Citation Nr: 18156671 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 16-21 051 DATE: December 10, 2018 ORDER New and material evidence has been received to reopen the Veteran’s service-connection claim for a left knee disability; the appeal to reopen is granted. New and material evidence has been received to reopen the Veteran’s service-connection claim for a low back disability; the appeal to reopen is granted. Entitlement to an initial 10 percent rating, but no higher, for right knee chondromalacia with degenerative arthritis is granted. Entitlement to a separate 10 percent initial rating, but no higher, for right knee instability is granted. Entitlement to an initial 50 percent rating, but no higher, for migraine headaches is granted. REMANDED Entitlement to service connection for a left upper arm condition is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle condition is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a June 2008 rating decision, the RO denied service connection for a left knee disability. The Veteran did not file a notice of disagreement with the decision, or submit new and material evidence within one year of the denial. 2. Evidence received since the final June 2008 rating decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a left knee disability. 3. In a June 2008 rating decision, the RO denied the Veteran’s application to reopen a previously-denied service-connection claim for a low back disability. The Veteran did not file a notice of disagreement with the decision, or submit new and material evidence within one year of the denial. 4. Evidence received since the final June 2008 rating decision relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a low back disability. 5. For the entire period on appeal from November 6, 2012, the Veteran’s right knee right knee chondromalacia with degenerative arthritis was manifested by limitation of flexion no worse than 55 degrees, with full extension, and without ankylosis, dislocated or removed cartilage, impairment of tibia and fibula, or genu recurvatum. 6. For the entire period on appeal from November 6, 2012, the Veteran’s right knee chondromalacia with degenerative arthritis has manifested instability that is slight 7. For the entire appeal period from November 27, 2012, the Veteran’s migraine headaches have been manifested by very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The June 2008 rating decision that denied the claim of entitlement to service connection for a left knee disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.1103. 2. The criteria for reopening a previously denied claim of entitlement to service connection for a left knee disability, have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156. 3. The June 2008 rating decision that denied the Veteran’s application to reopen her claim of entitlement to service connection for a low back disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.1103. 4. The criteria for reopening a previously denied claim of entitlement to service connection for a low back disability, have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156. 5. The criteria for an initial evaluation of 10 percent, but no higher, for right knee chondromalacia with degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5010-5260, 5010-5261. 6. Throughout the appeal period from November 6, 2012, the criteria for the award of a separate initial evaluation of 10 percent for slight instability of the right knee have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5257. 7. Throughout the appeal period from November 27, 2010, the criteria for an initial maximum disability rating of 50 percent for migraine headaches are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, DC 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1978 to March 1985. The Veteran testified before the undersigned Veterans Law Judge during an April 2018 hearing. These matters are on appeal from June 2013, September 2013, September 2017 rating decisions. Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a TDIU is part of an initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. During her August 2017 VA headache examination, the examiner reported that the Veteran would be unable to work with occasional prostrating headaches and her concentration and visual tasks would be limited during an acute episode of a headache. Additionally, during her April 2018 hearing, the Veteran stated that she has not worked since February 2012 due to her migraine headaches. Therefore, the Board has jurisdiction over this issue as part and parcel of her increased rating claim and has listed such on the title page. I. New and Material Evidence If a claim of entitlement to service connection has previously been denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 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 evidence VA is required to review for newness and materiality is that which has been submitted by the claimant since the last final disallowance of the claim on any basis. See Evans v. Brown, 9 Vet. App 273 (1996). The prior evidence of record is important in determining newness and materiality for the purposes of deciding whether to reopen a claim. Id. For the purpose of determining