Citation Nr: 21062709 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 17-43 024 DATE: October 12, 2021 ORDER The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected right knee disability is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected left knee disability is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 10 percent for service-connected lumbar spine disability is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 20 percent for service-connected right shoulder disability is denied. REMANDED The appeal as to the claim of entitlement to service connection for a right wrist disorder claimed as carpel tunnel syndrome (CTS), to include as secondary to the service-connected right shoulder disability, is remanded. The appeal as to the claim of entitlement to service connection for a left wrist disorder claimed as CTS, to include as secondary to the service-connected right shoulder disability, is remanded. The appeal as to the claim of entitlement to service connection for a right ankle disorder, to include as secondary to the service-connected right and/or left knee disabilities, is remanded. The appeal as to the claim of entitlement to service connection for a left ankle disorder, to include as secondary to the service-connected right and/or left knee disabilities, is remanded. The appeal as to the claim of entitlement to service connection for a left hip disorder, to include as secondary to the service-connected right and/or left knee disabilities, is remanded. The appeal as to the claim of entitlement to service connection for a right hip disorder, to include as secondary to the service-connected right and/or left knee disabilities, is remanded. The appeal as to the claim of entitlement to an initial evaluation in excess of 50 percent for service-connected adjustment disorder, depression, and bipolar disorder is remanded. The appeal as to the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. The appeal as to the claim of entitlement to a total disability evaluation based upon individual unemployability (TDIU), due to service-connected disabilities, is remanded. FINDINGS OF FACT 1. Throughout the pendency of the appeal, the Veteran's right knee has been manifested by pain and flexion limited to no more than 100 degrees; there was no limitation of extension to 5 degrees or more, ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, impairment of the tibia and fibula, or genu recurvatum. 2. Throughout the pendency of the appeal, the Veteran's left knee has been manifested by pain and flexion limited to no more than 100 degrees; there was no limitation of extension to 5 degrees or more, ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, impairment of the tibia and fibula, or genu recurvatum. 3. Throughout the pendency of the appeal, the Veteran's lumbar spine disability has been manifested by flexion limited to no more than 70 degrees and combined range of motion to 130 degrees; there was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, and there was no evidence of ankylosis. 4. Throughout the pendency of the appeal, the Veteran's right shoulder disability has been manifested by forward flexion limited to 95 degrees, abduction to 90 degrees, external rotation to 70 degrees, and internal rotation to 80 degrees. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for service-connected right knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for an initial rating in excess of 10 percent for service-connected left knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, Code 5260 (2020). 3. The criteria for an initial rating in excess of 10 percent for service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2020). 4. The criteria for an initial evaluation in excess of 20 percent for service-connected right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.71a, Diagnostic Code 5201 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from December 1992 to December 2012, to include service in Iraq from January 2003 to July 2003, from January 2005 to January 2003, and from June 2011 to October 2011. Her service was under honorable conditions. Amongst other commendations, the Veteran is the recipient of the Combat Action Badge. The matters are on appeal from June 2013, May 2014, and April 2015 rating decisions. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Legal Criteria Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2020). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2020). 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. 38 C.F.R. § 4.7 (2020). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2020) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. In both initial rating claims and subsequent increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of 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 v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2020). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2020). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather pain, 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., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2020). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2020). In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Entitlement to an initial evaluation in excess of 10 percent for service-connected right knee disability. See argument Below at 2 2. Entitlement to an initial evaluation in excess of 10 percent for service-connected left knee disability. The Veteran asserts that his service-connected right and left knee limitation of flexion disabilities are more severe than her current 10 percent ratings, respectively. Limitation of flexion of the knee is rated pursuant to Code 5260. The Code provides that limitation of flexion of the knee to 60 degrees is noncompensable; limitation of flexion to 45 degrees warrants a 10 percent rating; limitation of flexion to 30 degrees warrants a 20 percent disability rating; and limitation of flexion to 15 degrees warrants a 30 percent disability rating. Limitation of extension of the knee to 5 degrees warrants a noncompensable disability rating; limited to 10 degrees warrants a 10 percent disability rating; limited to 15 degrees warrants a 20 percent disability rating; limited to 20 degrees warrants a 30 percent disability rating; limited to 30 degrees warrants a 40 percent disability rating; and limited to 45 degrees warrants a 50 percent disability rating. Separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Normal range of motion of the knee is to 0 degrees (full extension) and to 140 degrees (full flexion). 38 C.F.R. § 4.71a, Plate II. A June 2013 VA examination report indicates a diagnosis of mild bilateral knee osteoarthritis. The examiner did not perform any testing, to include range of motion. A March 2014 VA examination report indicates a diagnosis of bilateral knee degenerative joint disease. On range of motion testing, the Veteran demonstrated right knee flexion to 140 degrees and normal extension to 0 degrees, and left knee flexion to 140 degrees and normal extension to 0 degrees. Repetitive range of motion testing did not result in any additional loss of range of motion, bilaterally; there was functional impairment, bilaterally, that manifested by swelling. There was no evidence of tenderness or pain to palpation for joint line or soft tissue of either knee. Muscle strength testing was normal (5/5), bilaterally. There was no evidence of recurrent subluxation or lateral instability, ankylosis, dislocated cartilage, impairment of the tibia and fibula, or genu recurvatum, bilaterally. X-ray examination was negative for degenerative or traumatic arthritis. An October 2019 VA examination report indicates a diagnosis of bilateral knee degenerative arthritis. The Veteran reported bilateral knee flare-ups manifested by difficulty kneeling and squatting and increased pain when walking for more than 15 minutes. On range of motion testing, the Veteran demonstrated right knee flexion to 100 degrees and normal extension to 0 degrees, and left knee flexion to 100 degrees and normal extension to 0 degrees. Repetitive range of motion testing did not result in any additional loss of range of motion or functional loss, bilaterally. There was no objective evidence of pain in non-weight bearing, bilaterally. There was objective evidence of pain in passive range of motion, bilaterally; however, no additional loss of range of motion. There was evidence of tenderness to palpation of the anterior aspect of the knee, bilaterally. There was evidence of pain with weight bearing and crepitus, bilaterally. There was no evidence of additional loss of range of motion or limited functional ability with repeated use over time or flare-ups, bilaterally. The examiner noted there was interference with standing, bilaterally. There was no evidence of muscle atrophy, bilaterally. Muscle strength testing was normal (5/5), bilaterally. There was no evidence of recurrent subluxation or lateral instability, ankylosis, dislocated cartilage, impairment of the tibia and fibula, or genu recurvatum, bilaterally. X-ray examination revealed degenerative arthritis, bilaterally. Upon review, the evidence of record shows that an initial rating in excess of 10 percent is not warranted for the service-connected right knee limitation of flexion disability, or the service-connected left knee limitation of flexion disability. Here, the record reflects the Veteran does have limitation of right and left knee flexion (limited to no more than 100 degrees), but not to the extent necessary for an initial rating in excess of 10 percent under Code 5260. Moreover, the record indicates normal right and left knee extension; with no evidence of limitation of such so as to warrant a compensable rating under Code 5261. Specifically, the record does not reflect that the Veteran's right or left knee demonstrated flexion to 15 degrees, or less, nor extension limited to 5 degrees or more. In addition, the evidence of record does not demonstrate that the next higher 20 percent rating is warranted due to functional loss, even when taking into account the Veteran's complaints of pain and flare-ups. The Board has also considered whether any other relevant Code might permit a higher or separate rating. Included within 38 C.F.R. § 4.71a are multiple Codes that evaluate impairment resulting from service-connected knee disabilities, including Code 5256 (ankylosis), Code 5257 (recurrent subluxation or lateral instability), Code 5258 (dislocated semilunar cartilage), Code 5259 (symptomatic removal of semilunar cartilage), Code 5260 (limitation of flexion), Code 5262 (impairment of the tibia and fibula), and Code 5263 (genu recurvatum). However, the preceding Codes are not applicable to the Veteran's claim. For the entire rating period, the Veteran did not exhibit limitation of extension to 5 degrees, or beyond. As such, Code 