Citation Nr: 20006407 Decision Date: 01/27/20 Archive Date: 01/27/20 DOCKET NO. 17-40 679 DATE: January 27, 2020 ORDER Service connection for urticaria, including as due to a qualifying chronic disability to include an undiagnosed illness, is denied. Service connection for xerosis, including as due to a qualifying chronic disability to include an undiagnosed illness, denied. Service connection for vaginitis, including as due to a qualifying chronic disability to include an undiagnosed illness, is denied. Service connection for insomnia is denied. Service connection for a left shoulder disorder, including as due to a qualifying chronic disability to include an undiagnosed illness, is denied. Service connection for varicose veins, including as due to a qualifying chronic disability to include an undiagnosed illness, is denied. Service connection for a gynecological disorder, to include polycystic ovaries with pain (claimed as abdominal pain), is granted. For the initial rating period from August 18, 2015, a compensable (10 percent) disability rating for a residual of fracture of the left pinky finger (left little finger disability) is denied. REMANDED Service connection for a right foot disorder is remanded. Service connection for a gastrointestinal disorder (claimed as abdominal pain), including as due to a qualifying chronic disability to include an undiagnosed illness, is remanded. FINDINGS OF FACT 1. The Veteran has current diagnoses of urticaria, xerosis, vaginitis, and polycystic ovaries. 2. The Veteran had service in the Southwest Asian Theater of operations during the Persian Gulf War. 3. The current urticaria, xerosis, and vaginitis are diagnosed disabilities with clear etiologies. 4. The preexisting urticaria, xerosis, and vaginitis disabilities were noted prior to entry onto active duty service. 5. The preexisting urticaria, xerosis, and vaginitis did not increase in severity beyond normal progression during service. 6. The Veteran, who is already service-connected for posttraumatic stress disorder with depression and alcohol use disorder (PTSD), does not have a current diagnosis of insomnia; the claimed insomnia is a symptom of the service-connected PTSD. 7. The Veteran does not have current diagnoses of a left shoulder disorder and varicose veins. 8. A qualifying chronic disability of varicose veins and a left shoulder disorder did not manifest during service in Southwest Asia, or to a compensable degree for any six-month period since service. 9. Symptoms of polycystic ovaries with pain began during active service and have been present since active service. 10. For the initial rating period from August 18, 2015, the left little finger disability manifested as symptoms of intermittent pain or aches and tenderness of left little finger without limitation of motion of the left little finger. CONCLUSIONS OF LAW 1. The preexisting urticaria was not aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1153, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.317. 2. The preexisting xerosis was not aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1153, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.317. 3. The preexisting vaginitis was not aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1153, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.317. 4. The criteria for service connection for insomnia have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.130, Diagnostic Code 9411. 5. The criteria for service connection for varicose veins have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317, 4.104, Diagnostic Code 7120. 6. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317, 4.71a, Diagnostic Code 5201. 7. The criteria for service connection for a gynecological disorder, to include polycystic ovaries with pain (claimed as abdominal pain), have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 8. For the initial rating period from August 18, 2015, the criteria for a compensable (10 percent) disability rating for a left little finger disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5230. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from November 2007 to March 2008, from April 2008 to August 2008, from February 2009 to June 2009, from September 2010 to February 2011, and from October 2013 to March 2014. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision from the Regional Office (RO), which, in pertinent part, granted service connection for a left little finger disability, assigning a 0 percent initial disability rating (effective August 18, 2015), and denied service connection for insomnia, a right foot disorder, a left shoulder disorder, varicose veins, vaginitis, a stomach injury (claimed as abdominal pain), xerosis, and urticaria. Regarding the claimed service connection for abdominal pain, which the RO has characterized as service connection for a stomach injury (see February 2016 Rating decision), upon review of the evidence of record, the Board finds it appropriate to recharacterize the claim for abdominal pain into two separate issues. The evidence of the record reflects that the Veteran has reported symptoms of lower abdominal/pelvic pain and cramping, which was worked up as a gynecological problem that was initially diagnosed as left lower quadrant abdominal pain, and later diagnosed as a gynecological disorder. See March 2009, December 2010, June 2016 private treatment records. The Veteran has also reported separate complaints of abdominal discomfort with gas, bloating and alternating diarrhea and constipation, which has been worked up as a gastrointestinal problem and provided an initial diagnosis of unspecified abdominal pain and change in bowel habits. See May 2018, October 2018, May 2019 private treatment records. Therefore, the Board has liberally construed the claim for service connection for “abdominal pain” and recharacterized the issue into two separate issues: service connection for a gynecological disorder, to include polycystic ovaries with pain (claimed as abdominal pain) and service connection for a gastrointestinal disorder (claimed as abdominal pain). The Board finds that the duties to notify and assist in this case have been rendered moot by the grant of service connection for a gynecological disorder, to include polycystic ovaries with pain, which is a full grant of the benefit sought on appeal as to this issue. The Board is remanding the issues of service connection for a gastrointestinal disorder (claimed as abdominal pain) and service connection for a right foot disorder for additional development, so need not discuss the duties to notify and assist regarding service connection for a gastrointestinal disorder and a right foot disorder at this time. As for the remaining issues adjudicated on the merits herein, the Veterans Claims Assistance Act of 2000 (VCAA) notice requirements were satisfied by way of the notice provided with the August 2015 Fully Developed Claim. The VCAA duty to assist has been met in this case. The complete service treatment records and all identified post-service treatment records are associated with the record. Regarding the appeal for higher initial rating for the service-connected left little finger and service connection for insomnia, urticaria, xerosis, and vaginitis, VA hand and finger, skin, psychological, and gynecological examinations with a medical opinion were provided in October 2015 and June 2017. Supplemental VA medical opinions were obtained in February 2016 that reported on the relevant symptomatology and functional impairment of the claimed disabilities and medical opinions with adequate rationale were provided. In the November 2019 