whether a case should be reopened, the credibility of the evidence added to the record is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary’s duty to assist. Shade, 24 Vet. App. at 118. Here in a June 2008 rating decision, the RO denied the Veteran’s service connection claim for a left knee disability, and denied the Veteran’s application to reopen her service-connection claim for a low back disability. The RO denied the left knee claim based on a finding that a left knee condition was not shown to be incurred in or caused by service, or arthritis was not shown to have manifested within the first post service year. The RO declined to reopen the Veteran’s low back claim based on a finding that new and material evidence demonstrating the presence of a chronic disability had not been submitted. The Veteran did not appeal, nor did she submit new and material evidence within one year of being notified of the determination, and the decision became final as to both issues. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.1103 (2017). In November 2012, the Veteran filed a new service-connection claim for a left knee disability, and an application to reopen her back claim. Evidence received since the previous denial includes the Veteran’s testimony during the April 2018 hearing indicating that her left knee disorder may be aggravated through overcompensation due to her service-connected right knee disability. In April 2013, MRI results showed the presence of degenerative changes of the lumbar spine, at L4-L5 and L5-S1. The lay and medical evidence described is new in that it was not previously considered. It is also material insofar as it relates to unestablished elements of each claim, and at the very least triggers VA’s duty to assist. Thus, the Board finds that the additional evidence is both new and material, and both claims are reopened. II. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 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. 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. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Further, the Board must evaluate the medical evidence of record and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). The basis of disability evaluation is the ability of the body, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. A. Right Knee Chondromalacia with Degenerative Arthritis The Veteran contends that she is entitled to an increased rating for her right knee disability for the appeal periods prior to and from July 31, 2017. The intent of the Rating Schedule is 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. § 4.40. 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, 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. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disabilities of the knee are rated under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under DC 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. 38 C.F.R. § 4.71a. Standard motion of a knee joint is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Degenerative and/or traumatic arthritis as shown by X-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate DC, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, DC 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Consideration of other DCs for rating knee disability (5256, 5258, 5259, 5262, 5263) is inappropriate in this case as the Veteran’s right knee disability does not include the pathology required in the criteria for those DCs (ankylosis, dislocated semilunar cartilage, malunion or nonunion of tibia or fibula, symptomatic removal of semilunar cartilage, or genu recurvatum). 38 C.F.R. § 4.71a. In this case, the Veteran’s right knee disability has currently been assigned an initial noncompensable evaluation for limitation of flexion from November 6, 2012, under DC 5010-5260 and a 10 percent evaluation from July 31, 2017 for painful extension under DC 5010-5261. The hyphenated DCs indicate the Veteran's right knee disability is evaluated under the criteria for painful limitation of motion (DC 5010) and limitation of flexion (DC 5260) and extension (DC 5261). When rated under DCs 5260 or 5261, a separate rating for instability may also be warranted under DC 5257 based on recurrent subluxation or lateral instability. See VAOPGCPREC 23-97 (July 1, 1997). VA treatment records included x-ray findings of degenerative changes in the knees in April 2010 and ongoing complaints of right knee pain throughout the appeal period. A February 2012 record noted that the Veteran had a right knee flare-up for the last 1-2 months, with an intermittent flare-up of knee pain with no instability. The Veteran was afforded a VA knee and lower leg conditions examination in March 2013, during which she was diagnosed with chondromalacia of the patella. The Veteran did not report any flare-ups. The examiner added that no flare-ups were reported or observed that would affect functionality. Range of motion studies showed that bilateral knee flexion was to 125 degrees and extension was 0 degrees with no objective evidence of painful motion. The examiner reported that the Veteran’s range of motion was normal for her age and body habitus. There was no additional limitation in range of motion, functional