Citation Nr: 20008299 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 18-49 138 DATE: January 31, 2020 ORDER The appeal for entitlement to service connection for a right shin condition is dismissed. The appeal for entitlement to service connection for a cellulitis of the right thigh is dismissed. The appeal for entitlement to service connection for sleep apnea is dismissed. Entitlement to service connection for tension headaches is granted. Entitlement to a rating in excess of 20 percent for the Veteran’s right shoulder disability based on limitation of arm motion is denied. An initial 30 percent rating for Bartholin’s gland cyst, postoperative, is granted from December 23, 2014. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right-hand disability, claimed as a soft tissue injury to hand and thumb, is remanded. Entitlement to service connection for a right wrist disability is remanded. Entitlement to service connection for temporomandibular joint disorder (TMJ) is remanded. Entitlement to service connection for a right foot disability, claimed as plantar fasciitis, is remanded. Entitlement to service connection for a low back disability, to include as secondary to service-connected fibromyalgia, is remanded. Entitlement to service connection for an endocrine gland disorder, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression, to include as secondary to service-connected fibromyalgia and/or as due to an undiagnosed illness, is remanded. FINDINGS OF FACT 1. Prior to promulgation of a decision, in a November 2019 statement, the Veteran withdrew her appeal regarding the issues of entitlement to service connection for right shin, cellulitis of the right thigh, and sleep apnea disabilities. 2. The Veteran’s tension headaches had their onset during active duty. 3. Throughout the appeal period, even when considering DeLuca factors and flare-ups, the Veteran has not evidenced right shoulder forward flexion or abduction to midway between side and shoulder; instead right shoulder motion more closely approximates limitation of motion of the right arm to the shoulder level. 4. The Veteran’s Bartholin’s gland cyst, postoperative, is manifested by symptoms not controlled by continuous treatment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal for service connection for right shin, cellulitis of the right thigh, and sleep apnea disabilities are met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. The criteria for entitlement to service connection for tension headaches are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a rating in excess of 20 percent for limitation of motion of the right shoulder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code (DC) 5201. 4. The criteria for an initial maximum 30 percent rating for Bartholin’s gland cyst, postoperative, are met from December 23, 2014. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.116, DC 7628-7615. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from August 1997 to August 2011, including service during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for right shoulder osteoarthritis of the AC joint and Bartholin’s gland cyst and assigned noncompensable ratings, effective December 23, 2014. In a June 2018 rating decision, the RO increased the rating to 20 percent for right shoulder osteoarthritis of the AC joint, effective December 23, 2014. The Board has recharacterized and broadened his psychiatric claim as reflected on the title page to include consideration of all psychiatric disorders reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Withdrawal 1. The appeal for entitlement to service connection for a right shin condition is dismissed. 2. The appeal for entitlement to service connection for a cellulitis of the right thigh is dismissed. 3. The appeal for entitlement to service connection for sleep apnea is dismissed. In the present case, the Veteran, in a November 2019 statement, advised that she wished to withdraw her appeal concerning her service connection claims for right shin, cellulitis of the right thigh, and sleep apnea. See November 2019 VA Form 21-4138; 38 C.F.R. § 20.204. Accordingly, she has withdrawn the appeal and, hence, there remains no allegation of error of fact or law for appellate consideration regarding these issues. Accordingly, the Board does not have jurisdiction to review the issues of entitlement to service connection for right shin, cellulitis of the right thigh, and sleep apnea and they are dismissed. Service Connection 4. Entitlement to service connection for tension headaches is granted. The Veteran asserts that her headaches had their onset during service and have continued since service. Alternatively, she maintains that her headaches are due to a chronic multi-symptom or undiagnosed illness due to her Persian Gulf War service and/or are secondary to her service-connected fibromyalgia. See October 2018 and November 2019 Correspondences. As the discussion below is favorable regarding direct service connection, no other theories of entitlement will be addressed. Service connection may be granted for a disability resulting from disease or injury incurred in active service and for in-service aggravation of a preexisting injury