Citation Nr: 21026168 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 18-31 599 DATE: April 30, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for a service-connected left knee disability is DENIED. Entitlement to service connection for anemia is DENIED. Entitlement to service connection for metrorrhagia and stress incontinence is DENIED. REMANDED On and after February 7, 2021, entitlement to a separate rating for instability of the left knee disability is REMANDED. FINDINGS OF FACT 1. During the claim period, at worst, the Veteran demonstrated 70 degrees of left knee flexion. 2. The weight of the evidence does not establish that the Veteran has a current anemia disorder. 3. The weight of the evidence does not establish that the Veteran has a current metrorrhagia and stress incontinence disorder. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the service-connected left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260 (2020). 2. The criteria for service connection for anemia have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 3. The criteria for service connection for metrorrhagia and stress incontinence have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020).   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Air Force from September 1989 to February 1990, and in the United States Army from March 1995 to August 2003. The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany her service-connected left knee disability. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). As noted above, the Veteran’s entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must consider whether there have been times when his disabilities on appeal have been more severe than at others, and rate them accordingly. 1. Entitlement to an initial rating in excess of 10 percent for a service-connected left knee disability is denied. In January 2013, the Veteran submitted a VA Form 21-526. Therein, the Veteran initiated a claim for service connection for a left knee disability. In December 2013, the agency of original jurisdiction (AOJ) issued a rating decision. Therein, the AOJ granted service connection for left knee osteoarthritis, assigning a 10 percent rating. On September 24, 2014, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran requested an increased rating for the service-connected left knee osteoarthritis disability. Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). “Staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying scheduler criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 should only be considered in conjunction with the Diagnostic Codes (DCs) predicated on limitation of motion. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, including knee joints, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran has been in receipt of a 10 percent evaluation under DC 5003-5260 since January 17, 2013. See 38 C.F.R. § 4.71 (a). In addition to the service-connection compensation available under DC 5260, this claim requires consideration of the other possibly applicable Diagnostic Codes. Under DC 5260, degenerative joint disease shall be rated based on limitation of motion of the right knee, as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. 38 C.F.R. § 4.71a, DC 5260. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated based on limitation of motion under appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. If there is limitation of motion but it is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion—to be combined, not added. If there is no limitation of motion, a 10 percent rating applies if there is X-ray evidence that two or more major joints or two or more minor joint groups are involved. A 20 percent rating applies if there is X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 U.S.C. § 4 .71a, DC 5003. For purposes of rating disability from arthritis, the major joints include the knee. 38 C.F.R. § 4.45. Although “incapacitating exacerbations” is not defined under DC 5003, the Board analogizes it to “incapacitating episodes,” which is defined in the IVDS Formula at Note (1) as “a period of acute signs and symptoms . . . that requires bed rest prescribed by a physician and treatment by a physician.” 38 C.F.R. § 4.71a, DC 5003, IVDS Formula at Note (1). Under DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71 (a), DC 5257. Diagnostic Code 5257 was revised, effective February 7, 2021. Part 4 - Schedule for Rating Disabilities, § 4.71a Schedule of ratings musculoskeletal system, 85 Fed. Reg. 230, 76463 (November 30, 2020). Effective February 7, 2021, Diagnostic Code 5257, concerning recurrent subluxation or instability, provides a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 30 percent award is also warranted for sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. A 20 percent rating applies where the evidence shows unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is for application for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5258 assigns a 20 percent evaluation for dislocated semilunar cartilage (meniscus) with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71 (a), DC 5258. Under DC 5260, which provides disability evaluations based on limitation of flexion, a 10 percent evaluation is warranted when flexion is limited to 45 degrees; a 20 percent evaluation is warranted when flexion is limited to 30 degrees; and a 30 percent evaluation is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71 (a), DC 5260. Under DC 5261, a 10 percent evaluation is warranted when extension is limited to 10 degrees, a 20 percent evaluation is warranted when extension is limited to 15 degrees, a 30 percent evaluation is warranted when extension is limited to 20 degrees, a 40 percent evaluation is warranted when extension is limited to 30 degrees, and a 50 percent evaluation is warranted when extension is limited to 45 degrees. 