brief, the representative asserted that the VA medical opinions were inadequate because they did not accept the Veteran’s statements as credible. First, the Board notes that the VA examiner interviewed the Veteran, conducted the appropriate examinations, reviewed the record, and provided opinions supported by adequate rationale based on the aforementioned. The VA opinions made no findings regarding the credibility of the Veteran, and VA examiners are not required to accept the Veteran’s statements as fact when rendering opinions if the Veteran’s statements are based on an inaccurate factual history and there is other contrary lay and medical evidence of record. Moreover, the Board will weigh the credibility of the Veteran’s lay statements upon review of all the evidence, lay and medical, in adjudicating the issues herein. As for the claims for service connection for varicose veins and a left shoulder disorder, the Veteran has not been afforded a VA medical examination and opinion in relation to these claims. VA must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In this case, because there is sufficient competent medical evidence to show that the Veteran does not have a current varicose veins or left shoulder disability for which service connection may be established, there is no duty to provide a VA medical examination or opinion. For these reasons, the Board finds that a remand for a VA examination is not warranted, as all relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issues on appeal that are adjudicated on the merits herein. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in the appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the appeal. In view of the foregoing, the Board will proceed with appellate review. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. The Veteran is currently diagnosed with urticaria, xerosis, vaginitis, and polycystic ovaries which are not listed as a “chronic disease” under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) for “chronic” in-service symptoms and “continuous” post-service symptoms do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Lay persons are competent to report objective signs of illness. The term “Persian Gulf veteran” means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The DD Form 214 reflects that the Veteran was deployed to Iraq in Southwest Asia from February 2009 to June 2009; therefore, this Veteran is a “Persian Gulf veteran” as defined by 38 C.F.R. § 3.317. A “qualifying chronic disability” for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317 (a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317 (b). As noted above, the Veteran had service in the Southwest Asia Theater of operations during the Persian Gulf War. As pertinent here, a “qualifying chronic disability” for VA purposes is a chronic disability resulting from an undiagnosed illness. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(A). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(b). Nexus evidence is not required. Gutierrez, 19 Vet. App. at 10. 1. Service Connection for Urticaria 2. Service Connection for Xerosis 3. Service Connection for Vaginitis The Veteran contends that service connection for urticaria, xerosis, and vaginitis is warranted. With regard to the service connection for urticaria and xerosis, the Veteran claims that she was exposed to solvents, paints, and dusty munitions storage units during seasonal training at Carswell Air Force Base in Texas from April 2008 to August 2008 that caused her to itch and became more bothersome two weeks after service, causing severe small, red itchy bumps. The Veteran contends she eventually sought private treatment in September 2008, during which she was prescribed an antihistamine, Atarax, for itching, which relieved the symptoms. The Veteran contends that her skin problems where aggravated when she deployed to Iraq due to exposure to the dirt and dust; therefore, she sought treatment and was provided Allegra. The Veteran asserts that she currently has flare ups of hives three to four times a month that are alleviated by medications. See March 2017 Correspondence. As for the claimed vaginitis, the Veteran generally claims that she never had problems with vaginitis until she entered service and that the condition started in approximately 2008 to 2009. See October 2015 VA examination report. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306; see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306. Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered ‘aggravation in service’ unless the underlying condition, as contrasted to symptoms, is worsened.” Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Of note is that the burdens and evidentiary standard to determine whether conditions noted at entrance into service were aggravated by service are different than the burdens and evidentiary standard to determine whether conditions not noted at entrance into service were aggravated. If a preexisting condition noted at entrance into service is not shown to have as likely as not increased in severity during service, the analysis stops. Only if such condition is shown by an as likely as not standard to have increased in severity during service does the analysis continue. In such cases, the increase is presumed to have been due to service unless there is clear and unmistakable evidence that the increase during service was not beyond the natural progression of the condition. Initially, the Board finds that the Veteran has a current diagnosis of urticaria, xerosis, and vaginitis, as reflected in the October 2015 VA examination reports. See also November 2009, December 2014 private treatment records; November 2016 VA treatment record. At the outset, the Board has considered whether service connection is warranted for urticaria, xerosis, and vaginitis under the Persian Gulf War presumptions. See 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board finds that urticaria, xerosis, and vaginitis are not an undiagnosed illness, as the disabilities do, in fact, carry a diagnosis. For urticaria, xerosis, and vaginitis to be due to an undiagnosed illness, the symptoms would have to be not attributable to another, specific cause. The VA examiner noted that urticaria is caused by the release of histamine in skin causing hives and other urticarial lesions, which can have a specific allergic cause or can be idiopathic in nature. Xerosis, that is dry skin, is a common condition that is caused by a lack of moisture in the skin and easily treated with moisturizers. Additionally, vaginitis also has a clear and specific etiology, as the condition occurs when there is an upset in the vaginal flora caused by the replacement of normal lactobacilli of the vagina with mainly anaerobic bacteria. Yeast and trichomonas are also common causes of vaginitis. See October 2015 VA examination reports. Only if such symptoms are not related to a diagnosed disability, i.e., hives that are not related to urticaria, dry skin that is not related to xerosis, and vaginal discharge, odor, and inflammation not due to vaginitis, may it be found to be due to an undiagnosed illness. As such, urticaria, xerosis, and vaginitis are not undiagnosed illnesses or medically unexplained chronic multi symptom illnesses. As the disabilities have been diagnosed, the provisions pertaining to undiagnosed illnesses are not applicable. See U.S.C. § 1117; 38 C.F.R. § 3.317. After a review of all the evidence of record, lay and medical, the Board finds the weight of the evidence is against the claims for service connection for urticaria, xerosis, and vaginitis. In this case, the weight of the lay