Citation Nr: 20053428 Decision Date: 08/12/20 Archive Date: 08/12/20 DOCKET NO. 10-26 053 DATE: August 12, 2020 ORDER Entitlement to service connection for a hair loss disorder is denied. Entitlement to a rating in excess of 10 percent for a thyroid disability prior to June 11, 2013 and from January 1, 2014 is denied. Entitlement to a rating in excess of 30 percent for a thyroid disability from June 11, 2013 to January 1, 2014 is denied. Entitlement to an initial rating in excess of 10 percent for a left knee condition is denied. Entitlement to an initial rating in excess of 10 percent for a right ankle condition is denied. Entitlement to an initial rating in excess of 10 percent for a left ankle condition is denied. Entitlement to an initial rating in excess of 10 percent for right foot bone spurs is denied. Entitlement to an initial rating in excess of 10 percent for left foot bone spurs is denied. REMANDED Entitlement to service connection for a skin condition is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The competent evidence does not demonstrate that the Veteran currently has a diagnosable hair loss disorder, nor has she experienced symptomatology which would warrant such a diagnosis during the pendency of the appeal or recent to the filing of the claim. 2. For the entire appeal period, the Veteran’s thyroid disability was not manifested by tachycardia, increased pulse pressure or blood pressure, tremor, emotional instability, fatigability, thyroid enlargement, eye involvement, muscular weakness, increased sweating, flushing, heat intolerance, frequent bowel movements, weight loss, pressure on adjacent organs, or findings, signs, or symptoms attributable to a hypothyroid condition, hyperparathyroid condition, or hypoparathyroid condition. 3. The 30 percent rating for Grave’s disease is the highest schedular rating available for this condition, and the evidence does not indicate that the Veteran is entitled to an extraschedular evaluation for her thyroid disability during the six-month period from June 11, 2013 to January 1, 2014. 4. The Veteran’s left knee condition is manifested by flexion limited to no less than 115 degrees, and no ankylosis, objective indicia of instability, or impairment of the tibia or fibula or semilunar cartilage. 5. For the entirety of the appeals period, the Veteran’s right ankle condition has not more nearly approximated marked limitation of motion; furthermore, there is no evidence of ankylosis. 6. For the entirety of the appeals period, the Veteran’s left ankle condition has not more nearly approximated marked limitation of motion; furthermore, there is no evidence of ankylosis. 7. Throughout the entire period on appeal, the Veteran’s right heel spur condition has caused painful motion and pain on prolonged walking or standing, which is most closely defined as moderate in severity, but does not result in a moderately severe foot injury. 8. Throughout the entire period on appeal, the Veteran’s right heel spur condition has caused painful motion and pain on prolonged walking or standing, which is most closely defined as moderate in severity, but does not result in a moderately severe foot injury. CONCLUSIONS OF LAW 1. The criteria for service connection for a hair loss disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. 2. The criteria for a disability rating in excess of 10 percent for a thyroid disability prior to June 11, 2013 and from January 1, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7903, 7904. 3. The criteria for a disability rating in excess of 30 percent for a thyroid disability from June 11, 2013 to January 1, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7900. 4. The criteria for a rating in excess of 10 percent for a left knee condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.71a, Diagnostic Codes 5003-5257, 5260, 5261. 5. The criteria for an initial rating in excess of 10 percent for a right ankle condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5271. 6. The criteria for an initial rating in excess of 10 percent for a left ankle condition have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5271. 7. The criteria for an initial rating in excess of 10 percent for a right foot heel spur condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. 8. The criteria for an initial rating in excess of 10 percent for a left foot heel spur condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from July 1988 to July 2008. These matters were last before the Board in April 2016, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. In an April 2020 rating decision, the AOJ granted staged increased ratings for several of the service-connected disabilities on appeal. Furthermore, in a corresponding April 2020 supplemental statement of the case, the AOJ continued the denial of the two service-connection claims on appeal. All of the claimed issues were then returned to the Board for its adjudication. The Veteran testified at a September 2015 hearing before the undersigned Veterans Law Judge; a copy of the transcript of that hearing is of record. In view of the facts found, and to provide broader consideration on appeal, the Board has recharacterized the claim of entitlement to service connection for residuals of radioactive and thyroidectomy surgical treatment as one for a thyroid disability. The issue of entitlement to TDIU has been raised by the Veteran during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that VA must address the issue of entitlement to TDIU in increased-rating claims when the issue of unemployability either is raised expressly or by the record. Specifically, during the September 2015 hearing, the Veteran asserted that her service-connected disabilities precluded her from obtaining and following substantially gainful employment. Accordingly, the issue has been added for the Board’s consideration and is addressed in the Remand section below. Entitlement to Service Connection for a Hair Loss Disorder is Denied. The Veteran seeks service connection for a hair loss disorder which she contends is attributable to her hypothyroidism. Without delving into the question of the potential etiology of this condition, the Board finds that the Veteran has never been diagnosed with a hair loss disorder and there is insufficient evidence to suggest that such a diagnosis is appropriate; as such, entitlement to service connection must be denied. During the appeal period, the Veteran was first evaluated for a hair loss disorder in an August 2008 general medical examination. She reported a history of hair loss beginning in 1990 but acknowledged that it had resolved and that she hadn’t undergone any treatment in the 12 months prior to the examination. According to the Veteran she was treated in the past with steroid injections and reduction in life stressors. In conclusion, the examiner did not find that there was diagnosable alopecia and declined to set forth an opinion as to the etiology of the