Citation Nr: 18154351 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 17-37 570 DATE: November 29, 2018 ORDER New and material evidence having been received, the claim of service connection for a right hip disorder is reopened; the appeal is granted to this extent only. New and material evidence having been received, the claim of service connection for left hand carpal tunnel syndrome is reopened; the appeal is granted to this extent only. Service connection for right thumb stenosing tenosynovitis is denied. Service connection for a neck disorder is denied. Service connection for bilateral tinnitus is granted. Service connection for sleep apnea is granted. Service connection for chronic fatigue syndrome (CFS) is denied. Service connection for allergic rhinitis is denied. Service connection for pain in right hand with numbness and tingling is denied. Service connection for left upper extremity peripheral neuropathy is denied. Service connection for right upper extremity peripheral neuropathy is denied. Service connection for left hand carpal tunnel syndrome is denied. Service connection for a status-post hernia surgical scar is denied. Service connection for transient ischemic attacks is denied. A 10 percent rating for left great toe bunion is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for chronic coccydynia is denied. An initial 10 percent rating for scar status-post left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. A 30 percent rating, but no higher, for migraine headaches is granted; subject to the laws and regulations governing the payment of monetary benefits. Prior to November 22, 2017, an initial rating in excess of 30 percent for major depressive disorder (MDD) is denied. Since November 22, 2017, a 50 percent rating, but no higher, for MDD is granted; subject to the laws and regulations governing the payment of monetary benefits. REMANDED Service connection for right ear pain is remanded. Service connection for a left hip disorder is remanded. Service connection for a right hip disorder is remanded. Service connection for a right ankle disorder is remanded. Service connection for urinary incontinence is remanded. Service connection for endometriosis is remanded. Service connection for scars status-post cesarean is remanded. Service connection for status-post hysterectomy scar is remanded. Service connection for hysterectomy residuals is remanded. Service connection for appendectomy scar is remanded. Service connection for left lower extremity peripheral neuropathy is remanded. Service connection for right lower extremity peripheral neuropathy is remanded. Service connection for left leg tibia pain, to include peripheral neuropathy, is remanded. Entitlement to a rating in excess of 10 percent for degenerative joint disease (DJD) of the left knee is remanded. Entitlement to a rating in excess of 10 percent for DJD of the right knee is remanded. Entitlement to a rating in excess of 10 percent for lumbosacral strain is remanded. Entitlement to a compensable rating for medial epicondylitis (left elbow pain) is remanded. Entitlement to a compensable rating for left distal fibula stress reaction is remanded. Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. In a final decision issued in April 2004, the Agency of Original Jurisdiction (AOJ) denied service connection for right hip pain and left carpal tunnel syndrome. 2. Evidence associated with the record since the final April 2004 denial of service connection for right hip pain and left carpal tunnel syndrome is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the claims. 3. Service treatment records do not demonstrate complaints of, treatment for, or a diagnosis related to right thumb stenosing tenosynovitis and the record does not reflect assertions that such is related to an event, injury, or illness during service. 4. The preponderance of the competent evidence does not demonstrate the Veteran’s DDD of the cervical spine is related to an in-service event, injury, or illness. 5. Resolving all doubt in the Veteran’s favor, the Veteran’s tinnitus is related to noise exposure during service. 6. Resolving all doubt in the Veteran’s favor, the Veteran’s sleep apnea was caused or aggravated by service-connected MDD. 7. The competent evidence does not reflect a current diagnosis of CFS or other sleep disorder separate and distinct from the Veteran’s service-connected disabilities of sleep apnea and MDD. 8. The competent evidence does not demonstrate a current diagnosis of allergic rhinitis, other sinus disorder, or symptoms thereof. 9. Service treatment records do not reflect complaints of, treatment for, or a diagnosis related to right hand disorder, and the record does not reflect assertions that such is related to an in-service event, injury, or illness. 10. The competent evidence does not reflect a diagnosis of right or left upper extremity peripheral neuropathy or carpal tunnel syndrome or symptoms thereof that cause functional impairment. 11. A status-post hernia surgical scar pre-existed entry into service and the competent evidence does not show such was aggravated beyond the natural progression by service. 12. The competent evidence does not demonstrate a separate and distinct diagnosis of transient ischemic attacks for which service connection may be granted. 13. Throughout the pendency of the appeal, the Veteran’s left great toe bunion is manifested by pain. 14. Throughout the pendency of the appeal, the Veteran is in receipt of the highest schedular rating for chronic coccydynia. 15. Throughout the pendency of the appeal, the Veteran’s scar status-post left knee is manifested by pain. 16. Throughout the pendency of the appeal, the Veteran has 4-5 prostrating migraines per month that are prostrating but that are not prolonged or productive of severe economic inadaptability. 17. Prior to November 22, 2017, the Veteran’s MDD was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform due to her psychiatric symptomatology without more severe manifestations that more nearly approximated occupational and social impairment with reduced reliability. 