Citation Nr: 1806848 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 14-14 672 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability rating greater than 10 percent for post-appendectomy scars. 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). 3. Entitlement to service connection for disability of the right wrist. 4. Entitlement to service connection for residuals of a left foot and ankle sprain. 5. Whether new and material evidence has been submitted to reopen a finally-denied claim for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars. 6. Whether new and material evidence has been submitted to reopen a finally-denied claim for entitlement to service connection for residuals of a hysterectomy, including the removal of both ovaries. 7. Entitlement to service connection for cancerous cells of the cervix. 8. Entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars. 9. Entitlement to service connection for residuals of a hysterectomy, including the removal of both ovaries 10. Entitlement to service connection for a disability of the right arm above the wrist, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service. 11. Entitlement to service connection for a cervical spine disability, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service. 12. Entitlement to service connection for a chest wall muscle disability and back muscle disability, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service. 13. Entitlement to service connection for a disability of the left shoulder, arm and hand, claimed as caused by overuse of the left arm secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service. 14. Entitlement to increased disability ratings for impairment of the right thumb and hand, including surgical residuals, metacarpophalangeal fusion, and scars of the right thumb and wrist. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and her husband ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from January 1982 to September 1987. These matters come before the Board of Veterans' Appeals (Board) from a July 2010 decision by the New Orleans RO. The Veteran has relocated several times in the intervening time period. The Veteran presented sworn testimony in support of her appeal during an April 2017 Board hearing before the undersigned Veterans Law Judge in Montgomery, Alabama, and this RO should now have responsibility for her appeal. The Board has recharacterized the issues on appeal, as shown on the title page of this decision, to better reflect the procedural posture of some issues and our understanding of the medical facts of other issues. Notably, the RO adjudicated an issue of whether new and material evidence had been submitted to reopen a claim of entitlement to service connection for residuals of a left foot and ankle sprain. However, the Veteran submitted previously unconsidered service treatment records pertinent to this claim. As such, this claim must be reconsidered. 38 C.F.R. § 3.156(c). The issues of entitlement to service connection for residuals of a left foot and ankle sprain; residuals of an inservice Caesarian-section surgery, to include scars; residuals of a hysterectomy, including the removal of both ovaries; a disability of the right arm above the wrist, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service; a cervical spine disability, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service; a chest wall muscle disability and back muscle disability, claimed as secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service; a disability of the left shoulder, arm and hand, claimed as caused by overuse of the left arm secondary to right hand and wrist impairment, or as caused by lifting heavy bags during service; and entitlement to increased disability ratings for impairment of the right thumb and hand, including surgical residuals, metacarpophalangeal fusion, and scars of the right thumb and wrist are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. During the April 2017 hearing on appeal, prior to promulgation of a decision in this appeal, the Veteran requested a withdrawal of the appeal for a disability rating greater than 10 percent for post-appendectomy scars. 2. The Veteran is rendered unable to secure and follow a substantially gainful occupation by reason of her service-connected disabilities. 3. Poor position of the right thumb following 1992 fusion surgery caused injury to the right wrist. 4. The Veteran's claims for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries, were denied by the RO in December 2007. She did not appeal that decision to the Board, nor was any new and material evidence received within the following year. 5. New evidence has been received after the December 2007 denial which is not cumulative or redundant and relates to an unestablished fact or raises a reasonable possibility of substantiating the claim for entitlement to service connection for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries. 6. The Veteran does not have cervical cancer. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for a disability rating greater than 10 percent for post-appendectomy scars by the Veteran have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. A total disability rating for compensation based upon individual unemployability due to service-connected disabilities is warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). 3. Service connection for right wrist disability is warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The December 2007 RO decision denying service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 5. Because new and material evidence has been received, the claims for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries, are reopened. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156 (2017). 