Citation Nr: 19141019 Decision Date: 05/28/19 Archive Date: 05/28/19 DOCKET NO. 09-27 734A DATE: May 28, 2019 ORDER Entitlement to service connection for metromenorrhagia, claimed as abnormal vaginal bleeding, is granted. Entitlement to service connection for a kidney disorder is denied. Entitlement to service connection for asthma is granted. Entitlement to service connection for costochondritis, claimed as chest pain, is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for diabetes mellitus, type 2, is denied. Entitlement to an initial rating higher than 10 percent for left wrist sprain with tendonitis is denied. REMAND Entitlement to service connection for residuals of a left knee injury is remanded. FINDINGS OF FACT 1. The Veteran’s metromenorrhagia was incurred during a period of ACDUTRA. 2. There is no current diagnosis of a kidney disorder. 3. The Veteran’s asthma was aggravated during a period of ACDUTRA. 4. The Veteran’s chest pain, diagnosed as costochondritis, was not incurred or aggravated during active service, or a period of INACDUTRA. 5. The Veteran’s hypertension was not incurred or aggravated by active service, is not attributable to any period of ACDUTRA, did not have an onset within one year of active service, and is not proximately due to or aggravated by a service-connected disability. 6. The Veteran’s diabetes mellitus, type 2, was not incurred or aggravated by active service, is not attributable to any period of ACDUTRA, and did not have an onset within one year of active service. 7. The Veteran’s left wrist sprain with tendonitis is not manifested by ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for metromenorrhagia, claimed as abnormal vaginal bleeding, have been met. U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for entitlement to service connection for a kidney disorder are not met. U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for entitlement to service connection for asthma are met. U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2018). 4. The criteria for entitlement to service connection for chest pain have not been met. U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 5. The criteria for entitlement to service connection for hypertension have not been met. U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 6. The criteria for entitlement to service connection for diabetes mellitus, type 2, have not been met. U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 7. The criteria for entitlement to an initial rating higher than 10 percent for left wrist sprain with tendonitis have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3. 3.321, 4.71a, Diagnostic Code 5024, 5214, 5215 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran was a member of the Army Reserves from May 1989 to January 2012, when she was medically disqualified and transferred to the retired reserve. She served qualifying periods of active duty for training (ACDUTRA) from August 2, 1989 to December 11, 1989, July 15, 2005 to July 22, 2005, June 30, 2007 to July 21, 2007, and additional periods of ACDUTRA and inactive duty training (INACDUTRA). Service connection is in effect for disabilities that were incurred during the 1989, 2005, and 2007 periods of service. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from February 2008 and June 2008 rating decisions. In a July 2008 rating decision, the RO granted an increased initial evaluation of 10 percent for the left wrist, effective November 2006. Despite the grant of this increased initial evaluation, the Veteran has not been awarded the highest possible evaluation. As a result, she is presumed to be seeking the maximum possible evaluation. The issue remains on appeal, as the Veteran has not indicated satisfaction with the 10 percent rating. A.B. v. Brown, 6 Vet. App. 35 (1993). The Veteran requested a hearing before the Board. The requested hearing was conducted in January 2017 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In June 2017, the Board remanded these claims for additional development. In August 2018, the Board requested a medical expert opinion from the Veterans Health Administration (VHA). A VHA medical opinion was rendered in September 2018. Service Connection The Veteran seeks entitlement to service connection for abnormal vaginal bleeding, a kidney disorder, asthma, chest pains, hypertension, and diabetes mellitus, type 2. Special rules apply to National Guard and Reserve service. The first step in any claim for Veterans’ benefits is whether the claimant is considered a “Veteran” as defined under VA law. Active Duty for Training (ACDUTRA) is, among other things, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C. § 101 (22); 38 C.F.R. § 3.6 (c). Thus, to establish “Veteran” status with respect to service in the National Guard, and eligibility for service connection, the record must show that a claimant was disabled due to a disease or injury incurred or aggravated in the line of duty during a period of ACDUTRA. Alternatively, service connection can be granted for an injury (but not a disease) incurred during INACDUTRA service. See Mercado-Martinez, 11 Vet. App. at 419; Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991); see also 38 U.S.C. § 101 (24); 38 C.F.R. § 3.6 (a). Regarding ACDUTRA, the presumptions available to a claimant are limited. Unless and until “Veteran” status is established for any period of ACDUTRA, the presumptions of soundness and aggravation, as well as the presumptions of service connection for certain diseases under the statute and pertinent regulations, do not apply. See 38 U.S.C. §§ 1111, 1153; Bowers v. Shinseki, 26 Vet. App. 201, 206-07 (2013). A claimant whose claim is based on a period of ACDUTRA can never be entitled to the presumptions of service connection for chronic diseases. Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). For a claim to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Entitlement to service connection for metromenorrhagia, claimed as abnormal vaginal bleeding, is granted. The Veteran asserts her abnormal vaginal bleeding had an onset during active duty for training purposes. First, the Board notes that the Veteran has a current diagnosis of metromenorrhagia. See June 2008 VA examination. As such, Shedden element (1) is met. Next, the Board notes that the Veteran was diagnosed with metromenorrhagia during her period of qualifying active service in October 1989. Additionally, the Veteran was noted to have abnormal uterine bleeding during active duty for training purposes on August 4, 2006. An ultrasound revealed a small ovarian cyst with internal debris and hemorrhage, as well as multiple nabothian cysts. A Statement of Medical Examination and Duty Status indicates the Veteran had a possible ovarian cyst on that date, which was incurred in the line of duty. She again had heavy bleeding noted during her period of qualifying active service in July 2007. The Board finds that Shedden element (2) is met. Next, the Board notes that the August 2006 VA examiner opined that the Veteran’s metromenorrhagia was due to her uterine fibroids and left ovarian cyst. Importantly, the Veteran is currently service connected for ovarian cysts. See July 2008 rating decision. Based on the Veteran’s current diagnosis, a diagnosis during active service, and a medical opinion relating her current diagnosis to her time in service, the Board finds entitlement to service connection for metromenorrhagia is warranted. 2. Entitlement to service connection for a kidney disorder is denied. The Veteran seeks entitlement to service connection for a kidney disorder. The Veteran asserts she has a kidney disorder that is due to pancreatitis that occurred during service. Unfortunately, the preponderance of the evidence indicates the Veteran is not diagnosed with a post-service kidney disorder. In March 2012, the Veteran was afforded a VA examination, at which time it was noted that the Veteran had elevated creatinine and blood urea nitrogen (BUN) levels in 2008 but had no current residuals. She indicated she was not being followed/treated by nephrology. It was noted that the Veteran’s kidneys did not cause any functional impact. Similarly, in September 2017, the Veteran was afforded a VA examination, at which time the examiner noted the Veteran’s kidneys were normal. It was also specifically noted that the Veteran’s kidneys did not cause any functional impact. The Board has considered the Veteran’s arguments. The Board notes that the Veteran is competent to give evidence about what she experiences; for example, she is competent to discuss current pain and other experienced symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). However, because no functional impairment has been demonstrated and there is no post-service diagnosis of kidney disorder, the Board finds that the Veteran does not have a current disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. §§ 1110, 1131; see also 38 C.F.R. §§ 3.303, 3.304. Thus, as no disability is shown, there can be no valid claim for service connection. In the absence of a disability, the other elements of service connection need not be discussed, and service connection must be denied. 3. Entitlement to service connection for asthma is granted. The Veteran seeks entitlement to service connection for asthma. The Veteran has a current diagnosis of asthma. See August 2017 VA examination. Service connection on a presumptive basis is generally not warranted for periods of ACDUTRA. See, e.g., Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). This includes the presumption of aggravation under 38 U.S.C. § 1153. Donnellan v. Shinseki, 24 Vet. App. 167, 171 (2010). However, where a Veteran has been granted service connection for a disability based on a period of ACDUTRA, that Veteran “is then entitled to the presumption of aggravation with respect to a different, preexisting disability shown to have worsened during the same period of ACDUTRA.” Hill v. McDonald, 28 Vet. App. 243, 252 (2016). In this regard, the Board notes that the Veteran is currently service connected for migraines that occurred during her period of active service in June 2007 through July 2007. She is therefore entitled to the presumption of aggravation with respect to a different, preexisting disability, if shown to have worsened during the same period of ACDUTRA. Id. Evidence indicates that the Veteran had asthma prior to her period of service beginning in June 2007; a May 2007 Dental Patient Medical History notes that the Veteran had asthma, with two to three attacks per year. The Board finds that her asthma was aggravated during her period of active service in June 2007 to July 2007. As noted, prior to this period of active service, the Veteran was reported to have two to three asthma attacks per year. Importantly, during the Veteran’s period of active service in June thru July 2007, lasting approximately three weeks, the Veteran experienced at least two asthma attacks that were noted to be during the line of duty. See, e.g., July 2007 Statement of Medical Examination and Duty Status. One of the July 2007 reports specifically indicated that the Veteran needed better control and follow-up for her asthma. She was placed on a profile due to her asthma. Similarly, a July 2007 Sick Slip indicates the Veteran’s asthma was in the line of duty and she was advised to avoid her asthma triggers. Given that the Veteran experienced as many asthma attacks in three weeks during active service as she normally would experience per year, the Board finds that the evidence suggests that the Veteran’s asthma underwent an increase in severity during her service. Thus, the presumption of aggravation attaches. The VA opinion that address the aggravation question is inadequate. Consequently, the Board finds that the evidence does not clearly and unmistakably show that the Veteran’s asthma was not aggravated in service. Accordingly, as the presumption of aggravation has not been rebutted, the Board finds entitlement to service connection for asthma is warranted. 