18. As of November 22, 2017, the Veteran’s MDD was productive of occupational and social impairment with reduced reliability and productivity due to her psychiatric symptomatology without more severe manifestations that more nearly approximated occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The April 2004 rating decision denying service connection for right hip pain and left carpal tunnel syndrome is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. The criteria to reopen a claim of entitlement to service connection for right hip disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria to reopen a claim of entitlement to service connection for left hand carpal tunnel syndrome have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for entitlement to service connection for right thumb stenosing tenosynovitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for a neck disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1133, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for bilateral tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. The criteria for entitlement to service connection for CFS have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for entitlement to service connection for allergic rhinitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for entitlement to service connection for pain in right hand with numbness and tingling have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for entitlement to service connection for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for entitlement to service connection for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for entitlement to service connection for left hand carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 14. The criteria for service connection for status-post hernia surgical scar have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.306. 15. The criteria for service connection for transient ischemic attacks have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 16. As of June 2, 2014, the criteria for a 10 percent rating for left great toe bunion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5280. 17. The criteria for a rating in excess of 10 percent for chronic coccydynia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5298. 18. The criteria for to an initial 10 percent rating for scar status-post left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.118, DC 7800-7805. 19. As of June 2, 2014, the criteria for a 30 percent rating for migraine headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8100. 20. Prior to November 22, 2017, the criteria for an initial rating in excess of 30 percent for MDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9434. 21. Since November 22, 2017, the criteria for a rating of 50 percent for MDD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, DC 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1984 to February 2004. The issues in this case are primarily on appeal from a May 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. However, the issue of service connection for endometriosis arises from a May 2017 rating decision. The Board finds the issue of entitlement to a total disability rating based on individual employability due to service-connected disability has not yet been raised as part of this appeal under Rice v. Shinseki, 22 Vet. App. 447 (2009). From the most recent indication, the Veteran is still in gainful full-time employment that is not protected or marginal. If circumstances have changed, the Veteran should file a formal claim for such. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).   New and Material Evidence 1. Whether new and material evidence has been received to reopen a claim for service connection for a right hip disorder. 2. Whether new and material evidence has been received to reopen a claim for service connection for left hand carpal tunnel syndrome. Finality By an April 2004 rating decision, claims of service connection for right hip pain and carpal tunnel syndrome were denied. The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. Thereafter, nothing further regarding the claim was received until the present claim to reopen in June 2014. No new evidence, notice of disagreement, or service treatment records were received by VA within one year of the issuance of the April 2004 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Reopen Legal Criteria VA may reopen and review a claim, which has been previously denied, if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) held in Shade v. Shinseki that the language of 38 C.F.R. § 3.156 (a) creates a low threshold to reopen, and emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” 24 Vet. App. 110, 120-21 (2010). The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). For purposes of the new and material analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). 3 Vet. App. 510, 512-13 (1992). Right Hip Since the final April 2004 rating decision, evidence received reflects a diagnosis of right hip DJD. As this evidence is new and raises a reasonable possibility of substantiating the claim, the Board finds this evidence sufficient to reopen the claim for service connection for a right hip disorder. 38 C.F.R. § 3.156. Left Hand Carpal Tunnel Syndrome Since the final April 2004 rating decision, the Veteran has reported some left upper extremity pain and numbness, also claimed as peripheral neuropathy. While these symptoms are similar to those reported on the May 2003 VA examination report, the Board finds the Veteran’s lay statements may shed new light on a current diagnosis. Notably, the RO has implicitly reopened the claim and decided the service connection claim on the merits. As a result, the Board finds such evidence is new and raises a reasonable possibility of substantiating the claim, and therefore such is reopened. 38 C.F.R. § 3.156. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(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.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection for a “chronic disease,” including arthritis and organic diseases of the nervous system such as tinnitus, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1131; 38 C.F.R. §§ 3.307, 3.309. For preexisting disorders noted upon entry into service, service connection is available only on the basis of aggravation beyond the natural progression of the disorder. 38 C.F.R. § 3.306. Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. 3. Service connection for right thumb stenosing tenosynovitis The Veteran is claiming that her right thumb stenosing tenosynovitis is related to service. The Veteran’s service treatment records (STRs) are silent as to an injury or symptoms related to stenosing tenosynovitis, and the Veteran has not stated how she believes her stenosing tenosynovitis is related to service. Therefore, the Board finds the record does not contain an indication that stenosing tenosynovitis is related to service, and VA examination would not illuminate the nature of the Veteran’s claim. Therefore, no VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). On this basis, service connection for stenosing tenosynovitis is denied. 