loss, or functional impairment of the knee and lower leg following repetitive-use testing. There was pain on palpitation and subpatellar crepitus was present. Muscle strength and joint stability testing were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. She never had “shin splints”, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. She did not have any medical conditions or surgical procedures for a meniscal condition. She did not use any assistive devices. The Veteran’s knee and lower leg conditions did not impact her ability to work. The Veteran was afforded another VA examination in August 2017. She was diagnosed with degenerative arthritis and chondromalacia. The examiner commented that the Veteran’s right knee chondromalacia was active and progressed to a new diagnosis of patellofemoral degenerative joint disease, which was consistent with the Veteran’s history of chondromalacia with prior trauma to the knee. The Veteran described flare-ups occurring while she was asleep that caused her to wake up in pain. She indicated that her knee buckled when she walked and at times her knee was stiff and would swell. She reported functional loss or impairment as not being able to “walk like her friends” or exercise and having difficulty with stairs. Range of motion testing of the right knee showed flexion from 0 to 55 degrees and extension was 55 to 0 degrees. On the left knee, flexion was from 0 to 90 degrees and extension was from 90 to 0 degrees. Bilaterally, there was pain on flexion and extension as well as with weightbearing. The examiner added that there was objective evidence of pain on passive range of motion and on nonweight bearing testing of the bilateral knees. Functional loss was described as difficulty with certain knee flexion maneuvers and performing full squatting tasks. There was no objective evidence of localized tenderness or pain on palpation. There was no additional loss of function or range of motion after three repetitions. Regarding repeated use over time, the examiner indicated that pain, fatigue, weakness, and lack of endurance would significantly limit functional ability, but the examiner was unable to describe in terms of range of motion because the examination as not being conducted after repeated use over time and any change of range of motion would be based on the severity of symptoms. The examiner did report that the examination was being conducted during a period of flare-up and that pain, fatigue, and weakness did limit functional ability as forward flexion was to 55 degrees and extension was to 0 degrees. Additional symptoms included less movement than normal, swelling, disturbance of locomotion, interference with sitting, difficulty with certain prolonged standing, walking, sitting, and climbing (including stairs, kneeling, and impact tasks during flare-ups). There was no reduction in strength or muscle atrophy. There was no ankylosis, recurrent subluxation, or lateral instability. There was recurrent effusion described as right knee swelling 2-3 times per week. She did not have “shin splints”, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. She did not have any medical conditions or surgical procedures for a meniscal condition. She used a regular walker. There was no functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. The Veteran’s right knee disability impacted the Veteran’s ability to perform certain occupational tasks due to difficulty with prolonged standing, walking, squatting, climbing (including stairs), kneeling, and impact tasks during flare-ups. During her April 2018 Travel Board hearing, the Veteran indicated that the 0 percent rating from 2012 and the 10 percent rating from 2017 did not account for the amount of pain that she lived with regarding her right knee. The Veteran and her representative reported that the Veteran was unable to exercise and had to shift her weight from the right knee while walking due to pain. She added that she has had arthritis and been living with pain since she first filed her claim. She also indicated that she has fallen due to her right knee. She stated that wore braces for her knee and used a cane, a walker, and a wheelchair to help her ambulate or move around. She stated that she sometimes had flare-ups when it was cold and had symptoms of stiffness and popping. She reported that her flare-ups caused problems with walking and balance. Here, in June 2013, the RO granted service connection for chondromalacia patella of the right knee and assigned a noncompensable rating. In a September 2017 rating decision, the RO continued to rate the Veteran’s right knee disability based on limitation of flexion as noncompensable and assigned a 10 percent for right knee degenerative arthritis, limitation of extension, effective July 31,2017, due to objective painful motion of the right knee, which met the criteria for a minimum rating under 38 C.F.R. § 4.59. Notably, from the beginning of the appeal period from November 6, 2012, the Veteran had a diagnosis of degenerative changes of the knee, did not meet the criteria for a compensable rating for limitation of flexion or limitation of extension, and has credibly described pain on use with functional impairment, i.e. when trying to walk. See hearing transcript, p. 12. The Veteran’s description of recurrent episodes of right knee pain on use is credible and consistent with the evidentiary record. Although objective evidence of pain was not shown during range of motions studies at the time of the July 2013 VA examination, there was pain on palpation and evidence of crepitus. There was objective evidence of painful motion of the knee joint during the August 2017 VA examination. As such, giving due consideration to the Veteran’s lay report as well as the provisions of 38 C.F.R. § 4.59, the Board finds that, for the entire appeal period, the Veteran’s right knee disabilities have more nearly approximated objective evidence of painful motion. As such, a uniform 10 percent rating is warranted. Although the Board has acknowledged the Veteran’s complaints of knee pain, the objective evidence of record indicates that such pain does not limit the Veteran’s functional range of motion of the right knee to a compensable level at any point throughout the appeal period. The Veteran has had no point during this period where her flexion has been 45 degrees or less under DC 5260 or her extension been limited to 10 degrees or more under DC 5261. See Mitchell v. Shinseki, 25 Vet. App. 32 (“pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system”). As noted above, the Veteran’s most recent examination took place during a flare-up, and the Veteran was able to flex and extend her knee to a level commensurate with a 10 percent rating, but no higher. The Board will also award a separate 10 percent rating based on the Veteran’s complaints of, and treatment for right knee instability throughout the appeal period. The Board finds it informative that in a May 12, 2010 VA treatment report, it was noted that the Veteran’s right knee exhibited “off and on” instability, with symptoms worse in the winter. The Veteran has offered competent testimony indicating that her right knee has caused her to fall at times, and that she has issues with balance during flare-ups. The also has reported use of braces for her knee. That stated, objective testing at the two VA examinations did not show the presence of instability or subluxation. Notwithstanding these results, given the Veteran’s competent lay descriptions of her balance and stability problems, and the fact that at one time just prior to the period under review, a VA physician noted that she exhibits off and on instability of the right knee, the Board will resolve all doubt in the Veteran’s favor and award a separate 10 percent rating based on the presence of right knee instability that is “slight.” The Board does not find that the Veteran’s right knee instability is more than slight in degree, as objective medical testing intended to detect the presence of stability problems were negative at both VA examinations, and that various treatment reports during the appeal period show a “stable” right knee. Thus, in weighing the Veteran’s competent and credible assertions against the medical evidence of record, the Board finds that moderate or severe instability is not shown by the record. Indeed, the Veteran does not attest as much. In sum, an initial 10 percent rating, but no higher, is warranted for the Veteran’s right knee chondromalacia with degenerative arthritis from November 6, 2012 under the provisions of 38 C.F.R. § 4.59. A separate 10 percent rating from November 6, 2012 is also warranted for slight instability of the right knee. B. Migraine Headaches The Veteran’s migraine headaches disability is assigned a 30 percent rating under 38 C.F.R. § 4.124a, Diagnostic Code 8100. She filed the present claim on February 27, 2012. Under Diagnostic Code 8100, a 30 percent rating is warranted for characteristic prostrating attacks occurring on an average of once a month over last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board resolves all reasonable doubt in the Veteran’s favor and concludes that the maximum 50 percent rating is warranted for her headache disability during the entire appeal period. In this regard, on July 2013 VA Disability Benefits Questionnaire (DBQ), the examiner determined that the Veteran had characteristic prostrating attacks of migraine headache pain once every month with symptoms of pulsating or throbbing head pain, nausea, and sensitivity to light and sound, that lasted less than a day. While the examiner indicated that the Veteran’s headache condition did not impact her ability to work, there is no indication that the examiner solicited any type of information regarding the Veteran’s work history, including how often she missed work or was sent home due to her headaches. Moreover, just three months later, while seeking treatment for an unrelated condition in November 2013, a VA provider noted that the Veteran was no longer working as a stacker due to migraine headaches, which were occurring 2-3 times per week. Additional VA treatment records reflect that the Veteran was prescribed sumatriptan that she took as needed for her headaches. During an August 2017 examination, the Veteran reported that she had chronic migraine headaches that lasted 3-4 hours or sometimes longer, during which she was sensitive to light and nauseous. During these times, she had to lay down in a dark room with no sound and would