Citation Nr: 18158794 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 14-24 705A DATE: December 17, 2018 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. Entitlement to increased or additional disability ratings in excess of 10 percent for patellofemoral syndrome of the right knee is denied. Entitlement to increased or additional disability ratings in excess of 10 percent for patellofemoral syndrome of the left knee is denied. REMANDED The issue of entitlement to service connection for a right shoulder disability is remanded. The issue of entitlement to service connection for a left shoulder disability is remanded. The issue of entitlement to service connection for a disability manifested by a weak right ankle is remanded. The issue of entitlement to service connection for a disability manifested by a weak left ankle is remanded. The issue of entitlement to service connection for a disability manifested by left arm numbness with tingling fingers is remanded. The issue of entitlement to service connection for sciatica is remanded. The issue of entitlement to a rating in excess of 10 percent for lumbar strain with rotary scoliosis of the thoracic spine is remanded. The issue of entitlement to a rating in excess of 10 percent for cervical spine degenerative joint disease is remanded. The issue of entitlement to a compensable rating for bilateral plantar fasciitis is remanded. The issue of entitlement to a compensable rating for hypertension is remanded. The issue of entitlement to a rating in excess of 20 percent for postpartum urinary stress incontinence / recurrent acute bacterial cystitis is remanded. The issue of entitlement to a compensable rating for acne vulgaris is remanded. The issue of entitlement to a compensable rating for tension headaches is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of GERD that is reasonably shown to have been incurred during her active duty service. 2. The Veteran’s right knee patellofemoral syndrome is productive of functional impairment due to pain; it is not productive of ankylosis, nor recurrent subluxation, nor lateral instability, nor symptomatic dislocated semilunar cartilage, nor symptomatic removal of semilunar cartilage, nor flexion limited to 45 degrees, nor extension limited to the 10 degrees position, nor malunion of the tibia and fibula, nor genu recurvatum. 3. The Veteran’s left knee patellofemoral syndrome is productive of functional impairment due to pain; it is not productive of ankylosis, nor recurrent subluxation, nor lateral instability, nor symptomatic dislocated semilunar cartilage, nor symptomatic removal of semilunar cartilage, nor flexion limited to 45 degrees, nor extension limited to the 10 degrees position, nor malunion of the tibia and fibula, nor genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for increased or additional ratings in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 3. The criteria for increased or additional ratings in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1989 to December 2011. This case comes to the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that recently during the pendency of this appeal, the Veteran suffered an injury to her right knee and underwent right knee surgery in April 2018. The RO issued a rating decision in September 2018 that awarded a temporary 100 percent rating for convalescence following right knee surgery, effective from April 25, 2018, to July 1, 2018. In connection with the adjudication, prior to the new rating decision but after the completion of the determined convalescent period, the Veteran underwent a new VA knee rating examination in August 2018. The RO considered this VA examination report in the new decision issued in September 2018. The RO adjudication defined the temporary convalescent rating period and determined that a 10 percent rating for right knee disability rating was warranted following the convalescent rating period, based upon the August 2018 VA examination report. Aside from also granting service connection for a scar, the September 2018 rating decision found no other change of rating to be warranted upon consideration of the pertinent evidence added to the record. The Board has considered whether a remand of the knee rating issues is required so that the Board might direct the Agency of Original Jurisdiction (AOJ) to issue a supplemental statement of the case readjudicating the claim. See 38 C.F.R. §§ 19.31, 19.37, and 20.1304. However, the Board is able to avoid further delay and proceed with final appellate review without any prejudice to the Veteran in this case. This is because the RO has considered all of the new evidence of record and issued the September 2018 rating decision, itself a readjudication contemplating all of the new information and assigned ratings addressing all pertinent changes raised by the new evidence concerning the Veteran’s knee health. 1. Entitlement to service connection for GERD is granted. The Veteran asserts that she suffers from GERD as a result of her active duty military service. After resolution of reasonable doubt in the Veteran’s favor, the Board finds that service connection can be granted in this case for GERD based upon in-service incurrence of the disability. The Board concludes that the Veteran has reasonably established that she has a current diagnosis of GERD that had its onset / incurrence during her active duty military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran filed her VA 21-526c Pre-Discharge Compensation Claim in June 2011, reporting at that time that she had “reflux/gerd.” In September 2011, during her first VA examination following the filing of the claim, a VA examiner confirmed “DIAGNOSIS: GERD.” Accordingly, the Board is satisfied that the evidence reasonably shows (1) that the Veteran has a current diagnosis of GERD, and (2) that the GERD had its incurrence during the Veteran’s greater than 22 years of active duty military service. The Board finds no significant persuasive contrary evidence of record, and the Board finds that the evidentiary record is adequate to support an appellate determination at this time. Accordingly, service connection for GERD is warranted. Increased Rating 2. Entitlement to increased or additional disability ratings in excess of 10 percent for patellofemoral syndrome of the right knee is denied. 