5256 and 5261 are inapplicable. In addition, there was no evidence of recurrent subluxation or lateral instability, impairment of the semilunar cartilage, impairment of the tibia and/or fibula, or genu recurvatum. Therefore, Codes 5257, 5258, 5259, 5262 and 5263 are inapplicable, too. Further, the Board has considered the lay evidence offered by the Veteran in the form of correspondence, in addition to the medical evidence cited above. In this regard, the Board acknowledges the Veteran's consistent report of pain, swelling, and limitation of motion. However, even affording the lay statements full competence and credibility, the evidence simply does not show entitlement to a higher rating under any applicable Code. In view of the foregoing, the Board finds the Veteran's service-connected right knee limitation of flexion disability and left knee limitation of flexion disability do not warrant an initial rating in excess of 10, respectively, to include as a "staged" rating(s) pursuant to Fenderson and Hart. 3. Entitlement to an initial evaluation in excess of 10 percent for service-connected lumbar spine disability. The Veteran also contends that his service-connected lumbar spine disability is more severe than his current 10 percent rating. The Veteran's lumbar spine disability is rated under Diagnostic Code 5237 for a strain of the lumbar spine, which utilizes the General Rating Formula for Diseases and Injuries of the Spine (General Formula). Under the General Rating Formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motions for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. Intervertebral disc syndrome (IVDS) will be evaluated under the General Rating Formula or under the formula for rating IVDS based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the formula for rating IVDS based on incapacitating episodes, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). For purposes of evaluation under Diagnostic Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Formula for Rating IVDS, Note 1. The Veteran underwent a VA examination in June 2013, during which she reported ongoing symptoms of low back pain. Degenerative arthritis was diagnosed; however, the examiner did not perform any testing, to include range of motion testing. The Veteran underwent a VA examination in January 2015, during which she reported symptoms of increased back pain. She denied flare-ups. She reported functional loss of the lumbar spine, to include decreased ability to walk long distances. Physical examination demonstrated no tenderness to palpation. Range of motion testing revealed forward flexion of the lumbar spine to 90 degrees, extension to 0 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 10 degrees. Combined range of motion was 130 degrees. There was evidence of pain during all range of motion testing, but it did not result in further functional loss. There was no evidence of pain with weight bearing. The Veteran performed repetitive-use testing with three repetitions and there was no additional loss of function or range of motion or functional loss of the lumbar spine. With repeated use over time, there was no evidence of limited functional ability or additional loss of range of motion. With flare-ups, there was no evidence of limited functional ability or additional loss of range of motion. There was no evidence of guarding or muscle spasm. There was no evidence of ankylosis. Muscle strength testing was normal (5/5) and there was no muscle atrophy. Sensory examination was normal. Reflex examination was normal (2+). Straight leg test was negative. There was no evidence of IVDS of the lumbar spine. There was no evidence of radiculopathy. The diagnosis was degenerative arthritis. The Veteran underwent a VA examination in October 2019, during which she reported symptoms of increased back pain. She reported flare-ups, to include increased pain with increased activity. She reported functional loss of the lumbar spine, to include limited ability to lift more than 20 pounds, and decreased ability to walk or stand for a prolonged period of time. Physical examination demonstrated tenderness to palpation. Range of motion testing revealed forward flexion of the lumbar spine to 70 degrees, extension to 30 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Combined range of motion was 190 degrees. There was evidence of pain during all range of motion testing that resulted in limited forward flexion, as above. There was no evidence of pain with weight bearing. There was no evidence of pain in non-weight bearing. The examiner noted that passive range of motion was not performed because it was not feasible to do it in a safe and reasonable manner. The Veteran performed repetitive-use testing with three repetitions and there was no additional loss of function or range of motion or functional loss of the lumbar spine. With repeated use over time, there was no evidence of limited functional ability or additional loss of range of motion. With flare-ups, there was no evidence of limited functional ability or additional loss of range of motion. There was evidence of guarding and muscle spasm and neither resulted in abnormal gait or abnormal spinal contour. There was no evidence of ankylosis. Muscle strength testing was normal (5/5) and there was no muscle atrophy. Sensory examination was normal. Reflex examination was normal (2+). Straight leg test was negative. There was no evidence of IVDS of the lumbar spine. There was no evidence of radiculopathy. The diagnosis was mild degenerative arthritis. The Board finds that the Veteran's lumbar spine disability does not warrant an initial rating in excess of 10 percent for the entire rating period. The above evidence shows forward flexion of the lumbar spine was limited to no more than 70 degrees, and combined range of motion was more than 120 degrees, to no more than 190 degrees. In addition, there is no evidence of additional limitation of range of motion or functional impairment upon repetitive motion testing. 