38 C.F.R. § 4.71 (a), DC 5261. Normal range of motion of the knee is 0 to 140 degrees of extension to flexion. 38 C.F.R. § 4.71 (a), Plate II. VAOPGCPREC 23-97 provides that a Veteran may be assigned separate ratings for arthritis with limitation of motion under DC 5260 or 5261, and for instability or subluxation under DC 5257. See VAOPGCPREC 23-97 (July 1, 1997). In VAOPGCPREC 9-98, VA General Counsel held that if a veteran has a disability rating under DC 5257 for instability or subluxation of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be assigned based on painful motion under 38 C.F.R. § 4.59. The VA General Counsel has issued a precedential opinion holding that “separate ratings may be assigned under DC 5260 and DC 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg.” See VAOPGCPREC 9-2004 (September 17, 2004). In November 2013, the Veteran underwent a VA examination that addressed the severity of the severity the service-connected left knee disability. The VA examiner noted a diagnosis for left knee osteoarthritis. The VA examiner did not note left knee ankylosis. The VA examiner noted the following initial left knee range of motion (ROM) in degrees: 120 flexion and 0 extension. The Veteran’s left knee ROM was unchanged after repetitive testing. The VA examiner noted less movement than normal, pain on movement, and disturbance of locomotion. The Veteran demonstrated 5/5 strength testing in flexion and extension. During stability testing, the Veteran demonstrated normal values for all tests. The VA examiner did not note a history of recurrent patellar subluxation/dislocation. The VA examiner did not note a history of “shin splints”, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The VA examiner noted a history that included a meniscal tear. The Veteran reported occasional use of a brace or crutch for normal locomotion. In September 2016, the Veteran underwent a VA examination that addressed the severity of the severity the service-connected left knee disability. The VA examiner noted a diagnosis for left knee osteoarthritis. The Veteran reported that left knee flare-ups were accompanied by pain and stiffness. The VA examiner noted the following initial left knee ROM (in degrees): 95 flexion and 0 extension. The Veteran demonstrated the following left knee ROM after repetitive testing: 85 flexion and 0 extension. The VA examiner reported that pain limited functional ability with repeated use over a period of time. The VA examiner supplied the following ROM values: 75 flexion and 0 extension. The VA examiner reported that pain and lack of endurance limited functional ability with flare-ups. The following ROM values were supplied: 70 flexion and 0 extension. The VA examiner did not note the presence of ankylosis. The Veteran demonstrated 5/5 strength testing in flexion and extension without the presence of atrophy. The VA examiner did not note a history of recurrent patellar subluxation, lateral instability, or recurrent effusion. During stability testing, the Veteran demonstrated normal values for all tests. The VA examiner did not note a history of “shin splints”, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The VA examiner noted a history that included a surgery in December 2008. The Veteran reported occasional use of a crutches for normal locomotion. In June 2019, the Veteran supplied sworn testimony to the undersigned Veterans’ Law Judge (VLJ). The Veteran testified that she wore a left knee brace on a daily basis because, “the knee will buckle on me and it will give out, and I’ve fallen several times due to it.” The Veteran testified that, “last orthopedics that looked at me was explaining that I need a replacement, but due to my age, I don't qualify for a total knee replacement. So, I was being given injections in my knee. It helped a little, but the last injection (in March 2017), my knee swelled up and I had a reaction to it, so they had to stop with the injections.” In September 2019, an Orthopedic Surgery Note was generated at the Audie L. Murphy Memorial Hospital. Therein, a provider noted that the Veteran sustained a left knee lateral malleolus fracture in August 2019. In January 2020, the Board considered the Veteran’s claim for an increased rating for a service-connected left knee disability. At that time, the Board found that the Veteran’s June 2019 hearing testimony suggested an increase in the severity of the service-connected left knee osteoarthritis. The Board remanded the claim for a new examination that addressed the severity of the service-connected left knee disability. In March 2020, the Veteran underwent a VA video telehealth examination to address