6. Service connection for cervical cancer is not warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Standard of review Once the evidence has been assembled, it is the Board's responsibility to evaluate the record. 38 U.S.C. § 7104(a). When there is an approximate balance of 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. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board must consider all the evidence of record and discuss in its decision all "potentially applicable" provisions of law and regulation. See 38 U.S.C. § 7104(a); Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). The Board is also required to provide a statement of reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for its decision, as well as to facilitate further appellate review. See 38 U.S.C. § 7104(d)(1); Allday v. Brown, 7 Vet. App. 517, 527 (1995); Gilbert, 56 (1990). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for the evidence it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the claimant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Duties to notify and assist In this case, neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). A disability rating greater than 10 percent for post-appendectomy scars During the April 2017 hearing on appeal, the Veteran withdrew her appeal for a disability rating greater than 10 percent for post-appendectomy scars. She subsequently submitted a written statement bearing her signature, confirming her wish to withdraw the appeal. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran has withdrawn this appeal and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal for a disability rating greater than 10 percent for post-appendectomy scars and it is dismissed. TDIU The Veteran contends her service-connected disabilities render her unable to maintain gainful employment. Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran's employment history, educational and vocational attainment, as well as her particular physical disabilities are to be considered in making a determination on unemployability. It is further provided that the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service-connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the Veteran unemployable. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether the Veteran is entitled to a total disability rating based upon individual unemployability, neither her nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose, supra. The Veteran reported that she has completed one year of college. After her discharge from service, she participated in VA-sponsored vocational rehabilitation, to further her education. Her relevant service experience was in the field of airport services, including passenger service, baggage service, and flight-line duties. She reports post-service work experience as an accountant and in human resources. She also performed significant volunteer work for the Red Cross, teaching classes and working in disaster relief. According to the Social Security disability records in the file, she has held significantly-gainful employment since 2007. A statement from a former employer reflects that she attempted to work as an accountant in 2009, but was only able to work for six weeks, during which time, she lost sixty hours of time due to disabilities. The employer indicated that the Veteran's medical condition with her right arm prevented adequate work performance. Service connection has been granted for post-traumatic stress disorder (PTSD), rated as 70 percent disabling; residuals of multiple surgeries to the right hand and thumb, currently rated as 10 percent disabling; sinus headaches, rated as 50 percent disabling; and multiple scar residuals, rated as 10 percent and 0 percent disabling. The combined disability rating is 80 percent. As such, she meets the schedular criteria for an award of a total disability rating for compensation based on individual unemployability under the provisions of 38 C.F.R. § 4.16(a), iF in the judgment of VA, her service-connected disabilities render her unemployable. At the time of the prior denial, in July 2010, service connection had not been granted for PTSD, meaning that impairment from PTSD was not considered in the TDIU analysis. Given this significant change in her service-connected status, a view on her employability with fresh eyes is warranted. The medical evidence of record includes several statements from the Veteran's treating physiatrist that her right hand and thumb impairment makes basic activities of daily living such as dressing, grooming, cooking, household chores, and driving difficult. With regard to her PTSD, the report of a June 2014 VA examination reflects the examiner's assessment that the Veteran has severe interpersonal difficulty, that she is quite challenged and angry, that when she perceives she is being blocked from getting her needs met, she becomes volatile, irrational, and interpersonally ineffective. Review of the Veteran's voluminous medical records includes many instances corroborating these tendencies. During the hearing on appeal, the Veteran provided credible and extensive testimony as to her frustrations with her pain and her inability to use her right hand normally. She testified that she basically just sits around the house, and that her husband has to perform many of the usual household chores. She also related several stories illustrating her frustrations and interpersonal difficulties. The veteran's hearing testimony is deemed helpful to the Board and credible as it comports with the medical evidence of record. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The impact of her PTSD on her employability is illustrated by review of the hearing transcript and of VA medical records, both of which reflect significant difficulty in interacting with others effectively. The impact of her right hand and thumb impairment is also significant to our analysis of her employability. Especially as she is right-handed, and her prior work experience requires the use of fine motor skills in the right hand, this service-connected disability can only have an adverse effect upon her ability to perform most jobs. When the combined impact of the physical disability and the mental disability is considered, her difficulty in maintaining a job is greatly heightened. Upon review of the evidence, the Board finds reasonable doubt exists as to whether the Veteran is rendered unemployable due to her service-connected disabilities. Her difficulties in working effectively with others, combined with the impairment of her right hand and thumb, buttressed by her credible hearing testimony and the thoughtful, informed statements of her treating physicians add up to the conclusion that she is unemployable, without consideration of her age or other nonservice-connected disabilities. A TDIU is therefore granted. Right wrist Service connection is established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during periods of active service. 38 U.S.C. § 1110. In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Disability which is proximately due to or the result of a service-connected disease or injury also shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. The Veteran has had a series of surgeries affecting her right thumb, with the initial injury and surgery occurring in service. She has undergone multiple VA examinations and evaluations of the thumb over the years, so there is a body of evidence regarding the condition of the thumb and right hand. She now contends that she has impairment involving her right arm, shoulders, chest, and left arm related to the accommodations she has made over the years to compensate for her decreased right thumb and hand function. Service connection for disability of the right arm was denied in July 2010, and the question of service connection for disability above the wrist is remanded below. However, careful review of the medical evidence convinces the Board we can grant service connection for disability of the right wrist at this time. The report of an April 2010 fingers examination reflects the examiner's assessment that poor position of the right thumb due to the 1992 fusion surgery caused injury to the right wrist. The examination was requested to evaluate the right thumb, and the extent of the wrist impairment is not fully described, unfortunately. However, the medical opinion is unambiguous, as well as being in accordance with generally accepted medical principles as to the physiological relationships in the hand and wrist. Therefore, service connection for impairment of the right wrist, secondary to the service-connected thumb disability is granted. Claims to reopen In December 2007, the RO denied claims for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries. Essentially, service connection for these disabilities was denied because the record did not contain evidence of a current disability, and the Veteran had failed to report for scheduled examinations to identify such. In the case of the hysterectomy, the RO noted that the Veteran's available service treatment records did not contain any indication of treatment during service. The Veteran did not appeal this decision and it thus became final one year after she was notified of the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Veteran continues to assert that service connection is warranted for disabilities in these areas. The RO denied the claims in July 2010 finding that the Veteran had not submitted new and material evidence sufficient to reopen the previously-denied claims. RO decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, 20.302(a). If new and material evidence is received during an applicable appellate period following a RO decision (one year for a rating decision and 60 days for a statement of the case), the new and material evidence will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Thus, under § 3.156(b), "VA must evaluate submissions received during the relevant [appeal] period and determine whether they contain new evidence relevant to a pending claim, whether or not the relevant submission might otherwise support a new claim." Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means evidence not previously submitted. Material evidence means existing evidence that by itself or when considered with previous evidence 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 last final decision, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). "[N]ew and material evidence" under 38 C.F.R. § 3.156(b) has the same meaning as "new and material evidence" as defined in 38 C.F.R. § 3.156(a). See Young v. Shinseki, 22 Vet. App. 461, 468 (2011). Generally, an appellant's own recitation of his medical history does not constitute new and material evidence sufficient to reopen his claim when this account has already been rejected by the VA. Chavarria v. Brown, 5 Vet. App. 468 (1993). In Shade v. Shinseki, 24 Vet. App 110 (2010), the Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Additionally, for the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New evidence received since the December 2007 denial includes the Veteran's hearing testimony where she stated that she is seeking service connection for painful scars related to the C-section and the hysterectomy, that she believes the hysterectomy was necessitated by the complicated pregnancy she experienced during service, as well as surgery she underwent to remove her appendix during service. Also new are multiple medical records added to her file after December 2007. The new evidence was not previously considered by agency decision-makers and is neither redundant nor cumulative, when considered in conjunction with the previous evidence of record. Furthermore, it relates to