Citation Nr: 18141522 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 14-32 173A DATE: October 10, 2018 ORDER Service connection for a left hip disorder is denied. Service connection for a right hip disorder is denied. Service connection for a right knee disorder is denied. Service connection for rhabdomyolysis is denied. Service connection for bilateral hearing loss is denied. Service connection for vertigo is denied. Service connection for polyuria and dysuria is denied. An initial compensable disability rating for right shoulder myofascial pain syndrome is denied. An initial disability rating greater than 10 percent for cervical spine strain is denied. An initial disability rating greater than 10 percent for lumbar spine strain is denied. An initial compensable disability rating for acne is denied. An initial disability rating of 50 percent prior to October 8, 2013 and 70 percent beginning October 8, 2013 for an acquired psychiatric disability, variously characterized as major depressive disorder and posttraumatic stress disorder (PTSD), is granted. REMANDED Service connection for a gynecological disorder, to include recurrent ovarian cysts is remanded. Service connection for a skin disorder other than acne, to include sarcoidosis and perioral dermatitis is remanded. FINDINGS OF FACT 1. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of a left hip disorder or a separate undiagnosed disability manifested by objective symptoms involving the left hip. 2. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of a right hip disorder or a separate undiagnosed disability manifested by objective symptoms involving the right hip. 3. There is no evidence of a right knee disorder in service and no competent medical evidence linking the Veteran’s current right knee disorders with his period of service. 4. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of rhabdomyolysis or a separate undiagnosed disability manifested by objective symptoms involving rhabdomyolysis. 5. At no time during the pendency of the claim has the Veteran had a current bilateral hearing loss disability as defined by VA regulations, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. 6. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of vertigo or a separate undiagnosed disability manifested by objective symptoms involving vertigo. 7. The available medical evidence does not demonstrate that the Veteran has, or at any pertinent point during the current appeal period has had, a diagnosis of polyuria/dysuria or a separate undiagnosed disability manifested by objective symptoms involving polyuria/dysuria. 8. Since the grant of service connection, the Veteran’s right shoulder myofascial pain syndrome has been manifested by complaints of pain with no loss of range of motion of the arm; without ankylosis of the scapulohumeral articulation, malunion of the humerus, recurrent dislocation of the humerus at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus, flail shoulder, dislocation of the clavicle or scapula, or malunion or nonunion of the clavicle or scapula. 9. Since the grant of service connection, the Veteran’s cervical spine strain has not resulted in forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the cervical spine is not greater than 170 degrees, even in consideration of functional loss based on pain, fatigue, weakness, lack of endurance, and/or incoordination after repetitive use; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; intervertebral disc syndrome with incapacitating episodes; or neurologic impairment. 10. Since the grant of service connection, the Veteran’s lumbar spine strain has not resulted in 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 is not greater than 120 degrees, even in consideration of functional loss based on pain, fatigue, weakness, lack of endurance, and/or incoordination after repetitive use; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; intervertebral disc syndrome with incapacitating episodes; or neurologic impairment. 11. Since the grant of service connection, the Veteran’s acne has been manifested by superficial acne, and not deep acne that affected less than 40 percent of the face and neck, or deep acne other than on the face and the neck. 12. Prior to October 8, 2013, the Veteran’s psychiatric disability was productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood; chronic sleep impairment; flattened affect; and disturbance in motivation and mood; without more severe manifestations. 13. Beginning October 8, 2013, the Veteran’s psychiatric disability has been manifested by occupational and social impairment with deficiencies in areas such as work, thinking and mood due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; flattened affect; disturbance in motivation and mood; difficulty in establishing maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work life setting. There is no evidence of more severe manifestations that more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left hip disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 2. The criteria for service connection for a right hip disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 3. The criteria for service connection for a right knee disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 4. The criteria for service connection for rhabdomyolysis are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 5. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 6. The criteria for service connection for vertigo are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 7. The criteria for service connection for polyuria/dysuria are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 8. The criteria for an initial disability rating greater than 10 percent for right shoulder myofascial pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5201. 9. The criteria for an initial disability rating greater than 10 percent for cervical spine strain are not met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5237. 10. The criteria for an initial disability rating greater than 10 percent for lumbar spine strain are not met. 38 U.S.C.§§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5237. 11. The criteria for an initial compensable disability rating for acne have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.97, DC 7828. 12. The criteria for an initial disability rating disability of 50 percent, and no greater, for psychiatric disability prior to October 8, 2013 have been met. 38 U.S.C. § 1155, 5107, 5110, 5111; 38 C.F.R. §§ 3.31, 3.400, 3.401, 4.1, 4.3, 4.7, 4.71a, DC 9434. 13. The criteria for a disability rating of 70 percent, and no higher, for psychiatric disability beginning October 8, 2013 have been met. 38 U.S.C. § 1155, 5107, 5110, 5111; 38 C.F.R. §§ 3.31, 3.400, 3.401, 4.1, 4.3, 4.7, 4.71a, DC 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 2008 to November 2012. Significantly, the Veteran was deployed to Afghanistan during this service. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The Veteran testified before the undersigned Veterans Law Judge at a Board videoconference hearing in February 2018. A transcript of this proceeding has been associated with the claims file. This case was previously before the Board in April 2018 at which time it was remanded for additional development. Notably, by rating decision dated in July 2018, the RO increased the Veteran’s disability rating for psychiatric disability from 30 to 70 percent effective October 17, 2013, the date of the Veteran’s notice of disagreement. With regard to the Veteran’s claimed bilateral hip, right knee, and gynecological disorders, the Board notes that such claimed disorders were previously characterized as bilateral hip bursitis, right knee retropatellar pain syndrome, and ovarian cysts. However, at this time the Board finds that it would be more beneficial to the Veteran to expand these issues to include any hip/right knee/gynecological disorder. Also, the Board notes that the cover page of the April 2018 Board remand mistakenly referred to the claimed right knee condition as a left knee condition. As such, the Board has recharacterized these issues as noted above. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Certain chronic diseases, such as hearing loss and/or arthritis, will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). A “Persian Gulf veteran” is a veteran who served in the Southwest Asia theater of operations during the Persian Gulf War as defined in 38 C.F.R. § 3.2 and 38 C.F.R. § 3.17(a)(1)(ii) and is eligible for consideration of compensation for certain disabilities due to undiagnosed illnesses. 