and medical evidence shows that the Veteran had preexisting urticaria, xerosis, and vaginitis disorders that were “noted” at entrance into active duty service that did not increase in severity during a period of service. Preexistence of Urticaria and Xerosis With regard to the claimed urticaria and xerosis, the evidence of record shows that during the period of active duty service from February 2009 to June 2009, the Veteran presented for complaints of unpredictable episodic rashes, sometimes after working out, that seemed to have worsened since her arrival in the theater. The Veteran reported that she previously used Atarax for itching in the past. At the time the diagnosis was dermatitis, likely allergic dermatis, for which she is already service-connected and rated. See April 2009 service treatment record. A May 2009 line of duty memorandum reflects that the Veteran reported that the skin would break out from time to time and that these symptoms began around September 2008, prior to entering active duty service in February 2009. At the time, the Veteran’s contemporaneous lay reports did not relate the onset of skin problems to service, to include exposure to dust, paints or solvents during a previous period of service from April 2008 to August 2008. Instead, the Veteran only related the onset of symptoms to a period when she was not on active duty service in September 2008, so the skin disability was deemed not to have been incurred in the line of duty. See May 2009 service treatment record. Additionally, no diagnosis of urticaria or xerosis was rendered during a period of active duty service. The Veteran was first diagnosed with xerosis and urticaria in November 2009, five months after the separation from active duty service in June 2009. At that time, the Veteran reported itching and small bumps that waxed and waned, resolved within minutes, and were more frequent when she was upset. The Veteran also reported her skin being very dry. The Veteran did not relate her symptoms of hives or dry skin to any prior period of service, to include exposure to dust or solvents during a previous period of active duty for training. At that time, diagnoses of xerosis cutis and urticaria were rendered for the first time, for which Atarax and a Cetaphil cream and cleanser were prescribed. See November 2009 private treatment record. During a December 2009 post-service follow up, the Veteran denied any additional hives since taking Atarax daily. See December 2009 private treatment record. To the extent that the Veteran now contends that the current urticaria and xerosis were incurred during a period of active duty service in Iraq, this assertion is inconsistent with more contemporaneous lay reports that were made for the purpose of treatment, which reflect that the Veteran reported no onset of any symptoms of a skin disability until in September 2008, when she was not on active duty, which symptoms were actually diagnosed as the currently service-connected dermatitis, not urticaria or xerosis. Additionally, contemporaneous lay statements made at the time of treatment did not relate the onset of skin symptoms of hive and dry skin to any prior period of active duty, to include exposure to dust or solvents during prior periods of training. See April 2009, May 2009 service treatment record. Symptoms of hives and dry skin were not reported and diagnosed until November 2009, five months after separation from active duty service in June 2009 and 10 months prior to reentering active duty service in September 2010. Moreover, while seeking treatment, the Veteran did not report that symptoms had been present since active duty service or otherwise correlate the symptoms to active service. As such, the weight of the evidence shows that the current urticaria and xerosis were “noted” prior to active duty service. Preexistence of Vaginitis As for the claimed vaginitis, the evidence of record reflects that prior to service entrance in November 2007, the Veteran was seen in September 2007 for treatment of chlamydia. At that time, the Veteran reported noticing a yellowish vaginal discharge three months prior to seeking treatment. The Veteran had a follow up test for cure of chlamydia in October 2007, during which laboratory studies were ordered. The lab studies were positive for bacterial vaginitis/vaginosis (BV) and vaginal yeast infection, for which antibiotics were prescribed. See October 2007 private treatment records. As urticaria, xerosis, and vaginitis were “noted” prior to active duty service entrance, the Board finds the presumption of soundness at entry into service does not attach. 38 U.S.C. § 1111. Because preexisting urticaria, xerosis, and vaginitis disorders were noted at the time of entry into service, service connection for a urticaria, xerosis, and vaginitis may be granted only if it is shown that the skin disorders and vaginitis worsened in severity beyond their natural progression during service, i.e., were “aggravated by” service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. If any in-service aggravation of a preexisting disorder noted at service entrance is shown, the in-service evidence of aggravation is considered sufficient to allow for service connection unless there is clear and unmistakable evidence that the disorder was not aggravated beyond the natural progression of the condition during service. See 38 C.F.R. § 3.306. In deciding a claim based on aggravation, after having determined the presence of a preexisting condition, the Board must first determine whether there has been any measured worsening of the disability during service, and then whether this constitutes an increase in the disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993). The primary question then is whether the preexisting bilateral foot disorder is shown to have increased in severity during active service. In explaining the meaning of an increase in disability, the Court has held that “temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered ‘aggravation in service’ unless the underlying condition, as contrasted to symptoms, is worsened.” Hunt, 1 Vet. App. at 297; see also Davis, 276 F.3d at 1346 (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). On the question of aggravation, in this case, the Board finds that the weight of the lay and medical evidence shows that the preexisting urticaria, xerosis, and vaginitis that was noted at entrance into service did not increase in severity beyond a normal progression during service. Whether there was Aggravation of the Preexisting Urticaria and Xerosis Regarding aggravation of the preexisting urticaria and xerosis, the Veteran denied any additional hives during a December 2009 follow up after starting Atarax daily. See December 2009 private treatment record. The service treatment records are silent for symptoms, treatment, or diagnosis of urticaria and xerosis during subsequent periods of active duty from September 2010 to February 2011, and from October 2013 to March 2014; therefore, no aggravation of the preexisting urticaria and xerosis is evidenced during a period of active duty service. The record reflects no additional symptoms or treatment for dry skin and itching until 2016, two years after service separation, which further indicates no aggravation during a period of service. See January 2016, March 2016 private treatment records; November 2016 VA treatment record. Additionally, the VA examiner opined that there was no aggravation of the claimed urticaria and xerosis during a period of active duty service. The VA examiner explained that the urticaria and xerosis were noted prior to the Veteran’s time on active duty and the evidence of record does not support any aggravation or worsening of the conditions during a period of active service. The VA examiner explained that urticaria is a condition that is known for episodes of resolution and recurrence and xerosis is a condition that is easily treated with moisturizer. See October 2015, February 2016 VA examination reports. Whether there was Aggravation of the Preexisting Vaginitis On the question of aggravation of the preexisting vaginitis, a review of contemporaneous treatment notes reflects that the Veteran was only seen and treated twice for vaginitis during the five periods of active duty service. During the period of active duty service from April 2008 to August 2008, the Veteran presented for an annual PAP smear in May 2008. At that time, it was noted that the Veteran had a history of an abnormal PAP with positive HPV (Human papillomavirus) in September 2007 and past exposure to chlamydia (both prior to service). The Veteran did not endorse any increase in symptoms of vaginitis at that time. A diagnosis of nonspecific vaginitis was rendered. The Veteran was also seen for an episode of bacterial vaginosis in December 2013, during the last period of active duty service from October 2013 to March 2014. See May 2008, December 2013 service treatment records. The service treatment records are otherwise silent for symptoms, diagnosis, or treatment of vaginitis during active duty service. By contrast, contemporaneous post-service treatment notes reflect that the Veteran was seen multiple times for complaints of vaginal discharge, itching, odor and/or pain and inflammation when she was not on active duty service from 2008 to 2015. Diagnoses included recurrent bacterial vaginosis/vaginitis, candidiasis (yeast infection), and acute gonorrhea. See, e.g., November 2008, December 2008, January 2009, June 2009, September 2009, August 2010, April 2012, June 2013, September 2013, July 2014, December 2014, February 2015, July 2015, September 2015 private treatment record. The Veteran was provided a VA examination in October 2015. At that time the Veteran reported that she did not have any problems with vaginitis until she entered service. The Veteran reported that problems with “vaginosis” started in 2008 or 2009. See October 2015 VA examination report. To the extent that the Veteran asserts that vaginitis or vaginosis began during active service, such assertions are inconsistent with and outweighed by other contemporaneous treatment records, which show that the Veteran was first diagnosed and treated for vaginitis in October 2007, prior to entrance onto active service. The weight of the evidence is against aggravation of the pre-existing vaginitis during any period of active service. As noted above, although the Veteran has a history of recurrent vaginitis, this was only treated on two occasions during the five periods of active duty service. Notably, although nonspecific vaginitis was diagnosed during a May 2008 annual PAP smear, the Veteran did not endorse any worsening of the preexisting vaginitis at that time. The Veteran was only seen for episodic treatment of vaginitis in December 2013. See May 2008, December 2013 private treatment records. Had the recurrent vaginitis increased in severity during a period of active service, the Veteran would have sought treatment for the conditions similar to the frequency with which she sought treatment for acute symptoms when she was not on active duty. Additionally, the VA examiner opined that the current vaginitis was already a chronic problem that existed prior to active service. The VA examiner noted that some women are prone to have recurring vaginitis, to include if a sexual partner is not treated simultaneously, and the evidence does not indicate whether the Veteran’s partner was being treated simultaneously; however, the evidence of record does not show aggravation of vaginitis beyond a natural progression during any active duty service. See October 2015, February 2016 VA examination reports. Summary As the urticaria, xerosis, and vaginitis disorders were “noted” at service entrance, and the weight of the evidence indicates that they did not increase in severity during service, the weight of the evidence demonstrates no aggravation of the preexisting urticaria, xerosis, and vaginitis by service. Because the evidence does not demonstrate worsening of the urticaria, xerosis, and vaginitis disorders during service (preponderance of the evidence is against a finding of worsening during service), the presumption of aggravation does not arise in this case, so the burden on VA to rebut the presumption (by clear and unmistakable evidence) does not arise. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran’s preexisting urticaria, xerosis, and vaginitis that were noted upon service entrance did not increase in severity during service, i.e., were not aggravated by service, as defined by 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. Because aggravation of the preexisting urticaria, xerosis, and vaginitis by service is not demonstrated, the benefit of the doubt doctrine does not apply, and the claims for service connection for urticaria, xerosis, and vaginitis must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Service Connection for Insomnia 5. Service Connection for a Left Shoulder Disorder 6. Service Connection for Varicose Veins The Veteran contends that service connection for insomnia, varicose veins, and a left shoulder disorder is warranted. Specifically, the Veteran contends that she has had problems with sleep disturbances and falling and staying asleep, among other symptoms, due to the service-connected PTSD. See March 2017 Correspondence, November 2019 representative brief. As for the claimed varicose veins, the Veteran contends that she first noticed varicose veins that were thick and dark in service, which were not present prior to service. The Veteran contends that the varicose veins are more visible now and seem darker. See March 2017 Correspondence. The Veteran has not put forth any specific contention as to how a left shoulder disorder might be related to active service. The requirement of a current disability is satisfied when a veteran has a disability at the time of filing a service connection claim, during the pendency of that claim, or just prior to the filing of a claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service Connection for Insomnia After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence is against finding a current insomnia disability. Service treatment records are silent for symptoms, diagnosis or treatment of insomnia. Post-service treatment notes reflect that the Veteran initially presented in December 2014 reporting a cluster of symptoms, including intermittent anxiety with increased irritability, depression, anhedonia, difficulty with memory, focus and concentration problems, low mood, and sleep disturbances for approximately one year, that were worse after deployment. An assessment of insomnia was initially rendered for which Trazodone was prescribed. In January 2015 the Veteran endorsed improved sleep with the use Trazodone, but continued to report low mood and anxiety. During a follow up in March 2016, the Veteran’s diagnosis was updated to anxiety disorder. See December 2014, January 2015, March 2016. Subsequent treatment notes reflect that although the Veteran has reported continued symptoms of anxiety, irritability, and difficulty falling and staying asleep. These symptoms have been attributed to the diagnoses of depressive disorder and anxiety disorder with PTSD, rather than an insomnia disability. See June 2016, August 2016, September 