or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, the evidence must show: (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 during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1377 (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). Here, the Veteran is competent to report current headaches, and a January 2016 VA examination examiner confirms a diagnosis of tension headaches. Additionally, her service treatment records (STRs) document complaints of headaches and a diagnosis of stress headaches. See June 2002, February 2003, January 2007, and July 2011 STRs. In this regard, she has competently and credibly reported that she first experienced headaches during service and that her headaches have been continuous ever since. The Board notes the January 2016 VA examination report indicates the Veteran reported the onset of her headache symptoms in 2014, however given the Veteran’s other lay statements of record and medical documentation of headache complaints and a diagnosis in her STRs, the examination report is outweighed by more favorable evidence. Thus, elements one and two of service connection are met. Regarding the final element, nexus, the Veteran is competent to determine that her in-service headaches are of the same nature as her post-service headaches; thus, she is competent to establish a nexus between her current headaches and service, and her statements in this regard are supported by her STRs and other information of record. Moreover, there is no adequate competent evidence to the contrary. The Board acknowledges the January 2016 VA examiner’s unfavorable opinion; however, the examiner incorrectly stated that the Veteran’s STRs did not document symptoms, diagnoses, or treatment for her headaches, thus relying on an inaccurate factual premise, and was not privy to and therefore did not address the Veteran’s favorable lay statements. Thus, the unfavorable opinion is inadequate and of no probative value. Accordingly, service connection for tension headaches is established. 38 C.F.R. § 3.303. Increased Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, coordination, and endurance. 38 C.F.R. § 4.40. The functional loss may be due to the loss of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology, and evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Other important factors include excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. With an initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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 evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. 5. Entitlement to a rating in excess of 20 percent for the Veteran’s right shoulder disability based on limitation of arm motion is denied. I. Rating Criteria The Veteran’s service-connected right shoulder osteoarthritis of the AC joint with resultant loss of motion is currently evaluated under DCs 5003-5201. Here, the RO has determined that the Veteran’s right shoulder osteoarthritis of the AC joint and accompanying painful motion is most appropriately rated under DC 5201 for limitation of motion of the arm. DC 5003 rates degenerative arthritis and instructs to rate based on limitation of motion, with a 10 percent rating for application when limitation of motion of the joint or joints involved is noncompensable. 38 C.F.R. § 4.71a, DC 5003. DC 5201 provides a 20 percent rating for limitation of motion of the major arm at the shoulder level and the minor arm at both the shoulder level and the midway between the side and shoulder level. A maximum 30 percent rating is warranted for limitation of motion of the minor arm to 25 degrees from the side or limitation of motion midway between side and shoulder of the major arm. A maximum 40 percent rating is warranted for limitation of the major arm to 25 degrees from the side. Normal range of motion of the shoulder is flexion and abduction from 0 to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with 0 degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. Id. DC 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to ‘limitation of motion of’ the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The “major” rating is for the dominant hand, whereas the “minor” rating is for the non-dominant hand. Under 38 C.F.R. § 4.69, handedness is determined by the evidence of record, or by testing on VA examination. Only one had may be considered dominant. In the case of an ambidextrous individual, the injured hand or most severely injured hand will be considered the dominant hand for rating purposes. Here, the record reflects that the Veteran is right handed, and therefore her right arm is her major (dominant) extremity and her left arm is her minor (non-dominant) extremity for rating purposes. See January 2016 VA examination report. II. Analysis The Veteran is currently in receipt of a 20 percent rating from December 23, 2014. The appeal period is from December 23, 2014, the date of award of service connection for her right shoulder osteoarthritis of AC joint. Throughout the appeal period, the Veteran has complained of chronic right shoulder pain with limitation of motion, difficulty lifting, and flare-ups. See October 20115 through February 2019 VA treatment records and January 2016 VA examination report. The