38 U.S.C. § 1117, 38 C.F.R. § 3.317. VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome (CFS), fibromyalgia or irritable bowel syndrome (IBS). 38 C.F.R. § 3.317(a)(2). 1. Service connection for bilateral hip disorders, rhabdomyolysis, vertigo, and polyuria/dysuria The Veteran contends that service connection is warranted for bilateral hip disorders, rhabdomyolysis, vertigo, and polyuria/dysuria. With regard to the bilateral hip issues, the Veteran contends that such disorders are due to general wear and tear during her military service. With regard to the remaining issues, the Veteran contends that such began during her military service and have continued since her service. The question for the Board is whether the Veteran has current bilateral hip disorders, rhabdomyolysis, vertigo, and/or polyuria/dysuria that began during service or are at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of bilateral hip disorders, rhabdomyolysis, vertigo, and/or polyuria/dysuria and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records shows that she was treated for bilateral hip pain and was assessed with rhabdomyolysis, vertigo, and polyuria/dysuria during her service. Specifically, with regard to the claimed hip disorder, she was treated for “hip pain” in May 2012 and was also treated for myalgia and myositis in November 2011 and January 2012. With regard to the claimed rhabdomyolysis, she was assessed with rhabdomyolysis in January 2009. With regard to the claimed vertigo, there is a complaint of dizziness for four days in an August 2009 treatment record and a diagnosis of benign paroxysmal positional vertigo in May 2010. Finally, problem lists dated as early as June 2009 show that the Veteran has a history of polyuria/dysuria. The Veteran submitted an initial claim for service connection for bilateral hip disorders, rhabdomyolysis, vertigo, and polyuria/dysuria in August 2012, during her active service. In connection with this claim, she was afforded multiple VA examinations in September 2012, also during her active service. During the September 2012 VA hip examination, the Veteran complained of occasional hip pain. Upon examination of the Veteran, the examiner found that the Veteran did not have nor had she ever had a hip and/or thigh disorder. During the September 2012 VA muscle examination, the Veteran reported that, during basic training, she developed chest pain but was told that she had no muscle injury. Upon examination of the Veteran, the examiner found that the Veteran did not have nor had she ever had a muscle disability. During the September 2012 VA ear examination, the Veteran denied experiencing a vestibular condition other than decreased hearing. Upon examination of the Veteran, the examiner found that the Veteran did not have nor had she ever had a peripheral vestibular condition, to include vertigo. During the September 2012 VA urinary examination, the Veteran reported a history of multiple bladder infections, the last one in April 2012 which had resolved. Upon examination of the Veteran, the examiner diagnosed cystitis which had resolved. Post-service VA treatment records are also negative for bilateral hip disorders, rhabdomyolysis, vertigo, and polyuria/dysuria. Significantly, March 2018 X-rays of the hips are normal and the Veteran denied dysuria in August/October 2016 and March 2017. While the Veteran believes she has current diagnoses of bilateral hip disorders, rhabdomyolysis, vertigo, and/or polyuria/dysuria, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. With regard to 38 C.F.R. § 3.17, the Board notes that neither the Veteran’s service treatment records nor her post-service medical records show subjective complaints regarding the hips, rhabdomyolysis, vertigo, and/or polyuria/dysuria and are negative for objective indications of such disorders. As there are no objective indications of either of bilateral hip disorders, rhabdomyolysis, vertigo, and/or polyuria/dysuria during service or to a degree of 10 percent or more within one year of separation from service, service connection under 38 C.F.R. § 3.317 is not warranted. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for of bilateral hip disorders, rhabdomyolysis, vertigo, and/or polyuria/dysuria. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for a right knee disorder The Veteran contends that service connection is warranted for a right knee disorder. Specifically, she contends that such disorder is due to general wear and tear during her military service. A review of the Veteran’s service treatment records shows that she complained of right knee pain in December 2008 and was diagnosed with patellar tendonitis. She was also treated for myalgia and myositis in November 2011 and January 2012. The Veteran submitted an initial claim for service connection for a right knee disorder in August 2012, during her active service. In connection with this claim, she was afforded a VA knee examination in September 2012, also during her active service. At that time, the Veteran reported that she first developed right knee pain during basic training. There was no injury and no treatment. She underwent X-ray of the right knee which was negative for any abnormality and the examiner found that there was no evidence of a right knee disability. However, subsequent VA treatment records dated as early as August 2013 show a history of degenerative joint disease of the knees so the Veteran was afforded a second VA examination in May 2018. This examination shows diagnoses of right knee strain and right knee tendonitis/tendinosis. Significantly, the examiner wrote that the Veteran’s right knee disorder was less likely than not incurred in or caused by the Veteran’s military service. As rationale for this opinion, the examiner noted that the Veteran was diagnosed with right patellar tendonitis in 2008, however, there was no medical evidence of chronicity following this diagnosis. Medical evidence in December 2017 noted swelling to the right knee and the Veteran underwent imaging which was negative for abnormalities. As such, there was no medical nexus between the Veteran’s patellar tendonitis diagnosed in 2008 and the current right knee strain. Initially, the Board notes that neither strain nor tendonitis/tendinosis are included as chronic conditions under 38 C.F.R. § 3.309(a). As such, presumptive service connection on the basis of continuity of symptomatology is not warranted for these conditions. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. With regard to the Persian Gulf presumption, there is no probative evidence of record establishing a chronic disability pattern for a right knee disability from either (1) an undiagnosed illness or (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology. See 38 C.F.R. § 3.317(a)(2)(i) and (ii). The May 2018 VA examiner, in particular, specifically diagnosed right knee strain as well as tendonitis/tendinosis. The claim is also denied on a direct basis. While the Veteran’s service treatment records show that she complained of right knee pain in December 2008, a September 2012 VA examination (conducted just two months prior to her discharge from service) is negative for a right knee disorder. While the record includes occasional complaints regarding the right knee following service, she was not diagnosed with an actual right knee disability until May 2018, approximately six years after service. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Finally, there is no medical evidence in the record that links the Veteran’s right knee disorders to an incident of the Veteran’s active military service. Significantly, while the Veteran contends that her right knee disorders were incurred during her military service, the May 2018 VA examiner indicated that the Veteran’s right knee disorders were not incurred during her military service as there was no medical evidence of chronicity following her December 2008 in-service complaints of right knee pain. While the Veteran has alleged that her right knee disorders were incurred during her military service, the Board finds that the question regarding the potential relationship between the Veteran’s right knee disorders and any instance of his military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). Furthermore, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation of a right knee disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for a right knee disorder. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for bilateral hearing loss The Veteran contends that service connection is warranted for bilateral hearing loss. Specifically, the Veteran contends that he was exposed to loud noises during her active service and that such resulted in current hearing loss. Significantly, the Veteran is service connected for tinnitus as a result of in-service noise exposure. 