Citation Nr: 21076412 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 17-00 214 DATE: December 23, 2021 ORDER Entitlement to a rating in excess of 10 percent for service-connected cholecystectomy, gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS) ("gastrointestinal disabilities") is denied. Entitlement to a compensable rating of 30 percent, but not higher, for service-connected tension headaches is granted. Entitlement to a compensable rating of 20 percent, but not higher, for service-connected right wrist peripheral nerve disorder is granted. Entitlement to a rating in excess of 10 percent for service-connected right wrist strain is denied. Entitlement to a rating in excess of 10 percent for service-connected right knee patellofemoral syndrome with shin splints ("right knee disability") is denied. Entitlement to a rating in excess of 10 percent for service-connected left knee patellofemoral syndrome with shin splints ("left knee disability") is denied. REMANDED Entitlement to service connection for right hand pain is remanded. Entitlement to service connection for lumbosacral strain is remanded. FINDINGS OF FACT 1. Throughout the entire rating period on appeal, the preponderance of the evidence reveals the Veteran's gastrointestinal disabilities more closely approximate that of removal of the gallbladder with mild symptoms, moderate irritable bowel syndrome with frequent episodes of bowel disturbance with abdominal distress, and/or GERD with two or more of the symptoms for the 30 percent evaluation of less severity. 2. Resolving all reasonable doubt in favor of the Veteran, throughout the rating period on appeal, the Veteran's tension headaches more closely approximate that of characteristic prostrating attacks occurring on average once a month over the last several months. 3. Resolving all reasonable doubt in favor of the Veteran, throughout the rating period on appeal, the Veteran's right wrist peripheral nerve disorder more closely approximates that of mild incomplete paralysis of the radial nerve. 4. Throughout the rating period on appeal, the preponderance of the evidence reveals the Veteran's right wrist strain is manifested by pain and limitation of motion, with no ankylosis. 5. Throughout the rating period on appeal, the preponderance of the evidence reveals the Veteran's right knee disability more closely approximates that of malunion of the tibia and fibula with slight knee disability. 6. Throughout the rating period on appeal, the preponderance of the evidence reveals the Veteran's left knee disability more closely approximates that of malunion of the tibia and fibula with slight knee disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for service-connected gastrointestinal disabilities have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.20, 4.21, 4.114, Diagnostic Codes (DC) 7318, 7319, and 7346. 2. The criteria for entitlement to a compensable rating of 30 percent, but not higher, for service-connected tension headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 3. The criteria for entitlement to a compensable rating of 20 percent, but not higher, for service-connected right wrist peripheral nerve disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, DC 8514. 4. The criteria for entitlement to a rating in excess of 10 percent for service-connected right wrist strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, DCs 5003, 5010, 5214-5215. 5. The criteria for entitlement to a rating in excess of 10 percent for service-connected right knee disability have not been met. U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.40, 4.45, 4.49, 4.71a, DC 5262. 6. The criteria for entitlement to a rating in excess of 10 percent for service-connected left knee disability have not been met. U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.40, 4.45, 4.49, 4.71a, DC 5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran service on active duty in the Air Force from October 2004 to August 2012. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office. In September 2019, the Board remanded the Veteran's claims for additional development. The Board notes that there was not substantial compliance with its September 2019 remand directives as it pertains to the issues of service connection for lumbosacral strain and right hand pain, which are remanded herein. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Increased Rating Disability ratings are determined by applying the criteria set forth in the schedule of ratings. The percentage ratings are based on the average impairment of earning capacity, and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings apply under a single diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Additionally, if the positive evidence supporting a claim and the negative evidence indicating a denial of the claim is relatively equal, the Veteran is entitled to the benefit of the doubt. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 4.3. Accordingly, any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. Id. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. When evaluating musculoskeletal disabilities based on limitation of motion, the Veteran is entitled to at least the minimum compensable evaluation if motion is accompanied by painful motion with joints. The joints involved 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. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Additionally, pain is also relevant to assignment of a rating in excess of the minimum compensable rating, but only if that pain results in demonstrated functional impairment. Mitchell, 25 Vet. App. at 3738; see 38 C.F.R. §§ 4.40, 4.45. Functional impairment as contemplated by 38 C.F.R. §§ 4.40 and 4.45 includes less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. See generally Mitchell, 25 Vet. App. 32 Moreover, the Board must consider functional loss caused by pain or other factors listed in 38 C.F.R. §§ 4.40 and 4.45 that could occur during flare-ups or after repeated use and, therefore, may not be reflected on range-of-motion testing. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, despite the relevance of the background factors delineated in § 4.40 or 4.45 when evaluating a disability, the rating to be assigned is based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); therefore, a separate or higher rating predicated solely on §§ 4.40 or 4.45 is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or § 4.73] criteria."). 1. Entitlement to a rating in excess of 10 percent for service-connected gastrointestinal disabilities. The Veteran contends that her gastrointestinal disabilities warrant an increased evaluation, as her symptoms reflect worsening. The Veteran's gastrointestinal disabilities are currently evaluated as 10 percent under the appropriate DC 7318, which evaluates the removal of the gallbladder. Under DC 7318, a noncompensable rating is warranted for removal of the gallbladder that is nonsymptomatic. A 10 percent rating is warranted for removal of the gallbladder with mild symptoms. The maximum rating of 30 percent is warranted for removal of the gallbladder with severe symptoms. 38 C.F.R. § 4.114, DC 7318. The Board notes that due to the Veteran's IBS and GERD, consideration of a higher rating under DCs 7319 and 7346 is also appropriate. Under DC 7319, which evaluates irritable colon syndrome, a noncompensable rating is warranted for mild irritable colon syndrome with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress. The maximum rating of 30 percent is warranted for severe irritable bowel syndrome, with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4114, DC 7319. Under DC 7346, which evaluates hernia hiatal, a 10 percent rating is warranted for hernia hiatal with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The maximum rating of 60 percent is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. VA treatment records throughout the appeal period reflect complaints of having intermittent on and off acid reflux symptoms that occur a couple times a week, with diagnoses of GERD and hiatal hernia. See Capri. In a July 2012 VA esophageal examination report, the examiner noted the Veteran's reports of having heartburn for 2 years and a burning sensation in the throat that started in the substernal area with excessive belching. Upon examination, the examiner reported that the Veteran's treatment plan did not include taking continuous medication for control. The examiner noted symptoms of pyrosis and reflux, which had no functional impact and/or complications. See C&P Exam, July 2012. In a July 2012 VA gallbladder examination report, the examiner noted the Veteran's reports of having alternating diarrhea and constipation since the removal of her gallbladder, but no pain in the area. Upon examination, the examiner noted the Veteran's treatment plan did not include taking continuous medication for control. There were no signs or symptoms attributable to the gallbladder and/or pancreas and no functional impact and/or complications. See C&P Exam, July 2012. In a July 2012 VA intestinal examination report, the examiner noted the Veteran's reports of having IBS since her gallbladder operation. She reported symptoms of hard stools alternating with loose stools and abdominal pain prior to defecating. Upon examination, the examiner noted that the Veteran's treatment plan did not include taking continuous medication for control, however, she did have symptoms of alternating diarrhea and constipation. There were no episodes of bowel disturbance with abdominal distress, or no exacerbations or attacks of the intestinal condition noted, nor any weight loss or malnutrition. See C&P Exam, July 2012. In a February 2020 VA gallbladder examination report, the examiner noted the Veteran's reports of having occasional nausea, heartburn and fecal urgency with acidic foods. She reported her symptoms as weekly heartburn, nausea a few times a month, abdominal pain, and almost daily diarrhea. Upon examination, the examiner noted the Veteran's treatment plan did not include taking continuous medication for control. The Veteran, however, did exhibit mild symptoms associated with her cholecystectomy, with no pancreas symptoms noted. The Veteran's condition had a functional impact, as her stomach and digestion were very sensitive to many foods that caused abdominal cramping, diarrhea, bloating, and heartburn. See C&P Exam, February 2020. The Veteran, through her representatives, contends that she experiences daily epigastric episodes accompanied by substernal arm and shoulder pain, with episodes of bowel disturbance with abdominal pain each week that require the use of daily medication to control symptoms. See Appellate Briefs, August 2019 and September 2021. Based on the above, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's gastrointestinal disabilities during any period on appeal. The weight of evidence of record throughout the appeal period is not sufficient to meet the criteria for the next-higher ratings, as the severity of the Veteran's gastrointestinal symptoms more closely