4. Entitlement to service connection for costochondritis, claimed as chest pain, is denied. The Veteran asserts she experiences chest pains that had an onset during service in 1999. She has set forth several theories of entitlement, including chest pains having an onset during service, as due to asthma, and/or as due to a psychiatric disorder. The Veteran has a current diagnosis of costochondritis. See March 2012 VA examination. Unfortunately, the Board finds the Veteran’s costochondritis was not incurred or aggravated during a period of ACDUTRA, she did not experience an injury causing costochondritis during INACDUTRA, and she does not have costochondritis as a result of a service-connected disability. Service records indicate the Veteran complained of generalized chest pains during service, but no diagnosis of costochondritis was given and there is no indication the Veteran suffered an injury to the chest during service. See, e.g., July 2007 service treatment record noting chest pain. The Veteran was afforded a VA examination in August 2017, at which time the examiner noted that the service treatment records were silent for any evidence of a muscle injury that would cause costochondritis or would result in chest pain during service; the examiner also opined that there was no evidence the Veteran’s chest pain was aggravated during service. Notably, the only evidence that the Veteran’s current costochondritis is related to her ACDUTRA or INACDUTRA service is the Veteran’s own lay assertions. The Veteran’s generalized statements of chest pain during service combined with her asserted multiple theories of entitlement are too vague to relate them to her currently diagnosed costochondritis. To the extent that the Veteran’s statements assert a nexus between her costochondritis, service and/or other service-connected disabilities, such statements are afforded little probative value, as the Veteran is not shown to possess the expertise necessary to render a nexus opinion regarding the etiology of costochondritis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, the Veteran’s statements that her costochondritis is related to an in-service event are outweighed by the August 2017 VA examination, wherein the VA examiner opines that the Veteran’s costochondritis is not related to service. In sum, the evidence of record is not sufficient to support the Veteran’s claim of service connection for costochondritis. The preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 5. Entitlement to service connection for hypertension is denied. The Veteran asserts her hypertension was diagnosed during service and has also asserted that it is secondary to chronic pain due to her service-connected disabilities. The Veteran has a current diagnosis of hypertension. See September 2018 VHA opinion. Unfortunately, the evidence indicates that the Veteran’s hypertension was not incurred or aggravated during active duty, is not proximately due to or aggravated by a service-connected disability, and did not have an onset within one year of active service. A February 2007 service treatment record indicates the Veteran did not have hypertension. A July 11, 2007 Individual Sick Slip then noted that the Veteran should have a blood pressure check. The Veteran’s blood pressure was then recorded for 5 days and did not yield a diagnosis of hypertension. Prior to the completion of the 5-day check, a July 2007 Statement of Medical Examination and Duty Status indicated the Veteran had high blood pressure that was not incurred in the line of duty. The note specifically stated that high blood pressure was not caused by the performance of duty. A September 2013 VA examiner opined that the Veteran’s hypertension was less likely than not proximately due to or related to her migraines as there is no viable medical connection between migraines and essential hypertension. An October 2013 VA examiner opined that the Veteran’s hypertension was less likely than not proximately due to or the result of the Veteran’s lumbar or cervical disabilities. The examiner explained that there was no evidence of elevated blood pressure during service and the Veteran had complaints of neck and back pain for several years prior to her hypertension diagnosis, and hypertension is a vascular disease, not related to a muscular or skeletal problem. A VHA opinion was obtained in September 2018. The Board notes that a cardiologist opinion was requested in August 2018, and the September 2018 opinion was provided by an internist. The Board finds this is a suitable substitution. The physician’s knowledge of the subject area and thorough review of the evidence is evident from his discussion. As noted in the September 2018 VHA opinion, the Veteran’s onset of true hypertension was in June 2013, where it was first documented that the Veteran was on medication for hypertension. The specialist specifically explained that at various times prior to 2013 there were concerns about her blood pressure, but she was always in pain from various conditions, which does not qualify for a hypertension diagnosis, which must be documented at rest and not in pain. The specialist noted that