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. As an initial matter, the Board finds that the Veteran’s allegations regarding her in-service noise exposure to be competent and credible. Specifically, the Veteran’s service personnel records show that she served in Persian Gulf during the Persian Gulf War which is consistent with the Veteran’s claim of noise exposure. Therefore, the Board acknowledges that the Veteran was exposed to loud noise in service. The Veteran’s service treatment records are negative for hearing loss. Significantly, a July 2012 audiological examination shows the following puretone thresholds: Puretone Threshold 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 dB 5 dB 10 dB 10 dB Left Ear 0 dB 10 dB 10 dB 5 dB In August 2012, the Veteran submitted an initial claim for service connection for bilateral hearing loss. A post-service August 2013 audiological examination shows the following puretone thresholds: Puretone Threshold 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 dB 5 dB 10 dB 10 dB Left Ear 0 dB 10 dB 10 dB 5 dB In connection with such claim, she was afforded a VA audiological examination in May 2018. This examination revealed the following puretone thresholds: Puretone Threshold 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 20 dB 10 dB 5 dB 15 dB Left Ear 5 dB 10 dB 5 dB 15 dB Speech Recognition Right Ear 98% Left Ear 98% Significantly, the May 2018 hearing thresholds did not meet the criteria for disability under VA regulations. Based on the foregoing, the Board finds that the Veteran does not have a current bilateral hearing loss under 38 C.F.R. § 3.385 as audiometric testing fails to reveal that the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater or that the auditory threshold in at least three frequencies are 26 decibels or greater; or that the speech recognition score using the Maryland CNC Test are less than 94 percent. In this regard, in McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. In this case, there is no indication that the Veteran has ever met the criteria for a diagnosis of hearing loss pursuant to 38 C.F.R. § 3.385. While the Veteran believes she has a current diagnosis of bilateral hearing loss, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Furthermore, when an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Also, the VA General Counsel held in VAOPGCPREC 9-98 after reiterating its holding in VAOPGCPREC 23-97 that pain as a factor must be considered in the evaluation of a joint disability with arthritis and that the provisions of 38 C.F.R. § 4.59 are for consideration. “Staged ratings” or separate ratings for separate periods of time may be assigned based on the facts found following the initial grant of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). 4. An initial compensable disability rating for right shoulder myofascial pain syndrome By way of history, service treatment records show that the Veteran was involved in a motor vehicle accident in July 2009 and injured her right shoulder. The Veteran submitted an initial claim for service connection for a right shoulder disorder in August 2012, prior to her discharge from military service. By rating decision dated in August 2013, the RO granted service connection for right shoulder myofascial pain syndrome, assigning a noncompensable disability rating effective November 4, 2012, the day after the Veteran’s discharge from military service. The Veteran disagreed with this decision and perfected an appeal. The Veteran’s right shoulder myofascial pain syndrome is rated under 38 C.F.R. § 4.71a, DC 5201. Pursuant to DC 5201, limitation of arm motion that is limited to shoulder level warrants a 20 percent rating in the major and minor extremity. Such limitation that is limited midway between the side and shoulder level warrants a 20 percent rating in the minor extremity and a 30 percent rating in the major extremity. Such limitation to 25 degrees from the side warrants a 30 percent rating in the minor extremity and a 40 percent rating in the major extremity. 38 C.F.R. § 4.71a, DC 5201. Normal range of motion in the shoulder is from zero to 180 degrees of forward elevation (flexion) and zero to 180 degrees of shoulder abduction. See 38 C.F.R. § 4.71a, Plate I. Looking to other related diagnostic codes, under 38 C.F.R. § 4.71a, DC 5200, pertains to ankylosis of the scapulohumeral articulation. DC 5202 pertains to impairment of the humerus and DC 5203 addresses impairment of the clavicle or scapula. Evidence relevant to the current level of severity of the Veteran’s right shoulder disorder includes VA examination reports dated in September 2012 and May 2018. During the September 2012 VA shoulder examination, the examiner diagnosed myofascial pain syndrome of the right shoulder, noting an onset of 2009. Significantly, it was noted that the Veteran was right hand dominant. The Veteran denied flare-ups that impact the function of the shoulder and/or arm. On range of motion testing of the right shoulder, the Veteran had flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions with no additional loss of motion. There was no functional loss and/or impairment of the shoulder. There was no localized tenderness or pain on palpation of joints/soft tissue/biceps tendon and/or guarding of the right shoulder. Muscle strength testing was normal and there was no ankylosis. Hawkins’ impingement, empty-can, external rotation/infraspinatus strength, and lift-off subscapularis tests were negative. There was no history of mechanical symptoms (clicking, catching, etc.) or a history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint. Crank apprehension and relocation tests were normal. There was no AC joint condition or any other impairment of the clavicle or scapula and there was no tenderness of palpation of the AC (acromioclavicular) joint. Cross-body adduction test was also negative. There was no history of total shoulder joint replacement, arthroscopic, or other shoulder surgery. There were no pertinent physical findings, complications, conditions, signs and/or symptoms related to the Veteran’s right shoulder disorder. There was no functional impairment of the right shoulder such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were negative for arthritis. The examiner opined that the Veteran’s right shoulder condition did not impact her ability to work. During the May 2018 VA shoulder examination, the examiner noted diagnoses of glenohumeral and acromioclavicular joint osteoarthritis of the right shoulder. The examiner noted that she was right hand dominant. The Veteran denied flare-ups of the right shoulder and denied any functional loss or functional impairment of the right shoulder. Range of motion testing of the right shoulder revealed flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. Pain was noted on flexion but this did not result in functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and there was no evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. While the Veteran’s right shoulder was not examined immediately after repetitive use over time, there was no indication that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength testing was normal and there was no reduction in muscle strength or muscle atrophy. There was no ankylosis. The Veteran was found to have a rotator cuff condition as Hawkins’ impingement test was positive but empty-can, external rotation/infraspinatus strength, and lift-off subscapularis tests were negative. There was no shoulder instability, dislocation, or lateral pathology suspected. There was also no clavicle, scapula, AC joint, or sternoclavicular joint condition suspected. There was no condition or impairment of the humerus. Also, there were no pertinent physical findings, complications, conditions, signs or symptoms related to any shoulder disorder. The Veteran did not use an assistive device and the examiner wrote that there was no functional impairment of the right shoulder such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were positive for arthritis. The examiner opined that the Veteran’s right shoulder condition did not impact her ability to work. Significantly, the examiner noted that there was no evidence of pain on passive range of motion testing and no evidence of pain when the joint was used in non-weight bearing. Also of record are VA treatment records dated through April 2018. These records show treatment for the Veteran’s right shoulder disorder but are negative for range of motion findings. Given the evidence of record, the Board finds that an initial compensable disability rating for right shoulder myofascial pain syndrome is not warranted. Significantly, there is no evidence that the Veteran has limitation of motion at shoulder level, or midway between the side and shoulder of the right shoulder. During both the September 2012 and May 2018 VA shoulder examinations, the Veteran’s range of motion of the right shoulder was completely normal with forward flexion from 0 to 180 degrees, abduction from 0 to190 degrees, internal rotation from 0 to 90 degrees, and external rotation from 0 to 90 degrees. This does not approximate limitation of motion at shoulder level, or midway between the side and shoulder of the right shoulder. There is also no evidence of ankylosis of the scapulohumeral articulation; malunion of the humerus, or malunion of the major clavicle or scapula or nonunion without loss movement. Therefore, there is no basis for a higher schedular rating under either DC 5200, 5201, 5202, or 5203. The Board also considered whether an initial compensable disability is warranted based on findings of pain and functional loss. Significantly, both the September 2012 and May 2018 VA shoulder examinations show no change in the range of motion due to pain, fatigue, weakness, lack of endurance, or incoordination. Even with consideration of pain, the range of motion does not more closely approximate limitation of motion to shoulder level. As such, a higher rating under Deluca is not warranted. 5. An initial disability rating greater than 10 percent for cervical spine strain and 10 percent for lumbar spine strain By way of history, service treatment records show that the Veteran was involved in a motor vehicle accident in July 2009 and injured her neck and back. The Veteran submitted an initial claim for service connection for neck/back disorders in August 2012, prior to her discharge from military service. By rating decision dated in August 2013, the RO granted service connection for cervical spine strain and lumbar spine strain, assigning separate 10 percent disability ratings effective November 4, 2012, the day after the Veteran’s discharge from military service. The Veteran disagreed with this decision and perfected an appeal. The rating for the Veteran’s cervical and lumbar spine disabilities has been assigned under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237 (lumbosacral or cervical strain). In this regard, the criteria for rating all spine disabilities is set forth in a General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine holds that for DCs 5235 to 5243, a rating of 100 percent is warranted when there is unfavorable ankylosis of the entire spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted when there is unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 30 percent rating is warranted where there is forward flexion of the cervical spine to 15 degrees of less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, if the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, the combined range of motion of the cervical spine is not greater than 170 degrees; or, there is 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 10 percent rating, which has been assigned for both the Veteran’s cervical and lumbar spine disabilities, is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, of the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, the combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or, there is muscle spasms, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, there is a vertebral body fracture with loss of 50 percent or more of the height. The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and 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. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is 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): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Intervertebral disc syndrome (IDS) (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating IDS Based on Incapacitating Episodes provides for a 60 percent rating when there are incapacitating episodes of IDS having a total duration of at least six weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 20 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 10 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least one week, but less than two weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. A. Cervical Spine Evidence relevant to the Veteran’s cervical spine strain includes VA cervical spine examinations in September 2012 and May 2018. During the September 2012 VA examination, the examiner diagnosed cervical spine strain, noting an onset of 2009. The Veteran denied flare-ups impacting the function of the cervical spine. On range of motion testing, the Veteran had flexion to 45 degrees (with pain beginning at 45 degrees), extension to 45 degrees (with no objective evidence of painful motion), right lateral flexion to 45 degrees (with no objective evidence of painful motion), left lateral flexion to 45 degrees (with no objective evidence of painful motion), right lateral rotation to 80 degrees (with no objective evidence of painful motion), and left lateral rotation to 80 degrees (with no objective evidence of painful motion). The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. There was functional loss/impairment of the cervical spine, specifically pain on movement. There was no localized tenderness or pain to palpation for joints/soft tissue, guarding, or muscle spasm of the cervical spine. Muscle strength testing was normal and there was no muscle atrophy. Reflex and sensory examination was normal and there was no radicular pain or any other signs or symptoms due to radiculopathy. There were no neurologic abnormalities related to the cervical spine disorder and there was no IDS. The Veteran did not use an assistive device and the examiner wrote that there was no functional impairment of the cervical spine such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies were negative for arthritis. The examiner opined that the Veteran’s cervical spine condition did not impact her ability to work. During the May 2018 VA examination, the examiner continued a diagnosis of cervical strain. The Veteran denied flare-ups of the neck and also denied any functional loss or functional impairment. Range of motion testing of the cervical spine revealed flexion to 45 degrees, extension to 45 degrees, right lateral flexion to 45 degrees, left lateral flexion to 45 degrees, right lateral rotation to 80 degrees, and left lateral rotation to 80 degrees. Pain was noted on flexion and extension but this did not result in functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. It was noted that the Veteran’s cervical spine was examined immediately after repetitive use over time but there was no indication that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. There was no guarding or muscle spasm of the cervical spine. Muscle strength testing was normal and there was no reduction in muscle strength or muscle atrophy. Reflex and sensory examination was normal and there was no radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis. There were no other neurologic abnormalities related to the cervical spine and there was no IDS. The Veteran did not use an assistive device and the examiner wrote that there was no functional impairment of the cervical spine such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no pertinent physical findings, complications, conditions, signs or symptoms related to any cervical spine disorder. Imaging studies were negative for arthritis and there was no vertebral fracture with loss of 50 percent or more of height. The examiner opined that the Veteran’s cervical spine disorder did not impact her ability to work. Significantly, the examiner noted that it was medically impossible to determine whether there was pain on passive range of motion testing and/or pain when the joint is used in non-weight bearing. Also of record are VA treatment records dated through April 2018. These records show treatment for the Veteran’s cervical spine disorder but are negative for range of motion findings. Upon review of the evidence, the Board finds that a rating higher than 10 percent is not warranted for the Veteran’s cervical spine strain. As above, under the General Rating, the next higher 20 percent rating is assignable where forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees. Significantly, range of motion testing for the cervical spine during the September 2012 and May 2018 VA examinations show full cervical flexion to 45 degrees. While the September 2012 VA examination report also notes that the Veteran experienced pain at 45 degrees of flexion, the Board finds that this was likely a mistake given the other findings in that report as well as the full flexion with no pain reported during the May 2018 VA examination. There are no other range of motion findings pertinent to the current claim on appeal. As the Veteran’s cervical flexion is greater than 30 degrees, a higher rating for the cervical spine is not warranted. The Board has also considered the Veteran’s functional impairment due to pain and other factors. As noted, the Veteran was able to accomplish the noted range of motion, even with pain. Moreover, the medical evidence simply does not reflect functional loss-in addition to that shown objectively-due to pain, weakness, excess fatigability, or incoordination (to include with flare-ups or on repeated use) warranting a disability rating in excess of the assigned rating. Significantly, the September 2012 VA examiner indicated that, even following repetitive range of motion testing, there was no evidence of painful motion, fatigue, impaired endurance, or weakened movements. Similarly, the May 2018 VA examiner found that no assignment of additional degrees of functional impairment appeared warranted for the cervical spine on the basis of repetitive use, due to pain with use, limited endurance, weakness, fatigability, or incoordination as the functional impairments appeared reflected in the measurements documented. In other words, even considering the Veteran’s complaints of pain and stiffness, there is no evidence that these symptoms effectively result in cervical spine forward flexion limited to 30 degrees. As such, the Board finds that the DeLuca factors (noted above) provide no basis for assignment of any higher rating for the Veteran’s cervical spine disability. With regard to Note 1 of the General Rating Formula, the Veteran is not shown to have any associated neurological impairment with regard to the cervical spine. As above, both the September 2012 and May 2018 VA examination reports are negative for radiculopathy and/or any other associated neurological impairment. With regard to a potential higher rating under IDS, both the September 2012 and May 2018 VA examination reports are negative for IDS. Therefore, the Board finds that a rating in excess of 10 percent for the Veteran’s cervical spine strain, to include based on the General Rating Formula, Note 1 pertaining to associated neurologic impairments, and the Formula for Rating IDS Based on Incapacitating Episodes, is not warranted. B. Lumbar Spine Evidence relevant to the Veteran’s lumbar spine strain includes VA lumbar spine examinations in September 2012, August 2016, and May 2018. During the September 2012 VA examination, the examiner diagnosed lumbar spine strain, noting an onset of 2009. The Veteran denied flare-ups impacting the function of the lumbar spine. On range of motion testing, the Veteran had flexion to 90 degrees (with pain beginning at 90 degrees), extension to 30 degrees (with no objective evidence of painful motion), right lateral flexion to 30 degrees (with no objective evidence of painful motion), left lateral flexion to 30 degrees (with no objective evidence of painful motion), right lateral rotation to 30 degrees (with no objective evidence of painful motion), and left lateral rotation to 30 degrees (with no objective evidence of painful motion). The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. There was functional loss/impairment of the lumbar spine, specifically pain on movement. There was no localized tenderness or pain to palpation for joints/soft tissue, guarding, or muscle spasm of the lumbar spine. Muscle strength testing was normal and there was no muscle atrophy. Reflex and sensory examination was normal and straight leg raising test was negative. There was no radicular pain or any other signs or symptoms due to radiculopathy. There were no neurologic abnormalities related to the lumbar spine disorder and there was no IDS. The Veteran did not use an assistive device and the examiner wrote that there was no functional impairment of the lumbar spine such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. Imaging studies were negative for arthritis and there was no evidence of a vertebral fracture. The examiner opined that the Veteran’s lumbar spine condition did not impact her ability to work. During the August 2016 VA examination, the examiner continued a diagnosis of lumbosacral strain. The Veteran reported experiencing flare-ups of the back, described as very hurtful and sometimes debilitating. She also reported experiencing functional loss/ impairment, particularly when cleaning, bathing, exercising, and driving. Range of motion testing of the lumbar spine revealed flexion to 90 degrees, extension to 25 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. According to the examiner, this loss of motion did not contribute to functional loss. The examiner noted that there was pain on forward flexion, extension, right lateral flexion, and right lateral rotation. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was able to perform repetitive-use testing with three repetitions and there was no additional loss of motion. The Veteran’s back was not examined immediately after repetitive use over time but the examiner wrote that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner noted that pain and lack of endurance significantly limited functional ability with repeated use over a period of time but that it was impossible to describe this functional loss in terms of range of motion. The Veteran’s back was not examined immediately during a flare-up but the examiner wrote that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare-up. The examiner noted that pain and weakness significantly limited functional ability during flare-ups but that it was impossible to describe this functional loss in terms of range of motion. There was no localized tenderness, guarding, or muscle spasm of the lumbar spine. Muscle strength testing was normal and there was no muscle atrophy. Reflex and sensory examination was also normal and straight leg raising test was negative. There was no radicular pain or any other signs or symptoms due to radiculopathy. There was no ankylosis. There were no neurologic abnormalities related to the lumbar spine disorder and there was no IDS. The Veteran regularly used a brace to assist with locomotion and examiner wrote that there was no functional impairment of the lumbar spine such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The examiner opined that the Veteran’s lumbar spine condition impacted her ability to work in that she could not sit or stand for more than two hours, could not climb up more than three flights of stairs or walk longer than two miles, and could not drive longer than three hours or lift more than 30 pounds. It was also noted that activities requiring repeated bending like weeding are painful and limited. During the May 2018 VA examination, the examiner continued a diagnosis of lumbosacral strain. The Veteran denied flare-ups of the back and also denied any functional loss or functional impairment. Range of motion testing of the lumbar spine revealed flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Pain was noted on flexion and extension but this did not result in functional loss. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, specifically paraspinal tenderness. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. It was noted that the Veteran’s lumbar spine was examined immediately after repetitive use over time but there was no indication that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. There was no guarding or muscle spasm of the lumbar spine. Muscle strength testing was normal and there was no muscle atrophy. Reflex and sensory examination was normal and straight leg raising test was negative. There was radiculopathy or ankylosis. There were no other neurologic abnormalities related to the lumbar spine and there was no IDS. The Veteran did not use an assistive device and the examiner wrote that there was no functional impairment of the lumbar spine such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. There were no pertinent physical findings, complications, conditions, signs or symptoms related to any lumbar spine disorder. Imaging studies were negative for arthritis and there was no vertebral fracture with loss of 50 percent or more of height. The examiner opined that the Veteran’s lumbar spine disorder did not impact her ability to work. Significantly, the examiner noted that it was medically impossible to determine whether there was pain on passive range of motion testing and/or pain when the joint is used in non-weight bearing. Also of record are VA