approximate that of removal of the gallbladder with mild symptoms, moderate irritable bowel syndrome with frequent episodes of bowel disturbance with abdominal distress, and/or GERD with two or more of the symptoms for the 30 percent evaluation of less severity; all of which are commensurate of a 10 percent evaluation under DC 7318, 7319, and 7346. The Board notes that the relevant medical evidence of record, to include the VA examinations and treatment records, reflect that the Veteran's gastrointestinal symptoms during the relevant period had manifested more closely with symptoms of such a severity, frequency, or duration as to warrant a 10 percent rating. Specifically, the evidence reflects the Veteran experiences pyrosis, acid reflux, abdominal pain, diarrhea, constipation, and nausea, with mild symptoms related to her cholecystectomy. While the Board acknowledges the Veteran's representative's contention that the Veteran experiences daily epigastric episodes accompanied by substernal arm and shoulder pain, symptoms of which are reflective in the higher 30 percent rating unde DC 7346, this evidence is heavily outweighed by the medical evidence of record that is essentially void of such symptoms. Additionally, even if the record did reflect the Veteran has substernal or arm and shoulder pain with daily epigastric episodes, in order to receive the higher rating, this must be accompanied by additional symptoms of dysphagia, pyrosis, and regurgitation productive of considerable impairment of health, which the medical evidence does not contain. Therefore, the Board finds that the preponderance of the evidence does not support the assignment of ratings higher than the currently assigned 10 percent rating in this case; and the claim is denied. The Board notes that the lay assertions of the Veteran have been considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran has argued that a higher rating for her gastrointestinal disabilities is warranted, these assertions are outweighed by more probative evidence provided by the examination of a qualified medical professional. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, her lay statements do not provide any basis upon which to assign any higher ratings. In reaching this determination, the Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C. § 5107 and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its applications. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Entitlement to a compensable rating of 30 percent, but not higher, for service-connected tension headaches. The Veteran contends that her tension headaches warrant a compensable evaluation, as her symptoms reflect worsening. The Veteran's tension headaches are currently evaluated as noncompensable under the appropriate DC 8100, which evaluates migraines. Under DC 8100, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in 2 months over last several months. A higher 30 percent rating is assigned for characteristic prostrating attacks occurring on an average once a month over last several months. The maximum rating of 50 percent is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. In a July 2012 VA headaches examination, the examiner noted the Veteran's history of headaches that occur daily and were relieved by sleep. Her reported symptoms included daily headaches that came and went throughout the day and lasted about 20 to 90 minutes; the Veteran was able to function with her headaches. Treatment of her symptoms included over-the-counter medication. Upon examination, the examiner recorded that the Veteran experienced headache pain on both sides of the head that lasted less than 1 day. There were no characteristic prostrating attacks or very prostrating and prolonged attacks of migraines or headache pain noted. However, the Veteran's condition impacted her ability to work, as she had decreased concentration but was still able to work. See C&P Exam, July 2012. A May 2015 VA treatment record reflects the Veteran's complaint of having episodes of headaches a couple times a month. See Capri, May 2015. In a December 2016 lay statement, the Veteran asserted that she continues to have headaches at least monthly. See Form 9, December 2016. The Veteran representatives indicated that she has multiple weekly tension headaches, and therefore, her current noncompensable rating does not reflect the severity of her disability. See Appellate Briefs, August 2019 and September 2021. In a February 2020 VA headaches examination, the examiner noted the Veteran experiences intermittent frontal and posterior headaches associated with office work, which occurs 5 out of 7 days a week, with a daily headaches pattern happening in the last year. Upon examination, the examiner noted the Veteran experiences pulsating or throbbing head pain on both sides of the head that lasts less than 1 day with non-headache associated symptoms of nausea, sensitivity to light, and sensitivity to sound. There were no characteristic prostrating attacks or very prostrating and prolonged attacks of migraines or headache pain noted. However, the Veteran's condition impacted her ability to work, as she is not as productive at work or home when experiencing a headache and she is less patient and cannot concentrate. Additionally, she noted she has lost 0 to 1 week of work time in the last 12 months. See C&P Exam, February 2020. Based on the above, the Board finds that an increased rating of 30 percent, but not higher, is warranted for the Veteran's tension headaches during the entire period on appeal. The weight of