regarding the right 5th toe fracture disability, the examiner should indicate whether the disability results in moderate, moderately severe, or severe impairment. (c.) All opinions are to be accompanied by a rationale consistent with the evidence of record. 4. Scheduled the Veteran for a VA respiratory examination before an appropriate physician to determine the current level of severity of his service-connected COPD disability. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination reports should reflect review of these items. (a.) The examination should include a pulmonary function test, as well as any other tests and studies deemed necessary by the examiner. The results of the PFT must indicate: (a) the percentage of predicted FEV-1 and FEV-1/FVC and (b) the percentage of predicted DLCO (SB). (b.) The examination report must include pre-bronchodilator and post-bronchodilator studies unless the examiner determines that post-bronchodilator studies should not be done and states why. 5. Schedule the Veteran for a VA knee examination to determine the current severity of her right and left knee disability. The claims file must be made available to and reviewed by the examiner. (a.) The examination must include range of motion studies of the right and left knee. In reporting the range of motion findings, the examiner must comment on the extent of any painful motion, functional loss due to pain, weakness, excess fatigability, and additional disability during flare-ups. (b.) The knees must be tested for pain on both active and passive range of motion with weight bearing and nonweight bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). 6. Schedule the Veteran for a VA skin examination to determine the current severity of her ingrown toenail disability. The claims file must be made available to and reviewed by the examiner. (a.) The examiner should indicate whether the Veteran continues to have ingrown toenail or whether symptoms have resolved due to partial and/or complete surgical removal of the toenails. (b.) If the Veteran continues to experience ingrown toenails, state all symptoms related to this disability (including pain, scarring, functional impairment, etc.). 7. Issue a Statement of the Case on the issue of entitlement to an earlier effective date prior to April 18, 2013 for the grant of a 60 percent rating for COPD. Only if the Veteran perfects an appeal should the claim be certified to the Board. 8. Then, readjudicate the remaining claims on appeal. If the benefits sought remain denied, issue a supplemental   statement of the case and provide the Veteran and her representative the requisite period of time to respond. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Casadei, Counsel