4. Service connection for a neck disorder The Veteran is claiming service connection for a cervical spine disorder. There are several in-service complaints of neck pain. One notation of complaints of in-service neck pain after a motor vehicle accident from 1997 is of record. She also reported neck pain in September 2006 after playing football for physical training. Recently, the Veteran submitted medical treatment records from September 2007 showing that her cervical spine disorder had its onset after a 2007 motor vehicle accident. Diagnosis at that time was cervical strain with radiculopathy. The Veteran has submitted a September 2018 statement in which she describes a February 1989 physical training neck injury as well as her current symptoms. However, the Veteran does not describe a connection between the two. For instance, the Veteran does not indicate pain since her 1989 injury. The Veteran was afforded a VA examination of her cervical spine in April 2015. She was diagnosed with degenerative disc disease (DDD) of the cervical spine. The examiner opined that her cervical spine disorder was less likely than not related to service. The examiner characterized her neck complaint during service as acute as there were no complaints during active duty service thereafter, a separation examination was negative for neck complaints, and the Veteran’s military occupational specialty (MOS) was not indicative of neck injuries. The Board finds the examiner’s medical opinion persuasive as it was based on a review of the evidence and included adequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). Specifically, the examiner’s opinion indicates that there is not a relationship between DDD of the cervical spine and any in-service injuries. This includes on the basis of continued symptomatology, as the examiner noted no continuing complaints in medical records of a neck disorder. Further, the examiner’s opinion is consistent with the September 2007 treatment records indicating the onset of current neck pain after a 2007 motor vehicle accident. The Veteran’s report of a February 1989 or 1997 neck injury is not to the contrary as she has not indicated on-going symptoms since the injury or claimed a connection between her current symptoms and the injury. Therefore, the Board finds that the Veteran’s claimed neck disorder is less likely than not related to service, and service connection for a neck disorder is denied. 5. Service connection for bilateral tinnitus The Veteran has been diagnosed with tinnitus, which she describes as an intermittent high-pitched ringing and humming in both ears that makes hearing others difficult. In a September 2018 statement, she states that due to her work as a finance specialist and other military experiences, she was exposed to frequent varying levels of noise trauma including tanks, track vehicles, generators, helicopters, jet engines, flight line noises, and airplanes, as well as rifles and grenades during basic training. Hearing protection was not routinely or correctly worn. Given the Veteran’s competent lay statements, the Board finds she has a current diagnosis of tinnitus and a credible report of in-service noise exposure. Thus, the only inquiry to resolve is whether her current tinnitus is related to her in-service noise exposure. In this regard, the Veteran was afforded a VA examination of her tinnitus in April 2015. The examiner opined that tinnitus was less likely than not related to service. Even though the Veteran claimed exposure to loud noise during live fire field training, her duty was military pay technician, for which the examiner found there is a low probability of acoustic trauma. Conversely, the Veteran submitted a September 2018 medical opinion from Dr. U. who opined that the Veteran’s tinnitus was at least as likely as not related to service. In support, she noted that, although the Veteran’s MOS had a low probability of acoustic trauma, in light of the Veteran’s non-MOS noise exposure, acoustic trauma should be conceded. The Board, in this instance, finds Dr. U.’s opinion more convincing, as she cited lay statements of record in support of her conclusion. See Nieves-Rodriguez, supra. By contrast, the VA examiner’s negative opinion cites only the Veteran’s MOS and disregards her lay statements of noise exposure without a medical explanation for why such exposure is insignificant or irrelevant to the nexus inquiry. Thus, the Board finds that the Veteran’s tinnitus is related to noise exposure during service and grants service connection for tinnitus. 6. Service connection for sleep apnea The Veteran is claiming service connection for sleep apnea. She has variously described the disorder as CFS and sleep disturbance. She states that she developed sleep apnea secondary to MDD, which led to weight gain. Specifically, she notes that she weighed 105 pounds upon entry to service, 130 pounds upon leaving service, and now weighs 140 pounds. She now uses a continuous positive airway pressure (CPAP) machine. In September 2018, Dr. U. submitted a completed Disability Benefits Questionnaire (DBQ), in which an October 2014 diagnosis of obstructive sleep apnea was reported. She noted the Veteran’s weight gain and sleep apnea symptoms. Dr. U. opined that the Veteran’s sleep apnea was caused or aggravated by her service-connected MDD and, specifically, weight gain related to and occurring after the onset of MDD. The Board notes Dr. U.’s medical opinion is the only one of record. Because it considers the Veteran’s lay statements as to the onset of sleep apnea and provides a link with MDD in the context of the relevant medical concepts and literature, the Board finds this opinion persuasive. Therefore, the Board concludes that the Veteran’s sleep apnea was caused or aggravated by MDD, and service connection for sleep apnea is granted. 7. Service connection for CFS As a result of this decision, the Veteran is service-connected for sleep apnea. In the September 2018 Sleep Apnea and Mental Disorders DBQs, symptoms such as chronic sleep impairment, daytime fatigue, and poor concentration were reported. These symptoms have been attributed to sleep apnea or MDD, and the record does not reflect discussion or indication of a separate sleep or fatigue disorder. Further, the Veteran did not serve in Southwest Asia. See 38 C.F.R. § 3.317 (providing for service connection for undiagnosed illnesses and CFS for those who served in certain southwest Asian countries). VA records do not reflect a diagnosis of CFS. Therefore, the Board finds the record does not demonstrate a current diagnosis of CFS or additional sleep disorder separate and distinct from the Veteran’s now-service-connected sleep apnea. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, service connection for CFS is denied. 8. Service connection for allergic rhinitis The Veteran is claiming that her allergic rhinitis is related to service. Specifically, she states that she began having seasonal sinus congestion and drainage in 2000 during service. Her separation examination notes that she had sinusitis several years prior and used medication for seasonal allergies. She was afforded a VA examination in April 2015. No current diagnosis was noted, and there were no symptoms reported related to a sinus disorder. On this basis, the Board finds the evidence does not reflect a current diagnosis of allergic rhinitis or similar disorder for which service connection may be granted. See Brammer, supra; see also Saunders, supra; Romanowsky, supra; McClain, supra. As a lack of disease process or symptoms have been noted, service connection for allergic rhinitis is denied. 9. Service connection for pain in right hand with numbness and tingling The Veteran is claiming that her right-hand pain with tingling and numbness is related to service. She has not indicated a specific in-service event or incident related to her right-hand pain with tingling and numbness, nor are her STRs instructive on the matter. Therefore, service connection for pain in right hand with numbness and tingling is denied. 10. Service connection for left upper extremity peripheral neuropathy 11. Service connection for right upper extremity peripheral neuropathy 12. Service connection for left hand carpal tunnel syndrome The Veteran is claiming service connection for peripheral neuropathy in each upper extremity as well as left hand carpal tunnel syndrome. Initially, the Board notes the Veteran has not reported any current symptoms related to her right upper extremity, and as such, service connection for right upper extremity peripheral neuropathy is denied. With respect to the left upper extremity, the April 2015 VA examination for her cervical spine shows the Veteran reported numbness in her left arm, which she stated began in 1995 during daily activities such as physical training, work, driving, bending, and sleeping. The Veteran reported that over time the neuropathy pain has increased in severity and lasted longer. On examination, reflexes were normal bilaterally. The examiner opined that the Veteran did not have peripheral neuropathy of the left upper extremity as testing did not reveal any symptoms. Further, although the Veteran has reported pain and numbness in the left upper extremity, she has not indicated that these symptoms cause functional impairment. Here, the Board finds the description of these symptoms overlaps with any complaints regarding left hand carpal tunnel syndrome. Therefore, without evidence of a diagnosed disorder of symptoms causing functional impairment, the Board finds that there is no current left upper extremity peripheral neuropathy, carpal tunnel syndrome disorder, or similar disorder under Saunders. As a result, service connection for left upper extremity peripheral neuropathy and left hand carpal tunnel syndrome are denied. 13. Service connection for a status-post hernia surgical scar Upon review, the Board finds the only indication of hernia in the records is on a medical prescreening report that reflects the Veteran’s report of hernia at birth. The Veteran’s report of medical history upon entry into service also notes an umbilical scar. From the description given by the Veteran and clinician, the Board finds these symptoms appear to be the same as the Veteran’s hernia surgical scar. The Veteran has given no other description of the scar, to include any aggravation of such, and the medical evidence of record does not provide any further insight as to whether such scar has undergone an increase in severity as a result of service. The Veteran also has not claimed that this scar was aggravated by service. Therefore, service connection is denied. 38 C.F.R. § 3.306. 14. Service connection for transient ischemic attacks, to include as secondary to migraine headaches The Veteran is claiming that she has transient ischemic attacks that are related to her headaches. The record does not reflect reports of or a diagnosis of transient ischemic attacks. Rather, the Veteran’s reports appear to be merely a reference to the prostrating attacks she suffers as part of her service-connected migraine headaches, for which the Board discusses in greater detail with regard to the increased rating claim for such. Therefore, as the record does not reflect a separate and distinct diagnosis of, or symptoms related to, transient ischemic attacks, service connection is denied. See Saunders, supra. Increased Ratings Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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 enervation, 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Extraschedular Ratings In her informal hearing presentation, the Veteran has asked for extraschedular consideration for her disability ratings. However, for the ratings adjudicated herein, the Board finds the evidence does not present symptomatology not contemplated by the ratings assigned. See Doucette v. Shulkin, 28 Vet. App. 366, 370-71 (2017). Therefore, the Board finds referral for extraschedular consideration is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). 