evidence of record throughout the appeal period is sufficient to meet the criteria for the higher 30 percent rating, as the severity of the Veteran's tension headaches symptoms more closely approximate that of characteristic prostrating attacks occurring on average once a month over last several months; her symptoms are commensurate of a 30 percent evaluation under DC 8100. The Board notes that the relevant medical evidence of record, to include the VA examinations and treatment records, reflect that the Veteran's tension headaches during the relevant period had manifested more closely with symptoms of such a severity, frequency, or duration as to warrant a higher 30 percent rating. Specifically, the evidence reflects the Veteran experiences tension headaches that range from a couple times a month to occurring daily. While the Board acknowledges the VA examinations of record indicate that the Veteran's tension headaches do not result in characteristic prostrating attacks and/or very frequent completely prostrating and prolonged attacks, the examination reports do indicate that they impact her ability to work. Additionally, the Veteran's competent and credible lay statements reflect the Veteran's tension headaches have a daily frequency that lasts for a prolonged period and sometimes requires sleep for relief. In this regard, the Board notes that the evidence is essentially in favor of the higher 30 percent rating, or at the very least, in relative equipoise, and thus, resolving all reasonable doubt in favor of the Veteran, the assignment of a 30 percent rating in this case is warranted; and to this extent, the claim is granted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). However, a rating in excess of 30 percent is not warranted, as the evidence of record does not reflect, nor otherwise suggest, that the Veteran's tension headaches result in very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. While the Board notes the Veteran experiences daily headaches that impact her ability to work and her lay statements reflect she sometimes needs sleep for relief, she has also repeatedly stated that she is able to function at work and at home while experiencing such headaches, which suggests that the headaches are not completely prostrating productive of severe economic inadaptability a requirement for the next-higher 50 percent rating. Therefore, the Board finds that the preponderance of the evidence does not support the assignment of ratings higher than a 30 percent rating in this case. The Board notes that the lay assertions of the Veteran have been considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran has argued that a higher rating than 30 percent for her tension headaches is warranted, these assertions are outweighed by more probative evidence provided by the examination of a qualified medical professional. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, her lay statements do not provide any basis upon which to assign any higher ratings. 3. Entitlement to a compensable rating of 20 percent, but not higher, for service-connected right wrist peripheral nerve disorder. The Veteran contends that her right wrist peripheral nerve disorder warrants a compensable rating, as her symptoms reflect worsening. The Board notes that diseases of the peripheral nerves of the upper extremities are generally rated under DCs 8510 to 8719. These DCs provide ratings for both the "minor" and the "major" hand, which refer to the dominant and nondominant side, respectively. Here, the Veteran's major hand (dominant) is the right upper extremity, and the minor hand is the left upper extremity; therefore, the Board will only consider evaluations of that of the major hand in this decision. The Veteran's peripheral nerve disorder is currently rated as noncompensable under DC 8514. Under DC 8514, (which provides rating criteria for evaluation of paralysis of the radial nerve), a 20 percent rating is warranted for mild incomplete paralysis affecting the major extremity. A 30 percent rating is warranted for moderate incomplete paralysis affecting the major extremity. A 50 percent rating is warranted for severe incomplete paralysis affecting the major extremity. The maximum rating of 70 percent is warranted for complete paralysis affecting the major extremity; a drop hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. 38 C.F.R. § 4.124a, DC 8514. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis. 38 C.F.R. § 4.123. The words "mild," "moderate" and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. A May 2015 VA treatment record reflects complaints of right wrist discomfort and intermittent numbness in a few fingers, with no weakness. See Capri, May 2015. In her lay statements, the Veteran asserted that she experiences painful motion in the right wrist that limits her daily activities and restricts her from the amount of time she can write or type and challenges her to maintain a grip. See NOD, August 2013; see also Form 9, December 2016. In a February 2020 VA peripheral nerves examination report, the examiner notated the Veteran's current symptoms of intermittent right wrist pain and numbness with hand and wrist activities, with the use of a wrist splint for treatment. Upon examination, the Veteran reported symptoms of mild, right upper extremity intermittent pain, paresthesias/dysesthesias, and numbness. Muscle strength testing of the right wrist revealed a 5 out of 5, with no muscle atrophy shown. Reflexes and sensory exam were normal. The examiner concluded that the Veteran's radial nerve of the right upper extremity was normal, however, the Veteran exhibits right wrist and palm numbness that results in the use of a brace regularly. Based on the above, the Board finds that a compensable rating of 20 percent, but not higher, is warranted for the Veteran's right wrist peripheral nerve disorder during the entire period on appeal. The weight of evidence of record throughout the appeal period is sufficient to meet the criteria for the compensable 20 percent rating, as the severity of the Veteran's right wrist peripheral nerve disorder symptoms more closely approximate that of mild incomplete paralysis; which is commensurate of a 20 percent evaluation under DC 8514. The Board notes that the relevant evidence of record reflect that the Veteran's right wrist peripheral nerve disorder during the relevant period had manifested more closely with symptoms of such a severity, frequency, or duration as to warrant a higher 20 percent rating. Specifically, the evidence reflects the Veteran experiences mild pain and numbness, with issues/limitations with the Veteran's right wrist arm movement and ability to grip. In this regard, the Board notes that the evidence is essentially in favor of the higher 20 percent rating, or at the very least, in relative equipoise, and thus, resolving all reasonable doubt in favor of the Veteran, the assignment of a 20 percent rating in this case is warranted; and to this extent, the claim is granted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). However, a rating in excess of 20 percent is not warranted, as the evidence of record does not reflect, nor otherwise suggest, that the Veteran's right wrist peripheral nerve disorder results in moderate incomplete paralysis. The Board notes that the lay assertions of the Veteran have been considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran has argued that a higher rating than 20 percent for her right wrist peripheral nerve disorder is warranted, these assertions are outweighed by more probative evidence provided by the examination of a qualified medical professional. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, her lay statements do not provide any basis upon which to assign any higher ratings. 4. Entitlement to a rating in excess of 10 percent for service-connected right wrist strain. The Veteran contends that her right wrist strain warrants a rating in excess of 10 percent, as her symptoms reflect worsening. The Veteran's right wrist strain is currently evaluated at 10 percent under the appropriate DC 5215, which evaluates limitation of motion of the wrist. Under DC 5215, a 10 percent rating is warranted when plantar flexion is limited in line with the forearm, or when dorsiflexion is less than 15 degrees. This is the only rating allowable under DC 5215. 38 C.F.R. § 4.71a, DC 5215. The Board notes that the Veteran is already in receipt of the maximum schedular rating available under DC 5215, and thus, the Board is unable to grant a higher schedular rating under this DC. However, the Board must also consider other applicable DCs pertaining to the Veteran's right wrist that could possibly warrant a higher schedular rating. In this case, DC 5214, which evaluates wrist ankylosis, is the only applicable DC that could possibly warrant a higher rating for the Veteran's right wrist strain. However, a review of the relevant medical evidence of record, to include VA examinations and VA treatment records, do not reflect the Veteran has ankylosis in the right wrist. Additionally, the lay statements of record do not indicate the Veteran has contended to have ankylosis in the right wrist. Therefore, the Board finds that a higher rating based on DC 5214 is not applicable. While the Board acknowledges the Veteran experiences painful and limited motion, the very fact that she retains motion in the right wrist demonstrates that a higher rating under DC 5214 is not warranted. Based on the above, the Board finds that preponderance of the evidence does not support the assignment of a rating higher than the currently assigned 10 percent rating in this case; and the claim is denied. The Board notes that the lay assertions of the Veteran have been considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran has argued that a higher rating for her right wrist strain is warranted, these assertions are outweighed by more probative evidence provided by the examination of a qualified medical professional. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, her lay statements do not provide any basis upon which to assign any higher ratings. In reaching this determination, the Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C. § 5107 and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its applications. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 5. Entitlement to a rating in excess of 10 percent for service-connected right knee disability. 