treatment records dated through April 2018. These records show treatment for the Veteran’s lumbar spine disorder but are negative for range of motion findings. Upon review of the evidence, the Board finds that a rating higher than 10 percent is not warranted for the Veteran’s lumbar spine strain. As above, under the General Rating, the next higher 20 percent rating is assignable where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees. Significantly, range of motion testing for the thoracolumbar spine during the September 2012, August 2016, and May 2018 VA examinations show full lumbar flexion to 90 degrees. While the September 2012 VA examination report also notes that the Veteran experienced pain at 90 degrees of flexion, the Board finds that this was likely a mistake given the other findings in that report as well as the full flexion with no pain reported during the May 2018 VA examination. There are no other range of motion findings pertinent to the current claim on appeal. As the Veteran’s thoracolumbar flexion is greater than 60 degrees, a higher rating for the lumbar spine is not warranted. The Board has also considered the Veteran’s functional impairment due to pain and other factors. As noted, the Veteran was able to accomplish the noted range of motion, even with pain. Moreover, the medical evidence simply does not reflect functional loss-in addition to that shown objectively-due to pain, weakness, excess fatigability, or incoordination (to include with flare-ups or on repeated use) warranting a disability rating in excess of the assigned rating. Significantly, the September 2012 VA examiner wrote that, even following repetitive range of motion testing, there was no evidence of painful motion, fatigue, impaired endurance, or weakened movements. Similarly, the May 2018 VA examiner found that no assignment of additional degrees of functional impairment appeared warranted for the lumbar spine on the basis of repetitive use, due to pain with use, limited endurance, weakness, fatigability, or incoordination as the functional impairments appeared reflected in the measurements documented. In other words, even considering the Veteran’s complaints of pain and stiffness, there is no evidence that these symptoms effectively result in thoracolumbar spine forward flexion limited to 60 degrees. As such, the Board finds that the DeLuca factors (noted above) provide no basis for assignment of any higher rating for the Veteran’s cervical spine disability. With regard to Note 1 of the General Rating Formula, the Veteran is not shown to have any associated neurological impairment. As above, the September 2012, August 2016, and May 2018 VA examination reports are negative for radiculopathy and/or any other associated neurological impairment. With regard to a potential higher rating under IDS, the September 2012, August 2016, and May 2018 VA examination reports are negative for IDS. Therefore, the Board finds that an initial disability rating greater than 10 percent for the Veteran’s lumbar spine disability, to include based on the General Rating Formula, Note 1 pertaining to associated neurologic impairments, and the Formula for Rating IDS Based on Incapacitating Episodes, is not warranted. 6. An initial compensable disability rating for acne By way of history, service treatment records show that the Veteran was treated for acne in service. The Veteran submitted an initial claim for service connection for a skin disorder in August 2012, prior to her discharge from military service. By rating decision dated in August 2013, the RO granted service connection for acne, assigning a noncompensable disability rating effective November 4, 2012, the day after the Veteran’s discharge from military service. The Veteran disagreed with this decision and perfected an appeal. The Veteran’s acne is currently rated 38 C.F.R. § 4.118, DC 7828. Under DC 7828, a noncompensable rating is warranted for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck, or, deep acne other than on the face and neck. A maximum 30 percent rating is warranted for deep acne affecting 40 percent or more of the face and neck. DC 7828 also provides for alternately rating the disability on the basis of disfigurement of the head, face, or neck under DC 7800, or as scars under DCs 7801, 7802, 7803, 7804, or 7805, depending on the predominant disability. Evidence relevant to the current level of severity of the Veteran’s acne include VA skin examination reports dated in September 2012 and May 2018. There is also a September 2016 VA skin examination of record but this examination report does not pertain to the Veteran’s acne. During the September 2012 VA examination, the examiner noted diagnoses of contact dermatitis which had resolved and acne, both with an onset in 2012. At the time of the examination, the Veteran reported that she had had acne for two years and that she treated her acne with topical cream. The Veteran’s acne had not caused scarring or disfigurement of the head, face, or neck. The Veteran did not have any benign or malignant skin neoplasms and there were no systemic manifestations due to any skin disease. She had not been treated with oral or topical medications in the past 12 months. She had not had any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. She also denied any episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examiner described the Veteran’s acne as superficial in nature (comedones, papules, pustules, superficial cysts). There were no benign or malignant neoplasm or metastases related to the Veteran’s acne. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the Veteran’s acne. The examiner opined that the Veteran’s acne did not impact her ability to work. During the May 2018 VA examination, the examiner continued a diagnosis of acne and also noted a diagnosis of sarcoidosis. The examiner noted that the Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck. The Veteran did not have any benign or malignant skin neoplasms and there were no systemic manifestations due to any skin disease. The Veteran reported that she had been treated with oral or topical medications in the past 12 months but that this was due to her nonservice-connected sarcoidosis. There were no other treatments or procedures other than systemic or topical medications in the past 12 months. The Veteran denied any episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. On physical examination, the examiner noted that the Veteran’s sarcoidosis manifested as hyperpigmented, rough patches on the bilateral inner elbow, right 2nd and 3rd fingers and posterior neck (no blisters or pustules were noted) and that this affected less than five percent of the total body area. There were no tumors or neoplasms and there were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran’s skin conditions. The examiner opined that the Veteran’s skin conditions did not impact her ability to work. Also of record are VA treatment records dated through April 2018. These records show a history of acne but do not describe the severity of the Veteran’s acne. In fact, August and September 2016 treatment records show that the Veteran denied symptoms of acne. Upon review of the evidence, the Board finds that a compensable disability rating is not warranted for the Veteran’s acne. As above, a 10 percent rating is warranted for deep acne (deep inflamed nodules and pus-filled cysts). Significantly, the Veteran’s acne has never been found to be deep acne. Rather, the September 2012 VA examiner found that her acne was chronic but superficial. Therefore, the Board finds that a noncompensable rating is appropriate for the Veteran’s acne given the superficial nature of this condition. 