condition. Pursuant to the Board’s remand instructions, the Veteran was afforded a new VA examination in January 2020 to evaluate whether she had a diagnosable hair loss disorder and, if so, to elicit an opinion as to the likely etiology of any diagnosed hair loss disorder. After an in-person evaluation and a review of the claims file, the examiner concluded that any past hair loss symptomatology had resolved and that there was no diagnosable hair loss disorder; accordingly, the examiner declined to set forth an etiology opinion. A review of available medical records does not reflect that the Veteran has ever been diagnosed with or treated for a hair loss disorder. As noted in the Board’s prior remand instructions, it does acknowledge that a past history of hair loss was documented while the Veteran was still in service; however, service medical records from the time of her discharge, to include her discharge examination, do not reflect that the Veteran was evaluated as having a hair loss disorder when she left service or in the year leading up to her discharge from service. A July 2013 outpatient record does detail that the Veteran experienced hair loss second to her hyperthyroidism but does not specify whether this referred to the in-service history of hair loss or whether the Veteran experienced such symptomatology after service. During the September 2015 hearing, the Veteran asserted that she experienced daily hair loss. Ultimately, there is no objective medical evidence to suggest that the Veteran currently has a diagnosable hair loss disorder or has had one during the pendency of the appeal. While she did state during the September 2015 hearing that she experienced hair loss daily, this is not corroborated whatsoever by the available VA and private medical records, which show repeated instances of the Veteran denying any hair loss symptomatology when being evaluated on a regular basis for her various other medical issues. Moreover, the Board finds probative the two VA examinations of record, on which two different VA examiners separated by over ten years of time both concluded that the Veteran’s hair loss symptomatology had resolved prior to her discharge from service. Accordingly, without supporting records, the Board concludes that the Veteran does not have a diagnosable hair loss disorder and has not had such a condition during the appeal period. The Veteran herself does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection is denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 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 will be assigned. See 38 C.F.R. § 4.7. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. 1. Thyroid Disability The Veteran’s thyroid disability was first diagnosed in service and characterized as Grave’s disease, or hyperthyroidism; however, when she was evaluated following her discharge, the condition had progressed to hypothyroidism, and was rated as 10 percent disabling under the criteria for hypothyroidism prior to June 11, 2013. As will be discussed, a June 11, 2013 medical record showed a recurrence of Graves’ disease, and so the Veteran was rated as 30 percent disabling from June 11, 2013 to January 1, 2014, pursuant to the applicable criteria for the rating of hyperthyroidism. Those criteria as well as the shifting of her symptoms back to hypothyroidism necessitated a continuation of the prior 10 percent rating from January 1, 2014 under the criteria for rating hypothyroidism. The Veteran seeks an increased rating for her thyroid disability for the entirety of the appeal. As stated, the AOJ has rated the Veteran’s thyroid disability under 38 C.F.R. § 4.119, Diagnostic Codes 7900 and 7903, alternatively, since the award of service connection. The schedule of ratings for the endocrine system, which include the rating criteria for both hyperthyroidism under 7900 and hypothyroidism under 7903 was amended effective December 10, 2017. Where, as here, a claim is pending prior to the effective date of amended rating criteria, the claim will be considered under both the old and new rating criteria, and the more favorable criteria will be applied. The old criteria can apply to the entire appeal period, but new criteria can only apply as to the effective date of the change. The Board has evaluated the disability under the old criteria both prior to and from December 10, 2017, and under the new criteria as well from December 10, 2017. Under the prior criteria for Diagnostic Code 7900, hyperthyroidism with tachycardia, which may be intermittent, and tremor, or; continuous medication required for control, is rated 10 percent disabling. Hyperthyroidism with tachycardia, tremor, and increased pulse pressure or blood pressure is rated 30 percent disabling. A 60 percent rating is appropriate where there is hyperthyroidism with emotional instability, tachycardia, fatigability, and increased pulse pressure or blood pressure. Where there is thyroid enlargement, tachycardia (more than 100 beats per minute), eye involvement, muscular weakness, loss of weight, and sympathetic nervous system, cardiovascular, or gastrointestinal symptoms, the disability is rated 100 percent disabling. 38 C.F.R. § 4.119. Pursuant to the amended criteria, Diagnostic Code 7900 warrants a 30 percent rating for six months after initial diagnosis. Thereafter, the residuals of the disease or complications of medical treatment are rated within the appropriate diagnostic codes within the appropriate body system. Pursuant to Note (1), if hyperthyroid cardiovascular or cardiac disease is present, it is to be separately evaluated under Diagnostic Code 7008 (hyperthyroid heart disease). Note (2) provides that eye involvement occurring as a manifestation of Graves’ disease be evaluated as diplopia (Diagnostic Code 6090); impairment of central visual acuity (Diagnostic Codes 6061-6066); or under the most appropriate Diagnostic Codes in 38 C.F.R. § 4.79. That prior version of Diagnostic Code 7903 provided a 10 percent rating for hypothyroidism manifested by fatigability, or continuous medication is required for control. A 30 percent rating was warranted for fatigability, constipation, and mental sluggishness. A 60 percent rating was warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent rating was warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119, Diagnostic Code 7903. The current version of the criteria, effective December 10, 2017, provide that a 100 percent rating is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)) for a period of six months after an examiner has determined the condition is stabilized. Thereafter, the residual effects of hypothyroidism are rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). For hypothyroidism without myxedema, a 30 percent rating is assigned for six months after initial diagnosis. Thereafter, residuals of disease or medical treatment, to include eye conditions, are rated under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). 