unestablished facts necessary to substantiate the claims. Therefore, the Veteran's claims for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, to include the removal of both ovaries are reopened. Shade. Having reopened the claims, however, we are unable to render a decision without further information. This deficit is addressed in the remand which follows. Cancerous cells of the cervix Simply put, the Veteran has no current disability involving cancerous cells of her cervix. Although she had an abnormal Pap smear test in service, no cancer was identified at that time. During the hearing on appeal, she testified that she had had the abnormal cells treated with a cryogenic freeze. Her Pap smear tests have been normal since that time, with no evidence of cervical cancer in any of the available medical records. Furthermore, none of the recent medical records identify any residuals of the cryogenic freeze treatment. A threshold requirement for the grant of service connection for any disability is that the disability claimed must be shown present. 38 U.S.C. §§ 1110, 1131. The Court has interpreted the requirement of current disability thus: Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In addition to disease or injury in service, service connection requires competent medical evidence of a current related disability. Degmetich v. Brown, 104 F.23d 1328 (1997). Fortunately, there is no evidence of a current disability involving cervical cancer. Thus there can be no valid claim for such. The appeal must be denied. ORDER The appeal for a disability rating greater than 10 percent for post-appendectomy scars is dismissed. TDIU is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for right wrist disability is granted. New and material evidence having been presented, the claims for entitlement to service connection for residuals of an inservice Caesarian-section surgery, to include scars; and residuals of a hysterectomy, including the removal of both ovaries, are reopened; to this extent only the appeal is granted. Service connection for cancer of the cervix is denied. REMAND With regard to her left foot and ankle, the Veteran has reported several different histories of injury to the left foot. She has stated that she sustained an injury getting her bed ready for inspection, also she has reported that the foot was caught in a heavy gate and crushed. The only incident reported in her available service treatment records, however, is a sprain of the ankle. She has reported various treatments during service, including a cast, followed by a wooden shoe. To further develop this claim, the Veteran should be requested to identify exactly which medical facility provided treatment for her left foot/ankle during service. If indeed her foot was crushed in a gate, a record of treatment following the injury should be available. If further treatment reports are discovered, then another informed VA opinion to provide a nexus to current symptoms must be obtained. With regard to the Veteran's service treatment records, we note that clinical hospital records reflecting inpatient treatment during service have not been requested or received by VA. For instance, the report of her original June 1982 right thumb surgery is not available for review. Therefore, for completeness of the record, upon remand, the RO should request information about where the Veteran was hospitalized during service for any reason, but especially including treatment for a left foot/ankle injury. The question regarding the claim for service connection for residuals of an inservice Caesarian-section surgery, to include scars, simply involves whether any current disability exists to support a grant of service connection. The records contain the report of the C-section in service. However, the evidence regarding current residuals is less than clear. The Veteran claims she has a scar from "hip to hip." She does not specify any other residuals. The report of a January 2010 scars examination identifies a scar on the right lower abdomen which is identified as a residual of a December 1985 surgery. According to the Veteran's service treatment records, she had her appendix removed around this time, which would be consistent with a right-side scar. Her son was born, via C-section, in March 1986, however. Furthermore, service connection and a 10 percent disability rating are already in effect for the appendectomy scar. The Veteran has credibly testified that her C-section scar is both painful and unstable. Therefore, upon remand, another examination should be conducted to identify any current scar. We observe that in addition to the appendectomy and the C-section, the Veteran underwent an abdominal hysterectomy, which would be expected to result in a scar as well. With regard to the Veteran's claim for entitlement to service connection for residuals of a hysterectomy, including the removal of both ovaries, it is especially important to clarify that the report of the Veteran's March 2004 hysterectomy definitively shows that her ovaries were not removed at that time. The ovaries were visualized during the surgery, a spot of endometriosis was cauterized from the right ovary, and both ovaries were preserved during the surgery. Therefore, unless she has had them removed since that time, her understanding that her ovaries were removed is simply incorrect. The claim for residuals of a hysterectomy suffers from two deficits at the moment. The first is whether she has any current disability, and the second is whether such disability is related to service. Therefore, upon remand, an appropriate VA examination should be conducted to identify current residuals and, if necessary, a nexus to service. Right arm above the wrist, cervical spine, chest wall and back muscle disabilities, left shoulder, left arm and left hand These disabilities appear to be relatively recent in