the severity of the service-connected left knee disability. At that time, the VA examiner noted a left knee osteoarthritis, status post-surgery. The VA examiner supplied the following medical history: “Veteran says she had left patellar re-alignment surgery in 2008. She has L knee DJD. She notes increased pain since surgery and says has received viscosupplementation X 2. She notes give way of the L knee, last time was around 8/2019. She says she has been recommended to have surgery, but due to her age it has been deferred for now. She notes L knee locking and stiffness with prolonged standing or sitting. She was seen 8/8/2019 at SAMMC ER due to a L distal lateral malleolus fracture avulsion fracture which she says was due to her L knee giving out. She has not been seen for a flare up of her L knee pain in the last year.” The Veteran reported the following left-knee functional loss: “she can't do ‘prolonged sitting or standing because it will get stiff and painful, about 30 minutes or so.’ She avoids using stairs and kneeling on her L knee due to pain, and can't squat deeply and avoids heavy lifting from that position due to pain.” The VA examiner noted the following initial range of motion (ROM) in degrees: 110 flexion and 0 extension. The VA examiner reported that the Veteran’s initial ROM did not contribute to functional loss. The VA examiner did not report pain with weight bearing, but the Veteran demonstrated pain with flexion. The Veteran did not demonstrate pain or tenderness with palpation of the left knee. The Veteran did not demonstrate additional functional loss after three repetitions. The VA examiner relayed that pain significantly limited functional ability with repeated use over a period of time; however, the left-knee limitation could not be described in ROM values. The VA examiner did not note atrophy, and the Veteran demonstrated 4/5 muscle strength in flexion and extension. The Veteran did not demonstrate ankylosis. The VA examiner reported that there was not a history of recurrent subluxation or lateral instability. The Veteran reported occasional use of a left-knee brace for patellar stability. The VA examiner reported evidence of pain with passive ROM testing of the left knee. The VA examiner reported that pain was not noted with non-weight bearing. In November 2020, the Board addressed the Veteran’s claim for an increased rating for the service-connected left knee disability. At that time, the Board found that the March 2020 VA examiner’s opinion may have been based on in inaccurate factual premise. The Board noted that the VA examiner did not note a history of lateral instability, but the examination report indicated that the Veteran reported the left knee gave out twice in August 2019. The Board remanded the Veteran’s claim to the agency of original jurisdiction (AOJ) to obtain an addendum VA examination report. In November 2020, an addendum VA opinion was associated with the claims file. After review and discussion of the evidence during the claim period, the VA examiner opined that, “even though Veteran may have subjective symptoms / complaints as noted above on C&P examination from Dr. Pinter, review of medical evidence to include physical exam findings, imaging studies (MRI) of the left knee and most current medical records from the STVAHCS, do not show medical evidence of such complaints and/or diagnosis of ‘left knee lateral instability’, and thus to warrant a diagnosis of left knee lateral instability.” In January 2021, the Veteran underwent a VA examination that considered the severity of the service-connected left knee disability. The VA examiner noted a diagnosis for left knee degenerative arthritis and osteoarthritis. The Veteran reported current pain with ROM. The Veteran did not report left knee flare-ups. The VA examiner noted the following initial left knee ROM (in degrees): 100 flexion and 0 extension. The VA examiner noted pain during flexion, but it did not result in/cause functional loss. After repetitive testing, the Veteran did not demonstrate additional function or ROM loss. The VA examiner noted that pain limited functional ability with repeated use over a period of time. The VA examiner noted the following ROM values (in degrees): 90 flexion and 0 extension. The VA examiner reported that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. The Veteran demonstrated 5/5 muscle strength in flexion and extension without evidence of atrophy. The Veteran did not demonstrate ankylosis. The VA examiner noted that there was not a history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran demonstrated normal values during all instability testing. The VA examiner reported that the Veteran had never had recurrent patellar dislocation, “shin splints”, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The VA examiner noted that the Veteran underwent patellar realignment surgeries in 2008 and 2019. The Veteran reported occasional use of a brace for the service-connected left knee disability. The VA examiner noted that there was no objective evidence of pain in non-weight bearing, but there was pain during passive ROM testing. The Board finds that a 20 percent rating is not warranted under 38 U.S.C. § 4 .71a, DC 5003, because the Veteran did not have two or more major joints, or two or more minor joint groups, that required doctor prescribed bed rest. The Board notes that the Veteran competently testified that her left knee would buckle and give out. The Veteran also testified that she would utilize a left knee brace daily. However, the Veteran reported that she occasionally used a left knee brace to the November 2013, March 2020, and January 2021 VA examiners. During the claim period, the Veteran’s treatment records have been associated with the claims file on multiple occasions, to include those generated at the Cumberland County VA Clinic, Fayetteville VAMC, Tejeda VA Outpatient Clinic, and Audie L. Murphy Memorial VAMC. After review, the Board notes that records do not contain a diagnosis for left knee lateral instability. With regard to the left knee stability, the Board affords probative weight to the competent VA examination reports. In this regard, the November 2013, September 2016, and January 2021 VA examiners all reported normal left knee stability values during the Veteran’s physical examination. Moreover, the May 2020 addendum report confirmed that the Veteran’s medical records did not support the presence of left knee instability. Consequently, during this claim period, a separate disability rating is not warranted under 38 C.F.R. § 4.71 (a), DC 5257 for lateral instability or recurrent subluxation. In reaching this conclusion, the Board acknowledges that the revised DC 5257 provides for a 10 percent rating for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability. However, as noted above, the record does not establish that he has persistent instability. Accordingly, entitlement to a separate rating based on lateral instability or recurrent subluxation under the revised rating criteria. The Board notes that the November 2013 VA examiner reported a history that included a left knee meniscal tear. The Board also notes that the Veteran reported that her left knee locks to the March 2020 VA examiner. However, the September 2016 and January 2021 VA examiners reported that the medical history did not include left knee recurrent effusion. Consequently, a separate rating under 38 C.F.R. § 4.71 (a), DC 5258 is not warranted. During the claim period, at worst, the Veteran demonstrated 70 degrees of left knee flexion. Consequently, a rating in excess of 10 percent is not warranted under 38 C.F.R. § 4.71 (a), DC 5260. During the claim period, the Veteran repeatedly demonstrated 0 degrees of left knee extension. Consequently, a separate rating under 38 C.F.R. § 4.71 (a), DC 5261 is not warranted. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for an initial rating in excess of 10 percent for the service-connected left knee disability. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for a rating in excess of 10 percent for the service-connected left knee disability must be denied, because the preponderance of the evidence weighs against her claim. The Board notes that the Veteran and her representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran’s service as shown by the Veteran’s service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). (This standard of assessing aggravation of disability under 38 C.F.R. § 3.310 was established in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310)). Although VA indicated that the purpose of the regulation was merely to apply the Court’s 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place the burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA’s practice, which strongly suggests that the revision amounted to a substantive change in the regulation. Because the Veteran’s claim was received after the regulatory change, his claim will be adjudicated under the current version of the regulation. The VA is responsible for determining whether the evidence supports the claim or is in relative equipoise (with the Veteran prevailing in either event) or whether a preponderance of the evidence is against the claim (in which case the claim is denied). Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for anemia is denied. In April 2016, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran expressed a desire to reopen a claim for service connection for anemia. In January 2020, the Board addressed the claims listed on the title page. At that time, the Board found that new and material evidence had been submitted sufficient to reopen a claim for service connection for anemia. Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In December 2013, the Veteran underwent a VA examination that considered the nature and etiology of gynecological conditions. At that time, the VA examiner noted that test results supported an anemia diagnosis in November 2013, which predates the current claim period. In September 2016, the Veteran underwent a VA examination that considered the nature and etiology of currently endured gynecological conditions. At that time the VA examiner noted that the Veteran had not been diagnosed with anemia. In February 2017, a letter from the Veteran’s peer in the United States Air Force was associated with the claims file. Therein, the peer relayed that, “(s)he started having bad cramps, heavy bleeding and even difficulty getting pregnant. She has also confided in me that she has learned that because of the trauma that she went through because of the assault that caused to have female problems.” In June 2019, the Veteran supplied sworn testimony to the undersigned Veterans Law Judge (VLJ). The Veteran testified that, “I have MST, or military sexual trauma, and behind it, I have had a couple miscarriages. So, I --the anemia, it comes and goes . . . It did happen in service, and it's because I'll lose a lot of blood at certain periods . . . and they would put me on --what is that? --iron pills and I've had to take --I was also told to take like the Children's Flintstones or whatever else . . ..” The Veteran testified that she believes the anemia is secondary to the in-service military sexual trauma. In September 2019, an Ortho Follow-Up Note was generated at the Audie L. Murphy Memorial VA Medical Clinic (VAMC). At that time, a VA provider commented that, “Hgb separation by HPLC suggests possible presence of anemia, polycythemia or a hemoglobin variant; Alc is not effected.” In January 2020, the Board considered the Veteran’s claim for service connection for anemia. At that time, the Board observed that the December 2013 and September 2016 VA providers did not consider or address whether the Veteran’s diagnosed gynecological conditions were secondary to military sexual trauma, which was the identified stressor for the service-connected PTSD disability. The Board remanded the Veteran’s claim to obtain an adequate VA examination report that considered the etiology of any currently endured anemia. The Board specifically directed the VA examiner to opine on whether any currently endured anemia was etiologically related to the Veteran’s in-service MST. In March 2020, the Veteran underwent a VA examination that considered the nature and etiology of gynecological conditions. The VA examiner reported that the Veteran had not been diagnosed with anemia. In July 2020, the Veteran’s lab reports from Audie L. Murphy Memorial VAMC were associated with the claims file. Therein, a VA provider noted that, “Hgb separation by HPLC suggests possible presence of anemia, polycythemia or a hemoglobin variant.” In November 2020, the Board addressed the Veteran’s claim for service connection for anemia. At that time, the Board found that the March 2020 VA examination report was not adequate. The Board remanded the claim to the AOJ to obtain an addendum report that addressed whether the Veteran received an anemia diagnosis during the claim period and, if so, whether any currently endured anemia was etiological related to the service-connected military sexual trauma (MST). In November 2020, an addendum VA opinion was associated with the claims file. After review and discussion of the evidence during the claim period, the VA examiner reported that, “even though the Veteran may have subjective symptoms/complaints as noted above on documentation from C&P examination from Dr. Pinter, review of most current medical records from the STVAHCS and Tricare do not show any medical evidence of such complaints and/or diagnosis of ‘anemia’, and thus to report the nature and etiology of such conditions is not warranted.” In January 2021, the Veteran underwent a VA examination that addressed the nature and etiology of hematologic and lymphatic conditions. The VA examiner reported that the Veteran did not maintain a current diagnosis for anemia or an anemia variant. The VA examiner noted that, “(s)he reports she has sickle cell trait but states she has symptoms as if she has the actual disorder. She also states her symptoms of anemia are attributed to her SC MST. C-file/STR's do not support this theory. Last labs (not shown in c-file but mentions on 9/6/2019 possible polycythemia or a hemoglobin variant which is consistent with sickle cell anemia trait. Previous CBC in c-file/str's do not show anemia.” At that time, the Veteran reported heavy menses with breakthrough bleeding monthly. The VA examiner noted that the Veteran did not currently receive treatment for anemia. The VA examiner noted that no diagnosis of a hematologic or lymphatic condition confirmed; therefore, a diagnosis was not rendered on the day of examination. During the claim period, the Veteran’s treatment records have been associated with the claims file on multiple occasions, to include those generated at the Cumberland County VA Clinic, Fayetteville VAMC, Tejeda VA OPC, and Audie L. Murphy Memorial VAMC. After review, the Board notes that a competent diagnosis for anemia has not been rendered during the claim period. The Board notes that, under any theory of entitlement, a current disability is required. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (2001). After carefully reviewing the Veteran’s medical and lay evidence, the Board concludes that the probative weight of the evidence does not show that the Veteran has a current anemia disorder. Again, the Board finds that the competent medical evidence does not report that the Veteran has endured anemia at any point during the appellate period. The Board notes that the December 2013 VA examiner reported an anemia diagnosis that predates the current claim period. However, during the claim period, a competent medical diagnosis for anemia has not been rendered. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for anemia. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for anemia must be denied, because the preponderance of the evidence weighs against her claim. 3. Entitlement to service connection for metrorrhagia and stress incontinence is denied. In April 2016, the Veteran submitted a VA Form 21-526EZ. Therein, the Veteran expressed a desire to reopen a claim for service connection for metrorrhagia and stress incontinence. In January 2020, the Board addressed the claims listed on the title page. At that time, the Board found that new and material evidence had been submitted sufficient to reopen a claim for service connection for metrorrhagia and stress incontinence. Again, in order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 516-17. In February 2017, a letter from the Veteran’s peer in the United States Air Force was associated with the claims file. Therein, the peer relayed that, “(s)he has also confided in me that she has learned that because of the trauma that she went through because of the assault that caused to have female problems.” In January 2020, the Board considered the Veteran’s claim for service connection for metrorrhagia and stress incontinence. At that time, the Board observed that the December 2013 and September 2016 VA providers did not consider or address whether the Veteran’s diagnosed gynecological conditions were secondary to military sexual trauma, which was the identified stressor for the service-connected PTSD disability. The Board remanded the Veteran’s claim to obtain an adequate VA examination report that considered the etiology of the Veteran’s metrorrhagia and stress incontinence. The Board specifically directed the VA examiner to opine on whether any currently endured metrorrhagia and stress incontinence was etiologically related to the Veteran’s military sexual trauma (MST). In March 2020, the Veteran underwent a VA examination that considered the nature and etiology of gynecological conditions. The VA examiner noted that the Veteran has endured urinary incontinence/leakage, but relayed that it was not due to a gynecologic condition. In November 2020, the Board addressed the Veteran’s claim for service connection for metrorrhagia and stress incontinence. At that time, the Board found the March 2020 VA examination report inadequate and non-compliant. The Board remanded the Veteran’s claim to the AOJ to secure an addendum VA examination report. In November 2020, an addendum VA opinion was associated with the claims file. After review and discussion of the evidence during the claim period, the VA examiner reported that, “even though the Veteran may have subjective symptoms/complaints as noted above on documentation from C&P examination from Dr. Pinter, review of most current medical records from the STVAHCS and Tricare do not show any medical evidence of such complaints and/or diagnosis of ‘metrorrhagia’ and/or ‘stress incontinence’, and thus to report the nature and etiology of such conditions is not warranted.” In January 2021, the Veteran underwent a VA examination that addressed the nature and etiology of gynecological conditions. The VA examiner reported that the Veteran did not maintain a current diagnosis for metrorrhagia and stress incontinence. At that time, the Veteran reported that, “she started to have these conditions as a result of her MST (1996) she feels it is a direct correlation to her gynecological/urinary conditions. C-file/STR's do not show evidence of evaluation, diagnosis or treatment of metrorrhagia or stress incontinence while in service or during presumptive period. She states she has not sought care r/t to her concerns. She reports abnormal bleeding occurs monthly she states she would have her initial flow with irregular bleeding in between.” During the claim period, the Veteran’s treatment records have been associated with the claims file on multiple occasions, to include those generated at the Cumberland County VA Clinic, Fayetteville VAMC, Tejeda VA OPC, and Audie L. Murphy Memorial VAMC. After review, the Board notes that a competent diagnosis for metrorrhagia and stress incontinence has not been rendered during the claim period. The Board notes that, under any theory of entitlement, a current disability is required. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (2001). After carefully reviewing the Veteran’s medical and lay evidence, the Board concludes that the probative weight of the evidence does not show that the Veteran has a current metrorrhagia and stress incontinence disorder. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for metrorrhagia and stress incontinence. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for metrorrhagia and stress incontinence must be denied because the preponderance of the evidence weighs against her claim. REASON FOR REMAND Upon review of the record, the Board concludes that further evidentiary development is necessary. A remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing her claim prior to final adjudication. 4. On and after February 7, 2021, entitlement to a rating a separate rating based on patellar instability is remanded. The Board notes that, effective February 7, 2021, the VA regulations that address knee disability ratings have been revised. Importantly, under the newly revised 38 C.F.R. § 4.71a, DC 5257 (2021), the following criteria are applicable for patellar instability: a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent disability rating. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following a brace, cane, or walker warrants a 20 percent disability rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent disability rating. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). In January 2020, the Veteran’s treatment notations from the Fayetteville VAMC were associated with the claims file. After review, the Board observes that the Veteran endured chronic left knee pain secondary to hypermobile patella and recurrent patellar dislocation in February 2014. In January 2016, the VA facility ordered the Veteran a knee brace. In March 2020, the Veteran underwent a VA video telehealth examination to address the severity of the service-connected left knee disability. At that time, the Veteran reported that she wore a left knee patellar brace at times when she was “out and about.” In January 2021, the Veteran underwent a VA examination that considered the severity of the service-connected left knee disability. The VA examiner noted a diagnosis for left knee degenerative arthritis and osteoarthritis. The VA examiner did not report a diagnosis for patellofemoral pain syndrome. However, the VA examiner noted that the Veteran underwent patellar realignment surgeries in 2008 and 2019. The Veteran reported occasional use of a brace for the service-connected left knee disability. In April 2021, the Veteran’s treatment notations from the Audie L. Murphy Memorial Hospital were associated with the claims file. After review, the Board notes that the records contain a March 10, 2021 pre-operation Nursing Notation for a left knee surgery. However, after review of the remainder of the treatment notes, the Board observes that the Veteran underwent a left ankle arthroscopy on March 10, 2021. Additionally, the Board observes that the treatment notations do not address whether the Veteran demonstrated left knee recurrent subluxation or instability, patellar instability, and/or impairment of the tibia and fibula on or after February 7, 2021. In light of the evidence in the claims file, and the change in VA regulations that address compensation for service-connected knee disabilities, the Board finds that a remand of this increased rating claim is warranted. On remand, the AOJ should secure an examination report that addresses the severity of the Veteran’s service-connected left knee patellar instability. Consequently, the matter is REMANDED to the AOJ for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment of the Veteran’s left knee. Request that the Veteran identify any recent private treatment pertinent to her claim and provide information and authorization sufficient for VA to assist her in obtaining any pertinent medical records not yet associated with the record. 2. Schedule a VA examination to ascertain the severity of the Veteran’s service-connected left knee disability on and after February 7, 2021. The VBMS and Virtual VA electronic claims files must be made available to, and be reviewed by, the examiner. All indicated testing should be accomplished and all symptomatology associated with left knee disability should be identified. The VA examiner is must consider the severity of the Veteran’s left knee in light of the new VA regulations, which are effective February 7, 2021. The VA examiner must address whether the Veteran maintains a current diagnosis with regard to the left knee patellofemoral complex. The VA examiner must specifically address the criteria under the new DC 5257. The VA examiner must address the evidence regarding previous patellar movement, surgeries, and the use of assistive device(s). In addition to all findings identified on the appropriate examination form, the examiner should determine the effective range of motion in the Veteran’s left knee and present the results of range of motion tests in a written report which complies with 38 C.F.R. § 4.59 by recording separate sets of the range of motion test results for both active and passive motion, and in weight bearing and nonweight-bearing, and the range of motion in the opposite, undamaged joint. The examiner’s report should describe objective evidence of painful motion, if any, during each test. (It is not sufficient merely to indicate whether or not pain was present during one of the required range of motion tests.) If any of these findings are not possible, please provide an explanation. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the examiner is asked to describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran’s description of reduced range of motion during flares or repetitive use. 3. The AOJ must ensure that the examination report requested above is in compliance with the directives of this remand. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures at once. 3. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the claim for an increased left knee disability rating. If the benefit sought is not granted, the AOJ must then issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and her representative an opportunity to respond. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.