38 C.F.R. § 4.119, Diagnostic Code 7903. The Court has addressed the specific application of the rating criteria for Diagnostic Code 7903 and found that all the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 and resolved based on the evidence of record. The Court also stated that the rating criteria for Diagnostic Code 7903 are not successive. Tatum, 23 Vet. App. at 155. A claimant could potentially establish all the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. As indicated by the above outlined criteria, the current diagnostic criteria for thyroid disabilities does not allow for a rating lower than 30 percent under either Code 7900 or Code 7903. However, as the AOJ continued the 10 percent rating for the entirety of the appeal period other than the 30 percent assigned for the 6-month period following the confirmation of the Grave’s disease diagnosis, the Board must conclude that the AOJ instead applied the rating criteria under Diagnostic Code 7904, which provides a 10 percent rating for continuous medication control required for hyperparathyroidism. Diagnostic Code 7904 also provides a 60 percent evaluation for hypercalcemia and a 100 percent for six months from the date of discharge following surgery. To afford the Veteran all possible avenues to a higher rating, the Board herein has considered all potentially applicable Diagnostic Codes. During the pendency of the appeal, the severity of the thyroid disability was first evaluated in an August 2008 examination administered immediately following the Veteran’s discharge from service. She reported that she was first diagnosed with Grave’s disease in service in 2000 and underwent radioactive treatment at that time. Following this treatment, she detailed taking medication daily. According to the Veteran, her symptomatology largely consisted of uncontrolled weight gain, a total of 30 pounds since her initial diagnosis. She denied fatigability, sleepiness, tremor, emotional instability, depression, slowing of thought, poor memory, difficulty breathing and/or swallowing, and intolerance of hot or cold weather. In summation, she stated that she did not experience any functional impairment from her thyroid disability. After a thorough examination, the August 2008 examiner found no symptomatology attributable to the thyroid disability other than the documented history of weight gain. It was the examiner’s impression that there was no functional impairment caused by the thyroid disability. The severity of the thyroid disability was next evaluated in an June 2013 examination, during which the Veteran reported that she believed her thyroid levels to be well managed by her regular medication and was not aware of any symptomatology that could be attributable to her thyroid disability. The examiner noted that the Veteran did required continuous medication for the regulation of her thyroid disability and detailed that at the time of the examination the disability manifested as hypothyroid endocrine dysfunction; however, the examiner dismissed any finding of symptomatology attributable to the disability. Laboratory testing also did not reveal any abnormalities. In summation, the examiner found that the thyroid disability did not result in any functional impairment. Pursuant to the Board’s April 2016 remand instructions, the Veteran was afforded an examination in January 2020 to again evaluate the severity of the thyroid disability. She detailed that she took regular medication since she was first diagnosed with Grave’s disease in service in 2000 which appeared to alleviate her symptoms; however, she still developed a thyroid mass and goiter in 2013 which was removed in September 2013 via thyroidectomy. According to the examiner, the Veteran still experienced endocrine dysfunction, but the examiner did not identify any specific symptomatology attributable to the thyroid disability. An in-person physical examination as well as laboratory testing did not reveal any abnormalities. Ultimately, the examiner concluded that the Veteran did not experience any functional impairment as due to the thyroid disability. A review of post-service VA and medical records shows that the Veteran has continued to receive treatment for her thyroid disability for the entirety of the appeal period. Without detailing the extensive medical history of her treatment from the point of her discharge, the Board notes that it has thoroughly evaluated this evidence, and does not find that there is objective medical evidence that the Veteran experienced any specific symptomatology attributable to her thyroid other than dysphagia prior to and/or following her diagnosis with the recurrent Grave’s disease in 2013 and subsequent thyroidectomy in September 2013. Specifically, although the Board does acknowledge that there are well-documented instances of the Veteran reporting a variety of other symptoms during the appeal period that could potentially be attributable to her thyroid disability, to include fatigue, a feeling of cold throughout her body, constipation, anxiety and depression, there is no indication from the record that these symptoms have ever been directly attributed to the thyroid disability. Moreover, the Board highlights that the Veteran is already receiving a separate disability rating for gastroesophageal reflux disease, which contemplates symptoms of dysphagia and constipation; as such, the Board will not address these specific symptoms as they may relate to the Veteran’s thyroid disability since this would violate the rule against pyramiding of like symptoms. 38 C.F.R. § 4.14. To the extent that the Veteran has asserted that her thyroid disability has contributed to her development of a variety of other symptoms, the Board does note that during the September 2015 hearing the Veteran detailed that she had her thyroid checked every six months, and over the course of her continuing treatment her medication was altered 11 times in response to changes in her thyroid disability. According to the Veteran, especially when her medication is adjusted, she experiences a variety of symptoms attributable to the thyroid disability, to include bulging eyes, emotional instability, memory and cognitive impairment, difficulty breathing and swallowing, and constipation. Upon consideration of the evidence, to include under all potentially applicable rating criteria, the Board does not find that an evaluation in excess of 10 percent is warranted for either the period prior to June 11, 2013 or for the period from January 1, 2014. To begin, at no point during these two appeal periods did any medical professional who evaluated the Veteran ever find that the thyroid disability was not well-managed by prescribed medication. Although there is copious documentation of the Veteran adjusting her medication, as she attested to during the September 2015 hearing, there is no objective medical evidence to support her contention that this adjustment of medication resulted in the manifestation of additional symptomatology. The Board recognizes that the Veteran is competent to report her symptomatology and acknowledges her belief that this symptomatology is attributable to her thyroid disability. See Layno v. Brown, 6 Vet. App. 465 (1994). However, there is no indication in the record that the Veteran has the requisite knowledge or training to be deemed competent to identify a specific level of disability for her thyroid disability according to the appropriate diagnostic code criteria. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, supra; Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). This determination is corroborated by the three examinations of record, during which the three separate examiners came to the same distinct conclusion that the thyroid disability was well-managed by medication and did not result in any additional symptomatology. The 10 percent rating currently assigned during the two periods detailed above contemplates a thyroid disability that is controlled by medication, and the preponderance of the objective medical evidence does support the conclusion that the thyroid disability was well-managed by medication and did not contribute to additional symptomatology. The Veteran has not submitted objective medical evidence which suggests otherwise, and there is no indication from the record that such evidence exists and has yet to be added to the record. Accordingly, the Board does not find that the record warrants a rating in excess of the 10 percent currently assigned for the thyroid disability during either the period prior to June 11, 2013 or the period from January 1, 2014. As for the period from June 11, 2013 to January 1, 2014, the Board notes that the currently assigned 30 percent rating is the highest schedular rating available for the evaluation of Grave’s disease under Diagnostic Code 7900. There are no other applicable criteria for the evaluation of the thyroid disability during this time period that would result in a rating in excess of 30 percent (to include Diagnostic Codes 7901 and 7902 pertaining to toxic and nontoxic adenoma or Diagnostic Code 7904), and the Veteran has not asserted that she is entitled to an extraschedular rating for the Grave’s disease during the six-month period that she has been assigned a 30 percent rating. Following the cessation of that six-month period, as dictated by the criteria under Diagnostic Code 7900, the thyroid disability is to be rated for residual symptomatology under the applicable diagnostic code. In light of the Board’s finding that there is no residual symptomatology attributable to the thyroid disability, it is appropriate to then continue the previous 10 percent rating under Diagnostic Code 7904 for the period from January 1, 2014. In summation, the Board finds that ratings in excess of 10 percent prior to June 11, 2013 and from January 1, 2014, as well as a rating in excess of 30 percent from June 11, 2013 to January 1, 2014 are not warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107. 2. Left Knee Condition The Veteran is currently in receipt of a 10 percent rating for a left knee condition, characterized as degenerative arthritis with subluxation. She seeks a rating in excess of that 10 percent for the entirety of the appeal period. The evaluation for the left knee condition was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003-5257. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that the symptomatology of the left knee condition is manifested as degenerative arthritis pursuant to Diagnostic Code 5003, with Diagnostic Code 5257, corresponding to subluxation and/or lateral instability, representing the most prominent manifestation of the degenerative arthritis. Diagnostic Code 5003 provides for a rating of 10 percent for each major joint or group of minor joints affected by noncompensable limitation of motion. An increased rating of 20 percent is warranted with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board will consider additional diagnostic codes pertinent to the evaluation of knee disabilities in order to determine the highest possible evaluation for the left knee condition during the entire period of the appeal. However, in considering the applicability of those diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5258 (dislocated semilunar cartilage with locking and effusion), 5259 (symptomatic removal of semilunar cartilage) and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not show that the Veteran experiences these conditions. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5259, 5263. Under Diagnostic Code 5257, recurrent subluxation or lateral instability, a 10 percent rating is assigned when the impairment is slight, while a 20 percent rating is assigned for moderate impairment and a 30 percent rating is for severe impairment. Under Diagnostic Code 5260, limitation of flexion of the leg, a noncompensable rating is assigned when flexion is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg, a noncompensable rating is assigned when extension is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a. For VA purposes, “normal” extension and flexion of the knee is from zero to 140 degrees, and references to normal motion below indicate that the Veteran, in fact, had motion from zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The Board notes that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. The Veteran was afforded a VA examination in August 2008 to evaluate the severity of her left knee condition upon her discharge from service, during which she reported experiencing weakness, stiffness, swelling and giving way in her knees bilaterally. She also endorsed experiencing chronic pain throughout her left knee exacerbated by physical activity as well as walking or even sitting. According to the Veteran her bilateral knee symptomatology restricted how long she could engage in physical activities. Range of motion testing on the August 2008 examination revealed no limitation of flexion or extension. The examiner did not note any additional indicia of disability, and further detailed that there was no instability as reflected by testing. A radiographic examination revealed minimal spurring off the patella, with an impression of mild subluxation. After concluding the evaluation, the examiner set forth a diagnosis of degenerative arthritis with patellar spurring and mild subluxation. The severity of the left knee condition was next evaluated in a September 2009 VA joint examination, during which the Veteran reported that she underwent arthroscopic surgery of the left knee in June 2009. She further endorsed experiencing symptoms of chronic pain, stiffness, and occasional swelling, but acknowledged that this symptomatology did not result in any functional limitations. Range of motion testing revealed no limitation of flexion or extension, and the examiner also did not note crepitus or instability. The Veteran was next afforded an examination to evaluate