origin, initially manifesting many years after service. As yet, they are ill-defined, despite multiple attempts by multiple physicians with different areas of specialty, to identify one or several diagnoses. The Veteran experiences pain, muscle spasms and other impairment in these areas which is significant and impacts her daily life negatively. Her statements and assertions regarding the extent of her symptoms and her daily impairment are credible and are being taken seriously by her care providers. The etiology of these symptoms has not yet been determined-although the claims file does not contain fully up-to-date records, so it is possible that her physicians have assigned a diagnosis by now. It is clear from the Veteran's VA treatment records and the doctor statements she has submitted, that her medical team is working hard to identify the cause(s) of her symptoms so as to be able to form a plan to help alleviate these symptoms. The Veteran has proposed two theories of entitlement to service connection for her symptoms in these areas: that years of compensating for her right hand pain caused repeated overuse of her left arm to include her shoulder, neck, chest and back, and/or that the heavy bags she had to lift during service in the course of performing her military occupational specialty caused an overuse syndrome in these areas. The Board finds that medical examination and opinion is warranted. Increased disability ratings for right thumb impairment Currently, the Veteran's right thumb disabilities are rated 10 percent for limitation of motion of the thumb. Two additional 10 percent ratings are in place for post-surgical scars on the right palm and the right wrist. During the hearing on appeal, the Veteran testified that her right hand impairment has worsened since the hand was last evaluated medically, and that she can grasp a pen to write for less than fifteen minutes at a time due to painful spasms in the hand. Additionally it was observed during the hearing that she had difficulty grasping with the right hand and using the hand. In addition to updating her treatment records, another VA examination should be provided to evaluate bony impairment, muscle impairment, and nerve impairment, if any, as well as the scars. A thorough discussion of functional impairment should be included. With regard to the examinations requested by the Board, the Board acknowledges the Veteran's difficulties and frustrations involved with the scheduling of prior examinations and medical appointments in general. For this reason, the Board urges the Veteran to utilize the assistance of her representative and to work closely with the RO to ensure her examinations are scheduled at a time and place convenient for the Veteran. Once this has been accomplished, the Board urges her to make every effort to be there; and if attendance is not possible, to formally submit her reason for missing the examination(s), so that a good cause analysis can be conducted. Accordingly, the case is REMANDED for the following action: 1. The RO should request that the Veteran complete a thorough list of the different medical facilities where she received inpatient treatment during her five and a half years of service, but especially where she would have been treated for a left foot/ankle disability. The RO should then request copies of all clinical hospital records from the locations identified by the Veteran, through official channels, for inclusion in the claims file. 2. The RO should ascertain where the Veteran has received VA medical care since June 2015, and request complete records of this treatment from all VA Medical Centers and related clinics, to include, but not limited to the Gulf Coast Veterans Health Care System, the Pensacola Joint Ambulatory Care Center, and the Overton Brooks VA Medical Center, for inclusion in the claims file. 3. IF further service treatment reports pertaining to the left foot/ankle are obtained, then another informed VA opinion regarding whether it is more, less, or equally likely the current impairment is related to service should be obtained. 4. The Veteran should be afforded a VA examination to identify current disability relating to the C-section surgery in service, and the hysterectomy after service, including any internal impairment as well as external scar residuals. IF current disability involving the hysterectomy is identified, then an opinion as to whether the hysterectomy was necessitated by any event during service or is otherwise related to service, must be proffered. The claims folder must be made available to the examiner for review before the examination. Any tests and studies deemed helpful by the examiner should be accomplished in conjunction with the examination. The complete rationale for all opinions offered must be fully explained. 5. The Veteran should be afforded a VA examination by a provider with expertise in the hand to another VA examination should be provided to evaluate currently-shown bony impairment, muscle impairment, and nerve impairment, if any, as well as the scars. A thorough discussion of functional impairment should be included. The claims folder must be made available to the examiner for review before the examination. All tests and studies deemed helpful by the examiner should be accomplished in conjunction with the examination. The complete rationale for all opinions offered must be fully explained. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced range of motion during flares or repetitive use. Also, in order to comply with the Court's decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the VA examination must include range of motion testing with regard to the non-fused joints, in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. 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. 6. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs