Citation Nr: 18151646 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 15-43 796 DATE: November 20, 2018 ORDER Entitlement to service connection for a dental disorder is denied. Entitlement to an initial compensable evaluation for service-connected hemorrhoids is denied. Entitlement to an initial 30 percent evaluation for service-connected dermatitis is granted. Entitlement to an evaluation higher than 10 percent on and after September 21, 2015 for service-connected dermatitis is denied. Entitlement to an initial 30 percent evaluation, but no higher, for service-connected migraine headaches is granted. Entitlement to an evaluation higher than 30 percent on and after September 21, 2015 for service-connected migraine headaches is denied. Entitlement to an initial evaluation higher than 10 percent for service-connected left wrist strain is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service-connection for lumbar strain with lumbar disc disease and degenerative arthritis is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for dermatitis is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for right knee patellofemoral syndrome and shin splints is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for left knee patellofemoral syndrome and shin splints is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for hemorrhoids is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for migraine headaches is denied. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for left wrist strain is denied. REMANDED Entitlement to an initial rating higher than 20 percent for service-connected lumbar strain with degenerative disc disease is remanded. Entitlement to an initial compensable evaluation, and to an evaluation higher than 10 percent on and after September 21, 2015 for service-connected left knee patellofemoral syndrome and shin splints is remanded. Entitlement to an initial compensable evaluation for service-connected right knee patellofemoral syndrome and shin splints is remanded. FINDINGS OF FACT 1. The Veteran does not have a diagnosed dental disorder eligible for VA compensation. 2. Throughout the appeal, the Veteran’s hemorrhoids have been small to moderate, and productive of mild to moderate symptoms. 3. Prior to September 21, 2015, the Veteran’s dermatitis covered more than 5 but less than 20 percent of the total body area, and was treated with oral antibiotics and topical cream for 6 weeks or more, but did not require constant treatment. 4. On and after September 21, 2015, the Veteran’s dermatitis covered more than 5 but less than 20 percent of the total body area and required treatment with topical antifungal cream for 6 weeks or more, but not constant use. 5. For the entire period on appeal, the Veteran’s migraines resulted in characteristic prostrating attacks of migraine and non-migraine pain that occurred once per month but did not result in severe economic inadaptability. 6. For the entire period on appeal, the Veteran has not been shown to have left wrist ankylosis. 7. The Veteran was discharged from active duty on March 16, 2013 and service connection for left wrist strain, lumbar strain with degenerative arthritis, dermatitis, right and left knee patellofemoral syndrome with shin splints, hemorrhoids, and migraines was granted from March 17, 2013 onward. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a dental disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.381, 4.150 (2018). 2. The criteria for entitlement to an initial compensable evaluation for service-connected hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114 Diagnostic Code 7336 (2018). 3. The criteria for entitlement to an initial 30 percent evaluation for service-connected dermatitis have been met prior to September 21, 2015. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.118 Diagnostic Codes (DCs) 7800 – 7806 (2018); 83 Fed. Reg. 32, 592 (July 13, 2018). 4. The criteria for entitlement to an evaluation higher than 10 percent on and after September 21, 2015 for service-connected dermatitis are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.118 Diagnostic Codes (DCs) 7800 – 7806 (2018); 83 Fed. Reg. 32, 592 (July 13, 2018). 5. The criteria for entitlement to an initial 30 percent evaluation for service-connected migraine headaches have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8100 (2018). 6. The criteria for entitlement to an evaluation higher than 30 percent on and after September 21, 2015 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.21, 4.124a, Diagnostic Code 8100 (2018). 7. The criteria for entitlement to an initial evaluation higher than 10 percent for service-connected left wrist strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.59, 4.71a Diagnostic Codes 5214, 5215 (2018). 8. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for lumbar strain with lumbar disc disease and degenerative arthritis have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 9. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for dermatitis have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 10. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for right knee patellofemoral syndrome and shin splints have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 11. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for left knee patellofemoral syndrome and shin splints have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 12. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for hemorrhoids have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 13. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for migraine headaches have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). 14. The criteria for entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service connection for left wrist strain have not been met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served under honorably conditions on active duty in the U.S. Marine Corps from March 2009 until March 2013. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. During the pendency of the appeal, an August 2014 rating decision granted entitlement to service connection for right and left lower extremity radiculopathy and assigned respective ratings of 10 and 20 percent effective March 27, 2014. The Veteran initially filed an NOD to the ratings and effective dates assigned in the August 2014 decision, but did not perfect the appeal after issuance of a March 2017 statement of the case. Thus, those issues are not in appellate status and will not be considered along with the Veteran’s lumbar spine increased rating claim. An October 2015 rating decision increased the evaluation of service-connected headaches to 30 percent effective September 21, 2015. An August 2018 decision increased the evaluation of left knee patellofemoral syndrome and shin splints to 10 percent effective July 20, 2018. As higher evaluations are available throughout the appeal period for the headache and left knee disorders, those increased rating claims remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). 1. Entitlement to service connection for a dental disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). Notwithstanding the foregoing, under current VA regulations, service connection for VA compensation purposes is only available for specified dental and oral conditions which are specifically delineated in 38 C.F.R. § 4.150. A veteran may be entitled to service connection for other dental conditions not listed in section 4.150, including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. 38 U.S.C. § 1712 (2012); 38 C.F.R. §§ 3.381(a), 17.161 (2018). The dental and oral conditions which may be service-connected for VA compensation purposes are delineated at 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916 (2018) and include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible (Diagnostic Code 9900). Compensation is also available for loss of teeth but only if such loss is due to loss of substance of body of maxilla or mandible due to trauma or due to disease such as osteomyelitis, but not due to the loss of the alveolar process from periodontal disease. 38 C.F.R. § 4.150, Diagnostic Code 9913 (2018). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence of the record; every item of evidence does not have the same probative value. When there is an approximate balance of evidence for and against the issue, reasonable doubt will be resolved in the Veteran’s favor. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The evidence of record fails to show a diagnosed dental disorder for which VA compensation may be paid. The Veteran underwent a VA dental disorder examination in November 2012, at which time he reported that he had teeth sensitivity to cold or warm that he treated with Tylenol, but denied being diagnosed with a dental condition. The Veteran did not have any anatomical loss or bony injury of the mandible or maxilla. The Veteran did not have any anatomical loss or bony injury of any of his teeth. The Veteran had never been diagnosed with osteomyelitis or osteoradionecrosis of the mandible, and did not have any benign or malignant neoplasms or metastases related to any diagnosis. Dental x-rays were within normal limits. In a February 2013 report of medical history, the Veteran indicated he had severe tooth trouble, which the physician clarified was sensitivity to hot and cold, with a history of teeth removal. Tooth sensitivity is not a dental condition for which service connection may be granted, and the Veteran has not been shown to have any other dental disorder eligible for VA compensation according to the November 2012 VA examination. There is no evidence to the contrary. Therefore, there is no reasonable doubt to be resolved and the claim of entitlement to service connection for a dental disorder is denied. 38 C.F.R. § 3.102 (2018); Gilbert, 1 Vet. App. at 53. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). 