the severity of the left knee condition in June 2013. She reported experiencing intermittent anterior knee pain aggravated by pressure on the knee, descending stairs or squatting. She also endorsed experiencing instability with navigating stairs, searing from a standing position, and with lateral or twisting movements. According to the Veteran, she also noted some popping and grinding noises. With regards to flare-ups, the Veteran detailed that she experienced inflammation with stiffness and pain about once per month relieved with elevation and icing. Range of motion testing on the June 2013 examination revealed flexion limited to 130 degrees and no limitation of extension. The examiner did not note any evidence of painful motion, and further did not note any additional loss of range of motion after repetitive use testing. In the examiner’s estimation the only functional impairment attributable to the bilateral knee symptomatology was pain on movement. No instability or recurrent subluxation was noted after testing. In summation, it was the examiner’s impression that the bilateral knee conditions did not result in any functional impairment. During the September 2015 hearing the Veteran asserted that she had been diagnosed with patellofemoral syndrome of the left knee resulting in inflammation and pain. According to the Veteran she received an injection regularly to alleviate her chronic pain and also taped her left knee to prevent her kneecap from sliding and causing pain. She also detailed that the left knee symptomatology restricted her ability to engage in physical activity. Pursuant to Board’s April 2016 remand instructions, the Veteran was scheduled for a new VA knee examination in January 2020, during which it was noted that she experienced a left knee meniscal tear in 2017. She endorsed experiencing flare-ups of left knee symptomatology precipitated by walking or prolonged standing and alleviated by rest and elevation. The Veteran did not endorse experiencing any functional loss or functional impairment of the left knee when queried. Range of motion testing did not reveal any loss of flexion or extension, although pain was note in the left knee in flexion as well as in extension. The examiner also noted mild localized tenderness in the medial and lateral knee as well as pain with weight bearing. After repetitive use testing the examiner did not find any additional loss of range of motion or function. Furthermore, although both of these were not tested, the examiner estimated that there also would not be any loss of range of motion or function following repeated use after time or during a flare-up. Testing did not reveal any ankylosis or joint instability. The examiner did note the history of a left knee meniscal tear but found no evidence of additional symptomatology as due to the tear and also related that the Veteran had not undergone surgery to repair the meniscus at the time of the examination. A radiographic examination revealed mild patellofemoral degenerative joint disease. In summation, it was the examiner’s impression that the bilateral knee symptomatology precluded prolonged standing or walking. A review of post-service VA and private medical records reflects that the Veteran has received continued care for her left knee symptomatology ever since leaving service. A May 2012 left knee MRI examination revealed patellar tendinitis and a suspected meniscal tear; however, a subsequent June 2012 outpatient record shows that a meniscal tear was not actually diagnosed at this time. Furthermore, that outpatient record also reflected that the Veteran exhibited full range of motion and no instability. Physical therapy records dating from 2015 and 2016 show continued complaints of left knee pain and tenderness. Range of motion testing during an April 2015 evaluation revealed flexion reduced to 115 degrees; however, subsequent records from this time period do not show any indication of reduced range of motion. November 2015 radiographic examinations revealed patella femoral chondromalacia as well as a medical meniscal tear. These records also reflect that at this time the Veteran was receiving cortisone injections to relieve her symptoms. Thereafter, an August 2017 MRI examination also revealed a left knee meniscal tear as well as small joint effusion. Upon consideration of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the left knee condition at any point during the appeal period. To begin, the Veteran has not exhibited a loss of range of motion commensurate with even the 10 percent rating under Diagnostic Codes 5260 and 5261 at any point during the appeal period. Specifically, she has not exhibited flexion limited to 30 degrees or less or extension limited to 15 degrees or less, which would be necessary for a rating in excess of the 10 percent he is currently assigned. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Indeed, the most severe limitation of motion exhibited by the Veteran was flexion limited to 115 degrees, which would typically warrant a noncompensable rating under the applicable criteria. That being said, the currently assigned 10 percent rating is still appropriate under Diagnostic Code 5003, which does provide for a minimum 10 percent rating for any limitation of motion of the affected joint. The Board further notes that although the Veteran has reported experiencing grinding and effusion of the left knee, there is insufficient evidence to support that it occurs with such frequency to warrant a compensable rating pursuant to Diagnostic Code 5258. Indeed, at no point has any examiner or treating medical professional noted that the Veteran experiences any locking of the left knee. A finding of grinding and effusion alone would not meet the criteria; rather, locking must be present as well. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (use of conjunctive “and” indicates all criteria must be met). To date, no examiner has noted joint locking, pain, and effusion together, and so a separate rating under Diagnostic Code 5258 is not warranted. As for the instability which would be necessary for a compensable rating under the diagnostic code utilized by the AOJ, that is, Diagnostic Code 5257, the Board notes that although the Veteran has reported experiencing instability, at no point during the appeal period has she ever been evaluated as actually experiencing demonstrable instability in the left knee. This includes on the multiple VA examinations afforded her during the appeal period as well as in the copious private and VA medical records in the claims file. Therefore, a separate 10 percent rating for left knee instability is not warranted either. The Board has reviewed the Veteran’s lay testimony and the VA treatment records in the claims file, but this evidence does not tend to show that the symptoms of her left knee condition have warranted a rating in excess of the current 10 percent rating at any point during the appeal. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of the more restricted flexion or extension represented by the ratings in excess of 10 percent and/or must show objective medical evidence of instability. Indeed, the limitation of motion of the left knee exhibited during the appeal period does not equate to the currently assigned 10 percent rating, and so that rating has already taken into consideration the pain and functional loss that is exhibited by the Veteran outside the loss of range of motion. Furthermore, although the Veteran reported experiencing flare-ups of left knee pain on the most recent January 2020 examination, there is no indication from that examination or the available treatment records that any increase in pain during such flare-ups would equate to an increase in limitation of motion or objective evidence of instability, as would be necessary for an evaluation in excess of the currently assigned 10 percent rating. Sharp v. Shinseki, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). Therefore, the Board finds that the current 10 percent initial rating adequately contemplates the functional impairment resulting from the Veteran’s left knee condition. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 20. 3. Right and Left Ankle Condition The Veteran is currently in receipt of separate 10 percent ratings for right and left ankle conditions, characterized as achilles tendonitis. She seeks an increased rating for both conditions for the entirety of the appeal. The 10 percent ratings were assigned pursuant to Diagnostic Code 5024-5271. As stated above, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that the symptomatology of the right and left ankle conditions is manifested as traumatic arthritis pursuant to Diagnostic Code 5024, with Diagnostic Code 5271, corresponding to tenosynovitis, representing the most prominent manifestation of the arthritis. The diseases under Diagnostic Codes 5013 through 5024 will be rated on the basis of loss of range of motion of the affected parts under the criteria for rating degenerative arthritis pursuant to Diagnostic Code 5003. As a reminder, Diagnostic Code 5003 provides for a rating of 10 percent for each major joint or group of minor joints affected by noncompensable limitation of motion. An increased rating of 20 percent is warranted with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board will consider additional diagnostic codes pertinent to the evaluation of ankle disabilities in order to determine the highest possible evaluation for the left knee condition during the entire period of the appeal. However, in considering the applicability of those diagnostic codes, the Board finds that Diagnostic Codes 5270 (ankylosis of the ankle in plantar flexion), 5272 (ankylosis of the subastragalar or tarsal joint), 5273 (malunion of the os calcis or astragalus) and 5274 (astragalectomy) are not applicable in this instance, as the medical evidence does not show that the Veteran experiences these conditions. 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, 5274. Limitation of motion of the ankle is evaluated under Diagnostic Code 5271. A 10 percent evaluation is assigned for moderate limitation of the ankle, and a maximum 20 percent evaluation is assigned for marked limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Overton v. Wilkie, 30 Vet. App. 257 (2018). Normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 8 C.F.R. § 4.71a, Plate II. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Veteran was afforded a VA examination in August 2008 to evaluate the severity of her bilateral ankle conditions upon her discharge from service, during which she reported experiencing weakness, stiffness, fatigability and pain in her ankles bilaterally. She noted that her pain and stiffness were exacerbated by physical activity as well as walking or even sitting. According to the Veteran her bilateral ankle symptomatology restricted how long she could engage in physical activities and also restricted how long she could stand without experiencing significant pain. Range of motion testing on the August 2008 examination revealed no limitation of flexion or extension bilaterally. The examiner did not note any additional indicia of disability other than tenderness at the Achilles tendon and plantar fascia bilaterally. A radiographic examination revealed small calcaneal spurs in each foot that were unremarkable. After concluding the evaluation, the examiner set forth a diagnosis of bilateral achilles tendonitis. The severity of the bilateral ankle conditions was next evaluated in a September 2009 VA joint examination, during which the Veteran reported experiencing symptoms of chronic pain in both ankles but acknowledged that this symptomatology did not result in any functional limitations. Range of motion testing revealed no limitations although the examiner did note that the Veteran complained of tenderness to palpation in both ankles. The Veteran was next afforded an examination to evaluate the severity of the bilateral ankle conditions in June 2013. She reported experiencing pain, stiffness and soreness throughout her bilateral ankles. She did not endorse experiencing flare-ups of symptomatology. Range of motion testing revealed no limitations or objective evidence of painful motion, even following repetitive use testing. In the examiner’s estimation there was no functional impairment attributable to the bilateral ankle symptomatology. No instability or ankylosis was noted after testing. In summation, it was the examiner’s impression that the bilateral ankle conditions did not result in any functional impairment. During the September 2015 hearing the Veteran asserted that her feet swelled up whenever she spent more than two hours on her feet and did not elevate her ankles while sleeping. She further contended that her feet were constantly in pain which made it very difficult to ambulate. Pursuant to the Board’s April 2016 remand instructions, the Veteran was scheduled for a new VA foot examination in January 2020 to evaluate the severity of the bilateral ankle conditions, during which it was noted that she experienced a burning, tingling pain in the foot and heel when stepping or standing. She did not endorse experiencing flare-ups of bilateral ankle symptomatology and also did not endorse experiencing any functional loss or functional impairment of the ankles when queried. Following a physical evaluation, the examiner found that the severity of the bilateral ankle condition was mild, although the examiner did acknowledge that the ankle conditions compromised weight-bearing and required custom orthotics to alleviate symptomatology. While the examiner did not report the results of range of motion testing, they did note that there was evidence of pain on active range of motion testing and on weight bearing bilaterally. A review of post-service private medical records shows that the Veteran began seeking regular care for chronic left ankle pain, stiffness and swelling