6. Entitlement to a rating in excess of 10 percent for service-connected left knee disability. The Veteran contends that her bilateral knee disability warrants higher ratings, as her symptoms reflect worsening. The Veteran's bilateral knee disability is currently evaluated at 10 percent each under DC 5262, which evaluates impairment of the tibia and fibula. Under DC 5262, a 10 percent rating is warranted for malunion of tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. The maximum rating of 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Board notes that during the course of the appeal, effective February 7, 2021, 38 C.F.R. § 4.71a Schedule of Ratings-Musculoskeletal System including Diagnostic Code 5262 was amended. Under the amended DC 5262, a noncompensable rating is warranted for medial tibial stress syndrome, or shin splints with treatment less than 12 consecutive months for one or both extremities. A 10 percent rating is warranted for medial tibial stress syndrome, or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment for one or both extremities. A 20 percent rating is warranted for medial tibial stress syndrome, or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment for one lower extremity. A 30 percent rating is warranted for medial tibial stress syndrome, or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment for one lower extremity. The maximum rating of 40 percent is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. Additionally, malunion of the tibia and fibula is to be evaluated under DCs 5256, 5257, 5260, or 5261 for the knee. The Board notes that a review of the record does not reflect any medical evidence pertaining to the Veteran's bilateral knee disability on or after February 7, 2012, and therefore, the amended DC 5262 is not applicable in this case. VA treatment records during the appeal period reflect complaints for increased intermittent bilateral knee pain with shin splints. See Capri. In her lay statements, the Veteran asserted that she has continuous daily bilateral knee pain that is moderate to severe, and limits her daily activities. See NOD, August 2013; see also Form 9, December 2016. In a July 2012 VA knee examination report, the examiner noted the Veteran experienced constant dull pain in the knees that increased with high impact activity. The Veteran was able to walk 2 miles a day without difficulty. The Veteran reported she experienced flare-ups with consistent activities, with pain that last for approximately 2 days; her pain was alleviated by stopping activities, time, rest, and taking over-the-counter medication. Upon examination, the Veteran's range of motion testing in the right and left knee resulted in a flexion and extension of 135 degrees and 0 degrees, respectively, with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with at least three repetitions in the right and left knee without any additional functional loss or range of motion, nor any functional loss/impairment. Muscle strength testing resulted in a 5 out 5 for the bilateral knee flexion and extension, with no joint instability (anterior, posterior, or medial-lateral) or subluxation/dislocation shown. The Veteran was noted to have shin splints that affect both knees, but no meniscal conditions/surgery. See C&P Exam, July 2012. In a February 2020 VA knee examination, the examiner noted the Veteran currently experiences intermittent bilateral knee pain and tightness in the shins that worsens with kneeling, squatting, or walking over 30 minutes. The Veteran reported having functional loss/impairment in the bilateral knee and shin, described as the right knee hurting and shin burning when she walks on a treadmill or rides a bike, and difficulty kneeling or squatting with the left knee. She made no reports of any flare-ups. Upon examination, the Veteran's range of motion testing in the right knee resulted in a flexion of 125 degrees and extension of 0 degrees, and the left knee resulted in a flexion of 135 degrees and extension of 0 degrees. Range of motion itself contributes to her functional loss during bilateral knee bends, squatting, and kneeling on the floor. Pain was noted on examination, which causes functional loss on flexion of both knees. There was no objective evidence of localized tenderness or pain to palpation, evidence of pain with weight-bearing, or objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions in the right and left knee without any additional functional loss or range of motion. The Veteran was not examined immediately after repetitive use over time, and the examiner noted the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner noted pain, fatigue, and lack of endurance significantly limits the Veteran's functional ability with repeated use over time in the bilateral knee, described in terms of range of motion as right knee flexion of 120 degrees and extension of 0 degrees, and left knee flexion of 125 degrees and extension of 0 degrees. The Veteran denied having any flare-ups of the knees. There were no additional factors noted to contribute to her bilateral knee disability. Muscle strength testing resulted in a 5 out 5 for the bilateral knee flexion and extension, with no muscle atrophy, ankylosis, history of recurrent subluxation or lateral instability, joint instability (anterior, posterior, or medial-lateral), or meniscal conditions/surgery shown. The Veteran was noted to have bilateral shin splints that affect the range of motion in both knees; the examiner noted the symptoms are acute and have resolved. Additionally, the examiner specifically addressed the Correia criteria (see Correia v. McDonald, 28 Vet. App. 158 (2016)), and noted that there was bilateral objective evidence of pain on passive range of motion testing, but no objective evidence of pain when either joint is used in non-weight bearing. See C&P Exam, February 2020. Considering the foregoing, to include consideration of the provisions of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, the Board finds that increased ratings exceeding the separate 10 percent evaluations currently assigned for the Veteran's bilateral knee disability are not warranted during any period on appeal. The weight of the