there was no hypertension present during any periods of ACDUTRA, and therefore, no evidence of aggravation during service either. Continuing, the specialist also explained that he conducted research to determine if neck pain, migraines, or any pain in general would cause or aggravate hypertension. The specialist noted that painful conditions may cause brief or temporary elevations/aggravations of blood pressure, but they will not cause permanent elevations or aggravations and once the pain is controlled, the elevated readings due to pain will subside. The Board notes the Veteran submitted a positive medical opinion, dated December 2012, which opined that the Veteran’s hypertension started during her military service. The physician stated that the Veteran had “elevated blood pressure since 1997” and that she was diagnosed with hypertension during her active duty status. The Board notes that while the evidence indicates the Veteran may have had elevated blood pressures during service, at no time during active service was the Veteran diagnosed with true hypertension, as explained by the September 2018 VHA opinion. The Board finds the September 2018 VHA opinion to be more probative than the December 2012 private medical opinion. In this regard, the September 2018 specialist specifically cited the Veteran’s blood pressure readings throughout service, and fully explained why the Veteran did not meet the diagnostic criteria for a hypertension diagnosis during service. The December 2012 physician failed to note any specific blood pressure readings or explain why the Veteran met the definition of hypertension during service. In sum, the evidence of record is not sufficient to support the Veteran’s claim of service connection for hypertension, to include on a secondary basis. The preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved, and the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 6. Entitlement to service connection for diabetes mellitus, type 2, is denied. The Veteran asserts she was diagnosed with diabetes mellitus, type 2, in 1997. First, the Board notes that a September 2017 VA examination indicates the Veteran does not meet the diagnostic criteria for diabetes mellitus, type 2; however, a March 2012 VA examination indicates the Veteran has a post-service diagnosis of diabetes. Unfortunately, there is no evidence that the Veteran’s diabetes was incurred or aggravated during active duty or within one year of active duty. Based upon a careful review of the Veteran’s statements and the evidence of record, the Board finds that not only are the Veteran’s statements not corroborated by the evidence of record, they are contradicted by it. A September 1997 service treatment record indicates the Veteran had glycosuria (the excretion of glucose into the urine) and was to be evaluated for possible diabetes. However, there is no subsequent diagnosis of diabetes mellitus, type 2, in the qualifying period of service treatment records. A February 2007 service treatment note indicates the Veteran did not have a history of diabetes. In fact, during a May 2007 Report of Medical History, the Veteran herself did not indicate that she had diabetes presently or in the past. See May 2007 Patient Medical History. Similarly, a March 2008 service treatment record notes that the Veteran had an impaired fasting glucose but did not meet the criteria for diabetes. Accordingly, the Board affords no probative weight to the Veteran’s statements regarding the onset of diabetes during service. The Board notes the Veteran submitted a positive medical opinion dated December 2012, which stated the Veteran had intermittent glycosuria during service and she has been diagnosed with diabetes. The physician opined that the Veteran’s diabetes was incurred during her military service because she was diagnosed while on active duty, active duty for training, and in and out training events. The Board acknowledges that the Veteran had glycosuria during service; however, the medical evidence of record specifically indicates that the Veteran did not meet the criteria for diabetes during qualifying service. Elevated glucose levels do not always lead to diabetes and diabetes can be reversible. The conditions necessary to produce the chronic condition of diabetes did not occur during a period of qualifying service. Put simply, the record contains no competent contemporaneous evidence of a diagnosis of diabetes during any qualifying period of service. In making this determination, the Board has also considered the Veteran’s numerous statements to VA and various other treating and examining medical professionals regarding when her diabetes was first diagnosed. The Board recognizes that the Veteran is competent to provide a statement regarding when a medical professional first informed her of her diagnosis of diabetes. However, as explained above, no such diagnosis appears in the Veteran’s treatment records during active service and service treatment records specifically contradict the Veteran’s assertion that she was diagnosed in 1997 or during a period of qualifying service. For these reasons, the Board finds that the preponderance of the evidence does not show that the Veteran’s diabetes manifested during a period of qualifying service or is otherwise related to a period of qualifying service. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appeal is denied. Increased Rating 7. Entitlement to an initial rating higher than 10 percent for left wrist sprain with tendonitis is denied. Service connection for a left wrist sprain with tendonitis was established by a February 2008 rating decision, at which time a noncompensable rating was assigned, effective November 2006. The Veteran disagreed with the noncompensable rating in a February 2008 statement. In a July 2008 rating decision, the RO granted an increased initial evaluation of 10 percent, effective November 2006. The Veteran continues to seek an increased rating. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4. 40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. VA must consider “functional loss” of a musculoskeletal disability separately from consideration under the Diagnostic Codes; “functional loss” may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4. 40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be “seriously disabled.” Under 38 C.F.R. §§ 4. 40 and 4.45, a Veteran’s pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion Diagnostic Codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran. Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran’s complaints of pain have been considered in the Board’s review of the Diagnostic Codes for limitation of motion. The Board has considered the entire record, including the Veteran’s VA clinical records and private treatment records. These show complaints and treatment but will not be referenced in detail. The Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disability. The Veteran is currently rated under Diagnostic Code 5024 for tenosynitis, which directs the disability to be rated based on limitation of motion of the affected part. The Veteran is right handed, making her service-connected left wrist her minor extremity. See June 2008 VA examination. Under Diagnostic Code 5215, a 10 percent rating is assigned when dorsiflexion of the wrist is less than 15 degrees, or when palmar flexion is limited in line with the forearm. Under Diagnostic Code 5214, higher ratings of 20, 30, and 40 percent, for the minor extremity, are available if the Veteran experiences ankylosis of the wrist. At no time has the medical evidence indicated that the Veteran experiences ankylosis of the wrist. For example, as recently as August 2017, although limited by pain, the Veteran had a range of motion of 40 degrees of palmar flexion and dorsiflexion. She was able to perform repetitive-use testing with no additional loss of function or range of motion. It was also noted that the Veteran had a reduction in muscle strength of the left wrist, but the examiner indicated that it was partially due to suboptimal effort. There was no muscle atrophy and the examiner specifically noted there was no ankylosis. Prior VA examinations and medical treatment records also do not indicate ankylosis of the left wrist. See, e.g., October 2007, June 2008, March 2012, and September 2013 VA examination. The Veteran reported symptoms of pain on motion of the joint and indicated she is unable to write due to pain. See August 2017 VA examination. The Board notes, however, that the service-connected wrist disability affects her left wrist, and the Veteran has indicated multiple times that she is right-handed. See, e.g., June 2008, September 2013, and August 2017 VA examinations. The Board acknowledges the Veteran’s painful movement and periods of flare-ups, and although she does not meet the requirements for a compensable evaluation under Diagnostic Code 5215 based on her range of motion, she is entitled to the current 10 percent rating based on her painful joint shown to produce functional impairment. The Veteran is receiving the maximum disability rating for limitation of motion, so 38 C.F.R. §§ 4.40 and 4.45 are not applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In sum, the Veteran’s left wrist symptoms are fully contemplated by the currently assigned 10 percent evaluation and there is no other potentially applicable diagnostic code that would yield a higher rating. As the medical evidence does not show that she has ankylosis of the wrist at any time during this appeal period a higher rating is not available. Accordingly, a rating higher than 10 percent for the left wrist must be denied. REASONS FOR REMAND 8. Entitlement to service connection for residuals of a left knee injury is remanded. The Veteran has a current diagnosis of a left knee strain. See September 2017 VA examination. She suffered a fracture of the left tibial plateau post service in February 2012. See September 2017 VA examination. She asserts she also injured her left knee during active service in July 2007. A July 2007 service treatment note indicates the Veteran suffered a “knee injury” in the line of duty. See July 2007 Individual Sick Slip. Although the September 2017 VA examiner opined that the Veteran’s current knee disorder was not due to service, the VA examiner did not discuss the prior July 2007 knee injury noted during service. On remand, a medical opinion must be obtained that discusses this documented injury during service. The matter is REMANDED for the following action: Obtain an addendum opinion for the Veteran’s claimed left knee disorder. The examiner should opine as to whether it is at least as likely as not that the Veteran’s left tibial plateau fracture and/or left knee strain is causally or etiologically due to service, to include the documented “knee injury” during service in July 2007; or is proximately due to or aggravated (beyond a natural progression) by her service-connected chronic lumbar strain. The examiner must address the Veteran’s assertions that her left knee was injured during service, and that she fell in 2012 due to her lumbar spine disability, causing her tibial fracture. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The file must be provided to the examiner for review. The examiner must state in the examination report that the file has been reviewed. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Andersen, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.