Citation Nr: 21069683 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 16-22 482 DATE: November 19, 2021 ORDER Service connection for a left wrist disability is dismissed. Service connection for residuals of a traumatic brain injury (TBI) is dismissed. An initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. An initial rating of 50 percent, but no higher, for tension headaches, is granted. Service connection for a right wrist disability is denied. REMANDED Entitlement to service connection for a back disability (claimed as mid-back and lumbar disability) is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. FINDINGS OF FACT 1. At the July 2021 Board hearing on the record, prior to the promulgation of a decision in the appeal, the Veteran notified the undersigned Veterans Law Judge that a withdrawal of the issues of service connection for TBI and a left wrist disability was requested. 2. The competent and probative evidence shows that the Veteran's PTSD is manifested as occupational and social impairment with deficiencies in most areas for the period on appeal. 3. The competent and probative evidence shows that the Veteran's tension headaches have been manifested by very frequent prostrating and prolonged migraine headache attacks productive of severe economic inadaptability. 4. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a right wrist disability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issues of service connection for TBI and a left wrist disability by the Veteran are met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for a rating of 70 percent, but no higher, for PTSD are met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for a rating of 50 percent, but no higher, for tension headaches are met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8100. 4. The criteria for entitlement to service connection for a right wrist disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Navy from June 2001 to August 2001, and in the Army from December 2010 to January 2012. This matter is before the Board of Veterans' Appeals (Board) on appeal from January 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. Dismissed Issues 1. Service connection for TBI. 2. Service connection for a left wrist disability. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. Only an appellant, or an appellant's authorized representative, may withdraw an appeal. An appeal may be withdrawn as to any or all issues involved in the appeal. 38 C.F.R. § 19.55(a). "[I]t is well settled that withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant." DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); Acree v. O'Rourke, 891 F.3d 1009, 1012-13 (Fed. Cir. 2018). In the present case, the Veteran, through his appearance at the July 2021 Board videoconference hearing, expressed his desire to withdraw his appeal of the issues of service connection for TBI and a left wrist disability. See 7/7/2021 Hearing Transcript, at page 2. The Veteran affirmed the withdrawal of the issues and was informed that no decision would be made, the issues would be dismissed, and it would end the issues thus possibly changing any effective date. Based on the undersigned's observations at the hearing, the Board finds that such withdrawal was explicit, unambiguous, and done with a full understanding of the consequences. Indeed, the Veteran and his authorized representative showed no desire to continue the appeal for these issues. As such, the Board finds that there remains no allegations of errors of fact or law for appellate consideration since the withdrawal of the issues was an effective one. Accordingly, the Board does not have jurisdiction to review these issues and they are dismissed. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate in this case. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. In view of the number of atypical instances 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, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the U.S. Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran is competent to report symptoms observable by sense and contemporaneous medical diagnoses, but not competent to diagnose or assess the etiology of complex medical disorders. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 3. An initial rating in excess of 50 percent for PTSD. The Veteran contends an increased rating for his PTSD. Specifically, at the Board hearing, the Veteran testified that due to his psychiatric disability, he experiences difficulty keeping jobs. He testified that he has had 14 jobs since active duty and has always been terminated due to issues with attendance, patience, attitude, lack of focus, and physical altercations. Additionally, he testified that he experiences issues with his memory, sleep deprivation, concentration, nightmares, and distractibility. Further, he testified that his disability has caused problems with his ex-wife and his son; he sees him once per month for a few hours. Moreover, his friends usually come to him because he does not like to leave the house. See 7/7/2021 Hearing Transcript, at pages 3, 5, 6, 7, 9, 12, and 14. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material; forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are: total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Initially, the Board notes that this claim for a higher rating for the acquired psychiatric disorder was pending before the agency of original jurisdiction on or after August 4, 2014. Therefore, the Board finds that the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-5) applies to the current appeal. See 53 Fed. Reg. 14308 (Mar. 19, 2015); 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. Accordingly, the Board's adjudication of this claim cannot include any discussion of the Global Assessment of Functioning (GAF) scores found in the record. See Golden v. Shulkin, 29 Vet. App. 221, 224 (2018). The record showed that the Veteran was assigned an initial disability rating of 50 percent under 38 C.F.R. § 4.130, DC 9411, effective January 25, 2012. After review of the relevant medical and lay evidence, the Board finds that a rating of 70 percent, but no higher, for PTSD is warranted. Turning to the evidence, a December 2013 VA psychiatric examination noted that the Veteran had symptoms, such as anxiety, depressed mood, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner stated that the Veteran had an occupational and social with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. See 12/19/2013 C&P Examination. The Veteran underwent another VA psychiatric examination in March 2016. The Veteran reported symptoms of depression. The examiner noted symptoms, such as a depressed mood, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. Additionally, the Veteran had difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances including work or a worklike setting. The objective examination showed that the Veteran had logical and linear thought processes and his hygiene was within normal limits. Additionally, he had no indicators of significant distress, psychosis, memory, or concentration issues. However, although the objective examination showed that the Veteran had intact judgment, his statements suggested that there are times that he does not have good insight into his rapid rise to anger. Further, the Veteran was irritable and endorsed thoughts of death. Finally, the examiner stated that the Veteran had an occupational and social impairment with reduced reliability and productivity. See 3/7/2016 C&P Examination. The most recent VA examination was performed in March 2019. The Veteran reported that he experiences anxiety with driving, he socially isolates, and he does not get along with his co-workers due to impatience and irritability. The examiner noted symptoms, such as a depressed mood, anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. Further, he had difficulty in adapting to stressful circumstances and suicidal ideation. The objective examination showed that the Veteran was alert, oriented, polite, and cooperative. Additionally, he had an adequate grooming and hygiene, and logical, linear, and goal directed thought processes, and no hallucinations or delusions. However, the objective examination also showed that the Veteran had an anxious and agitated mood, and an agitated and irritable affect at times. Finally, the examiner stated that the Veteran had an occupational and social impairment with reduced reliability and productivity. See 3/22/2019 C&P Examination. VA treatment records generally showed that the Veteran was oriented and had a neat appearance, an appropriate speech, an average intelligence, fair judgment, and his memory and associations were within normal limits. However, the Veteran also had an anxious manner, a flat and blunted affect, and a tense motor activity. Further, the Veteran struggled with severe exacerbated PTSD symptoms and maintaining employment. See 5/7/2013 CAPRI, at page 21; see also 12/18/2015 Medical Treatment Record Government Facility, at pages 3, 6, and 7. Based on the totality of the evidence above, the Board finds that the Veteran's disability most nearly approximates the criteria for a rating of 70 percent for the entire period on appeal. In this regard, the record generally showed that the Veteran had suicidal ideation. See Bankhead 29 Vet. App. at 20 ("[T]he presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas."); Id. (affirming that suicidal ideation does not require suicidal intent, a plan, or preparatory behavior). Furthermore, the record generally showed that the Veteran had symptoms, such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. In addition, he had difficulty in adapting to stressful circumstances and suicidal ideation. As such, the Board finds that the frequency and severity of such symptoms most nearly approximate deficiencies in most areas, such as judgment, thinking, or mood. The Board finds that the preponderance of the evidence weighs against a higher, 100 percent rating as the competent evidence does not reflect total social and occupational impairment. As persuasive competent medical evidence, the examination report marked by the examiners from the December 2013, March 2016, and March 2019 VA psychiatric examinations did not reflect an indication of the Veteran's PTSD as having a total occupational and social impairment. See Total, Merriam-Webster, https://www.merriam-webster.com/dictionary/total (defining the adjective "total" as, among other entries, absolute). Additionally, the record showed that the Veteran has a good relationship with his fiancé. Further, the examiner from the March 2019 VA examination reported that the Veteran was polite and cooperative. See 3/22/2019 C&P examination, at page 4 and 6. Moreover, at the Board hearing, he testified that he sees his son once per month for a few hours. In addition, he maintains relationship with friends who usually come to his home. See 7/7/2021 Hearing Transcript, at pages 12 and 14. The Board finds that the foregoing probative and competent evidence does not tend to support total social impairment. In light of the overall competent evidence, the Board finds that the preponderance of the evidence weighs against a higher 100 percent rating, to include a finding of total social impairment for the period on appeal. The Board acknowledges the Veteran's suicidal ideation and notes that it is contemplated and compensated in the current 70 percent rating. However, the Board also finds that when evaluating the period on appeal as a whole, he is not in persistent danger of harming himself or others as shown by the March 2019 VA psychiatric examination report noting that the Veteran's suicide thoughts consist of a desire to be free of pain. In addition, the examiner noted that the Veteran currently does not have a plan or any intent, and that he does not believe that the Veteran should be considered a current imminent or increased risk for suicide. The Board recognizes the Veteran's contentions regarding experiencing worsening psychiatric symptoms, such as issues with his memory, sleep deprivation, focus, concentration, nightmares, and distractibility. See 7/7/2021 Hearing Transcript, at page 7. He is competent to make those assertions based on his observable symptomatology and the Board finds him credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has considered that statement as supporting evidence; however, it finds that the symptomology described by the record is contemplated by the current 70 percent rating. The weight of the competent, probative evidence shows the Veteran's symptomatology reflects a frequency, severity, and duration commensurate with the criteria for a rating of 70 percent disabling. In sum, after review of all the relevant competent medical and lay evidence of record, the Board finds that the overall disability picture is more nearly approximated by a rating of 70 percent for the entire period on appeal. 4. An initial compensable rating for tension headaches. The Veteran contends that a compensable disability rating is warranted for his service-connected tension headaches. Specifically, at the Board hearing, the Veteran testified that he experiences headaches a minimum of 2 to 4 times per week and can sometimes be on a daily basis. Additionally, it affects his vision, and he experiences nausea, vomiting, weakness, and dizziness where his motor skills and balance are severely affected. Further, he testified that a couple of times he had to go to urgent care because he passed out. Moreover, he testified that his headaches result in light and noise sensitivity, as he experiences headaches 3 to 4 times per month that last for the entire day and he needs to lock himself in a dark room. In addition, he testified that he has missed work because of headaches. Furthermore, sometimes his fiancé had to call in sick on his behalf because he is incapacitated and other times, he has had to leave work early because of headaches. See 7/7/2021 Hearing Transcript, at pages 16, 18, and 19. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. 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; 38 C.F.R. §§ 4.1. 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. The Veteran's migraine headaches are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100, which directs that a 10 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. A maximum schedular disability rating of 50 percent is warranted for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The Board notes that § 4.7 is not applicable to DCs that apply successive rating criteria, such as DC 8100. See Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018) (holding that criteria of DC 8100 are successive). Though Diagnostic Code 8100 does not provide a definition for "prostrating," prostration is defined as "extreme exhaustion or powerlessness." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st ed. 2007). Similarly, the term "productive of severe economic inadaptability" is also not defined in veterans' law. However, the Court has stated that this term is not synonymous with being completely unable to work and VA has conceded that the phrase "productive of" could be read to mean either "producing" or "capable of producing" economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004) (stating that nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50% rating"). Additionally, "Characteristic" is "a trait, quality, or property or a group of them distinguishing an individual, group, or type." WEBSTER'S THIRD NEW INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE UNABRIDGED 376 (1966). "Prostrating" means "lacking in vitality or will: powerless to rise: laid low." Id. at 1822. "Completely" is defined as "to complete degree: entirely." Id. at 465. In other words, the headaches must render the veteran entirely powerless. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). The record shows that the January 2014 rating decision on appeal granted service connection for tension headaches and assigned an initial non-compensable disability under DC 8100 from January 25, 2012. Upon a thorough review of the evidence of record, the Board finds that the Veteran's tension headaches have manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability throughout the appeal period. The Veteran was afforded a VA examination in December 2013. The Veteran reported headaches with a dull throbbing pain on top of his head twice per week. Additionally, the Veteran endorsed nausea and light and sound sensitivity associated with his headaches. Further, the Veteran also stated that his headaches last approximately a couple of hours to a day. The examiner diagnosed the Veteran with tension headaches. Additionally, the examiner stated that the Veteran's headaches were not prostrating, and that the Veteran had no functional impact. See 12/26/2013 C&P Examination. VA treatment records showed that the Veteran reported experiencing frequent headaches that slowly build during the day, usually starting on the top of his head, sometimes associated with a tight feeling in the neck. Additionally, he reported that sometimes, after a headache has been building, he gets a rather abrupt onset of eye pain and visual disturbance, followed by nausea, which he describes as his migraine. These headaches are more intense and will sometimes push him to urgent care or the emergency department for pain relief. See 3/21/2019 Medical Treatment Record Government Facility, at page 41. Resolving reasonable doubt in the Veteran's favor on this material issue, the Board finds that a 50 percent rating is warranted for tension headaches, based on the Veteran's reports of very frequent headache pain that interferes with his ability to work. The Board finds the Veteran's lay statements competent and credible regarding his severe headache pain more frequently than once per month that render him unable to work due to pain, light sensitivity, and nausea. The Board acknowledges that the December 2013 VA examiner found that the Veteran's headaches were not prostrating and did not affect his ability to work. However, throughout the period on appeal, the Veteran has consistently reported severe headache pain and frequency to VA providers and its interference with work, to include during his July 2021 testimony. Therefore, the Board finds that the Veteran's tension headaches are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.3. Based on the foregoing, the Board finds that an increased rating of 50 percent is warranted for the period on appeal. The Board further notes that this is the maximum schedular rating available under Diagnostic Code 8100. 5. Service connection for a right wrist disability. Service connection Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection generally requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the condition incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Veteran contends service connection for a right wrist disability. Specifically, the Veteran reported that he has issues with his wrist when doing push-ups. Additionally, at the Board hearing, the Veteran testified that he experienced right wrist pain during physical training, when training with equipment on, when he had weight on it for too long, or when holding something heavy for too long. Further, he testified that a lot of times it would give out on him. Moreover, he testified that it caused problems while being a mechanic; his wrist would not allow him to hold as long as he needed to get into certain positions to fix pieces of equipment. See 7/22/2013 VA 21-4138; see also 7/7/2021 Hearing Transcript, at pages 31 and 32. Here, the Veteran's treatment records lack a diagnosis of a right wrist disability. For example, post-service records show no complains of a right wrist disability and no indication of any symptoms that functionally impair the Veteran's earning capacity. Accordingly, the Board finds that the preponderance of the record weighs against a finding that the Veteran has a current diagnosis of a right wrist disability. The Board acknowledges the Veteran's reports that he experiences right wrist pain and his problems while being a mechanic. See 7/7/2021 Hearing Transcript, at pages 31 and 32. He is competent to describe such observable symptoms. However, as a lay person without medical training or expertise, he is not competent to say that he has a right wrist disability, a complex medical issue concerning the body's musculoskeletal system that does not lend itself to lay opinion. The Veteran has not been shown to have the knowledge, and/or expertise necessary to diagnose such complex medical issues. Therefore, the Veteran's statements that he has a right wrist disability are not considered competent evidence demonstrating a current disability and lack weight. See Jandreau, 492 F.3d at 1377. Thus, based on the evidence above, the Board finds that, while the Veteran asserts that he has a current right wrist disability, the more probative evidence weighs against finding that the Veteran either has a current diagnosis of a right wrist disability, or that such a diagnosis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection claims require that the Veteran have a current disability. 38 U.S.C. § 1110. The claimant satisfies the current disability requirement when the claimant has a disability proximate to the filing of a claim for VA benefits or has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). For the reasons explained above, this has not been met here. The preponderance of the evidence weighs against finding that the Veteran has a right wrist disability; therefore, the service connection claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Service connection for a back disability (claimed as mid-back and lumbar disability). 2. Service connection for a right shoulder disability. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends service connection for a back disability and a right shoulder disability. Regarding the back disability, service treatment records showed complains of back pain. See 8/8/2013 STR Medical Photocopy, at page 35. Additionally, post-service treatment records showed that the Veteran was diagnosed with a back strain and mild chronic degenerative disc changes. See 5/7/2013 CAPRI, at page 5; see also 1/24/2014 CAPRI, at page 14. Regarding the in-service incident, at the Board hearing, the Veteran testified that in Afghanistan, he was stuck in a tunnel and had to offload to get out. While he was coming out of the back of the MaxxPro vehicle while offloading, he slipped on the steps and landed on the back step of the rear ramp on his back. He further testified that his disability got progressively worse over time, especially with ruck marches. Finally, he testified that he still has problems with his back. See 7/7/2021 Hearing Transcript, at pages 33 and 34. The Veteran was afforded a VA examination in January 2014. The report shows a diagnosis of intervertebral disc syndrome and lumbar spine degenerative disc disease. At the conclusion of the examination, the examiner rendered a negative nexus opinion. As rationale, the examiner relied on a lack of an in-service diagnosis. See 1/22/2014 C&P Examination, at page 9. However, the Board finds this examination inadequate. The examiner relied on a lack of an in-service diagnosis and did not cite to specific medical evidence of record or medical history of this Veteran to justify this conclusion. Regarding the right shoulder disability, service treatment records showed complains of shoulder pain. See 8/8/2013 STR Medical Photocopy, at page 35. Additionally, post-service treatment records showed that the Veteran was diagnosed with a shoulder strain and right shoulder rotator cuff tendinopathy. See 5/7/2013 CAPRI, at page 5; see also 1/22/2014 CAPRI, at page 16. Regarding the in-service incident, at the Board hearing, the Veteran testified that in Afghanistan he was running a mission and the truck directly in front of him in the convoy hit an improvised explosive device. In an attempt of moving the rig out of the blast area and to get to a point for recovery, they got jarred up pretty good in a ditch and he got slammed into the butt end of a.50-caliber gun because he was in the turret. Additionally, he testified that he still experiences problems with his right shoulder; he has a lot of pain and if he is on his back, he cannot put his arm straight up for a long time. See 7/7/2021 Hearing Transcript, at page 28. VA afforded the Veteran an VA examination in January 2014. The examiner diagnosed right rotator cuff tendinopathy. At the conclusion of the examination, the examiner rendered a negative nexus opinion. As rationale, the examiner relied on a lack of an in-service diagnosis. See 1/22/2014 C&P Examination, at page 9. However, the Board finds this examination inadequate. The examiner relied on a lack of an in-service diagnosis and did not cite to specific medical evidence of record or medical history of this Veteran to justify his conclusion. As such, on remand, the RO should take appropriate action to obtain addendum opinions to determine if the Veteran's back disability and right shoulder disability were caused by service, and not to rely solely on the absence of documented treatment. 3. Service connection for a right knee disability. The Veteran contends service connection for a right knee disability. Specifically, at the Board hearing, the Veteran testified that he injured his knee in 2008 while doing mock foot patrols in the Army National Guard and then reinjured it at Fort Stewart, GA. Additionally, he testified that he did not play football and he did not injure his right knee in high school. Further, he testified that he continues to have problems with the right knee; it swells often, and he has a hard time walking and maneuvering around. See 7/7/2021 Hearing Transcript, at pages 22 to 24. VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities, or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. § 1111. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the veteran later complains was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Here, the record shows that the entrance examination is silent for a diagnosis of a right knee disability. See 11/1/2012 STR, at page 30; see also 8/8/2013 STR Medical Photocopy, at page 62. As such, there is no evidence of a right knee disability being identified at the entrance examination. As such, he is presumed sound. During a January 2014 VA examination, the examiner reported that he was unable to opine without resorting to mere speculation about whether the Veteran's right knee disability was incurred in or caused by service. He further stated that the medical documentation was confusing and contradictory, and concluded that the record was insufficient to determine if the right knee disability was aggravated beyond its natural course by service. However, the Board finds this opinion inadequate. The evidence does not tend to show, let alone to a higher clear and unmistakable level, that the Veteran's right knee disability pre-existed service. As mentioned above, the entrance examination is silent for any diagnosis of a right knee disability, so the Veteran is presumed sound. 38 U.S.C. § 1111. Additionally, the record shows a diagnostic magnetic resonance imaging test result, which showed chondromalacia of the articular cartilage of the patella and also the possibility of medial meniscal tear of the right knee in 2008. Furthermore, a Report of Investigation Line of Duty and Misconduct Status showed that the Veteran suffered a "tear of the posterior horn of [the] medial meniscus and chondromalacia patella of the right knee" in the line of duty. See 8/8/2013 STR Medical Photocopy, at pages 22 and 60. Therefore, this opinion does not align with the record. As such, on remand, the RO should obtain an addendum opinion to clarify whether the Veteran's current right knee disability is due to his in line of duty injury. 4. Service connection for a left knee disability. Regarding the Veteran's left knee disability, the Board finds that this claim is inextricably intertwined with his pending service connection claims for a right knee disability. 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 on the other claim meaningless and a waste of judicial resources the two claims are inextricably intertwined). During the Board hearing, the Veteran testified that his doctors told him that he has a "compensation injury." His doctors told him that he is having issues with his left knee because he is naturally compensating to that side because of the injury of the right knee. Additionally, the Veteran testified that he experiences a "lot of swelling" in his left knee. See 7/7/2021 Hearing Transcript, at page 26. Post-service treatment records showed complaints of left knee pain. See 4/12/2016 CAPRI, at page 11. The Veteran was afforded a VA knee and lower leg conditions examination in January 2014. The examiner did not render a diagnosis for a left knee disability. See 1/22/2014 CAPRI, at page 10. However, the Board finds this medical finding inadequate. In this regard, the examination did not show adequate consideration of all relevant evidence, to include the Veteran's lay statements that he experiences left knee swelling due to him compensating for his right knee disability. Moreover, concerning the Veteran's contentions of left knee pain and swelling, in the absence of proof of a present disability, there can be no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is generally satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 318, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that the Veteran satisfies the current disability requirement when a disability exists at the time the claim is filed or during its pendency, even if it resolved itself prior to adjudication). However, the Board notes that the Court of Appeals for the Federal Circuit recently found that pain alone can constitute a "disability" under § 1110, because pain can cause functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). In light of Saunders, the Board finds that the Veteran's reports of left knee pain and swelling may indicate chronic pain and/or a persistent disability. As such, the Board finds that a remand is necessary so that an in-person VA examination be conducted to determine the nature and etiology of any left knee disability and address any relationship to service. If there is a finding of functional impairment, then a medical nexus opinion must be rendered. These matters are REMANDED for the following actions: 1. Obtain any and all of the Veteran's outstanding records from appropriate repositories, to include record of disciplinary actions. All records and/or responses received should be associated with the claims file. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile and allowed the opportunity to provide the records. 2. After completion of step #1, return the claims file to the reviewing clinician who conducted the January 2014 VA back (thoracolumbar spine) examination and authored the opinion. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: Whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's current back disability is related to an in-service injury, event, or disease. **In doing so, please address the Veteran's in-service complaints of back pain. See 8/8/2013 STR Medical Photocopy, at page 35. Additionally, please address the Veteran's lay contentions that in Afghanistan he was stuck in a tunnel and had to offload to get out. While he was coming out of the back of the MaxxPro vehicle while offloading, he slipped on the steps and landed on the back step of the rear ramp on his back. He further testified that his disability got progressively worse over time, especially with ruck marches. Finally, he testified that he still has problems with his back. See 7/7/2021 Hearing Transcript, at pages 33 and 34.** If the January 2014 examiner is no longer available, then the claims file and the January 2014 examination report and opinion is to be forwarded to another examiner of at least equal qualifications to obtain the requested opinion. A new physical examination is not required unless deemed necessary by the clinician. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If medical literature is reference, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. After completion of step #1, return the claims file to the reviewing clinician who conducted the January 2014 VA shoulder and arm conditions examination and authored the opinion. The clinician is to review the virtual file, including a copy of this Remand. After review of the claims file, the reviewing clinician must address: Whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's current right shoulder disability is related to an in-service injury, event, or disease. **In doing so, please address the Veteran's in-service complaints of shoulder pain. See 8/8/2013 STR Medical Photocopy, at page 35. Additionally, please address the Veteran's lay contentions that in Afghanistan he was running a mission and the truck directly in front of him in the convoy, hit an improvised explosive device. In an attempt of moving the rig out of the blast area and to get to a point for recovery, they got jarred up pretty good in a ditch and he got slammed into the butt end of a .50-caliber gun because he was in the turret. Additionally, he testified that he still experiences problems with his right shoulder; he has a lot pain and if he is on his back, he cannot put his arm straight up for a long time. See 7/7/2021 Hearing Transcript, at page 28.** If the January 2014 examiner is no longer available, then the claims file and the January 2014 examination report and opinion is to be forwarded to another examiner of at least equal qualifications to obtain the requested opinion. A new physical examination is not required unless deemed necessary by the clinician. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If medical literature is reference, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After completion of step #1, schedule the Veteran for a VA musculoskeletal examination by an appropriate clinician to determine the nature and etiology of any current right knee disability and left knee disability. The examiner is to provide a diagnosis which accounts for the Veteran's present symptoms for his left knee. If a medical diagnosis cannot be given, the examiner must state whether the Veteran has any functional impairment, such as loss of range of motion, pain, or instability. Complete the "Functional Impact" section of the report. The clinician is to review the virtual file, including a copy of this Remand. Please complete the functional impact section of the report. After a review of the claims file, the examiner must address: (a.) Whether the Veteran's current right knee disability is at least as likely as not (approximately 50 percent or greater probability) related to an in-service injury, event, or disease. **In doing so, please address the Veteran's lay contentions that he injured his knee in 2008 while doing mock foot patrols in the Army National Guard and then reinjured it at Fort Stewart, GA. Additionally, he testified that he did not play football or injured his right knee in high school. Further, he testified that he continues to have problems with the right knee; it swells often, and he has a hard time walking and maneuvering around. See 7/7/2021 Hearing Transcript, at pages 22 to 24.** (b.) Whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's current left knee disability is related to an in-service injury, event, or disease. (c.) If the answer to question (a.) is yes, then is it at least as likely as not (approximately 50 percent or greater probability) that the Veteran's current left knee disability is at least as likely as not (1) caused by OR (2) aggravated by the right knee? **In doing so, the examiner must address the Veteran's post-service complaints of left knee pain. See 4/12/2016 CAPRI, at page 11. Additionally, please address the Veteran's contentions that his doctors told him that he has a "compensation injury." His doctors told him that he is having issues with his left knee because he is naturally compensating to that side because of the injury of the right knee. Additionally, the Veteran testified that he experiences a "lot of swelling" in his left knee. See 7/7/2021 Hearing Transcript, at page 26.** A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. All pertinent evidence, including both lay and medical evidence, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.F., Associate 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.