in January 2009 from a Dr. M.W. A radiographic examination at that time revealed chronic left ankle insertional achilles tendonitis. A March 2009 evaluation by a Dr. H.C. shows that the Veteran reported experiencing bilateral ankle pain, with a provisional diagnosis of psoriatic arthritis. Thereafter, outpatient records from a Dr. F.G. dated in 2012 shows that the Veteran reported experiencing chronic pain bilaterally in her feet and ankles. She was diagnosed with tarsal tunnel syndrome on the left side and fascia on the right side. Moreover, it was Dr. F.G.’s impression that both conditions would require corrective surgery. Available post-service VA medical records also show that the Veteran began seeking regular care for chronic bilateral ankle pain in late 2008 that was characterized as plantar fasciitis as well as chronic ankle pain. Subsequent records show different characterizations to include achilles tendonitis and tarsal tunnel syndrome. Upon consideration of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the right or left ankle condition at any point during the appeal period. At no point has the Veteran exhibited a loss of range of motion when tested, and although range of motion testing results were not reported on the January 2020 examination, there is no indication from that examination that the she experiences any loss of range of motion of her ankles. Moreover, the January 2020 examiner specifically evaluated the bilateral ankle symptomatology as being mild in severity. This comports with the prior VA examiners of record all of whom found that the bilateral ankle conditions would not have an impact on the Veteran’s occupational functioning other than to restrict how long she could stand. The available VA and private medical records also do not indicate that the Veteran’s ankle conditions resulted in a marked limitation in motion. As such, the Board finds that the currently assigned 10 percent rating is still appropriate under Diagnostic Code 5271, which does provide for a minimum 10 percent rating for moderate limitation of the ankle. The Board has reviewed the Veteran’s lay testimony, but this evidence does not tend to show that the symptoms of her right and left ankle conditions have warranted a rating in excess of the current 10 percent rating at any point during the appeal. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of marked limitation of motion. In light of the lack of evidence of any significant limitation of motion, the Board must conclude that the current 10 percent rating already takes into consideration the pain and functional loss that is exhibited by the Veteran outside the loss of range of motion. Furthermore, the Board highlights that the Veteran has never endorsed experiencing flare-ups of bilateral ankle symptomatology. Sharp, supra; Correia, supra. Therefore, the Board finds that the current 10 percent initial ratings adequately contemplates the functional impairment resulting from the Veteran’s right and left ankle conditions. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 20. 4. Right and Left Foot Heel Spurs The Veteran is service-connected for right and left heel bone spurs with separate 10 percent ratings. She seeks a rating in excess of 10 percent for the entirety of the appeal. The 10 percent ratings in the case were assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5284, which pertains to non-specified foot injuries of the foot without an analogous disability. Under Diagnostic Code 5284, a 10 percent rating is warranted for a moderate condition, 20 percent for a moderately severe condition, and 30 percent for a severe condition. The note corresponding to the Diagnostic Code indicates that the actual loss of use of the foot is rated at 40 percent. 38 C.F.R. § 4.71a. Moreover, VA’s General Counsel has determined that Diagnostic Code 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion. VAOPGCPREC 9-98. The words “moderate,” “moderately severe,” and “severe” are not defined by Diagnostic Code 5284. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is “equitable and just.” 38 C.F.R. § 4.6. The Board has also considered the applicability of other Diagnostic Codes related to the feet. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5284. However, as there is no evidence of any of the disabilities corresponding to those Diagnostic Codes, the Board concludes that there is no analogous disability that can account for the symptomatology of the bilateral heel spur conditions. Therefore, the Board confirms that Diagnostic Code 5284 is the most appropriate Code in this case because the Veteran’s bilateral heel spurs are not specifically contemplated under another Diagnostic Code. See 38 C.F.R. § 4.20; Yancy v. McDonald, 27 Vet. App. 484, 491 (2016). The Veteran was afforded a VA examination in August 2008 to evaluate the severity of her bilateral heel spurs upon her discharge from service, during which she reported experiencing burning, aching pain as well as inflammation while standing or walking. According to the Veteran her bilateral ankle symptomatology restricted how long she could engage in physical activities and also restricted how long she could stand without experiencing significant pain. An in-person evaluation did not indicate that she had any limitation with standing or walking, and the examiner also did not find that the Veteran required any support with her shoes. A radiographic examination of the bilateral feet did not show any abnormalities. After concluding the evaluation, the examiner set forth a diagnosis of bilateral plantar fasciitis. The severity of the bilateral heel spur conditions was next evaluated in a September 2009 VA joint examination, during which the Veteran reported experiencing symptoms of chronic pain in both feet and also noted that she was recommended inserts that helped with her foot pain. She did not endorse any weakness or fatigability. An in-person evaluation did not show any limitation of motion, edema, weakness, or instability. The examiner also noted that there was no tenderness to palpation over the plantar fascia or abnormal weight-bearing. In summation, the examiner found that there was no loss of function with activities other than those reported by the Veteran, and further stated that any additional loss of function due to flare-ups could not be determined without resorting to speculation. After concluding the examination, the examiner set forth a diagnosis of bilateral heel spurs. The Veteran was next afforded an examination to evaluate the severity of the bilateral heel spur conditions in June 2013. She reported experiencing plantar heel pain and noted that she wore shoes with built in orthotics. After a review of the claims file and an in-person evaluation, the examiner found that there was no functional impairment attributable to the bilateral heel spur symptomatology. During the September 2015 hearing the Veteran asserted that her feet swelled up whenever she spent more