2. Entitlement to an initial compensable evaluation for service-connected hemorrhoids The Veteran desires an initial compensable evaluation for hemorrhoids. Hemorrhoids are rated under 38 C.F.R. § 4.114, DC 7336 (2018). A maximum 20 percent evaluation is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. A 10 percent evaluation is assigned for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A noncompensable evaluation is assigned for mild or moderate hemorrhoids. In this case, the evidence shows the Veteran’s hemorrhoids have been mild to moderate throughout the appeal period, and small to moderately sized. The Veteran underwent VA examinations in November 2012 and September 2015. In November 2012, the examiner noted the Veteran had small external hemorrhoids with recurrent symptoms once every 3 months lasting 1 to 2 weeks at a time. The examiner characterized the hemorrhoids as mild or moderate, and the hemorrhoids did not result in anemia. There were no other relevant findings for hemorrhoids. In September 2015, the Veteran reported intermittently symptomatic hemorrhoids with occasional bleeding and local discomfort, as well as intermittent prolapse of internal hemorrhoids. Examination showed multiple moderate sized external hemorrhoids and mildly prolapsing internal hemorrhoids, but no fissures or fistulae. There was no anemia, no thrombosis, and no active bleeding. In sum, the relevant evidence demonstrates that the Veteran’s hemorrhoids have been mild to moderate in severity and small to moderate in size. There is no evidence of thrombosis, irreducible hemorrhoids, excessive redundant tissues, persistent bleeding, anemia, or fissures. Therefore, the criteria for a compensable evaluation for hemorrhoids have not been more nearly approximated at any point during the appeal period and the claim for increase is denied. 38 C.F.R. § 4.114 DC 7336, Gilbert, 1 Vet. App. at 53. 3. Entitlement to an initial evaluation higher than 10 percent for service-connected dermatitis The Veteran asserts his service-connected dermatitis warrants a higher evaluation. Dermatitis is rated according to 38 C.F.R. § 4.118 DC 7806. A 60 percent rating is assigned for dermatitis or eczema affecting more than 40 percent of the entire body or exposed areas, or when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. A 30 percent rating is assigned when dermatitis or eczema affect 20 to 40 percent of the entire body or exposed areas, or when systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of 6 weeks or more during the past 12-month period, but not constantly. A 10 percent rating is assigned when dermatitis or eczema affects at least 5 percent but less than 20 percent of the entire body or exposed areas, or when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than 6 weeks during the past 12-month period. Prior to August 13, 2018 a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. Generally, topical is defined as pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Systemic pertains to or affects the body as a whole. See Dorland’s Illustrated Medical Dictionary 1865, 1940 (32d ed. 2012). Effective August 13, 2018, the regulations regarding skin disabilities were amended. After that date, the regulations provide that systemic therapy is treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin. See 83 Fed. Reg. 32, 592 (July 13, 2018). Effective August 13, 2018, DC 7806 is to be evaluated under the General Rating Formula for the Skin. See 38 C.F.R. § 4.118. The General Rating Formula for the Skin assigns a 60 percent rating when characteristic lesions affect more than 40 percent of the entire body or exposed areas; or when constant or near-constant systemic therapy is required including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period (hereinafter “systemic therapy.”) A 30 percent rating is assigned when characteristic lesions affect more than 20 to 40 percent of the entire body or exposed areas; or when systemic therapy is required for a total duration of 6 weeks or more but not constantly over the past 12-month period. A 10 percent rating is assigned when characteristic lesions affect at least 5 percent but less than 20 percent of the entire body or exposed areas, or when intermittent systemic therapy is required for a total duration of less than 6 weeks over the past 12-month period. Or, the disorder may be rated according to DCs 7800 to 7805 depending on the predominant disability. The changes effective August 13, 2018 are applicable for the whole period of claims that were pending on August 13, 2018 if that yields a more favorable result to the Veteran. See 83 Fed. Reg. 32, 592 (July 13, 2018). The evidence shows that entitlement to an initial rating of 30 percent prior to September 21, 2015 is warranted. At a November 2012 VA examination, the examiner noted dermatitis that covered more than 5 but less than 20 percent of the total body area, and none of the total exposed area. There was no scarring or disfigurement of head, face, or neck; no benign or malignant skin neoplasms; and no systemic manifestations due to any skin disease. The Veteran used oral antibiotics and topical cream to treat the rash 6 weeks or more but not constantly. Oral antibiotic constitutes systemic therapy because it is administrated orally and potentially affects the entire body. See 83 Fed. Reg. 32, 592 (July 13, 2018). Thus, the criteria for a 30 percent initial evaluation for a skin condition that requires systemic therapy 6 weeks or more but not constant are met. The dermatitis did not cover more than 40 percent of the total body area or total exposed areas, and did not require constant systemic therapy; therefore, entitlement to an initial evaluation higher than 30 percent is not warranted. There is no related scarring or disfigurement, therefore there are no other potentially applicable diagnostic codes that would allow for an initial rating higher than 30 percent. In sum, prior to September 21, 2015 the criteria for an initial 30 percent evaluation, but no higher, are met. See 38 C.F.R. § 4.118 DC 