apply a cold compression around her neck. The examiner determined that the Veteran had characteristic prostrating attacks of migraine headache pain with symptoms of constant head pain, pulsating or throbbing head pain, pain on both sides of her head, nausea, and sensitivity to light and sound, that lasted less than a day. While the August 2017 examiner indicated that the Veteran’s prostrating headaches were not productive of severe economic inadaptability, the examiner specifically found that the Veteran’s headache condition impacted her ability to work, in that she may have difficulty with certain concentration and visual tasks, including driving with acute episodes of headaches. The examiner also stated that the Veteran was unable to work with occasional prostrating headache, which the Board finds as suggestive that the Veteran’s headaches had the capacity to produce severe economic inadaptability. During her April 2018 hearing, the Veteran reported that she has not worked since 2012 due to her migraines. She competently described completely incapacitating episodes occurring 2-3 times per month and lasting up to 8 hours at a time, in which she shut down and was unable to function. She reported that when she was working and a headache occurred, she would use an ice pack from the refrigerator on her head and was sent home several times due to the severity of her headache and the office lighting bothering her eyes. The Board finds that the evidence is at the very least in relative equipoise as to whether the Veteran’s headaches were manifested by very frequent and completely prostrating and prolonged attacks that are productive of severe economic inadaptability, warranting a 50 percent rating under Diagnostic Code 8100. 38 C.F.R. § 4.3; Johnson v. Wilkie, 16-3808 (Vet. App. 2018) (indicating that section 4.3 remains applicable to DC 8100). Fifty percent is the maximum rating available for migraine headaches pursuant to Diagnostic Code 8100. No other diagnostic code is applicable and the Board cannot identify a diagnostic code which would afford a rating higher than 50 percent disabling for the migraine headaches. REASONS FOR REMAND 1. Left Upper Arm, Left Knee, and Right Ankle Disabilities. During her August 2017 VA knee and lower leg conditions examination, the Veteran reported that her ankle swelled during flare-ups of her right knee and impacted her hips, and legs. During her April 2018 Board hearing, the Veteran indicated that she injured her left upper arm and right ankle in service due to an explosion in 1979, during which she hit her left upper arm and ankle on impact. She also stated that that pain radiated from her right knee and into her foot and ankle. See hearing transcript, p. 28. She indicated that she favored her left side over the right side over the past 25-30 years due to her service-connected right knee disability. See hearing transcript, p. 15. Service treatment records include a record dated in January without an associated year (it has been reported by the Veteran as occurring in 1979, so hereinafter will be referred to as January 1979) that show that the Veteran was seen for facial burns due to stove/heater exploding in her face. In October 1981, she injured her right foot when a person fell on it while playing volleyball for which she was diagnosed with ankle strain. X-rays at the time were normal. An August 1982 report of medical history, the Veteran indicated that she had foot trouble. In January 1984, the Veteran was seen for a right ankle sprain. In June 1984, the Veteran was seen for pain after dropping an iron on her right foot and was diagnosed with a contusion. She returned to duty with the use of crutches for 24 hours. X-rays at the time were normal. Post service treatment records included a diagnosis of degenerative joint disease of the left knee. See November 2008 and April 2010 VA treatment records. In February 2015, there was evidence of ankle edema. The current nature of the Veteran’s left knee, right ankle, and left upper arm disabilities remains unclear. However, as there is evidence of a possible current disability, and a potential link between the current disability and her service, an examination is required to clarify the Veteran’s current diagnosis and to obtain an opinion regarding the etiology of the Veteran’s condition. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Low Back Disability During her August 2017 VA knee and lower leg conditions examination, the Veteran indicated that flare-ups of her right knee and impacted her lower back. During her April 2018 Board hearing, the Veteran indicated that complaints of her back issues were reported during service in 1978 and 1979. She claimed that she subsequently injured her back on impact due to an explosion in 1979. Service treatment records include a January 1978 enlistment examination that included a diagnosis of mild thoracic scoliosis. A January 1979 record revealed that the Veteran was seen for facial burns due to stove/heater exploding in her face. A June 1983 treatment record noted complaints of back pain for 7 years that was getting worse. The examiner noted the Veterans history of falling four years ago, which existed prior to service. She was diagnosed with functional back syndrome. Subsequent