than two hours on her feet and did not elevate her feet while sleeping. She further contended that her feet were constantly in pain which made it very difficult to ambulate. Pursuant to the Board’s April 2016 remand instructions, the Veteran was scheduled for a new VA foot examination in January 2020 to evaluate the severity of the bilateral heel spur conditions. As this examination was grouped together with the bilateral ankle condition examination, the results are largely identical, and will not be replicated in total here, except only to reiterate that the examiner found the bilateral foot symptomatology to be mild in severity. A review of post-service private medical records shows that the Veteran began seeking regular care for chronic foot pain, stiffness and swelling in January 2009 from a Dr. M.W. A March 2009 evaluation by a Dr. H.C. shows that the Veteran reported experiencing bilateral foot pain, with a provisional diagnosis of psoriatic arthritis. Thereafter, a radiographic examination report from a Dr. F.G. dated in May 2012 shows that the Veteran reported a history of plantar fibromatosis and was evaluated as having no other focal abnormalities other that rule-out stress injury to the right os calcis on the plantar aspect. Available post-service VA medical records also show that the Veteran began seeking regular care for chronic bilateral foot and heel pain in late 2008 that was characterized as plantar fasciitis as well as bilateral heel spurs. Subsequent records show only treatment for plantar fasciitis of the left foot until August 2011, when she began to receive treatment for foot pain bilaterally. Upon consideration of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the right or left heel spur condition at any point during the appeal period. At no point has the Veteran exhibited any symptomatology other than pain and swelling of the feet, and no examiner or other treating medical professional has ever asserted that she experiences functional impairment as due to the bilateral heel pain other than a restriction of extended walking or standing. Moreover, the January 2020 examiner specifically evaluated the bilateral foot symptomatology as being mild in severity. As such, the Board finds that the Veteran’s bilateral foot and heel symptomatology is contemplated by the currently assigned 10 percent rating under Diagnostic Code 5271 for moderate disability. The evidence does not suggest that her bilateral disability is moderately-severe or severe such as would warrant a 20 or 30 percent rating, respectively. The Board notes that disability ratings under Diagnostic Code 5284 and the accompanying codes for the feet are not based on limitation of motion. Instead, the Veteran’s disability is rated based on the overall severity of his left heel spur and associated impairment. As such, the examination requirements laid out by the Court in Correia do not apply to the Veteran’ s bilateral heel spur evaluation. See 38 C.F.R. § 5284; see also Correia, supra, 28 Vet. App. 158, 169-70 (2016). The Board has reviewed the Veteran’s lay testimony, but this evidence does not tend to show that the symptoms of her right and left heel spur conditions have warranted a rating in excess of the current 10 percent rating at any point during the appeal. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of moderately-severe disability. In light of the lack of evidence of any significant impairment or symptomatology other than pain and swelling, the Board must conclude that the current 10 percent rating already takes into consideration the pain and functional loss that is exhibited by the Veteran. Furthermore, the Board highlights that the Veteran has never endorsed experiencing flare-ups of bilateral foot symptomatology. Sharp, supra. Therefore, the Board finds that the current 10 percent initial ratings adequately contemplates the functional impairment resulting from the Veteran’s right and left heel spur conditions. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 20. REASONS FOR REMAND 1. Entitlement to Service Connection for a Skin Condition is Remanded. The issue of entitlement to service connection for a skin condition was remanded by the Board in April 2016 with explicit instructions for the AOJ to secure an examination to set forth a diagnosis that accounted for the Veteran’s history of complaints of skin symptomatology and then elicit an opinion as to the likely etiology of the diagnosed skin disorder. In a January 2020 disability benefits questionnaire, a VA examiner determined that the Veteran did not have a diagnosable skin disorder. The only detail provided in support of this determination was that the Veteran’s reported history of hair loss appeared to have resolved in service and was attributable to stress she underwent at that time. As a result, the examiner did not set forth an etiology opinion regarding the skin disorder. This examination and opinion are inadequate. The Board fails to understand why the Veteran’s history of hair loss is relevant to the determination regarding her claimed skin disorder, especially in light of substantial medical evidence of record showing a long history of complaints of and treatment for a skin disorder distinct from any complaints of hair loss. Under these circumstances, the Board must again remand this issue in order to schedule the Veteran for a new examination that sets forth a diagnosis or diagnoses which account for the Veteran’s documented skin disorder symptomatology and then secure an opinion as to the likely etiology of any such diagnosis or diagnoses. Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to TDIU is Remanded. A decision on the issue of entitlement to TDIU is also remanded pending resolution of the service connection claim also being remanded as such claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination to address the nature and etiology of her claimed skin disorder. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran’s documented medical history and assertions relating to any skin disorder symptomatology. All necessary special studies or tests must be accomplished. After setting forth a diagnosis or diagnoses which accounts for the documented history of complaints of and treatment for skin disorder symptomatology, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any such diagnosed skin disorder began in service, was caused by service, or is otherwise related to the Veteran’s military service. The examiner is also requested to address the functional impact that all of the Veteran’s service connected disabilities have on his ability to secure or follow a substantially gainful occupation. When addressing the functional impact, the examiner must consider the Veteran’s educational and occupational history but must not consider the Veteran’s age or any non-service connected disabilities. The examiner must provide a complete rationale for any opinion expressed. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.