7806; see 83 Fed. Reg. 32, 592 (July 13, 2018). On and after September 21, 2015, the criteria for an evaluation higher than 10 percent for dermatitis are not met. The Veteran underwent another VA skin disease examination on September 21, 2015. The examiner noted a rash on the right buttock and natal cleft that covered at least 5 but less than 20 percent of the total body area and none of the total exposed area. There was no scarring of the head, face, or neck; and no systemic manifestations. Over the prior 12 months, the rash had only required treatment with topical antifungal cream for 6 weeks or more but not constantly. The Veteran did not report oral medications at this examination or in any other statements of record. When dermatitis covers more than 5 but less than 20 percent of the total body are and requires no more than topical therapy, a 10 percent evaluation is assigned. Therefore, on and after September 21, 2015 the criteria for an evaluation higher than 10 percent for service-connected dermatitis is not warranted under either the old or new regulations. See 38 C.F.R. § 4.118 DC 7806; see 83 Fed. Reg. 32, 592 (July 13, 2018). 4. Entitlement to an initial compensable evaluation, and to an evaluation higher than 30 percent on and after September 21, 2015 for service-connected migraine headaches The Veteran’s migraine headache condition is rated according to 38 C.F.R. § 4.124a DC 8100. DC 8100 provides for a 50 percent evaluation when migraines cause very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent evaluation is assigned for characteristic prostrating attacks occurring on an average of once a month over the last several months. A 10 percent evaluation is assigned for characteristic prostrating attacks averaging one in 2 months over the last several months. The Veteran is competent to report symptoms of headaches that require medication, including pain, frequency of episodes of migraine headaches, and the severity of the migraines as these symptoms are observable and within the realm of his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). In addition, he is competent report the number of days he has missed work due to the symptomatology of his migraine headaches. The criteria for an initial 30 percent evaluation prior to September 21, 2015 are met based on characteristic prostrating attacks that occurred at least once per month, but did not result in severe economic inadaptability. The Veteran underwent a VA examination in November 2012, at which time he reported headaches that occurred once every two weeks and lasted hours to weeks. The examiner identified symptoms of constant head pain that worsened with physical activity, with nausea, sensitivity to light and sound, and changes in vision; however, the examiner explained that the Veteran did not have characteristic prostrating attacks and that the headache condition did not impact the Veteran’s ability to work. The available VA treatment records list migraines in the Veteran’s problem list, but there are no treatment records directly addressing migraine symptoms other than a November 2014 record where it was noted the Veteran had headache pain rated at a 4 on a scale of 1 to 10. The Veteran underwent another VA examination on September 21, 2015. At that time, the Veteran reported migraine headaches occurring once or twice per month and usually lasting for several hours. The headaches were accompanied by light and sound sensitivity with scotomata. He usually had to rest in a quiet and dark room until the symptoms subsided. The Veteran reported his headache frequency and intensity were about the same as when he was previously examined in 2012. The examiner identified the following symptoms of headache and migraines: pulsating/throbbing pain on both sides of the head, sensitivity to light and sound, and vision changes. The examiner then reported the Veteran had characteristic prostrating attacks of migraine/non-migraine pain that occurred once every month but that did not produce severe economic inadaptability. Resolving doubt in the Veteran’s favor, the criteria for a 30 percent evaluation are met for the entire period on appeal. Although the 2012 VA examiner found that the Veteran did not have prostrating attacks of migraine pain, the 2015 examiner documented the same symptoms as the 2012 examiner and found the Veteran did have characteristic prostrating attacks of migraine/non-migraine pain that occurred once every month. The Veteran has similarly testified at the 2015 exam that his headache severity was unchanged in 2015 as compared to when he was initially examined in 2012, and he is competent to report his symptoms and there is no reason to doubt his credibility. Therefore, for the entire period on appeal the criteria for a 30 percent evaluation for headaches are met. For the entire period on appeal, the criteria for an evaluation higher than 30 percent are not met as none of the available evidence shows the Veteran’s headaches resulted in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The 2012 VA examiner stated there were no effects on employment, and the 2015 VA examiner found that there were effects as the Veteran had to lay down in a dark room upon a headache. But neither examiner found the headaches caused severe economic inadaptability. 