treatment records in June 1978 documented low back pain. In December 1978, she was seen for complaints of low back pain for six months, for which she was diagnosed with muscle strain. In August 1982, an x-ray of the Veteran’s back revealed mild thoracic scoliosis. A June 1983 consultation sheet note complaints of a history of low back pain off and on and guarding on examination. The Veteran was given a provisional diagnosis of functional back syndrome. A subsequent June 1983 physical therapy note documented a four-year history of low back pain and an assessment of functional back syndrome. A few day later, muscle spasms were shown on examination in the lumbar/thoracic paraspinals. She was diagnosed with low back strain. An August 1983 record noted that the Veteran was seen in June 1983 for functional back syndrome. Although the Veteran was afforded a VA back examination in March 2013, the examiner indicated that there was no current back disability. During her April 2018 hearing, the Veteran claimed that she has had pain since service and a long history of treatment for back pain for which she underwent various therapies, including aqua therapy and treatment by a Dr. S., a private chiropractor. Post service VA treatment records show ongoing complaints of low back and an October 2013 record included a diagnosis of thoracic and lumbar segmental dysfunction as well as lumbar degenerative disc disease and degenerative joint disease. In light of treatment records during the appeal period showing a current diagnosis of a back disability, a new VA examination is indicated. 3. Bilateral Hearing Loss and Tinnitus During her April 2018 Board hearing, the Veteran indicated that she experienced hearing loss and tinnitus from the time that she was injured in an explosion during service to the present. A review of the Veteran’s service treatment records appear to show that the Veteran experienced an adverse threshold shift in her hearing acuity (See audiograms on January 1978 enlistment report of medical examination, in August 1980, August 1981, August 1982, and August 1983. On August 1982 report of medical history, the Veteran indicated that she had ear, nose, or throat trouble. A June 2016 private audiogram from indicates that the Veteran has a current hearing loss disability and noted a history of noise exposure in the military. As such, the Board finds a VA examination assessing the Veteran's current bilateral hearing loss and tinnitus, and an opinion discussing the explosion injury in January 1979 as well as her in-service threshold shift is necessary prior to adjudicating the claim. 38 C.F.R. § 3.159 (c)(4); McLendon, supra. 4. TDIU On remand, the Veteran should be afforded an opportunity to submit a VA Form 21-8940 (Veteran’s Application for Increased Compensation Based on Unemployability). The claim should then be adjudicated by the AOJ in the first instance. The matters are REMANDED for the following action: 1. Obtain any outstanding records of pertinent medical treatment from VA from August 2017 or private health care providers, including Dr. S., a private chiropractor. With the Veteran’s assistance, obtain copies of any pertinent records and add them to the claims file. 2. Send a notice letter to the Veteran and her representative notifying them of the information and evidence necessary to substantiate entitlement to service connection for low back, left knee, and right ankle disabilities on a theory of secondary service connection, as well as entitlement to a TDIU. 3. Contact the Veteran and her representative and request that she complete and submit a VA Form 21-8940, (Veteran’s Application for Increased Compensation Based on Unemployability) or a comparable statement as to the information requested on this Form. 4. After associating all newly acquired records with the claims file, schedule a VA examination to address the Veteran’s claimed left knee, right ankle, and left upper extremity disabilities. The entire claims file must be made available to the examiner. The report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished. The examiner should report the following: a) Left Knee Disability i. Indicate all left knee disabilities shown during the current appeal period, since November 6, 2012. ii. For each left knee disability identified, opine as to whether it is at least as likely as not (50 percent probability or greater) that such had its onset during active service, or is otherwise related to any in-service disease, event, or injury. In the alternative, the examiner should opine as to whether any knee disability was caused or aggravated beyond its natural progression by her service-connected right knee disability. iii. The examiner should consider the Veteran’s contentions that she injured her left knee while she landed on it from impact of a stove explosion during service in January 1979. The Veteran also claimed that she favored her left knee to compensate for her service-connected right knee disability. The examiner should include the underlying reasons for the opinions expressed. b) Right Ankle Disability i. Indicate all right ankle disabilities shown during the current appeal period, since November 6, 2012. If the Veteran exhibits right ankle pain manifesting in functional