3. Entitlement to increased or additional disability ratings in excess of 10 percent for patellofemoral syndrome of the left knee is denied. The Veteran appeals for higher and/or additional ratings beyond the 10 percent ratings (one for each knee) assigned for left and right knee patellofemoral pain syndrome. This appeal arises from the assignment of initial ratings with the grant of service connection for the knee disabilities, effect from January 1, 2012; the period for consideration in this appeal accordingly dates back to January 1, 2012. The Board’s appellate review in this matter concerns only the underlying 10 percent disability ratings (one for each knee) that have been in effect essentially from January 1, 2012, to the present time. The Board notes that the Veteran recently underwent right knee surgery and a September 2018 RO rating decision awarded a temporary 100 percent rating for convalescence effective from April 25, 2018, to July 1, 2018; that limited period of temporary convalescent 100 percent rating is not affected by the Board’s decision in this case. The Board also observes that the September 2018 RO rating decision is somewhat confusing in its processing of re-establishing the 10 percent rating for the right knee following the expiration of the temporary 100 percent rating. The September 2018 RO rating decision indicates that for the right knee disability “[a] noncompensable evaluation is assigned from July 1, 2018,” and then states that “[s]ervice connection for patellofemoral syndrome right knee, status post patellar tendon repair (limitation of flexion) is granted with an evaluation of 10 percent effective July 1, 2018.” To clarify the matter, the Board notes that both the pre-surgery and post-surgery right knee 10 percent ratings were based upon essentially the same impairment of patellofemoral syndrome, and that the RO’s change of the listed applied Diagnostic Code from 5261 to 5260 is of no practical significance in this case. Accordingly, the Board finds that this appeal is for an increased rating for the right knee disability at all times (except the period of the temporary 100 percent rating) from January 1, 2012, to the present; the Board shall consider all applicable Diagnostic Codes for all periods on appeal. Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA’s Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two ratings apply, the higher rating 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 there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s statements describing her symptoms and condition are competent evidence to the extent that she can describe what she experiences. However, these statements must be viewed in conjunction with the medical evidence and the pertinent rating criteria. Lay evidence is not competent evidence concerning complex medical questions requiring specialized training or expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans’ Court.) Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pain, in and of itself, that does not result in additional functional loss does not warrant a higher rating; the Court held that pain alone does not constitute functional loss, but is just one fact to be considered when evaluating functional impairment. Id. VA regulations require that a finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). 38 C.F.R. § 4.71a includes multiple diagnostic codes that evaluate impairment resulting from knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and [*36] fibula), and Diagnostic Code 5263 (genu recurvatum). Under Diagnostic Code 5256, a 30 percent rating may be assigned for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 60 percent rating may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a; Diagnostic Code 5256. Diagnostic Code 5257 provides for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of ‘locking,’ pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, removal of semilunar cartilage that is symptomatic warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5262, a 10 percent rating is available when there is malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating is available when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent is warranted for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent rating is warranted for genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Code 5263. Separate ratings may be assigned for knee disability under Diagnostic Code 5257 and 5003 where there is x-ray evidence of arthritis in addition to recurrent subluxation or lateral instability. See generally VAOPGCPREC 23- 97 and VAOPGCREC 9-98. A precedent opinion by VA General Counsel holds that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board notes that it has reviewed all of the evidence in the Veteran’s record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence.) Hence, the Board will summarize the relevant evidence, as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or does not show, as to the claim. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal. It is notable in this case that the initial 10 percent ratings assigned for the knees by the July 2012 RO rating decision were expressly awarded not on the basis of clinical measurements of range of motion. Rather, the 10 percent rating for the right knee disability and the 10 percent rating for the left knee disability were both awarded with the following explanation: “We have assigned a 10 percent evaluation for your knee condition based on: Painful motion of the knee,” with the RO citing that “38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Since you demonstrate painful motion of the knee, the minimum compensable evaluation of 10 percent is assigned. The explanation also cited “[t]he provisions of 38 C.F.R. §§ 4.40 and 4.45 concerning functional loss due to pain, fatigue, weakness, or lack of endurance, incoordination, and flare-ups, as cited in DeLuca ….” An August 2018 VA examination was conducted to assess the state of the Veteran’s health following her April 2018 right knee injury and surgery. The August 2018 VA examination report shows that the Veteran described swelling, pain, stiffness, numbness, and decreased range of motion. The Veteran reported “increased pain with flare-ups.” She also reported functional impairment featuring “difficulty going down stairs or sitting for long periods, as well as difficulty going from sitting to standing.” For the right knee, clinical testing revealed range of motion from 5 degrees to 90 degrees in flexion, and from the 90 degrees position to the 5 degrees position in extension. The VA examiner determined that “No,” the range of motion itself does not “contribute to a functional loss.” The VA examiner stated: “Pain noted on exam but does not result in/cause functional loss,” while noting pain on both flexion and extension. The VA examiner noted “objective evidence of localized tenderness or pain on palpation of the joint or associated with soft tissue,” specifying pain of severity “5/10” at the “[m]edial and lateral knee …. [r]elated to diagnosed patellofemoral pain syndrome.” The report notes pain with weight bearing and objective evidence of crepitus. The Veteran was able to perform repetitive-use testing of at least three repetitions, and the VA examiner found “No,” there was not additional loss of function or range of motion after three repetitions. The VA examiner noted that the clinical testing was not performed after repeated use over time, but acknowledged that the knee’s “pain” did “significantly limit functional ability with repeated use over a period of time.” The VA examiner was able to describe the limitation in terms of range of motion, finding that the functional impairment was the equivalent of range of motion limitation of flexion to the 90 degrees position and limitation of extension to the 5 degrees position. The VA examiner noted that the clinical testing was not performed during a flare-up, but acknowledged that the knee’s “pain,” “fatigue,” “weakness,” and “lack of endurance” did “significantly limit functional ability with flare ups.” The VA examiner was able to describe the limitation in terms of range of motion, finding that the functional impairment was the equivalent of range of motion limitation of flexion to the 80 degrees position and limitation of extension to the 5 degrees position. The VA examiner noted that the Veteran’s right knee was “currently swollen and warm to touch” during the examination. Muscle strength testing for the right knee revealed a “reduction in muscle strength,” with the knee producing “4/5 Active movement against some resistance” for both flexion and extension. For the left knee, clinical testing revealed range of motion from 0 degrees to 140 degrees in flexion, and from the 140 degrees position to the 0 degrees position in extension. This represents a fully normal range of motion for the left knee. The VA examiner stated: “No pain noted on exam,” and there was not any “objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.” The report notes that there was not any evidence of pain with weight bearing and there was not any objective evidence of crepitus. The Veteran was able to perform repetitive-use testing of at least three repetitions, and the VA examiner found “No,” there was not additional loss of function or range of motion after three repetitions. The VA examiner noted that the clinical testing was not performed after repeated use over time, but acknowledged that the knee’s “pain” did “significantly limit functional ability with repeated use over a period of time.” The VA examiner was able to describe the limitation in terms of range of motion, finding that the functional impairment was the equivalent of range of motion limitation of flexion to the 140 degrees position and limitation of extension to the 0 degrees position. The VA examiner noted that the clinical testing was not performed during a flare-up, but acknowledged that the knee’s “pain” did “significantly limit functional ability with flare ups.” The VA examiner was able to describe the limitation in terms of range of motion, finding that the functional impairment was the equivalent of range of motion limitation of flexion to the 140 degrees position and limitation of extension to the 0 degrees position. The VA examiner noted no other aspect of disability for the left knee. Muscle strength testing for the left knee revealed no reduction in muscle strength, with the knee producing “5/5 Normal strength” for both flexion and extension. For both knees, the VA examiner found that there was no muscle atrophy, no ankylosis, no history of recurrent subluxation, no history of lateral instability, and thorough clinical testing revealed no joint instability. The VA examiner noted a history of effusion for the post-surgical right knee, and stated that the “Veteran’s right knee is currently swollen and warm to touch.” For both knees, the VA examiner found that the Veteran had no history of recurrent patellar dislocation, ‘shin splints,’ stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The VA examiner