38 C.F.R. §§ 4.71a, 4.40, 4.45, 4.59; see Mitchell, 25 Vet. App. at 32; Deluca, 8 Vet. App. at 202. With repeated use over time, there was no evidence of limited functional ability or additional loss of range of motion. With flare-ups, there was no evidence of limited functional ability or additional loss of range of motion. On examination in January 2019, there was evidence of guarding and muscle spasm; however, it did not result in abnormal gait or abnormal spinal contour. There is no evidence of forward flexion to 30 degrees but not greater than 60 degrees; or the combined range of motion of the lumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; thus, a 20 percent rating is not warranted. Likewise, a 40 percent rating is not warranted, as there is no evidence of forward flexion to 30 degrees or less, or, favorable ankylosis of the entire lumbar spine. In addition, a 50 or 100 percent rating is not warranted, as there is no evidence of unfavorable ankylosis of the lumbar spine. Additionally, throughout the period of the appeal, the Veteran denied incapacitating episodes and he was not diagnosed with IVDS. Finally, the Veteran does not report, nor does the evidence demonstrate any neurological manifestations. Further, the Board has considered the lay evidence offered by the Veteran in the form of correspondence, in addition to the medical evidence cited above. In this regard, the Board acknowledges the Veteran's consistent report of pain and difficulty walking. However, even affording the lay statements full competence and credibility, the evidence simply does not show entitlement to a higher evaluation under any applicable diagnostic code. In view of the foregoing, the Board finds the Veteran's service-connected lumbar spine disability does not warrant an initial rating in excess of 10, to include as a "staged" rating(s) pursuant to Fenderson and Hart. 4. Entitlement to an initial evaluation in excess of 20 percent for service-connected right shoulder disability. The Veteran contends that her right shoulder disability is more severe than her current 20 percent evaluation, that is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5201. The evidence of record demonstrates that the Veteran is right-handed, and her disability is her right shoulder. Thus, schedular ratings for the major arm/shoulder are for application. 38 C.F.R. § 4.69 (2020). Limitation of motion of the major arm at shoulder level warrants a 20 percent disability rating; limitation of motion of the major arm midway between side and shoulder level warrants a 30 percent disability rating; and limitation of motion of the major arm to 25 degrees from side warrants a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal ranges of upper extremity motion are flexion from zero to 180 degrees, abduction from zero to 180 degrees, and internal and external rotation from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. Upon review, the evidence of record shows that an initial rating in excess of 20 percent is not warranted. The Veteran underwent a VA examination in March 2014. The Veteran reported that she experienced increased pain with flare-ups. The examination was negative for right shoulder tenderness and pain upon palpation of the joint. Range of motion testing showed right shoulder flexion to 160 degrees and abduction to 160 degrees with pain beginning at 160 degrees, respectively. The Veteran performed repetitive-use testing with three repetitions and there was no additional loss of range of motion, and functional loss was manifested by swelling. There was no evidence of guarding. Muscle strength testing was normal (5/5). There was no evidence of ankylosis of the glenohumeral articulation. There was no evidence of instability, dislocation, labral pathology, impairment of the AC joint, impairment of the clavicle or scapula, or acromioclavicular pathology. The examiner diagnosed right shoulder impingement. These measurements do not support a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Veteran underwent a VA examination in October 2019. The Veteran reported a history of arthroscopic shoulder surgery (rotator cuff repair). The Veteran reported pain and flare-ups. The examination revealed right shoulder tenderness and pain upon palpation of the joint. Range of motion testing showed right shoulder flexion to 95 degrees, abduction to 90 degrees, external rotation to 70 degrees, and internal rotation to 80 degrees. On passive range of motion, forward flexion was to 90 degrees and abduction was to 90 degrees. The Veteran performed repetitive-use testing with three repetitions and there was no additional loss of function or range of motion. With repeated use over time, there was some loss of range of motion, as forward flexion was to 90 degrees, and there was no loss of range of motion of abduction. The examiner indicated that there would be limited