2019, June 2017 VA treatment records. The Veteran is currently service connected, rated, and compensated for PTSD with depression and alcohol use disorder (PTSD). All psychiatric symptoms, including the claimed symptom of insomnia, that is impairment of sleep, have been attributed by competent evidence to the service-connected PTSD with depression. See June 2017 VA examination report; see also June 2016, June 2017, June 2019 VA treatment records. The Veteran has also endorsed chronic sleep impairment as a symptom of her PTSD, and the VA examiner attributed chronic sleep impairment to the Veteran’s PTSD with depression. See March 2017 Correspondence; June 2017 VA examination report. Although the Veteran was initially diagnosed with insomnia for the purpose of treating complaints of sleep, the record reflects that the Veteran reported a cluster of other psychiatric symptoms in addition to sleep impairment, including depression, anxiety, irritability, and focus problems, when she initially sought treatment. The diagnosis was subsequently updated to reflect the Veteran’s full disability picture, as sleep disturbances was not her only complaint. Under the VA rating criteria, all psychiatric disabilities other than eating disorders are rated under the General Rating Formula detailed at 38 C.F.R. § 4.130. In this matter, the practical effect is that all psychiatric symptomatology and impairment, including symptoms of chronic sleep impairment, are recognized as originating from the service-connected PTSD, and have already been considered in assigning the downstream initial rating. Specifically, the service-connected PTSD is already assigned a 50 percent rating under Diagnostic Code 9411, which compensates occupational and social impairment with symptoms of chronic sleep impairment. 38 C.F.R. § 4.130. Because symptoms of chronic sleep impairment have already been rated and compensated as a part of the service-connected PTSD, the same symptoms of chronic sleep impairment may not be separately service-connected, rated, and compensated as insomnia as to do so would constitute impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). In summary, the weight of the evidence shows no current separate disability of insomnia at any time during the pendency of this claim or in the time period just prior to the filing of this claim. The current symptom of chronic sleep impairment that is being claimed as insomnia is actually a symptom of the already service-connected PTSD. In view of the foregoing, the Board concludes that the preponderance of the evidence is against a current insomnia disability, and the claim for service connection must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for Varicose Veins and Left Shoulder Disorder After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran has a current varicose veins or left shoulder disability. The service treatment records are silent as to symptoms, diagnosis, or treatment of varicose veins and a left shoulder disorder during service. A May 2008 treatment note reflects that, while presenting for an STD screening, the Veteran exhibited normal movement of all extremities and no varicosities were noted in the lower extremities. An April 2009 post-deployment assessment reflects that the Veteran reported “good health,” denied any difficulties with her physical health and expressed that she had no interest in seeking follow up care with a health care provider. During a January 2014 post-deployment assessment, the Veteran endorsed a right foot injury during deployment, but otherwise reported “very good” health and made no mention of problems with left shoulder pain or varicose veins. See May 2008, April 2009, January 2014 service treatment records. Post-service treatments also make no reference to symptoms, diagnosis, or treatment for varicose veins or a left shoulder disorder. Post-service records indicate that while seeking treatment for other conditions the Veteran specifically denied musculoskeletal complaints, including joint and muscle pains, and denied leg cramps. See February 2015, October 2018 private treatment records. Additionally, treating physicians noted full active and passive range of motion in the left shoulder with no guarding and did not note any evidence of edema, pain, or varicose veins upon examination of the upper and lower extremities and peripheral vascular system. See May 2016, August 2016, November 2016 VA treatment records; see also October 2018 private treatment record. While the Veteran is competent to reports symptoms of left shoulder pain, she does not have the requisite medical knowledge, training, or experience to be able to diagnose the claimed disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Veteran is competent to report varicose veins; however, under the facts of this case, the Veteran’s single recent March 2017 lay report of varicose to support her appeal for compensation is outweighed by other more contemporaneous evidence of record, to include contemporaneous lay reports made for the purpose of treatment, which are silent for reports of symptoms of varicose veins, to include subjective reports of visible varicose veins, pain, or swelling in the lower extremities, during any period of active service or post-service encounters. Additionally, no treating or examining physician of record has noted visible varicose veins, pain, or edema in the lower extremities upon examination of the extremities and peripheral vascular system. Such findings are also is inconsistent with the Veteran’s current lay report of on onset of visible varicose veins during service, which she asserts that have become darker and more visible since service. See May 2008m April 2009, January 2014 service treatment records; May 2018, October 2018 private treatment records; November 2016 VA treatment record. As additional factors, the evidence also shows no symptoms or treatment for varicose veins and a left shoulder disorder during any period of active duty service, between periods of active duty service, or since service separation. For these reasons, the weight of the evidence demonstrates no in-service left shoulder or varicose veins injury or disease, no chronic symptoms of a left shoulder disorder or varicose veins in service, no continuous symptoms of a left shoulder disorder or varicose veins since service, and no left shoulder disorder or varicose veins manifested to a compensable degree within one year of service. Although not claimed as due to Persian Gulf War service, as noted above, because the Veteran is a Persian Gulf veteran, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 apply. Signs and symptoms listed that may be manifestations of undiagnosed illness include signs or symptoms of joint pain and cardiovascular disorders. The Board finds that service connection is not warranted for a left shoulder disorder or varicose veins under the Persian Gulf War presumption. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. After a review of all the lay and medical evidence of record, the Board finds that a qualified chronic disability characterized by varicose veins and a left shoulder disorder did not manifest during service in Southwest Asia. As noted above, the service treatment records are silent for any complaints of shoulder joint pain, as well as varicosities or edema in the lower extremities, and the Veteran specifically denied any physical conditions other than treatment for a right foot injury during post-deployment assessments. See May 2008, April 2009, January 2014 service treatment records. The absence of any in-service reports of complaints, findings, diagnosis, or reference to treatment related to a left shoulder disorder and varicose veins during service, under the facts of this case, is one factor, among other factors considered by the Board, including lay reports and treatment for multiple other conditions during service, including right foot injury, dermatitis, vaginitis, lower abdominal/pelvic pain, left pinky injury with hematoma, etc., during service without mention of problems with left shoulder pain or varicose veins during service. Given reports and treatment of multiple other medical problems during service, the presence of problems with left shoulder pain and varicose veins likely would have been reported had they occurred. Additionally, post-service treatment records are also silent as to contemporaneous subjective complaints, treatment, or diagnosis of a left shoulder disorder and varicose veins while seeking treatment for other conditions. Such evidence weighs against finding an in-service manifestation of varicose veins or a left shoulder disorder. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (the absence of a notation in a record may only be considered if it is first shown that the record is complete and also that the fact would have been recorded had it occurred); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (stating that VA may use silence in service treatment records as evidence contradictory to a veteran’s assertions if the service treatment records appear to be complete and injury, disease, or symptoms would ordinarily have been recorded had they occurred; Cf. AZ v. Shinseki, 731 F.3d 1303, 1315-18 (Fed. Cir. 2013) (recognizing and applying the rule that the absence of a notation in a record may be considered if it is first shown that the record is complete and also that the fact would have been recorded had it occurred, although holding that a veteran’s failure to report an in-service sexual assault to military authorities may not be considered as relevant evidence tending to prove that a sexual assault did not occur because military sexual trauma is not a fact that is normally reported); see also Fed. R. Evid. 803(7) (indicating that the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded). The Board also finds that the current subjective contention of a left shoulder disorder and varicose veins have not manifested to a compensable degree (10 percent or more) during a six-month period since service. 38 C.F.R. § 3.317 (a)(1)(i). Under Diagnostic Code 5201, a 20 percent rating is assigned when the shoulder manifest as limitation of motion at the shoulder level. 38 C.F.R. § 4.71a. Regarding the claimed left shoulder disorder, the Veteran has not asserted that the claimed left shoulder disorder has manifested as any specific symptoms or functional impairment, to include pain or limitation of motion. Additionally, physical examinations have revealed full active and passive range of motion of the left shoulder with no evidence of guarding or pain. See May 2016, August 2016 VA treatment records. As such, the weight of the evidence does not show that a left shoulder disability has manifested to a compensable degree during any six-month period since service separation. Under Diagnostic Code 7120, a 0 percent rating is assigned for asymptomatic palpable or visible varicose veins. A 10 percent rating is assigned when varicose veins manifest as intermittent edema, or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. 38 C.F.R. § 4.104. In this case no treating physician of record has noted any signs or symptoms of varicose veins on examination of the lower extremities, as the Veteran has been noted to have normal lower extremities with good movement and no evidence of edema or varicosities noted. See October 2018 private treatment record, August 2016, November 2016 VA treatment records. Therefore, the weight of the evidence does not show that a varicose veins disorder has manifested to a compensable degree during any six-month period since service separation. For the reasons discussed above, the Board finds that the weight of competent and credible evidence demonstrates no current diagnosis of a left shoulder or varicose veins disability and no current qualifying chronic disability characterized by symptoms of left shoulder joint pain or varicose veins that have manifested to a compensable degree during a six-month period since service. In the absence of proof of a current disability, there can be no valid claim for entitlement to service connection on either a direct, presumptive, or any other basis. As the preponderance of the evidence is against the claims for service connection, the benefit of the doubt doctrine is not for application, and the claims for service connection for a left shoulder disorder and varicose veins must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Service Connection for a Gynecological Disorder (claimed as abdominal pain) The Veteran generally contends that service connection for abdominal pain is warranted. See August 2016 Statement in Support of the Claim. Initially, the Board notes that the Veteran has a diagnosis of polycystic ovaries. See June 2016 private treatment record. After a review of all the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise on the question of whether there was an onset of symptoms of lower abdominal/pelvic pain and cramping, in service and since service separation, that were later diagnosed as polycystic ovaries, i.e., whether polycystic ovaries with pain was directly “incurred in” service. The service treatment records show that on March 23, 2009, during the period of active duty service from February 2009 to June 2009, the Veteran presented with complaints of abdominal pain in the left lower belly that felt crampy. The Veteran was one month into the deployment to Iraq (deployed to Iraq February 15, 2009 to June 13, 2009 per DD Form 214), and reported an onset of left lower quadrant abdominal pain intermittently over the past month, with increased pain during the menstrual cycle. Examination of the abdomen was normal with no guarding or rigidity and a pelvic examination and ultrasound was also unremarkable; however, the Veteran was noted to have a small amount of blood clotting in the vaginal vault. Diagnosis was abdominal pain in in the left lower quadrant. The treating physician noted that the Veteran had just deployed in February and advised that menstrual changes can be normal during the first several months of deployment. While on active duty in December 2010 the Veteran reported abdominal cramps off and on that she was able to control. See March 2009 and December 2010 private treatment records. Post-service records reflect that the Veteran was given a referral to gynecology in June 2016 due to pelvic cramping. The Veteran endorsed intermittent abdominal pain, cramping, and fibroid with two episodes of sharp right lower quadrant pain that last two to three minutes over the last two months. A transvaginal ultrasound revealed four fibroids and a left ovary that was polycystic in appearance. Diagnoses were abdominal pain in the right lower quadrant and polycystic ovaries. See June 2016 private treatment records. The Veteran has provided credible contemporaneous lay statements of symptoms of lower abdominal/pelvic pain that began in service and have continued since service separation and were later diagnosed as polycystic ovaries with pain. While the Veteran’s polycystic ovaries with pain is not a chronic disease listed under 38 C.F.R. § 3.309(a), as indicated above, the Board has nonetheless found the evidence at least in equipoise on the question of whether the Veteran had lower abdominal/pelvic cramping and pain symptoms that began during service and continued since service separation, which symptoms were later diagnosed as polycystic ovaries, thus tending to show direct service incurrence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). The Board is granting the service connection claim based on evidence, including that pertinent to service, which establishes that symptoms of a gynecological disability (later diagnosed as polycystic ovaries) began in service, so was “incurred in” service. The finding that the Veteran has had polycystic ovary symptoms since service is supportive of the overall direct service connection claim because it tends to show that the symptoms that began in service were the basis for the later diagnosed polycystic ovaries with pain. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Board finds that the criteria for service connection for a gynecological disorder of polycystic ovaries with pain have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. 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. Where there is a question as to which of two disability ratings shall be applied, 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran has appealed from the initial rating assigned for the left little finger disability. In an appeal for a higher initial rating after a grant of service connection, all evidence submitted in support of a veteran’s claim is to be considered. Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. 38 C.F.R. § 4.2; Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The Board does not find staged ratings to be appropriate in this appeal. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. 8. Rating the Left Little Finger from August 18, 2015 The left little finger disability is assigned a noncompensable (0 percent) initial disability rating from August 18, 2015 under Diagnostic Codes 5230. 38 C.F.R. § § 4.71a. The Veteran contends a compensable rating should be granted for the left pinky finger due to pain. See November 2019 representative brief. Diagnostic Code 5230 addresses limitation of motion of the ring or little finger. Under Diagnostic Code 5230, a noncompensable (0 percent) rating is assigned for limited ring or little finger motion in either the major (dominant) or minor hand. Id. For the index, long, ring, and little fingers (digits II, III, IV, and V), the metacarpophalangeal joint (MCP) has a range of motion of zero to 90 degrees of flexion, the proximal interphalangeal joint (PIP) has a range of motion of zero to 100 degrees of flexion, and the distal interphalangeal joint (DIP) has a range of motion of zero to 70 or 80 degrees of flexion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5230, Note (1). In this case, a higher rating is not possible for the left little finger based on pain or limitation of motion, as the rating schedule (Diagnostic Code 5230) provides only a zero percent (noncompensable) rating for limitation of motion of a little finger. As for the left little finger, the evidence of record reflects that the Veteran sustained an injury to the little finger and nail bed when she smashed it during a period of active duty service. The Veteran endorsed soft tissue pain in the left little finger and evidenced tenderness to palpation and a subungual hematoma on the finger nailbed; however, there was no swelling, erythema, warmth or deformity noted in fingers and the Veteran retained normal motion in the left little finger upon examination. See January 2012 private treatment record. Post-service treatment records are silent for any further complaints, diagnosis, or treatment of the left little finger disability since service separation. During an October 2015 VA examination, the Veteran reported some residual aches in the left pinky, but reported that she was still able to use the left hand and denied any flare ups of the left little finger. Upon examination, the left little finger manifested as slight tenderness to palpation of the distal phalanx of the left fifth digit but no obvious deformities. Moreover, range of motion of all the digits of the left hand, to include the left little finger, was normal with no functional loss of motion on repetitive use. See October 2015 VA examination report. Additionally, the Veteran has not alleged any increase in the severity of the symptomatology of the left little finger disability, but only asserts that she continues to have some pain in the left little finger. See November 2019 representative brief. As such, the evidence of record reflects that the overall disability picture of the left little finger disability has manifested as symptoms of intermittent aches or pain and tenderness in the left little finger that is not productive of limitation of motion. See October 2015 VA examination report. The Board has considered whether a compensable rating is warranted for the left little finger disability due to pain in the left pinky finger; however, 38 C.F.R. § 4.59, which recognizes painful, unstable, and malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint, is not applicable in this case because as the applicable Diagnostic Code 5230 only provides for a noncompensable (0 percent) rating for limitation of motion of the little finger, regardless of whether there is evidence of pain. 38 C.F.R. § 4.71a. Alternative Diagnostic Codes Considered The evidence of record does not reflect either favorable or unfavorable ankylosis of the left little finger. See October 2015 VA examination reports. Nor has the Veteran alleged ankylosis in any finger or thumb of the left hand. As such, Diagnostic Codes 5216 through 5227 do not apply. 38 C.F.R. § 4.71a. Next, the evidence does not reflect that the left little finger disability has resulted in amputation of the digit. Diagnostic Codes 5126 through 5156 provide ratings based on amputation of individual and multiple digits of the hand. Id. The treatment records do not show little finger disability analogous to amputation. The October 2015 VA examiner specifically indicated that the functional impairment of the hands, thumbs, and fingers was not such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The Board finds that the left little finger disability does not more nearly approximate amputation of any of the digits of the left hand. 38 C.F.R. § 4.71a; Diagnostic Codes 5126-5156. As the preponderance of the evidence is against a higher (compensable) rating for the service-connected left little finger disability for the initial rating period from August 18, 2015, and the appeal must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Service connection for a right foot disorder is remanded. The Veteran asserts that she injured the right foot while on deployment in Afghanistan when she jumped down from a munitions trailer and felt a sharp pain in the right foot that lasted a few minutes. The Veteran contends that overall pain in the right foot ceased within 30 minutes and she resumed her duties; however, the Veteran reports that she reinjured the right foot a day later while climbing down from a top bunk. The Veteran reports she had sharp aching pain each time she took a step while trying to perform her duties, so her supervisor instructed her to have her foot checked out at the clinic. The Veteran reports that a flight doctor advised that she had a minor sprain in the right foot and prescribed tiger balm and ibuprofen for treatment. The Veteran asserts that her supervisor wrote an incident report at that time, but she did not get a copy. The Veteran asserts that she continued to have pain in the right foot and limping when she returned to her duties the following day; however, she was able to do her work. The Veteran states that