found that the Veteran did not have, and had never had, a meniscus (semilunar cartilage) condition of either knee. The VA examiner noted the Veteran’s history of an April 2018 patella tendon repair surgery for the right knee, with no surgery in the left knee’s history. The report shows that the Veteran’s only assistive device was a brace for the right knee, which was used constantly. The VA examiner assessed that the “Veteran would experience difficulty with job functions that require prolonged walking, standing or climbing.” The VA examiner included findings to comply with the requirements discussed in the Court’s holding in Correia v. McDonald, 28 Vet. App. 158 (2016) (holding that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.). The VA examiner noted “evidence of pain with weight bearing” as part of the presentation of range of motion testing measurements for the right knee, and noted that there was no “evidence of pain with weight bearing for the left knee. The VA examiner noted that there was no objective evidence of pain on non-weightbearing for either knee. Active range of motion testing results were presented in detail. For the post-surgical right knee, the VA examiner noted that passive range of motion testing “[c]annot be performed or is not medically appropriate.” For the left knee, passive range of motion testing revealed the same range of motion as for active motion, and there was no objective evidence of pain on passive range of motion. The VA examiner also included clear estimates as to additional functional loss during flare-ups, noting that the Veteran was not undergoing a flare-up at the time of the examination, satisfying the requirements discussed in the Court’s holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017). The earlier September 2011 VA examination report assessing the Veteran’s knee disabilities does not indicate that the severity of any knee disability warranted higher or additional disability ratings at that time. The report shows that the Veteran described pain of “2/10” severity, “giving way,” stiffness, weakness, and decreased joint speed, but no instability, no incoordination, no locking episodes, no inflammation symptoms, and no other symptoms. The Veteran indicated some “giving way,” but the report specifically indicates that she did not describe “instability.” The Veteran reported “[s]evere” flare-ups occurring on a weekly frequency, lasting for “hours,” and precipitated by cold weather, running, and jumping. The Veteran reported the flare-ups were alleviated by motrin and physical therapy. The Veteran was able to stand for more than one hour, but not for three hours. The Veteran was able to walk for one to three miles. She used an orthotic insert for relief occasionally / intermittently. Her gait was normal, with no evidence of abnormal weight bearing. Clinical examination revealed no crepitus, no clicks or snaps, no grinding, no instability, no patellar abnormality, no meniscus abnormality, and no abnormal tendons or bursae. The September 2011 VA examination report shows that range of motion testing on active motion revealed objective evidence of pain for both knees. Both knees demonstrated flexion to 125 degrees, and both knees demonstrated fully normal extension to the 0 degrees position. There was objective evidence that the Veteran’s pain continued following repetitive motion, but there were “No” additional limitations after three repetitions of range of motion. The Veteran had fully normal “5/5” strength in both knees for flexion and extension representing active movement against full resistance. X-ray imaging of both knees revealed no evidence of arthritic changes and no abnormalities. Based on the evidence, the Board concludes that no increased or additional ratings are warranted for the Veteran’s patellofemoral syndrome disability in either knee. The evidence persuasively shows that knee flexion is not limited to 45 degrees in either knee, including with consideration of all pertinent forms of clinical testing and with consideration of functional loss in all pertinent contexts and circumstances, including during flare-ups. Instead, while the Veteran’s flexion of the right knee is somewhat impaired, functional flexion of each knee is well beyond 45 degrees. The evidence persuasively shows that knee extension is not limited to the 10-degree position in either knee, including with consideration of all pertinent forms of clinical testing and with consideration of functional loss in all pertinent contexts and circumstances, including during flare-ups. Instead, while the Veteran’s extension of the right knee is somewhat impaired (limited to the 5-degree position in all pertinent contexts), functional extension of each knee goes well beyond the 10-degree position. The Veteran’s right knee muscle strength is diminished, but still “4/5 Active movement against some resistance,” with no muscle atrophy. There is no diminishment of strength or muscle atrophy for the left knee. Additionally, the evidence shows that there is no recurrent subluxation or lateral instability, no dislocated semilunar cartilage of either knee with frequent episodes of “locking,” pain, and effusion into the joint (the right knee has effusion, but without semilunar cartilage pathology), and no symptomatic removal of the semilunar cartilage for either knee. Neither knee has been ankylosed. There is no suggestion in this case of tibia/fibula impairment or genu recurvatum of either leg. Accordingly, the Veteran’s right and left knee disabilities do not manifest in any impairment meeting the criteria for any increased or new compensable ratings under the rating criteria of 38 C.F.R. § 4.71a. The RO’s July 2012 rating decision explained that the 10 percent rating assigned for each knee contemplated “consideration of functional