7. An initial disability rating greater than 30 percent prior to October 17, 2013 and greater than 70 percent beginning October 17, 2013 for psychiatric disability By way of history, service treatment records show that the Veteran was treated for psychiatric problems in service. The Veteran submitted an initial claim for service connection for a psychiatric disorder in August 2012, prior to her discharge from military service. By rating decision dated in August 2013, the RO granted service connection for major depressive disorder, assigning an initial 30 percent disability rating effective November 4, 2012, the day after the Veteran’s discharge from military service. The Veteran disagreed with this decision and perfected an appeal. Subsequently, by rating decision dated in July 2018, the RO increased the Veteran’s disability rating for his psychiatric disability from 30 to 70 percent effective October 17, 2013, the date of the Veteran’s notice of disagreement. As above, the August 2013 rating decision grated service connection for major depressive disorder based, in part, on a September 2012 VA psychiatric examination diagnosing major depressive disorder. A subsequent May 2018 VA psychiatric examination report found that the Veteran’s previously diagnosed major depressive disorder had progressed to a diagnosis of PTSD. As such, the Board has characterized the Veteran’s psychiatric disability as noted above The Veteran’s psychiatric disability is rated under 38 C.F.R. § 4.130, DC 9434. Under that code, a 30 percent disability rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The nomenclature employed in the portion of VA’s Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between 0 and 100, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. VA has recently changed its regulations, and now requires the use of DSM-5, effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in the evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014, and is not applicable to cases certified to the Board prior to that date. As this case was certified to the Board after August 4, 2014, GAF scores will not be used in the evaluation of the psychiatric disorder. Symptoms listed in VA’s general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission must be considered. In addition, the rating must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Further, when rating the level of disability from a mental disorder, the extent of social impairment is considered, but a rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126. Evidence relevant to the level of severity of the Veteran’s psychiatric disability during the course of this appeal includes VA examination reports dated in September 2012 and August 2016. During the September 2012 VA examination, the examiner diagnosed major depressive disorder and found that this disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. At the time of the examination, it was noted that the Veteran had gotten married in September 2012 and had no children. She planned to attend college full time after her discharge from the military in November. It was also noted that the Veteran received psychological treatment while on active duty in 2010 and was still in treatment for her depression. She had a history of alcohol abuse from 2010 to 2011 but had not drank alcohol in the past 14 months. Upon examination of the Veteran, the examiner found that the Veteran’s major depressive disorder resulted in the following symptoms: depressed mood; chronic sleep impairment; flattened affect; and disturbance in motivation and mood. There were no other symptoms. During the August 2016 VA examination, the examiner found that the Veteran’s previously diagnosed major depressive disorder and progressed to a diagnosis of posttraumatic stress disorder (PTSD) and found that there were no other psychiatric diagnoses. According to the examiner, the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. At that time of this examination, the Veteran reported that she had been married for four years but separated for the past three years. She had no children and lived alone. After her discharge from service, the Veteran worked for approximately one year but had been unemployed since 2015. She reported the following symptoms: social isolation, crowd avoidance, depression, anxiety, insomnia, irritability, anger outbursts, hyper vigilance, intrusive thoughts, panic attacks, and suspiciousness. She reported a history of alcohol abuse from 2010 to 2011 but denied using alcohol since that time. Upon examination of the Veteran, the examiner found that the Veteran’s PTSD resulted in the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; flattened affect; disturbance in motivation and mood; difficulty in establishing maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work life setting. There were no other symptoms. Also of record are VA treatment records dated through April 2018. Significantly, as early as May 2013, the Veteran was assessed with moderately severe depression. An August 20, 2013 VA treatment record noted that the Veteran and her husband had been homeless since November 2012, living in their car, hotels when they could afford it, and with relatives. A September 16, 2013 VA treatment record shows that the Veteran was unemployed but attending college classes. An October 8, 2013 VA treatment record shows that the Veteran was alone and homeless. She was experiencing sleep problems, experiencing nightmares three to four times per week, due to intrusive thoughts of her service in Afghanistan and had lost 15 pounds due to poor appetite. She also experienced crying spells and transient suicidal ideation and felt paranoid all the time. As of June 2015, it appears that the Veteran was no longer homeless, however a February 2016 VA treatment record shows that the Veteran was having trouble paying her rent. Based on these findings, the Board finds that the evidence of record substantiates a 50 percent evaluation for the period of time prior to October 8, 2013. Notably, as early as May 2013, the Veteran was found to have moderately severe depression. This supports the proposition that, prior to October 8, 2013, the Veteran’s psychiatric disability affected her ability to function both in her occupation and socially, with such deficiencies as depressed mood; chronic sleep impairment; flattened affect; and disturbance in motivation and mood. Thus, as supported by the evidence of record, the Veteran’s psychiatric symptoms more nearly approximated the level of impairment associated with a 50 percent evaluation. Therefore, in light of the evidence as noted above, the Board concludes that the Veteran’s psychiatric disability was productive of impairment warranting the higher evaluation of 50 percent prior to October 8, 2013. As for the potential for a yet higher rating, the totality of the evidence reflects symptoms warranting no more than a 50 percent rating under the applicable criteria prior to October 8, 2013. Prior to October 8, 2013, the evidence did not demonstrate that the service-connected psychiatric disability was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood do to symptoms such as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships While the Veteran may have suffered from some level of social impairment, in that she was withdrawn and isolative, with minimal socialization, the evidence did not show that she necessarily was prevented from establishing and maintaining such relationships. Significantly, during this period the Veteran was living with her husband and attending college classes. Beginning October 8, 2013, the Veteran’s psychiatric disability appears to have increased in severity as, beginning this date, there is evidence of intrusive thoughts of Afghanistan, nightmares, loss of appetite, paranoia, and sleep disturbance. As such, the Board finds that the Veteran’s psychiatric disability was productive of impairment warranting a 70 percent disability rating effective October 8, 2013. As for the potential of a disability rating higher than 70 percent, the Board finds that the evidence does not show the symptomatology required for a 100 percent rating under the rating schedule. Significantly, there is no evidence of gross impairment of thought processes or communication, intermittent inability to perform activities of daily living, including maintenance of minimum personal hygiene, and disorientation to time or place, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, or memory loss for names of close relatives, own occupation, or own name. Significantly, the August 2016 VA examiner found that the Veteran’s psychiatric disability resulted in occupational and social impairment with deficiencies in most areas such as work school family relations judgment thinking and/or mood, which supports a 70 percent disability rating, and indicated that there was no evidence of total occupational and social impairment. As required by Mauerhan, the Board has looked at all the factors and evidence identified above to determine whether the Veteran has met or more closely approximated the criteria for a higher rating at any time pertinent to this appeal. However, when considering the overall evaluation of the examples which may support higher ratings, the frequency, duration and severity of symptoms, the Veteran’s capacity for adjustment, and the examiner’s assessments of the Veteran’s overall psychological, social and occupational functioning, the Board must conclude that the Veteran’s psychiatric disability has not met or more closely approximated the criteria for higher ratings at any relevant time. In this respect, the Veteran, even at her worst, the Veteran can efficiently converse with the VA examiners, and can generally manage her daily activities on her own. She is not psychotic or out of touch with reality. In so holding, the Board has generally found the statements and testimony of the Veteran to be truthful and credible evidence in support of this claim, which has been relied upon in awarding further compensation. However, even when taking into account this testimony, the Board finds that the criteria for higher ratings have not been met at any time pertinent to this appeal. To the extent that the descriptions provided by the Veteran can be construed as supporting a higher rating still, the Board places greater probative weight to the clinical findings of the VA physicians who have greater expertise and training than the Veteran in evaluating the extent and severity of a psychiatric disability. There is no doubt of material fact to be resolved in her favor. 