Veteran was afforded a VA examination in January 2016. The Veteran reported chronic right shoulder pain and flare-ups and functional loss described as chronic pain with limitation of range of motion and lifting. Physical examination results revealed forward flexion, abduction, internal rotation, and external rotation to 90 degrees with pain causing functional loss. The examiner found no additional limitation with repetitive use or during flare-ups or due to DeLuca factors. No additional contributing factors were indicated. The examiner noted no crepitus, muscle atrophy, instability, or ankylosis and muscle strength testing was normal (5/5). Empty can test and external rotation testing were positive. The examiner noted that the Veteran’s ability to work was impacted due to limitations in range or motion and lifting. No other shoulder conditions were found. Given the totality of the evidence, the Board finds that a rating in excess of 20 percent is not warranted under DC 5201 at any time during the appeal period, as range of motion measurements have been productive of right shoulder forward flexion and abduction to 90 degrees, even when considering pain and during flare-ups which equates to limitation of motion to the shoulder level. As such, even when considering DeLuca factors and flare-ups, the Veteran has not evidenced right shoulder forward flexion or abduction to midway between side and shoulder even at any time during the appeal period, thus a higher rating is not warranted. Finally, the Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes. However, there is no indication of ankylosis, clavicle or scapula, or humerus conditions. As such, ratings under DCs 5200, 5202, and 5203 are precluded. 6. An initial rating of 30 percent for Bartholin’s gland cyst, postoperative, is granted from December 23, 2014. For the reasons discussed below, the Board finds that an increase to 30 percent (maximum schedular) is warranted under DC 7628-7615. DC 7628 can be rated according to impairment in function of the urinary or gynecological systems, or skin. See 38 C.F.R. § 4.116, DC 7628. Although other diagnostic codes pertaining to gynecological system were considered, the nature of the Bartholin’s gland cyst (obstruction of the Bartholin’s gland on the vaginal opening) is most thoroughly encompassed by the criteria for a disease, injury, or adhesion of the female reproductive organs. See 38 C.F.R. § 4.116, DC 7615, General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs (DC’s 7610 through 7615); MedlinePlus Medical Encyclopedia, last updated on January 13, 2020. A noncompensable rating is warranted for symptoms that do not require continuous treatment. Id. A 10 percent rating is warranted for symptoms that require continuous treatment. Id. A 30 percent rating is warranted for symptoms not controlled by continuous treatment. Id. Additionally, diagnostic codes pertaining to the skin were considered, the nature of the related residual (flare-ups causing increased pain/discomfort) is most thoroughly encompassed by the criteria for a benign skin neoplasm, which can be rated as disfigured (of the head, face, or neck), scars, or impairment of function. See 38 C.F.R. § 4.118, DC 7819. Throughout the appeal period, the Veteran has complained of recurring cysts that cause her severe pain and hurt when she walks or sits. See February 2015 through October 2019 VA treatment records, January 2016 VA examination report, and October 2018 Correspondence. VA treatment records reveal recurring cysts/residuals and continuous treatments including incision and draining (I&D), antibiotics, and Sitz baths. See February 2015, June 2015, June 2016, July 2016, April 2019, September 2019, and October 2019 VA treatment records. The Veteran was afforded a VA examination in January 2016. The examiner diagnosed status post Bartholin’s gland abcess/cyst. The Veteran reported an onset of symptoms since 2003. The examiner noted severe intermittent pain with the recurring cysts and indicated her condition did not require continuous medication or treatment. No other conditions were noted, and the examiner found her condition did not impact her ability to work. The Board notes the Veteran is competent to report recurring cysts as the presence of cysts are capable of lay observation. See Layno, 6 Vet. App. 465, 470 (1994). To this end, the Veteran has stated that her cysts are recurring, do not respond to treatment, and she has flare-ups causing increased pain/discomfort when walking or sitting. Moreover, the Veteran’s reports are corroborated by VA treatment records which document recurring cysts despite a variety of treatments. Thus, the Board finds her Bartholin’s gland cysts more nearly approximate the criteria for a maximum 30 percent rating under DC 7615 due to recurring symptoms that are uncontrolled by continuous treatment since December 23, 2014. See 38 C.F.R. § 4.116, DC 7615, General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs. The Board has considered other potentially applicable diagnostic codes; however, the evidence does not reveal and the Veteran has not otherwise asserted any urinary symptomatology associated with her condition such that a rating under this criteria would apply. Similarly, although the recurring cysts may be considered a benign skin neoplasm, the Veteran’s reports of functional limitations due to flare-ups (pain and discomfort with walking and sitting) are not severe enough to surpass the 30 percent rating afforded under DC 7615; further, there were no associated scars assessed. See January 2016 VA examination report and September 2019 VA treatment record. As such, it is most advantageous to grant a 30 percent rating under DC 7615 and there is no basis to assign an evaluation in excess of the currently assigned rating. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Additionally, staged ratings are not warranted, as the Veteran has had a relatively stable level of symptomatology throughout the appeal. See Fenderson, 12 Vet. App. 119, 126-27. REASONS FOR REMAND 7. Entitlement to service connection for a right knee disability is remanded. 8. Entitlement to service connection for a left knee disability is remanded. The Veteran maintains that her bilateral knee disability had its onset during active duty due to military training and duties and that symptoms including knee pain, grinding, popping, and swelling have continued since service. See January 2016 VA examination report and October 2018 and November 2019 Correspondences. The Veteran was afforded a VA examination in January 2016. The examiner opined negatively on the Veteran’s bilateral knee disability. However, the examiner relied on unremarkable STRs in rendering his negative opinion and was not privy to and therefore did not address the Veteran’s lay statements regarding her continuous bilateral knee symptomatology since service. Thus, the opinion is inadequate, and an addendum opinion is warranted on remand that adequately addresses these issues. 9. Entitlement to service connection for a right hand disability, claimed as a soft tissue injury to hand and thumb, is remanded. The Veteran asserts that her right hand disability was incurred during service when she slammed a rack on her right hand and injured her hand. To this end, she maintains that the pain immediately shot up her elbow and that she continues to experience pain since that time, which affects her ability to grip objects, type, and work as a massage therapist. See October 2018 Correspondence. STRs document an incident where the Veteran slammed her finger on a rack and diagnosed a soft tissue injury. Moreover, recently the Court of Appeals for Veterans Claims held in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), that pain resulting in functional impairment could constitute a current disability, even if there is no diagnosis connecting the pain with a current underlying condition. In this regard, the Veteran has reported continuous right- hand pain since service and indicated that this pain limits her functional ability. Thus, the Board finds that a VA examination and a medical nexus opinion is warranted on remand to determine the etiology of any current right hand pain that results in functional impairment. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 10. Entitlement to service connection for a right wrist disability is remanded. The Veteran asserts that her right wrist disability was incurred during service when she slammed a rack on her right hand and injured her wrist. To this end, she maintains that the pain immediately shot up her elbow and that she continues to experience pain since that time, which affects her ability to grip objects, type, and work as a massage therapist. See August 2018 VA examination report and October 2018 and November 2019 Correspondences. The Veteran was afforded a VA examination in August 2018. The examiner opined negatively on the Veteran’s right wrist disability. However, the examiner relied on the lack of documentation of a right wrist strain in her STRs in rendering her negative opinion, did not address the Veteran’s complaints of right wrist pain in her STRs, and was not privy to and therefore did not address the Veteran’s lay statements regarding her continuous right wrist symptomatology since service. Thus, the opinion is inadequate, and an addendum opinion is warranted on remand that adequately addresses this issue. 11. Entitlement to service connection for TMJ is remanded. The Veteran asserts that her TMJ disorder was incurred during service during a wisdom teeth procedure. To this end, she maintains that her jaw locked up on her and she experienced jaw pain during the procedure and has continued to experience locking and pain since service. See October 2018 and November 2019 Correspondences. Post-service treatment records show her complaints of jaw pain and evidence of TMJ. STRs document complaints of jaw pain and limited range of motion in her jaw. Thus, based on an indication of a current diagnosis, the Veteran’s statements, and her STRs, the Board finds that a VA examination and a medical nexus opinion is warranted on remand to determine the etiology of her TMJ disorder. McLendon, 20 Vet. App. 79, 83. 