functional ability due to pain, fatigue, and weakness, with loss of use over time. With flare-ups, there was no additional loss of range of motion, and there was limited functional ability due to pain, fatigue, and weakness. Muscle strength testing was active movement against some resistance (4/5). There was no evidence of muscle atrophy. There was no evidence of ankylosis. There was no evidence of ankylosis of the glenohumeral articulation. There was no evidence of instability, dislocation, labral pathology, impairment of the clavicle or scapula, or acromioclavicular pathology. There was tenderness on palpation to the AC joint. There was no evidence of impairment of the humerus. The examiner diagnosed mild arthritis of the AC joint, adhesive capsulitis, and status post rotator cuff repair. These measurements do not support a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Consideration of functional loss and impairment does not lead to a higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; see Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011); Deluca v. Brown, 8 Vet. App. 202, 204-06 (1995). During the March 2014 examination, the Veteran reported pain and flare-ups of her right shoulder. The examiner accounted for the Veteran's symptoms and the Veteran could perform repetitive testing during the March 2014 examination, which revealed no additional loss of range of motion. Although there was evidence of additional functional loss manifested by swelling, such a symptom does not support a higher 30 percent evaluation. Indeed, the range of motion noted on the examination is at least 40 degrees greater than what is needed for a 30 percent rating. Similarly, during the October 2019 examination, the Veteran reported pain and flare-ups of her right shoulder. The examiner accounted for the Veteran's symptoms and the Veteran could perform repetitive testing during the October 2019 examination, which revealed no additional functional loss or limitation of motion. With repeated use over time, there was an additional loss of range of motion of 5 degrees, as forward flexion was to 90 degrees. With flare-ups, there was no additional loss of range of motion, and while there was limited functional ability due to pain, this has been accounted for in the current 20 percent evaluation. In addition, the frequency and severity of the Veteran's reported symptoms do not rise to the level needed for a 30 percent rating. Indeed, the range of motion noted on the examination is at least 30 degrees greater than what is needed for a 30 percent rating. The evidence of record does not demonstrate limitation of motion of the arm midway between the side and shoulder level, thus, a 30 percent disability rating is not warranted under Diagnostic Code 5201. There is no other evidence in the record which shows that the Veteran meets the criteria required for a higher rating. Further, the Board has considered the lay evidence offered by the Veteran in the form of correspondence, in addition to the medical evidence cited above. In this regard, the Board acknowledges the Veteran's consistent report of pain, swelling, and difficulty lifting. However, even affording the lay statements full competence and credibility, the evidence simply does not show entitlement to a higher evaluation under any applicable diagnostic code. In view of the foregoing, the Board finds the Veteran's service-connected right shoulder disability does not warrant an initial rating in excess of 20, to include as a "staged" rating(s) pursuant to Fenderson and Hart. REASONS FOR REMAND 1. Entitlement to service connection for a right wrist disorder claimed as CTS, to include as secondary to the service-connected right shoulder disability. See argument Below at 2 2. Entitlement to service connection for a left wrist disorder, claimed as CTS, to include as secondary to the service-connected right shoulder disability. The Veteran contends that her current right and left wrist disorders began during active service. In this regard, she reports ongoing bilateral wrist pain, numbness, and tingling, due to repetitive motions required to perform her duties as a cook. In the alternative, she reports that her right and left wrist disorders are due to her service-connected right shoulder disability. Service treatment records include the report of a May 1992 induction examination, which is negative for complaints of, treatment for, or a diagnosis of a right or left wrist disorder. Records dated in September 2008 that note the Veteran's report of bilateral wrist pain and involuntary twitching for the past year. An October 2008 record demonstrates the Veteran was given splints for CTS. Records dated in December 2008 through October 2012 show the Veteran sought ongoing treatment for bilateral wrist pain, swelling, numbness, and tingling; assessments of bilateral wrist strain and CTS were noted. A July 2009 record includes the examiner's notation that the Veteran experiences bilateral wrist pain due to repetitive movements while serving as a cook. A March 2010 record notes complaints of bilateral wrist stiffness and a diagnosis of CTS. A May 2011 record notes bilateral wrist pain, edema, and diminished tough of the right ring finger and the left middle finger; the Veteran was encouraged to wear splints and to participate in physical therapy. A January 2012 record indicates the Veteran was sent to occupational therapy for her bilateral wrist pain. The report