38 U.S.C. § 5107(b). As such, higher disability ratings are not warranted. Finally, a total disability rating based on individual unemployability (TDIU) is an element of a claim for a higher rating for a disability, if there is suggestion that disability renders the Veteran incapable of obtaining or maintaining substantially gainful employment. Rice v. Shinseki, 22 Vet. App. 447 (2009). As above, the Veteran has been unemployed during certain time periods since her discharge from service in November 2012. However, the Veteran has never explained why she was unemployed. Furthermore, it is unclear whether the Veteran continues to be unemployed. As such, the Board will not take jurisdiction of a claim for a TDIU pursuant to Rice at this time. REASONS FOR REMAND 1. Service connection for a gynecological disorder, to include recurrent ovarian cysts is remanded. With regard to the claimed gynecological disorder, the Veteran’s service treatment records show treatment for recurrent ovarian cysts from approximately June 2009 to June 2012. She underwent a VA gynecological examination and was diagnosed with ovarian cysts (2012) but no nexus opinion was provided as to the etiology of the Veteran’s ovarian cysts. During the February 2018 Board hearing, the Veteran testified that she experienced ovarian cysts every month during her menstrual cycle. The Veteran’s representative noted that women develop ovarian cysts, on average, once to twice per year and that the fact that the Veteran was developing ovarian cysts monthly was an indication that this was a chronic disability. The Veteran’s representative also noted that the Veteran was unsure whether she had developed adhesions due to her recurrent ovarian cysts. In April 2008, the Board remanded this issue so as to afford the Veteran a new VA examination to determine whether the Veteran currently has a disability manifested by recurrent ovarian cysts and, if so, whether it is related to her military service. Pursuant to the April 2008 Board remand, the Veteran was afforded a second VA gynecological examination in May 2018. Significantly, this examination is negative for a gynecological disability. The examiner then opined that it was less likely than not that a gynecological disability is related to the Veteran’s military service. As rationale for this opinion, the examiner wrote that there was no medical evidence of a diagnosis of ovarian cysts since May 2012. The Veteran’s last pelvic ultrasound in June 2012 was negative for ovarian cysts and the Veteran’s most recent gynecological examination in March 2017 was negative for ovarian abnormalities and/or complaints. Unfortunately, the May 2018 opinion did not consider the Veteran’s previously diagnosed ovarian cysts along with the holding in McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (finding that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). Therefore, on remand, the Veteran should be afforded a new VA examination to determine whether the Veteran has been diagnosed with a gynecological disability at any time since her November 2012 discharge from military service and, if so, whether is it at least as likely as not that a gynecological disability is etiologically related to active service. 2. Service connection for a skin disorder other than acne, to include sarcoidosis and perioral dermatitis is remanded. With regard to the skin issue, the Veteran’s service treatment records show treatment for various skin disabilities including a skin abscess in May 2011, dyshidrosis in September 2010, and dermatitis in October 2010, June 2012 (perioral dermatitis), and July 2012. She underwent a VA skin examination in September 2012 and was diagnosed with contact dermatitis but no nexus opinion was provided as to the etiology of the Veteran’s skin disorder. Subsequent VA treatment records show a history of dermatitis. In April 2008, the Board remanded this issue so as to afford the Veteran a new VA examination to determine whether the Veteran currently has a skin disability (other than her already service-connected acne) and, if so, whether it is related to her military service. Pursuant to the April 2008 Board remand, the Veteran was afforded a second VA skin examination in May 2018. Significantly, this examination shows a diagnosis of sarcoidosis and no other skin disability. The examiner then opined that it was less likely than not that the Veteran’s sarcoidosis is related to the Veteran’s military service. As rationale for this opinion, the examiner wrote that the Veteran was diagnosed with sarcoidosis after dermatologic biopsy in 2015 (three years post discharge) and that there was no medical evidence to suggest that the Veteran’s sarcoidosis is related to active duty service. Unfortunately, the May 2018 opinion does not address the Veteran’s previously diagnosed contact dermatitis along with the holding in McClain. Therefore, on remand, the Veteran should be afforded a new VA examination to determine whether the Veteran has been diagnosed with a skin disability (other than sarcoidosis and/or acne) at any time since her November 2012 discharge from military service, to include dermatitis, and, if so, whether is it at least as likely as not that such skin disability is etiologically related to active service. Finally, with regard to both remanded issues, the Board notes that the most recent VA treatment records in the claims file are dated in April 2018. Given the necessity to remand these issues for other reasons, VA treatment records dated since April 2018 should be obtained prior to readjudication of the remanded issues. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated since April 2018. 2. After completing the above and any other appropriate development, schedule the Veteran for an appropriate VA examination to determine the current nature and etiology of her claimed gynecological disorder. The record, to include a copy of this Remand, must be made available to the examiner for review and the examiner must state in the examination report that the record has been reviewed. All indicated tests should be performed. The examiner should identify all gynecological disorders found to be present, including possible recurrent ovarian cysts with resulting adhesions, since November 2012. In this regard, he/she should reconcile the September 2012 findings of ovarian cysts with the May 2018 VA examination finding of no gynecological disability. With respect to each disorder diagnosed, the examiner should then offer an opinion as to whether it is at least as likely as not related to the Veteran’s military service. A complete rationale should be given for all opinions and conclusions expressed. 3. After completing the above and any other appropriate development, schedule the Veteran for an appropriate VA examination to determine the current nature and etiology of her claimed skin disorder. The record, to include a copy of this Remand, must be made available to the examiner for review and the examiner must state in the examination report that the record has been reviewed. All indicated tests should be performed. The examiner should identify all skin disorders found to be present (other than acne and sarcoidosis), including dermatitis, since November 2012. In this regard, he/she should reconcile the September 2012 findings of contact dermatitis with the May 2018 VA examination finding of no contact dermatitis. With respect to each disorder diagnosed (other than acne and sarcoidosis), the examiner should then offer an opinion as to whether it is at least as likely as not related to the Veteran’s military service. A complete rationale should be given for all opinions and conclusions expressed. 4. Readjudicate the claim. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD April Maddox, Counsel