12. Entitlement to service connection for a right foot disability, claimed as plantar fasciitis, is remanded. The Veteran asserts that her right foot disability had its onset during service and manifested itself following bootcamp with symptoms of numbness and tingling in her toes, especially during physical training. To this end, she maintains that she continues to experience foot symptomatology to this day. See August 2018 VA examination report and October 2018 and November 2019 Correspondences. The Veteran was afforded a VA examination in August 2018. The examiner opined negatively on the Veteran’s right foot disability. However, the examiner relied on the lack of chronicity of right foot symptoms and was not privy to and therefore did not address the Veteran’s lay statements regarding her continuous right foot symptomatology since service. Thus, the opinion is inadequate, and an addendum opinion is warranted on remand that adequately addresses this issue. 13. Entitlement to service connection for a low back disability, to include as secondary to service-connected fibromyalgia, is remanded. The Veteran asserts that her low back disability was incurred during service due to duties of her military occupational specialty (MOS) in the deck department that included pulling heavy lines and lifting heavy 25-gallon paint. To this end, she maintains that she began to experience back pain during service and that it has been continuous since service. Alternatively, she maintains that her back disability is due to her service-connected fibromyalgia. See October 2018 and November 2019 Correspondences. STRs document complaints low back pain and a diagnosis of mechanical back pain. Thus, based on the Veteran’s statements, her STRs, and an indication of a current diagnosis, the Board finds that a VA examination and a medical nexus opinion is warranted on remand to determine the etiology of any current low back pain that results in functional impairment. McLendon, 20 Vet. App. 79, 83; Saunders, 886 F.3d 1356. 14. Entitlement to service connection for an endocrine gland disorder, to include as due to an undiagnosed illness, is remanded. The Veteran asserts that her endocrine disorder is due to an undiagnosed illness or unexplained multi-symptom unexplained illness due to her service in the Persian Gulf War. To this end, she maintains she currently experiences symptoms of an undiagnosed illness or unexplained multi-symptom illness. See October 2018 Correspondence. The Veteran was afforded a VA examination in September 2018. However, the examiner did not adequately address all of the Veteran’s reported symptoms or documentation of symptoms in her STRs. Thus, an addendum opinion is warranted on remand. 15. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression, to include as secondary to service-connected fibromyalgia and/or as due to an undiagnosed illness, is remanded. The Veteran asserts that her acquired psychiatric disorder was incurred during service and that her symptoms began during service and have continued since service. Alternatively, the Veteran maintains that her acquired psychiatric disorder is part of an undiagnosed or multi-symptom unexplained illness and/or is secondary to service-connected fibromyalgia. See October 2018 and November 2019 Correspondences. Post-service VA treatment records indicate diagnoses of depressive disorder and anxiety disorder. STRs diagnose anxiety disorder, not otherwise specified (NOS). However, the Veteran has not been afforded a VA psychiatric examination to determine whether she has a current diagnosis under the applicable DSM-5. Thus, given the Veteran’s current diagnoses and a documented diagnosis in her STRs, the Board finds that a VA examination and medical opinion are warranted on remand. See McLendon, 20 Vet. App. 79. Any VA outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Then obtain an addendum opinion from an examiner other than the January 2016 examiner that addresses the etiology of the Veteran’s bilateral knee disability. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that diagnosed bilateral knee degenerative arthritis (see January 2016 VA examination report) had its onset in service or within one year of separation from service or is otherwise related to service. In addressing this question, please address the Veteran’s statements that she incurred bilateral knee injuries due to military training and duties and that symptoms including knee pain, grinding, popping, and swelling have continued since service. See January 2016 VA examination report and October 2018 and November 2019 Correspondences. The examiner should also acknowledge and comment on her STRs which document complaints of swelling in her knees. See July 2011 STR. A complete rationale must be provided. The examiner should not rely on unremarkable STRs as the sole basis for a negative opinion, otherwise the opinion will be inadequate. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Then schedule the Veteran for a VA examination to determine the nature and etiology of her right hand disability. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. The examiner should address the following (a) Diagnose any right hand disability present since December 2014. If no diagnosis is rendered and only pain is identified, the examiner must indicate whether the Veteran’s reported right hand pain causes any functional impairment. (b) For each disability diagnosed in part (a), or any functional impairment identified, please opine on whether it is at least likely as not (a 50 percent or greater probability) that such disability had its onset in service or is otherwise related to service. In addressing this question, please acknowledge and comment on the Veteran’s December 2011 STR, which documents a soft tissue injury to her finger after she slammed her right hand on a rack. Additionally, please comment on the Veteran’s lay statement that her right hand disability was incurred during service due such injury and that problems with her right hand have been continuous since that time. See October 2018 Correspondence. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Then, obtain an addendum opinion from an examiner other than the August 2018 examiner that addresses the etiology of the Veteran’s right wrist disability. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that diagnosed right wrist strain (see August 2018 VA examination report) had its onset in service or is otherwise related to service. In addressing this question, please address the Veteran’s statements that she incurred a right wrist injury after slamming a rack on her hand during service and that her right wrist pain has continued since service. See August 2018 VA examination report and October 2018 and November 2019 Correspondences. The examiner should also acknowledge and comment on her STRs which document a soft tissue injury after she slammed her right hand on a rack and complaints of right wrist pain. See December 2001 and September 2002 STRs. A complete rationale must be provided. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Then schedule the Veteran for a VA examination to determine the nature and etiology of her TMJ disorder. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. The examiner should address the following (a) Diagnose any jaw disability present since December 2014, to include TMJ. If no diagnosis is rendered and only pain is identified, the examiner must indicate whether the Veteran’s reported jaw pain causes any functional impairment. If no diagnosis for TMJ is found, please reconcile your finding with diagnosis of the same in an October 2019 VA treatment record. (b) For each disability diagnosed in part (a), or any functional impairment identified, please opine on whether it is at least likely as not (a 50 percent or greater probability) that such disability had its onset in service or is otherwise related to service. In addressing this question, please acknowledge and comment on the Veteran’s June 2002 STR which documents a jaw injury, complaints of jaw pain, and decreased range of motion. Additionally, please comment on the Veteran’s lay statement that her TMJ was incurred during service due to a wisdom teeth procedure which caused jaw pain and locking of her jaw that have been continuous since that time. See October 2018 and November 2019 Correspondences. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. Then, obtain an addendum opinion from an examiner other than the August 2018 examiner that addresses the etiology of the Veteran’s right foot disability. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine on whether it is at least as likely as not (50 percent or greater probability) that diagnosed right foot strain (see August 2018 VA examination report) had its onset in service or is otherwise related to service. In addressing this question, please address the Veteran’s statements that she incurred a right foot injury during service that manifested itself following bootcamp with symptoms of numbness and tingling in her toes, especially during physical training, and that her right foot pain has continued since service. See August 2018 VA examination report and October 2018 and November 2019 Correspondences. The examiner should also acknowledge and comment on her STRs which document complaints of right foot pain and diagnoses of foot right pain with “suspect plantar fasciitis” and musculoskeletal foot pain. See January 1998, February 2000, and February 2006 STRs. A complete rationale must be provided. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 7. Then schedule the Veteran for a VA examination to determine the nature and etiology of her low back disability. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. The examiner should address the following (a) Diagnose any low back disability present since December 2014. If no diagnosis is rendered and only pain is identified, the examiner must indicate whether the Veteran’s reported low back pain causes any functional impairment. (b) For each disability diagnosed in part (a), or any functional impairment identified, please opine on whether it is at least likely as not (a 50 percent or greater probability) that such disability had its onset in service or is otherwise related to service. In addressing this question, please acknowledge and comment on the Veteran’s STRs, which complaints of low back pain and diagnoses of muscle strain, low back pain, and mechanical back pain. See May 1998, October 2001, December 2001, and June 2004 STRs. Additionally, please comment on the Veteran’s lay statement that her low back disability was incurred during service due to duties of her MOS working in the deck department which included pulling