of a June 2012 separation examination includes the Veteran's report of bilateral wrist pain and the use of braces for her wrists; the examiner assessed bilateral wrist pain. Post-service records include the report of a November 2012 VA examination during which the Veteran reported bilateral wrist pain, numbness, and tingling, since 2008. She further reported ongoing flare-ups that impacted her daily activities. Upon examination, the Veteran found no current right or left wrist diagnosis. In a May 2017 VA opinion, the examiner indicated that there was no evidence of a current right or left wrist disorder that is related to her active service. In providing the opinion, the examiner noted that the service treatment records are negative for a chronic wrist condition. The examiner further noted that a May 2007 service treatment record does not indicate a history of a wrist condition. The Board finds the May 2017 VA examiner's opinion inadequate to adjudicate the claim, as the examiner failed to address the Veteran's service treatment records dated from December 2008 through October 2012 that demonstrate complaints of, and treatment for, bilateral wrist strain and CTS, and symptoms of pain, numbness, and tingling. In this regard, clarification as to the Veteran's current right and left wrist disabilities, is necessary. Moreover, the examiner also failed to address the documented in-service treatment for the Veteran's right and left wrists, to include splints, physical therapy, and occupational therapy, during the aforementioned period. In addition, the examiner did not consider the Veteran's statements indicating that she experienced ongoing symptoms of bilateral wrist pain, numbness, and tingling, since active service. Finally, the examiner did not address whether the claimed right and/or left wrist disorders are secondary to the service-connected right shoulder disability. Accordingly, another medical examination and opinion are necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to service connection for a right ankle disorder to include as secondary to the service-connected right and/or left knee disabilities. See argument Below at 4 4. Entitlement to service connection for a left ankle disorder to include as secondary to the service-connected right and/or left knee disabilities. The Veteran contends that her current right and left ankle disorders began during active service. In this regard, she reports ongoing bilateral ankle pain and stiffness since active service, that has progressively worsened. In the alternative, she reports that her right and left ankle disorders are due to her service-connected right and/or left knee disabilities. Service treatment records include the report of a May 1992 induction examination, which is negative for complaints of, treatment for, or a diagnosis of a right or left knee disorder. Records dated in September 2008 through October 2012 show that Veteran sought treatment for bilateral ankle pain and stiffness. A September 2008 notes the Veteran's report of bilateral ankle pain for the past year. Subsequent records demonstrate ongoing complaints of, and treatment for, bilateral ankle pain and stiffness. The report of a June 2012 separation examination includes the Veteran's report of swollen or painful joints. Post-service records include the report of a March 2014 VA examination during which the Veteran reported that she experienced symptoms of bilateral ankle pain since 2001, during active service, due to wear and tear. Upon examination, the examiner diagnosed bilateral ankle subtalar synovitis and degenerative arthritis. The examiner concluded that the Veteran's current bilateral ankle subtalar synovitis was unlikely due to her active service. In a May 2017 opinion, a VA examination found that the current bilateral subtalar synovitis was not related to the Veteran's active service, as the service treatment records do not demonstrate a long term chronic ankle injury, and the Veteran did not report a history of ankle problems on May 29, 2007, during a healthcare visit. The Veteran underwent another VA examination in October 2019 during which the examiner diagnosed bilateral ankle subtalar synovitis and calcaneal enthesophyte. The examiner did not provide an opinion as to the etiology of the Veteran's current bilateral ankle disorders. The Board finds the March 2014 and May 2017 VA examiners opinions inadequate to adjudicate the claim, as the examiners failed to address the Veteran's service treatment records dated from September 2008 through October 2012 that demonstrate complaints of, and treatment for, bilateral ankle pain and stiffness. Moreover, the March 2014 VA examiner did not provide any rationale as to why he found that the current bilateral subtalar synovitis disorder was not related to the Veteran's active service, nor did any of the aforementioned VA examiners provide an opinion as to the etiology of the current bilateral ankle degenerative arthritis or calcaneal enthesophyte. In addition, the examiners did not consider the Veteran's statements indicating that she experienced ongoing symptoms of bilateral ankle pain and stiffness, since active service. Finally, the examiners did not address whether the claimed right and/or left ankle disorders are secondary to the service-connected right and/or left service-connected knee disabilities. Accordingly, another medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 5. Entitlement to