loss due to painful motion” warranting a compensable rating in each knee despite the fact that the schedular criteria for a compensable rating were not otherwise met. Those 10 percent ratings continue to be in effect at this time, and they contemplate the Veteran’s current functional loss, including her described “difficulty going down stairs or sitting for long periods, as well as difficulty going from sitting to standing.” For the periods on appeal in this case, the Board finds that the impairment shown in either knee has not met the criteria for any increased or additional disability ratings. Thus, no increased and/or additional rating is warranted for either knee’s patellofemoral syndrome. The Board again notes that the September 2011 VA examination report contains an indication that the Veteran described that she had experienced some “giving way” in at least one of her knees. The Board has considered whether the Veteran’s lay account of symptoms indicates instability of a knee. The Board notes that objective evidence does not necessarily mean medical evidence. Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). Where medical evidence is deficient or inconsistent in showing instability, a Veteran’s competent and credible lay statements may be sufficient objective evidence. However, in this case the same September 2011 VA examination report documents that the authoring medical expert documenting the Veteran’s description of symptoms understood her description as not indicating “instability.” Furthermore, the September 2011 VA examiner found no evidence of instability on clinical testing, and the later August 2018 VA examination report shows that the Veteran indicated no history of instability or either knee and clinical inspection revealed no instability at that time. Accordingly, the Board finds that the evidence in this case does not indicate instability of either knee during the period for consideration in this appeal. The Board notes that the September 2011 VA examination report does not include all of the information detailing functional loss in such contexts as painful motion and flare-ups contemplated by the requirements discussed by the Court in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the Board finds that the evidence of record is adequate in this case because (1) the August 2018 VA examination report does present the required information and indicates that no increased or additional ratings are warranted for such impairment, and (2) there is no suggestion in the record that the Veteran’s knee disabilities improved from September 2011 to August 2018 such that the severity of impairment in September 2011 would have been greater than that reported in thorough detail in August 2018. The Board notes that details in the evidence, including the August 2018 VA examination report, indicate functional impairment of the knees due to factors featuring pain, although not otherwise meeting the rating criteria of the applicable Diagnostic Codes for compensable ratings. As discussed above, the 10 percent ratings currently assigned for the knees (one for each knee) have been awarded expressly on the basis of contemplating the functional impairment due to pain in this case. The Board observes that the August 2018 VA examination report indicates that there was functional impairment following repetitive use and during flare-ups, and expressed the degree of impairment in terms of ranges of motion that were not compensably limited. The Board finds that the currently assigned 10 percent ratings contemplate the indicated functional impairment in each knee. The Board notes that the August 2018 VA examination report indicates that the Veteran did not have arthritis in either knee, and this indication is consistent with the diagnostic imaging (X-ray) findings presented in the September 2011 VA examination report showing “no arthritic changes.” Further references to the Veteran’s knee disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s knee disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. The Board has considered whether there is any other basis for granting increased and/or additional ratings, but has found none. The Board finds that no increased and/or additional ratings are warranted in this case. As the preponderance of the evidence is against assignment of any further increased and/or additional ratings in this case, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the knee disabilities. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. The issue of entitlement to service connection for a right shoulder disability is remanded. 2. The issue of entitlement to service connection for a left shoulder disability is remanded. 3. The issue of entitlement to service connection for a disability manifested by a weak right ankle is remanded. 4. The issue of entitlement to service connection for a disability manifested by a weak left ankle is remanded. 5. The issue of entitlement to service connection for a disability manifested by left arm numbness with tingling fingers is remanded. 6. The issue of entitlement to service connection for sciatica is remanded. 7. The issue of entitlement to a rating in excess of 10 percent for lumbar strain with rotary scoliosis of the thoracic spine is remanded. 8. The issue of entitlement to a rating in excess of 10 percent for cervical spine degenerative joint disease is remanded. 9. The issue of entitlement to a compensable rating for bilateral plantar fasciitis is remanded. 10. The issue of entitlement to a compensable rating for hypertension is remanded. 11. The issue of entitlement to a rating in excess of 20 percent for postpartum urinary stress incontinence / recurrent acute bacterial cystitis is remanded. 12. The issue of entitlement to a compensable rating for acne vulgaris is remanded. 