limitation or loss, such should be accepted as a disability for VA purposes even if no underlying diagnosis can be identified. ii. For each right ankle disability identified, opine as to whether it is at least as likely as not (50 percent probability or greater) that such had its onset during active service, or is otherwise related to any in-service disease, event, or injury. In the alternative, the examiner should opine as to whether any right ankle disability was caused or aggravated beyond its natural progression by her service-connected right knee disability. iii. The examiner should consider the Veteran’s contentions that she injured her right ankle while she landed on it from impact of a stove explosion during service in January 1979 and her reports that flare-ups of her right knee impacted her right ankle, and she had pain that radiated from her right knee into her right ankle/foot. Service treatment records documented treatment related to a stove explosion in January 1979, an ankle strain in October 1981, foot trouble in August 1982 an ankle sprain in January 1984, and a right foot contusion in June 1984. The examiner should include the underlying reasons for the opinions expressed. c) Left Upper Arm Disability i. Indicate all left upper arm disabilities shown during the current appeal period, since November 6, 2012. ii. For each left upper extremity disability identified, opine as to whether it is at least as likely as not (50 percent probability or greater) that such had its onset during active service, or is otherwise related to any in-service disease, event, or injury. iii. The examiner should consider the Veteran’s contentions that she injured her left upper arm while she landed on it from impact of a stove explosion during service in January 1979. The examiner should include the underlying reasons for the opinions expressed. 5. Schedule a VA examination to assess the nature and etiology of the Veteran’s claimed low back disabilities. The entire claims file must be made available to the examiner. The report of examination should include discussion of the Veteran’s documented history and assertions. All indicated tests and studies should be accomplished. The examiner should report the following: a) Indicate all low back disabilities shown during the current appeal period, since November 6, 2012. b) Regarding the Veteran’s preexisting thoracic scoliosis, noted on enlistment examination, is it at least as likely as not (50 percent probability or greater), that such disability worsened in disability during her period of active duty service? c) If the answer to (b) is “YES,” is it clear and unmistakable (i.e. undebatable) that this increase in disability was due to the natural progression of the disease? d) For all other low back disabilities identified, opine as to whether it is at least as likely as not (50 percent probability or greater) that such had onset during active service, or is otherwise related to any in-service disease, event or injury. In the alternative, the examiner should opine as to whether it is at least as likely as not that any low back disability was caused or aggravated beyond its natural progression by her service-connected right knee disability. e) The examiner should consider the Veteran’s contentions that she injured her low back while she landed on it from impact of a stove explosion during service in January 1979. She also indicated that flare-ups of her right knee impacted her back. Service treatment records include a January 1978 enlistment examination that included a diagnosis of mild thoracic scoliosis. In June 1978 she was seen for back pain and later seen December 1978 for back pain of a 6-month duration, diagnosed as a muscle strain. She was seen in January 1979 following a stove/heater explosion in her face. In August 1982, an x-ray of the Veteran’s back revealed mild thoracic scoliosis. In June 1983, she had complaints of worsening back pain that began 7 years ago. The provider noted a history of falling four years ago, prior to service. Guarding and muscle spasms were noted on examination and she was diagnosed with functional back syndrome. The examiner should include the underlying reasons for the opinions expressed. 6. Schedule the Veteran for a VA medical examination to address the nature and etiology of the Veteran’s claimed bilateral hearing loss and tinnitus. The entire claims file must be made available to the examiner. The report of examination should include discussion of the Veteran’s documented history and assertions. a) The examiner is requested to opine as to whether it is at least as likely as not (50 percent or greater) that the Veteran's bilateral hearing loss disability and/or tinnitus had its onset during active service or is otherwise related to any in-service disease, event, or injury. b) The examiner should consider the Veteran’s contentions that she has had hearing loss and tinnitus since the in-service stove/heater explosion in January 1979. The examiner is requested to discuss the Veteran's in-service threshold shift in her hearing. See audiograms on January 1978 enlistment report of medical examination, in August 1980, August 1981, August 1982, and August 1983. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Crohe, Counsel