heavy lines and lifting heavy 25-gallon paint and that her low back pain has been continuous since service. See October 2018 and November 2019 Correspondences. (c) For each disability diagnosed in part (a), or any functional impairment identified, please opine on whether it is at least likely as not (a 50 percent or greater probability) that such disability is (i) proximately due to her service-connected fibromyalgia disability or (ii) has been aggravated (worsened beyond natural progression) by her service-connected fibromyalgia disability. The examiner is advised that inquiries (c)(i) and (c)(ii) require separate opinions: one for proximate causation and one for aggravation for each diagnosed disability. Please note that it is not necessary that fibromyalgia be service-connected, or even diagnosed, at the time any other low back disability is incurred to support secondary service connection, and reliance on this fact in support of a negative opinion will render it inadequate. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 8. Then obtain an addendum opinion from an examiner other than the September 2018 examiner addressing the etiology of the Veteran’s endocrine gland disorder. The examiner should address the following: (a) Please state whether the Veteran’s claimed endocrine gland symptoms, including tremors, headaches, lethargic, dizziness, anger, loss of appetite, memory problems, fatigue, dry mouth, constant thirst, blurred vision, nausea, muscle aches and cramps, and decreased sense of smell and taste (see October 2018 Correspondence) are attributable to a known clinical diagnosis, and if so, identify the same. (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after reviewing the claims file, you determine that the Veteran’s disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology ((b)(2) above), or a disease with a clear and specific etiology and diagnosis ((b)(3) above), then please opine as to whether it is at least as likely as not (50 percent probability or greater) that such disability pattern had its onset during service or or within one year of separation from service or is otherwise related to service. In addressing these questions, the examiner must acknowledge and comment on the Veteran’s documented symptoms in the Veteran’s STRs including nausea, diarrhea, vomiting, chills, headaches, dizzy spells, dehydration, and a diagnosis of anxiety NOS. See June 2002, January 2003, February 2003, January 2007, July 2010, and July 2011 STRs. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 9. Then schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of any psychiatric disorder, including depressive disorder and anxiety disorder. The examiner must address each of the following: (a) Diagnose any psychiatric disorder present under the DSM-5 since December 2014. (b) For any psychiatric disorder diagnosed under the DSM-5, to include depressive disorder and anxiety disorder, please opine whether it is at least likely as not (50 percent or greater probability) that such disorder had its onset during service or is otherwise related to service. In addressing this question, the examiner should comment on the Veteran’s STRs which document a diagnosis of anxiety disorder NOS and her report of continuous mental health problems since active duty. See January 2007 and July 2011 STRs and October 2018 and November 2019 Correspondences. (c) For any psychiatric disorder diagnosed under the DSM-5, to include depressive disorder and anxiety disorder, please opine whether it is at least likely as not (50 percent or greater probability) that such disorder (i) proximately due to or (ii) has been aggravated (worsened) by her service-connected fibromyalgia disability. Please note inquiries (i) and (ii) require two opinions one for causation and one for aggravation. (d) If no psychiatric diagnosis is warranted under the DSM-5, please state whether the Veteran’s claimed psychiatric symptoms, including tremors, headaches, lethargic, dizziness, anger, loss of appetite, memory problems, fatigue, dry mouth, constant thirst, blurred vision, nausea, muscle aches and cramps, and decreased sense of smell and taste (see October 2018 Correspondence) are attributable to a known clinical diagnosis, and if so, identify the same. (e) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (f) If, after reviewing the claims file, you determine that the Veteran’s disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology ((b)(2) above), or a disease with a clear and specific etiology and diagnosis ((b)(3) above), then please opine as to whether it is at least as likely as not (50 percent probability or greater) that such disability pattern had its onset during service or within one year of separation from service or is otherwise related to service. In addressing these questions, the examiner must acknowledge and comment on the Veteran’s documented symptoms in the Veteran’s STRs including nausea, diarrhea, vomiting, chills, headaches, dizzy spells, dehydration, and a diagnosis of anxiety NOS. See June 2002, January 2003, February 2003, January 2007, July 2010, and July 2011 STRs. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Asante 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.