15. Entitlement to a compensable rating for left great toe bunion VA received the Veteran’s claim for an increased rating for left great toe bunion on June 2, 2014, and as such, the Board will consider the evidence dating back to the one-year period prior to such receipt. The Veteran, in a September 2018 statement, has noted painful motion, swelling, cracking, and popping related to her great toe bunion. She says pain occurs when she to walk long distances, stand for long periods, or does other daily activities. She treats the disability, in part, by tying her shoes loosely. The Veteran’s great left toe bunion is rated under DC 5280, which provides for a maximum 10 percent rating for severe hallux valgus equivalent to amputation of great toe; or for hallux valgus operated with resection of metatarsal head. 38 C.F.R. § 4.71a, DC 5280. The Veteran was afforded a VA examination of her feet in April 2015. The examiner stated that there was no bunion but that the Veteran did have DJD of her great big toe. She reported pain in her foot at that time. This, however, was not reflected on examination. Given the Veteran’s consistent reports of pain in her great big toe throughout the pendency of the appeal, the Board finds the minimum 10 percent rating is warranted. See Southall-Norman, supra (providing that Section 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is being evaluated is predicated on range of motion measurements). Therefore, the Board will grant a 10 percent rating for the Veteran’s great big toe disability, effective June 2, 2014, the date of receipt of her claim. 16. Entitlement to a rating in excess of 10 percent for chronic coccydynia VA received the Veteran’s claim for an increased rating for chronic coccydynia on June 2, 2014, and as such, the Board will consider the evidence dating back to the one-year period prior to such receipt. The Veteran has appealed her rating for chronic coccydynia, as she feels that the rating does not accurately reflect the severity of her symptoms. Throughout the pendency of the appeal, the Veteran’s chronic coccydynia is rated as 10 percent disabling under 38 C.F.R. § 4.71a, DC 5298, which provides a maximum 10 percent rating for partial or complete coccyx removal with painful residuals. The medical evidence of records and statements of the Veteran do not reveal additional symptomatology. Therefore, a rating in excess of 10 percent for chronic coccydynia is denied. 17. Entitlement to an initial compensable rating for scar status-post left knee The Veteran, in a September 2018 statement, reported that her left knee scar is painful. Specifically, she feels a burning, stabbing and aching pain whenever anything touches the scar and when she bends her knee. Relevant to the Veteran’s contention, 38 C.F.R. § 4.71a, DC 7804 provides for a 10 percent rating for one or two painful scars. Higher ratings of 20 percent and 30 percent are warranted for three or four unstable or painful scars and five or more scar unstable or painful scars, respectively. In a September 2018 opinion, Dr. U. has noted that a painful scar warrants a 10 percent rating. Dr. U. did not opine that the Veteran’s scar was manifested by additional symptoms, such as adherence to the underlying tissue, or that objective testing revealed additional scars related to the Veteran’s left knee. Based on this evidence, the Board finds a 10 percent rating, but no higher, is warranted for the Veteran’s left knee scar as it is painful. However, the record does not reflect additional symptomatology and only a single scar has been noted. Any effects on range of motion are contemplated by her left knee rating. 38 C.F.R. § 4.71a, DC 5260. Based on the facts presented, a 10 percent rating is warranted for scar status-post left knee. 18. Entitlement to a compensable rating for migraine headaches VA received the Veteran’s claim for an increased rating for migraine headaches on June 2, 2014, and as such, the Board will consider the evidence dating back to the one-year period prior to such receipt. The Veteran is currently in receipt of a noncompensable rating for migraine headaches. She claims that this rating does not accurately reflect the severity of her symptoms. Specifically, in a September 2018 statement, she wrote that she gets 4-5 headaches per month of varying severity, 3-4 of which will knock her out of commission. The latter render her totally incapacitated and bedridden because of light sensitivity, blind spots, throbbing and pulsating pain, weakness, lightheadedness, noise sensitivity, and nausea. She takes medication for control. She states that she has missed around 10 days of work in the previous year and missed social events in addition to resulting decreased productivity. The Veteran’s headaches are rated under 38 C.F.R. § 4.124a, DC 8100, which provides for a 50 percent rating for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability; a 30 percent rating for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months; and a 10 percent rating for migraines with characteristic prostrating attacks averaging one in 2 months over last several months; and a noncompensable rating for less frequent attacks. Id. In July 2014, a coworker described the Veteran’s headache symptoms. She noted that the Veteran, because of her headaches, had to have someone pick her up and be absent from work for several days. She noted the Veteran’s complaints of aura and bright squiggly lines that dissipate in 20-30 minutes as well as nausea and sensitivity to light and sound. She stated that the Veteran’s headaches occurred 15 days per month and lasted 2-3 hours. Another co-worker confirmed that the Veteran has had to be absent from work and have someone drive her home because of headaches. In April 2015, the Veteran was afforded a VA examination of her headaches. Constant head pain, pain on both sides of the head, and sensitivity to light and sound were noted. The examiner stated that there were no prostrating attacks or functional impact. An August 2015 treatment record reflects the Veteran’s reports of 4-5 days of headaches per month, with 5-7 headache episodes per month. A March 2017 private treatment record from Dr. K. notes that the Veteran has a history of chronic headaches since age 13. They occur at least 15 days per month, with only 1-2 days between headaches. She has visual auras, head pain, nausea, and light and sound sensitivity. In September 2018, Dr. U., after reviewing the Veteran’s lay statements, examining the Veteran, and reviewing the March 2017 notes from Dr. K., opined that the Veteran does, in fact, experience prostrating episodes 4-5 times per month. Dr. Uribe did not indicate that these attacks were “very frequent completely prostrating and prolonged” or “productive of severe economic inadaptability.” Based on the evidence reflecting the severity and frequency of the Veteran’s symptoms throughout the pendency of the appeal, the Board finds that a rating of 30 percent, but no higher, for migraine headaches is warranted. The Veteran has, at times described having more than 4-5 headaches per month; however, the more consistent reports are of only 4-5 headaches per month. Further, the Veteran’s symptoms, while prostrating and for short periods debilitating, are not productive of severe economic inadaptability.” The Veteran has reported missing 10 days and social events over the last year. However, she has not reported having to limit types or duration of work regularly, indicating the inability to progress in or maintain her career because of her headaches. Therefore, the Board finds that a 30 percent rating, but no higher, for migraine headaches is warranted, effective June 2, 2014, the date of receipt of her claim. 19. Entitlement to an initial rating in excess of 30 percent for MDD The Veteran is currently in receipt of a 30 percent rating for MDD, which she claims does not reflect the severity of her current symptoms. The Veteran’s MDD has been evaluated under the General Rating Formula for Mental Disorder. 38 C.F.R. § 4.130, DC 9434. Under the General Rating Formula, a 30 percent rating is warranted 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, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or 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); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted 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 medical evidence regarding the Veteran’s MDD comes primarily from two examinations of record. The first is a VA examination conducted in May 2015. At that time, the examiner opined that the Veteran experienced occupational and social impairment with decreased inefficiency and intermittent inability to perform. The examiner noted symptoms including depressed mood, anxiety, panic attacks that occur less than weekly, chronic sleep impairment, and disturbances of mood and motivation. During the interview, the Veteran’s mood was sad and she cried throughout. However, the Veteran maintained good eye contact and had normal speech, concentration, and attention. Prior to November 22, 2017, the Board finds the Veteran’s MDD warrants no more than a 30 percent rating. Here, the 30 percent criteria contemplate the Veteran’s symptomatology during the period, which included a depressed mood, anxiety, less than weekly panic attacks, and chronic sleep impairment. The Board finds more severe symptoms warranting a higher rating were not present at the May 2015 examination. Thereafter, the Veteran also submitted a November 2017 disability benefits questionnaire from a Dr. M. Dr. M. opined that the Veteran experienced social and occupational impairment in most areas. On interviewing the Veteran, Dr. M. noted a restricted affect, irritability, disturbances of mood or motivation, anxiety, panic, and self-isolation. Symptoms noted include depressed mood, suspiciousness, more than weekly panic attacks, chronic sleep impairment, impaired memory, flattened affect, circumstantial speech, impaired judgment, difficulty maintaining and establishing effective relationships, impaired impulse control, fatigue, poor self-esteem, helplessness, hopelessness, persistent guilt/shame, and reduced work performance/reliability. The Veteran had been working full time as a pay technician for the past six years; however, the Veteran reported that over the past year and a half she had more complaints about her attitude. She denied suicidal ideation, but had thoughts of wishing to die, sleep disturbance. By the time of the November 22, 2017, VA examination, however, the Board finds the Veteran’s MDD symptomatology had worsened and demonstrates symptoms indicative of a 50 percent rating. The Veteran had still maintained a full-time job, though noted complaints about her attitude and poor customer service at work, indicating a deterioration in her social and occupational function. The 50 percent criteria contemplate her symptoms, such as panic attacks more than weekly, stereotyped speech, memory impairment, impaired judgment, impaired abstract thinking, and difficulty maintaining and establishing effective relationships. The social isolation reported by the Veteran seems consistent with difficulty in maintaining and establishing effective relationships. The Veteran did not experience suicidal ideation, though reported wishing she would die. However, according to the November 2017 DBQ, this did not appear to be a primary feature of her MDD. While Dr. M. indicated that the Veteran experienced occupational and social impairment with deficiencies in most areas in the November 2017 DBQ, the Board finds the symptoms and functioning described in the DBQ itself align most closely with the 50 percent rating criteria. The November 2017 DBQ also reflects a separate physician’s opinion that a 70 percent rating should be assigned based on the Veteran’s symptoms. However, the Board finds the suggestion merely recites the findings of the November 2017 DBQ, which, as described above, the Board finds most closely approximate occupational and social impairment with reduced reliability. In this respect, the assignment of a disability rating is a question of law, which is the Board’s area of expertise. Since such statement does not rely on reported medical expertise, the Board finds the opinion is not helpful to the resolution of the claim. Nevertheless, resolving all doubt in the Veteran’s favor, the Board finds a rating of 50 percent, but no higher, is warranted for MDD, effective November 22, 2017. REASONS FOR REMAND 1. Service connection for right ear pain is remanded. The Veteran was afforded a right ear VA examination in April 2015. While the Veteran’s hearing was tested and tinnitus was assessed, the examination was silent as to the Veteran’s claimed right ear pain. No diagnosis, exploration, or medical opinion as to etiology was given. Therefore, an examination of the Veteran’s right ear pain will be ordered on remand. See Barr v. Nicholson, 21 Vet. App. 303, 310-12 (2007) (holding that, where VA makes reasonable efforts to assist a veteran in substantiating a claim by providing a medical examination, the medical examination and opinion must be adequate). 2. Service connection for a left hip disorder is remanded. 3. Service connection for a right hip disorder is remanded. The Veteran is claiming that her right and left hip disorders are related to service. She was afforded a VA examination of her hips in April 2015. Diagnoses of left and right hip DJD were noted. However, in the medical opinion as to the etiology of these disorders, the examiner found there was no diagnosis or pathology thereof. Though the examiner did cite to service treatment records, the Board finds the opinion was based on an inaccurate factual premise. Therefore, new medical opinions as to the etiologies of the Veteran’s left and right hip DJD are needed. 