5. Entitlement to an initial evaluation higher than 10 percent for service-connected left wrist strain The Veteran seeks entitlement to an initial evaluation higher than 10 percent for his left wrist strain. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2018). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2018). The Veteran’s left wrist strain is rated according to 38 C.F.R. § 4.71a DC 5215 for limitation of motion of the wrist. That DC provides for a 10 percent evaluation when dorsiflexion of the wrist is less than 15 degrees, or when palmar flexion is limited in line with the forearm. Higher evaluations for the wrist are available under DC 5214 when there is favorable or unfavorable ankylosis of the wrist. In this case, the Veteran is not entitled to a rating higher than 10 percent for the left wrist strain at any point on appeal as he does not have ankylosis of the left wrist. The Veteran underwent VA examinations in November 2012 and September 2015, and both examiners reported that the Veteran did not have ankylosis of the left wrist. As there is no evidence of ankylosis at any point during the appeal period, there is no basis to grant a higher rating for limitation of motion of the left wrist. In sum, the claim of entitlement to an initial evaluation higher than 10 percent for left wrist strain is denied. There are no other potentially applicable diagnostic codes. The Veteran reported symptoms of pain in motion of the joint and at rest that impacted his ability to drive and lift heavy equipment. See e.g. November 2012 VA examination report. At the time of the November 2012 VA examination, left palmar flexion was limited to 65 degrees and dorsiflexion was limited to 60 degrees. In September 2015, the range of motion of the left wrist was normal. While the Veteran does not meet the criteria for a compensable evaluation under DC 5215, he is entitled to a compensable evaluation for an actually painful joint shown to produce some functional impairment. See 38 C.F.R. § 4.40, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). In sum, the Veteran’s left wrist symptoms are fully contemplated by 10 percent evaluation and there is no other potentially applicable diagnostic code that would yield a higher rating. Effective Date Generally, the effective date of an award of disability compensation based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400 (2018). A Veteran is not entitled to service-connected compensation while they remain on active duty. 38 U.S.C. § 5110(b)(1). 6. – 12. Entitlement to an effective date prior to March 17, 2013 for the grant of entitlement to service-connection for left wrist strain lumbar strain with lumbar disc disease and degenerative arthritis, dermatitis, right and left knee patellofemoral syndrome and shin splints, hemorrhoids, and migraine headaches. The Veteran perfected an appeal on the issues of entitlement to earlier effective dates for the grants of service connection for left wrist strain, lumbar strain with lumbar disc disease and degenerative arthritis, dermatitis, right and left knee patellofemoral syndrome and shin splints, hemorrhoids, and migraine headaches. Service connection for the mentioned disabilities was granted effective March 17, 2013. The Veteran was discharged from the U.S. Marine Corps on March 16, 2013 according to his Certificate of Release or Discharge from Active Duty. Thus, the earliest date that he was entitled to receive VA benefits was from March 17, 2013 onward. The claims of entitlement to earlier effective dates for the grants of service connection for left wrist strain, lumbar strain with lumbar disc disease and degenerative arthritis, dermatitis, right and left knee patellofemoral syndrome and shin splints, hemorrhoids, and migraine headaches must therefore be denied. REASONS FOR REMAND 1. Entitlement to an initial rating higher than 20 percent for service-connected lumbar strain with degenerative disc disease This issue is remanded to obtain an adequate VA examination, and outstanding private and VA treatment records. Remand is also necessary to allow the AOJ to review relevant evidence obtained since the October 2015 statement of the claim (SOC). In increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. For example, a VA examination report is not adequate when the VA examiner failed to elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record- including the veteran’s lay information-or explain why she or he could not do so. Sharp, 29 Vet. App. at 34-35. The Veteran underwent VA back examinations in November 2012, September 2015, and August 2018. In November 2012 the Veteran reported flares of back symptoms that impacted his ability to lift heavy objects, and pain with bending, squatting, and prolonged standing. The examiner provided no opinion on the degree of additional functional impairment during a flare of symptoms. In September 2015, the Veteran reported flare ups of back pain and stiffness. The examiner stated they were unable to say whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during a flare without resorting to mere speculation as the Veteran was not flared at the time of the examination. In August 2018, the Veteran reported flares of back pain that caused his back to lock up without warning. The examiner stated they were unable to say whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during a flare without resorting to mere speculation. The examiner explained there was no conceptual or empirical basis for making such a determination without directly observing function under those conditions. None of the VA examiners of record has adequately addressed the degree of additional functional impairment experienced by the Veteran during flares per the VA Clinicians Guide as explained by the Court in Sharp v. Shulkin. Therefore, remand is required to obtain an adequate VA examination. Remand is required to attempt to obtain private medical records and to obtain VA treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2018). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). VA has a duty to assist also includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including VA medical records. 38 C.F.R. § 3.159(c)(2). VA will end its efforts to obtain records only where it concludes that the records sought do not exist or that further efforts to obtain those records would be futile, such as where the Federal department or agency advises VA that the requested records do not exist or the custodian does not have them. 38 C.F.R. § 3.159(c)(2). The record indicates that the Veteran receives private back treatment and those records have not been obtained. An October 2014 VA treatment record documents the Veteran had been going to Wellness Solutions for back treatment, and at a March 2015 VA appointment the Veteran indicated he continued to receive private treatment for his back. On remand, VA should attempt to identify and obtain the outstanding private treatment records. Additionally, of record are VA treatment records through October 2015. On remand, all outstanding treatment records from October 2015 onward should be obtained and associated with the claims folder. Last, the Veteran underwent another VA back examination in August 2018 and the most recent SOC was issued in October 2015. On remand the AOJ will have the opportunity to consider the 2018 VA examination. 2. – 3. Entitlement to higher evaluations for service-connected left and right knee patellofemoral syndrome and shin splints The issues of entitlement to higher evaluations for left and right knee disorders are remanded to obtain an adequate VA examination that addresses the additional degree of functional impairment during a flare of knee symptoms. Sharp, 29 Vet. App. at 34-35. The Veteran underwent VA knee examinations in November 2012, September 2015, and August 2018. In November 2012, the Veteran report flare ups of knee pain that limited his ability to walk, bend his knees, and caused pain going up stairs. The examiner provided no opinion on the additional degree of functional impairment experienced during a flare of knee symptoms. In September 2015, the Veteran reported flares of knee pain, crepitus, and weakness. The 2015 examiner stated they were unable to state whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during flares without resorting to mere speculation because the Veteran was not currently experiencing a flare of symptoms. In August 2018, the Veteran reported flares of moderately severe knee symptoms that were relieved by stopping the precipitating activity until the symptoms abated. The examiner reported they were unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during a flare without resorting to mere speculation. The examiner explained that there was no conceptual or empirical basis for making such a determination without directly observing functioning under those conditions. Again, none of the examiners provided an adequate opinion on the degree of functional impairment during a flare, or otherwise adequately explained why such an opinion could not be provided. Thus, remand is required to obtain an adequate VA examination. On remand, the AOJ will have the opportunity to review the August 2018 VA examination in connection with the appeal, which was received after the most recent October 2015 SOC. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment from October 2015 onward. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Specifically, request that the Veteran provide the necessary information to obtain outstanding records from Wellness Solutions. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected lumbar spine disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. (a.) The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must address whether there is pain of the back in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. (b.) If the Veteran describes flare-ups, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. (c.) Determine whether the Veteran has had any incapacitating episodes due to previously identified intervertebral disc syndrome. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected right and left knee disorders. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. (a.) The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must address whether there is pain of the left or right knee in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. (b.) If the Veteran describes flare-ups, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. (c.) Determine whether the Veteran’s previously diagnosed bilateral shin splints result in slight, moderate, or marked knee or ankle disability. 5. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Smith, Associate Counsel