service connection for a right hip disorder to include as secondary to the service-connected right and/or left knee disabilities. See argument Below at 6 6. Entitlement to service connection for a left hip disorder, to include as secondary to the service-connected right and/or left knee disabilities. The Veteran contends that her current right and left hip disorders began during active service. In this regard, she reports ongoing bilateral hip pain since active service, that has progressively worsened. In the alternative, she reports that her right and left hip disorders are due to her service-connected right and/or left knee disabilities. Service treatment records include the report of a May 1992 induction examination, which is negative for complaints of, treatment for, or a diagnosis of a right or left hip disorder. Records dated from February 2012 through October 2012 demonstrate the Veteran sought treatment for bilateral hip pain. An April 2012 record notes the Veteran's report of intermittent bilateral hip pain since 2009, as well as difficulty when getting up from a sitting position. The report of a June 2012 separation examination includes the Veteran's report of swollen or painful joints. Post-service records include the report of a June 2013 VA examination. The examiner did not perform range of motion testing, nor is there an indication that an x-ray examination was performed. In a May 2014 VA opinion, the examiner found that the current bilateral hip strain was not related to the Veteran's active service. In providing the opinion, the examiner suggests that the Veteran's in-service hip pain occurred during and as a result of pregnancy. In this regard, the service treatment records demonstrate a pregnancy in April 1996; however, the records indicate complaints of, and treatment for, bilateral hip pain in 2012, 16 years after the Veteran's only documented pregnancy. Further, while the examiner concluded that the Veteran's current bilateral hip strain resolved, as the June 2013 VA examination does not document a current diagnosis, the examination is inadequate, as range of motion and x-ray testing were not performed. Finally, the examiner did not address whether the claimed right and/or left hip disorders are secondary to the service-connected right and/or left service-connected knee disabilities. Accordingly, another medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 7. Entitlement to an initial evaluation in excess of 50 percent for service-connected adjustment disorder, depression, and bipolar disorder. The Veteran asserts that her service-connected adjustment disorder is more severe than her current rating reflects. Specifically, she reports that she has contemplated suicide and is unable to maintain employment, as a result of her psychiatric symptoms. The most recent July 2021 VA psychiatric examination is inadequate to adjudicate the claim, as the examiner did not indicate the Veteran's current symptoms, and he found that there was no current acquired psychiatric disorder. Significantly, the contemporaneous medical evidence of record shows treatment for, and diagnoses of acquired psychiatric disorders, to include bipolar disorder, diagnosed during a VA examination in 2019. Based on the above conflicting findings, the Board finds that a VA examination is necessary in order to determine the current severity of the Veteran's service-connected adjustment disorder, depression, and bipolar disorder. Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that where the record does not adequately reveal the current state of that disability, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination). 9. Entitlement to service connection for PTSD. The issue of entitlement to service connection for PTSD is deferred until the claim of entitlement to a rating in excess of 50 percent for service-connected adjustment disorder, depression, and bipolar disorder is adjudicated. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely ties together that a final Board decision cannot be rendered unless both are adjudicated). 10. Entitlement to a TDIU due to service-connected disabilities. As resolution of the claim of entitlement to service connection for right and left wrist, right and left ankle, right and left hip disorders, and the claim of entitlement to an increased rating for the Veteran's service-connected adjustment disorder, depression, and bipolar disorder will have an impact on the claim of entitlement to TDIU, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). As this claim is being remanded, updated VA outpatient treatment records should also be obtained. 38 C.F.R. § 3.159. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include VA outpatient treatment records dated from June 2021 to the present, and any addition records identified by the Veteran. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any right or left wrist disability. The examiner must review the record, to include service treatment records, VA treatment records, private treatment records, and the Veteran's statements. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must also clarify whether the Veteran has a current diagnosis of right and/or left CTS. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any identified right or left disorder(s), manifested during, or as a result of, active military service. If not, the physician should state a medical opinion with respect to right and left wrist disorder(s) present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any current right and left wrist disorder(s) was caused or permanently worsened by the service-connected right shoulder disability. If the physician believes that a right and/or left wrist disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must discuss the service treatment records dated in September 2008 that note the Veteran's report of bilateral wrist pain and involuntary twitching for the past year, an October 2008 record demonstrates the Veteran was given splints for CTS, records dated in December 2008 through October 2012 that show the Veteran sought ongoing treatment for bilateral wrist pain, swelling, numbness, and tingling; assessments of bilateral wrist strain and CTS were noted, a July 2009 record that includes the examiner's notation that the Veteran experiences bilateral wrist pain due to repetitive movements while serving as a cook, a March 2010 record that notes complaints of bilateral wrist stiffness, and a diagnosis of CTS, a May 2011 record that notes bilateral wrist pain, edema, and diminished tough of the right ring finger and the left middle finger; the Veteran was encouraged to wear splints and to participate in physical therapy, a January 2012 record that indicates the Veteran was sent to occupational therapy for her bilateral wrist pain, and the report of a June 2012 separation examination that includes the Veteran's report of bilateral wrist pain and the use of braces for her wrists; the examiner assessed bilateral wrist pain. For purposes of the opinion, the examiner should assume that the Veteran is a credible historian to report on in-service and post-service symptomology she experienced. If the examiner is unable to provide any required opinion, the examiner should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. All pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following the review of the record, the physician should provide a medical opinion with respect to the right and left ankle disorder, present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the right and left disorders, to include subtalar synovitis, degenerative arthritis, and calcaneal enthesophyte, manifested during, or as a result of, active military service. If not, the physician should state a medical opinion with respect to right and left ankle disorders present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the current right and left ankle disorder(s) was caused or permanently worsened by the service-connected right and/or left knee disability. If the physician believes that a right and/or left ankle disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must discuss the service treatment records dated in September 2008 through October 2012, that show the Veteran sought treatment for bilateral ankle pain and stiffness. For purposes of the opinion, the examiner should assume that the Veteran is a credible historian to report on in-service and post-service symptomology she experienced. If the examiner is unable to provide any required opinion, the examiner should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. All pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following the review of the record, the physician should provide a medical opinion with respect to the right and left hip disorder, present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the right and left disorder, to include strain, manifested during, or as a result of, active military service. If not, the physician should state a medical opinion with respect to right and left hip disorder present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the current right and left hip disorder was caused or permanently worsened by the service-connected right and/or left knee disability. If the physician believes that a right and/or left hip disorder was permanently worsened by a service-connected disorder(s), the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must discuss the service treatment records dated in February 2012 through October 2012, that demonstrate the Veteran sought treatment for bilateral hip pain. For purposes of the opinion, the examiner should assume that the Veteran is a credible historian to report on in-service and post-service symptomology she experienced. If the examiner is unable to provide any required opinion, the examiner should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Schedule the Veteran for a VA examination by an appropriate physician to assess the nature and severity of her service-connected adjustment disorder, depression, and bipolar disability. The examiner must review the record, to include service treatment records, VA and private treatment records, and the Veteran's assertions. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner is requested to describe all manifestations and symptoms of the adjustment disorder, depression, and bipolar disability, as well as information required for rating purposes. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should be directed to clearly explain why that is so. If the examiner is unable to provide any required opinion, the examiner should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on her claim. CONTINUED ON NEXT PAGE 7. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, she and her representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sara Schinnerer, 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.