4. Service connection for a right ankle disorder is remanded. The Veteran is currently service connected for left distal fibula stress reaction, which is rated as limitation of motion in the left ankle. An opinion was obtained in April 2015 that the Veteran’s claimed right ankle disorder was not caused or aggravated by her left ankle disability. However, the only rationale provided was no diagnosis or pathology. Furthermore, the Veteran is not claiming that her diagnosed right ankle DJD was caused or aggravated by her left distal fibula stress reaction. Here, the April 2015 VA examination showed a diagnosis of right ankle DJD but did not address the etiology of such, to include on the basis of secondary service connection. As a result, a new medical opinion as to the etiology of right ankle DJD is required. 5. Service connection for urinary incontinence is remanded. 6. Service connection for endometriosis is remanded. 7. Service connection for scars status-post cesarean is remanded. 8. Service connection for status-post hysterectomy scar is remanded. 9. Service connection for hysterectomy residuals is remanded. 10. Service connection for appendectomy scar is remanded. The Veteran is claiming that several gynecological disorders are related to service. An August 1989 STR notes heavy bleeding and pain during sex. In 1992, the Veteran gave birth during service. A January 2001 STR notes physical examination consistent with cystitis. Regarding her endometriosis, the Veteran submitted a September 2015 opinion from her gynecologist, Dr. Moore, that her endometriosis began during service. In support of her opinion, Dr. Moore noted the severity of endometriosis when she began treating the Veteran in 2009 and the Veteran’s diagnosis of dysmenorrhea during service. Dr. Moore’s opinion indicates that endometriosis and other gynecological disorder may be related to service. Upon review, the Board finds the language of “may be related” too general and inconclusive to support entitlement to service connection. In addition, further exploration is necessary to clarify any additional diagnoses, if present, related to the claimed conditions. Therefore, these claims are remanded to afford the Veteran a VA examination and obtain an opinion as to the etiologies of any current diagnosis and/or residuals of an in-service event, injury, or illness. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). By way of background, it appears that the Veteran also underwent an appendectomy in June 2009, shortly after a hysterectomy. It is unclear from the record whether or how the appendectomy is related to the claimed gynecological disorders, but remand for further exploration of this matter is warranted. 11. Service connection for left lower extremity peripheral neuropathy is remanded. 12. Service connection for right lower extremity peripheral neuropathy is remanded. 13. Service connection for left leg tibia pain, to include peripheral neuropathy, is remanded. The Veteran is claiming service connection for bilateral lower extremity peripheral neuropathy and left leg tibia pain as secondary to her service-connected lumbosacral strain. While no sensory deficit was shown on examination, the Veteran has noted symptoms in each extremity. See Saunders, supra. Additionally, the Board notes her assertions that such are related to her service-connected lumbosacral strain. Therefore, an examination is necessary to determine the etiology of any bilateral lower extremity symptoms, to include left leg tibia pain. See McLendon, supra. The Veteran’s left leg tibia pain includes a similar bundle of symptoms. Therefore, the Board will remand this claim as well for a medical opinion. 14. Entitlement to a rating in excess of 10 percent for DJD of the left knee is remanded. 15. Entitlement to a rating in excess of 10 percent for DJD of the right knee is remanded. The Veteran was afforded a VA examination of her knees in April 2015. However, the examination did not include passive range of motion testing or testing for pain on nonweight-bearing, as required by Correia v. McDonald, 28 Vet. App. 158 (2016) (instructing that VA orthopedic examinations should include tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing (if applicable) and, if possible, with the range of the opposite undamaged joint). At that time, she also reported that her knees often lock. As such, the Board finds consideration of additional ratings under additional DCs, to include DC 5258, should be undertaken. Lyles v. Shulkin, 29 Vet. App. 107 (2017); see also English v. Wilkie, No. 17-2083, slip op. at 6 (Vet. Ct. App. Nov. 1, 2018) (holding that the Board cannot categorically find objective medical evidence more probative than lay statements as to knee instability). 16. Entitlement to a rating in excess of 10 percent for lumbosacral strain is remanded. The Veteran was afforded a VA examination of her lumbosacral strain in April 2015. However, range of testing was not conducted on both active and passive range of motion or for pain on weight-bearing and nonweight-bearing. Therefore, a remand for a new examination is needed to complete the required testing. Correia, supra. 17. Entitlement to a compensable rating for left elbow pain is remanded. The Veteran claims that she is entitled to a compensable rating for her left elbow pain because of painful motion that causes functional limitation. She was afforded a VA examination in April 2015; however, testing was not conducted for range of motion or for pain on nonweight-bearing. Therefore, a remand for a new examination is necessary. Correia, supra. The examiner specifically should address the Veteran’s reports of painful motion. 18. Entitlement to a compensable rating for left distal fibula stress reaction is remanded. The Veteran claims that she is entitled to a compensable rating for her left distal fibula stress reaction. Specifically, she notes painful motion and swelling in the left ankle that make it difficult for her to walk more than short distances, carry heavy objects, jump, squat, and stand for long periods. This disability is rated under 38 C.F.R. § 4.71a, DC 5280 based on limitation of range of motion in the ankle. She was afforded a VA examination in April 2015; however, testing was not conducted for range of motion or for pain on nonweight-bearing. Therefore, a remand for a new examination is necessary. Correia, supra. The examiner should consider and address the Veteran’s reports of painful motion. 19. Entitlement to a compensable rating for GERD is remanded. A new examination of the Veteran’s GERD is necessary considering the Veteran’s September 2018 lay statement. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Specifically, the Veteran claims that her current noncompensable rating does not accurately reflect the severity of her symptoms. She states that she has been experiencing chest pain, shoulder pain, difficulty swallowing, frequent heartburn, acid reflux, regurgitation, a sore throat with painful swallowing, vomiting, and a persistent cough. She takes Ranitidine and Aciphex for control, avoids certain foods, and sleeps with the head of her bed elevated. She also claims that GERD affects her sleep, causing her to have difficulty concentrating, daytime fatigue, depressed mood, trouble thinking, mood changes, weight gain, low sex drive, frequent yawning, and irritability, all of which negatively impacts her personal life. Upon review, the Board finds these symptoms describe a marked worsening of GERD since April 2015, at which time the Veteran reported reflux, heartburn, epigastric discomfort, and using Nexium for control. Further, a May 2014 private treatment record from Dr. Barnes notes neck and radiating shoulder pain not related to her GERD. Chronic sleep impairment and other psychological symptoms have also been attributed to sleep apnea and MDD, for which the Veteran is already compensated. Thus, there is also a question of whether and to what extent distinct symptoms are attributable to GERD. Finally, in September 2018, based on the Veteran’s lay statements, Dr. Uribe suggested that VA rate her GERD as 30 percent disabling. However, the rating assigned to a particular disability is a question of law and therefore within the expertise of the Board, not a medical professional. Dr. Uribe does state that the Veteran’s symptoms would drastically increase without medication for control. This should be considered in any subsequent examination. Thus, a new medical examination is needed to further explore the current severity of the Veteran’s service-connected GERD. The matters are REMANDED for the following actions: 1. Obtain and associate with the record any outstanding, available treatment records. 2. Afford the Veteran a VA examination to determine the etiology of her right ear pain. The examiner should address the following: a. Identify any current diagnosis for the Veteran’s right ear symptoms. b. For each diagnosis, as well as any right ear pain that causes functional impairment, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that such is related to service. A complete rationale should be provided for any opinion rendered. 3. Afford the Veteran an examination to determine the current nature and etiology of her reported bilateral lower extremity symptomatology, to include peripheral neuropathy/radiculopathy and left leg tibia pain. A complete copy of the claims file, to include a copy of this Remand, should be provided to the examiner. The examiner should address the following: (a.) Identify any current diagnosis for symptoms related to bilateral lower extremities. (b.) For each diagnosis, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that such is related to service. (c.) For each diagnosis, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that such is proximately due to and/or aggravated by a service-connected disability. Aggravation is defined as the permanent worsening beyond the natural progression of the disease. A complete rationale should be provided for any opinion rendered. 4. Forward the claims file, to include a copy of this Remand, to an appropriate clinician for opinions as to the etiology of any current disability of the right ankle, right hip, and left hip. The examiner should address the following: (a.) Identify any current diagnosis for symptoms related to the right ankle, right hip, and left hip. (b.) For each diagnosis, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that such is related to service. (c.) For each diagnosis, provide an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that such is proximately due to and/or aggravated by a service-connected disability. Aggravation is defined as the permanent worsening beyond the natural progression of the disease. (d.) If arthritis is diagnosed, the examiner should address whether such manifested within one year of the Veteran’s separation from service, i.e. February 2005. A complete rationale should be provided for any opinion rendered. 5. Afford the Veteran a VA examination to determine the nature and etiology of her claimed gynecological disorders and residuals. A complete copy of the claims file, to include this Remand, should be provided to the examiner for review. The examiner is asked to address the following: (a.) Identify any diagnosis related to the claimed gynecological disorders and residuals, to include endometriosis. (b.) For each diagnosed disorder, provide an opinion as to whether is it at least as likely as not (ie. 50 percent or greater probability) that the disorder/residual had its onset during or is otherwise related to service. A complete rationale should be provided for any opinion rendered. The examiner is asked to discuss Dr. Moore’s September 2015 opinion that endometriosis had its onset during service. 6. Schedule the Veteran for additional examination(s) to determine the current nature and severity of her service-connected left elbow pain, left distal fibula stress reaction, and left and right knee disabilities. Testing should be completed for active and passive range of motion as well as for pain on weight-bearing and nonweight-bearing. The examiner should discuss the Veteran’s lay statements as to painful motion for the left elbow and left distal fibula as well as locking for her knees. 7. Afford the Veteran a VA examination to determine the current nature and severity of her lumbosacral strain disability. Testing for active and passive range of motion as well as for pain on weight-bearing and nonweight-bearing should be conducted. 8. Afford the Veteran a new VA examination to determine the current nature and severity of her GERD. The examiner should address her September 2018 lay statement regarding her symptoms and Dr. Uribe’s September 2018 medical opinion that her symptoms would be worse without medication for control. The examiner should also state whether any symptoms related to arm and/or shoulder pain are attributable to the Veteran’s service-connected GERD or a different disorder. M. M. CELLI Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. George