her right foot pain subsided after approximately one week; however, symptoms began to worsen in 2017, and she still experiences tightness and occasional right foot pain when she steps or jumps down on the foot. See March 2017, August 2019 Correspondence. Service Treatment Records and Service Personnel Records The service treatment and service personnel records may not be complete. A review of the service treatment records reflects that the Veteran reported a foot injury that has improved and noted that an accident report had been filed during a January 2014 post-deployment assessment. See January 2014 service treatment record. However, the service treatment and personnel records are silent for symptoms, injury, diagnosis, or treatment of a right foot disorder during deployment despite lay reports contemporaneous to deployment that an accident report had been filed related to the right foot injury and assertions that she was treated for the injury during deployment. As such, on remand the RO should attempt to associate with the claim file all service treatment and personnel records for the period from October 2013 to March 2014, to include any treatment of a right foot disorder. Addendum Medical Opinion The record reflects that a VA examination was provided in June 2019, during which bilateral plantar fasciitis was diagnosed. See June 2019 VA examination report; see also May 2018 and October 2018 private treatment records. The VA examiner in June 2019 opined that it was less likely as not that the currently diagnosed right foot plantar fasciitis was related to any specific exposure during service in Southwest Asia. However, the VA examiner did not render an opinion regarding whether the current right foot plantar fasciitis was caused by or is etiologically related to active service, to include injury to the right foot during a deployment for the period from 2013 to 2014. Therefore, a VA addendum medical opinion would be helpful to assess the etiology of the current right foot plantar fasciitis. 2. Service connection for a gastrointestinal disorder is remanded. The Veteran contends that service connection for a gastrointestinal disorder (claimed as abdominal pain) is warranted. Specifically, the Veteran contends that she was first treated for stomach pains during active duty service, and has continued to have problems with stomach pain and bloating in recent years to include problems with diarrhea and constipation for several months. See May 2019 Correspondence. The evidence of record reflects that the Veteran was first treated for abdominal pain in August 2006, prior to service, during which she was noted to have abnormal bowel sounds and abnormal tenderness in the mid-epigastric area and ascending colon. A diagnosis of abdominal pain was rendered, and the Veteran was prescribed anti-inflammatory and constipation medications. See August 2006 private treatment record. The service treatment records are silent for any other gastrointestinal complaints during a period of service, as reports of lower abdominal/pelvic pain and cramping around the Veteran’s menses during service were treated as a gynecological problem. The Veteran otherwise denied nausea or vomiting and made no mention of problems with constipation or diarrhea during service. See March 2009, December 2010 service treatment records. Post-service treatment notes reflect treatment for two episodes of acute gastroenteritis in February 2015 and April 2016, but otherwise reflect that the Veteran denied gastrointestinal complaints such as loss of appetite, heart burn and indigestion, nausea and vomiting, constipation or painful bowel movements, diarrhea, gastrointestinal bleed, and abdominal pain. See February 2015, April 2016, June 2016 private treatment records; see also August 2016 VA treatment record. In 2018, the Veteran endorsed, for the first time, chronic symptoms of a gastrointestinal disorder, to include abdominal pain, gas and bloating, and stools that alternate between constipation and diarrhea for the past eight months to a year. Diagnosis was unspecified abdominal pain and changes in bowel habit. See May 2018, October 2018 private treatment record. Additionally, a workup of symptoms, including an abdominal x-ray and laboratory studies, were ordered in May 2019, which appear to be normal. See May 2019 private treatment record. A VA intestinal disorders examination was provided in June 2019. The VA examiner assessed that the Veteran did not have a current undiagnosed illness or a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, to include irritable bowel syndrome (IBS), as there was no evidence in the medical records of complaints, evaluations, or treatment for IBS from service separation until present. See June 2019 VA examination report. However, a review of the record reflects that the VA examiner did not have access to recent private treatment records reflecting gastrointestinal complaints, treatment, and work up dated from May 2018 to May 2019, as the records were not uploaded to the claims file until after the June 2019 VA opinion was rendered. As such, an addendum medical opinion based on a full and accurate history is warranted to assess whether the Veteran has a currently diagnosable gastrointestinal disorder. Service connection for a right foot disorder and gastrointestinal disorder are REMANDED for the following action: 1. The RO should request any outstanding service treatment records and service personnel records for the period from October 2013 to March 2014, particularly those pertaining to a right foot disorder. 2. Return the VA foot and intestinal disorder medical examination reports to the VA examiner who provided the medical opinions in June 2019. If the original VA examiner is unavailable, a new examiner may be assigned to address the requested opinions. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the record. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The VA examiner should offer the following opinions: (Continued on the next page)   a) Is there a diagnosis that accounts for current gastrointestinal symptoms, to include abdominal gas and bloating and alternating diarrhea and constipation with abdominal pain? In rendering the requested opinion please review and comment on the pre-service August 2006 private treatment note of abdominal pain with abnormal bowel sounds and tenderness in the mid-epigastric area and ascending colon; post-service treatment for acute episodes of gastroenteritis in February 2015 and April 2016; the May 2018 and October 2018 gastrointestinal consult for abdominal pain, gas and bloating, and alternating constipation and diarrhea; and the May 2019 abdominal x-ray and laboratory study reports. b) Is it at least as likely as not (50 percent or higher degree of probability) that the currently diagnosed right foot plantar fasciitis disability was caused by or is etiologically related to service, to include injury to the right foot due to jumping down from a munition trailer and climbing down from a top bunk bed during a period of deployment from October 2013 to March 2014? In rendering the requested opinion please consider and discuss the January 2014 post-deployment assessment report, any new service treatment or personnel records related to treatment of a right foot disorder during service (if successfully obtained), and the Veteran’s contentions regarding the onset of symptoms and nature of the right foot disability found in the May 2018 and October 2018 private treatment records and the March 2017 and August 2019 Correspondence. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Moore 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.