evidence is not sufficient to meet the criteria for the next-higher rating under DC 5262, as the severity of the Veteran's bilateral knee disability more closely approximates that of malunion of the tibia and fibula with slight knee disability, which is commensurate of a 10 percent evaluation under DC 5262. The Board notes that the relevant medical evidence of record, to include the VA examinations and VA treatment records, shows that the Veteran's bilateral knee disability, during the relevant period on appeal manifested at worst to pain, fatigue and lack of endurance from shin splints. As such, an increased rating exceeding 10 percent under DC 5262 is not warranted. The Board has considered other applicable DCs of the knee that would possibly warrant an increased and/or separate rating; however, the current evidence of record does not reveal or otherwise suggest that the Veteran's bilateral knee disability has related ankylosis, lateral/recurrent instability and subluxation or patellar instability, meniscal conditions, or genu recurvatum as to warrant consideration of ratings under DCs 5256, 5257, 5258, 5259, and 5263. Additionally, the Veteran's bilateral knee disability has not resulted in limitation of flexion of 30 degrees or less, or extension of 5 degrees or more, to warrant consideration under DCs 5260 and 5261. Therefore, the Board finds that the preponderance of the evidence does not support the assignment of ratings higher than the currently assigned 10 percent ratings in this case; and the claim is denied. The Board notes that the lay assertions of the Veteran have been considered. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent that the Veteran has argued that higher ratings for her bilateral knee disability are warranted, these assertions are outweighed by more probative evidence provided by the examination of a qualified medical professional. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, her lay statements do not provide any basis upon which to assign any higher ratings. In reaching this determination, the Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C. § 5107 and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its applications. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for right hand pain is remanded. 2. Entitlement to service connection for lumbosacral strain is remanded. In September 2019, the Board remanded the Veteran's claims to provide the Veteran with VA examinations and medical opinions assessing the current nature and etiology of her claimed conditions. See BVA Decision, September 2019. In response to the Board's remand, the Veteran was afforded VA examinations in February 2020 for her current back and right hand condition. However, the examiner failed to provide etiology opinions. In July 2020, a deferred rating decision was issued noting the examiner's failure to provide the requested medical opinions, and directed that such opinions be uploaded to the claims file if completed, or if not completed, request new medical opinions per the September 2019 Board remand. See Deferred Rating and Rating Decision, July 2020. The Board notes that a review of the file does not reflect that such medical opinions have been uploaded to the Veteran's claims file and/or completed per the Board's remand. Therefore, the Board finds that a remand is necessary to obtain such medical opinions prior to adjudication of the claim, and in compliance with Stegall. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom she has received treatment for her lumbosacral strain and right hand pain, and obtain any outstanding records and associate them with the Veteran's claims file. 2. After associating all newly acquired records with the claims file, send the claims file back to the February 2020 VA examiner to provide VA medical opinions to determine the nature and etiology of the Veteran's claimed conditions. If the February 2020 VA examiner is not available, please forward the claims file to another appropriate clinician. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. Any indicated tests or studies should be performed, and all relevant evidence should be discussed. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. If the examiner finds that a new VA examination for the Veteran's lumbosacral strain and/or right hand pain must be scheduled prior to providing the opinion, schedule such an examination. Following complete review of the record, the examiner must address the following: (a) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's lumbosacral strain had its onset during any period of active duty, or is otherwise etiologically related to his active duty service, to include any reported in-service back pain. (b) Determine whether the Veteran's right hand pain results in any functional impairment. If so, identify any functional impairment(s) caused by any right hand pain. (c) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's right hand pain had its onset during any period of active duty, or is otherwise etiologically related to his active duty service, to include any reported in-service right hand pain. (d) Any opinion should include a detailed rationale. The examiner should consider the entire claims file, and discuss the Veteran's lay statements regarding the nature, onset, and chronicity of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that her reports must be considered in formulating the requested opinion. (e) If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Carter, 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.