13. The issue of entitlement to a compensable rating for tension headaches is remanded. The Veteran was last provided a VA examination for the purpose of assessing the severity of her urinary disorder, cervical spine disability, back disability, plantar fasciitis, acne vulgaris, hypertension, and tension headaches in September and October 2011, now more than seven years ago. Furthermore, for some of these disabilities the Veteran’s medical records suggest that she may have developed increased severity of potentially pertinent symptoms. Among other examples, the Board observes that the Veteran’s more recent medical records note problems with urinary symptoms including frequency and pain, and records document poorly controlled hypertension. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of these disabilities to inform appellate review of their rating assignments. In addition, the Board notes that the most recent VA examinations of the Veteran’s back and neck for rating purposes did not provide the findings necessary to satisfy the requirements of the holdings of the United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016) and in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The Board notes that the Veteran has appealed the denial of entitlement to service connection for sciatica, whereas the Veteran’s lumbar/thoracic spine (back) disability has been recognized as a service-connected disability. The RO relied upon the September 2011 VA examiner’s finding that the Veteran’s report of sciatica could not be confirmed with a diagnosis based upon the clinical examination at that time. The question of whether the Veteran’s service-connected back disability has caused or aggravated sciatica will be addressed in the forthcoming new VA examination of the Veteran’s back disability for rating purposes during the processing of this remand. Accordingly, the issue of entitlement to service connection for sciatica must be remanded as well, as the forthcoming development is directly pertinent to informing the outcome of the sciatica service connection issue on appeal. Similarly, the Board notes that the Veteran has appealed the denial of entitlement to service connection for left arm numbness with tingling fingers, whereas the Veteran’s cervical spine (neck) disability has been recognized as a service-connected disability. The RO relied upon the September 2011 VA examiner’s finding that the Veteran’s report of left arm numbness with tingling fingers could not be confirmed with a diagnosis based upon the clinical examination at that time. The Board notes that the Veteran’s in-service and post-service medical records both contain references to “cervical radiculopathy.” The question of whether the Veteran’s service-connected neck disability has caused or aggravated left arm numbness with tingling fingers will be addressed in the forthcoming new VA examination of the Veteran’s neck disability for rating purposes during the processing of this remand. Accordingly, the issue of entitlement to service connection for left arm numbness with tingling fingers must be remanded as well, as the forthcoming development is directly pertinent to informing the outcome of the left arm numbness with tingling fingers service connection issue on appeal. The September 2011 VA examination report determined that there was no ankle pathology found on clinical examination at that time, although the Veteran reported significant symptoms involving her ankles. The Board notes that the ankle issues on appeal have been characterized by the Veteran’s claim as featuring “weak ankles,” and this claim was presented adjacent to her claim concerning “sciatica.” It is reasonable to interpret the Veteran’s claimed disability of “weak ankles” as intertwined with the neurological deficit she reports as “sciatica” in this appeal. The question of whether the Veteran’s service-connected back disability and claimed sciatica have caused or aggravated her reported weakness in one or both of her ankles will be addressed in the forthcoming new VA examination of the Veteran’s back disability for rating purposes during the processing of this remand. Accordingly, the issues of entitlement to service connection for weak right ankle and weak left ankle must be remanded as well, as the forthcoming development is directly pertinent to informing the outcome of these service connection issues on appeal. The September 2011 VA examination report shows that the examiner was unable to diagnose a bilateral shoulder disability because “radiology report reveals no evidence of pathology.” The Veteran has reported some shoulder pain both during service prior to the VA examination, and also during the more than seven years that have passed since the VA examination. It is not entirely clear to the Board that the Veteran’s claim is limited to shoulder disabilities of a nature that would be revealed by the radiology reports, but in any event the Board finds that any disability associated with the Veteran’s reported shoulder symptoms may reasonably have manifested in more apparent diagnostic signs over the substantial period of more than seven years since the VA examiner’s determination in September 2011. Accordingly, the Board finds that a remand of this issue is warranted for the purpose of obtaining a new VA examination report with an updated determination as to whether the Veteran has a left and/or right shoulder disability related to her military service. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file). 2. After the record is determined to be complete, schedule the Veteran for an examination of the severity of her service-connected back disability. The examiner must test the Veteran’s active motion, passive motion, and with weight-bearing and without weight-bearing (including testing for pain). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies active motion, passive motion, pain with weight-bearing and without weight-bearing (to the extent medically appropriate) at each time the back disability was previously examined with documented range of motion testing for VA rating purposes. The VA examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA examiner should assess or estimate the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. A rationale should be provided for each medical opinion presented. 3. After the record is determined to be complete, schedule the Veteran for an examination of the severity of her service-connected neck disability. The examiner must test the Veteran’s active motion, passive motion, and with weight-bearing and without weight-bearing (including testing for pain). If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies active motion, passive motion, pain with weight-bearing and without weight-bearing (to the extent medically appropriate) at each time the neck disability was previously examined with documented range of motion testing for VA rating purposes. The VA examiner should also express an opinion concerning whether there would be additional limits on functional ability on repeated use or during flare-ups, and, to the extent possible, provide an assessment of the functional impairment on repeated use or during flare-ups. The VA examiner should assess or estimate the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. A rationale should be provided for each medical opinion presented. 4. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected postpartum urinary stress incontinence and recurrent acute bacterial cystitis. The examiner should provide a full description of the disability and report all signs and symptoms related to her service-connected postpartum urinary stress incontinence and recurrent acute bacterial cystitis. 5. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected bilateral plantar fasciitis. The examiner should provide a full description of the disability and report all signs and symptoms related to her service-connected bilateral plantar fasciitis. 6. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected acne vulgaris. The examiner should provide a full description of the disability and report all signs and symptoms related to her service-connected acne vulgaris. 7. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected hypertension. The examiner should provide a full description of the disability and report all signs and symptoms related to her service-connected hypertension. 8. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected tension headaches. The examiner should provide a full description of the disability and report all signs and symptoms related to her service-connected tension headaches. 9. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any disabilities of the right and left shoulders. The examiner must opine as to whether it is at least as likely as not that the Veteran has a disability of the right or left shoulder that is etiologically related to an in-service injury, event, or disease, including whether any current shoulder disability had incurrence or onset during the Veteran’s more than 22 years of active duty service. The VA examiner is asked to please clarify whether the Veteran has a diagnosis of any right or left shoulder disability, with attention to her history of symptoms complaints concerning her shoulders. 10. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s claimed sciatica. (This may be accomplished in tandem with the back disability rating examination, directed above, if determined to be medically appropriate.) The examiner must opine as to whether it is at least as likely as not that the Veteran has sciatica that is etiologically related to an in-service injury, event, or disease, including whether she has sciatica as a result of her service-connected back disability. The VA examiner is asked to please clarify whether the Veteran has a diagnosis of sciatica, with attention to her history of symptom complaints. 11. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s claimed weakness of the right and left ankles. (This may be accomplished in tandem with the back disability rating examination, directed above, if determined to be medically appropriate.) The examiner must opine as to whether it is at least as likely as not that the Veteran has a disability manifested by weakness in the right and/or left ankle that is etiologically related to an in-service injury, event, or disease, including whether she has any such ankle weakness as a result of her service-connected back disability or claimed sciatica. The VA examiner is asked to please clarify whether the Veteran has a diagnosis of any disability manifesting in her claimed right and left ankle symptoms, with attention to her history of symptom complaints. 12. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s claimed left arm numbness with tingling fingers. (This may be accomplished in tandem with the neck disability rating examination, directed above, if determined to be medically appropriate.) The examiner must opine as to whether it is at least as likely as not that the Veteran has left arm numbness with tingling fingers that is etiologically related to an in-service injury, event, or disease, including whether she has left arm numbness with tingling fingers as a result of her service-connected neck disability. The VA examiner is asked to please clarify whether the Veteran has a diagnosis of a disability manifesting in left arm numbness with tingling fingers, with attention to her history of symptom complaints and the references to “cervical radiculopathy” in her service treatment records and post-service medical records. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel