Citation Nr: 21028933 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-33 951 DATE: May 12, 2021 ORDER Entitlement to service connection for a gynecological disorder including cervical dysplasia is denied. Entitlement to service connection for right wrist disability is granted. Entitlement to a disability rating for anxiety disorder and posttraumatic stress disorder (PTSD) higher than 30 percent from November 25, 2014, to May 13, 2019, is denied. Entitlement to a disability rating for anxiety disorder and PTSD of 50 percent from May 14, 2019, is granted. Entitlement to a disability rating for anxiety disorder and PTSD, higher than 50 percent, from December 18, 2019, is denied. Entitlement to a disability rating for migraine headaches of 30 percent from November 25, 2014, is granted. Entitlement to a disability rating for migraine headaches higher than 30 percent is denied. Entitlement to a disability rating for lumbar strain higher than 10 percent from November 25, 2014, to July 30, 2015, is denied. Entitlement to a disability rating for lumbar strain and intervertebral disc syndrome higher than 20 percent from July 31, 2015, is denied. Entitlement to a disability rating for left knee patellofemoral pain syndrome higher than 10 percent is denied. Entitlement to a disability rating for right knee patellofemoral pain syndrome and strain higher than 10 percent is denied. REMANDED Entitlement to service connection for decreased sense of smell, or hyposmia, is remanded. FINDINGS OF FACT 1. The Veteran's recurrent cervical dysplasia resolved before the end of her most recent active service period; her diagnosed recurrent bacterial vaginosis did not manifest until more than two years after her most recent active service period. 2. The Veteran's service-connected cervical spine strain and degenerative joint disease at least as likely as not caused her right wrist radiculopathy and strain. 3. From November 25, 2014, to May 13, 2019, the Veteran's anxiety disorder and PTSD produced occupational and social impairment with occasional decrease in work efficiency, and intermittent periods of inability to perform occupational tasks, without preventing generally satisfactory functioning or normal routine behavior, self-care, and conversation. 4. From May 14, 2019, the Veteran's anxiety disorder and PTSD produced occupational and social impairment with reduced reliability and productivity, without producing deficiencies in most areas. 5. From December 18, 2019, the Veteran's anxiety disorder and PTSD have produced occupational and social impairment without producing deficiencies in most areas. 6. From November 24, 2014, the Veteran's migraine headaches made her miss one to four days of work a month. 7. The Veteran's migraine headaches have not made her unable to work frequently enough to produce severe economic inadaptability. 8. From November 25, 2014, to July 30, 2015, the Veteran's lumbar strain limited motion and produced pain on motion and diminished endurance, without limiting forward flexion to 60 degrees, limiting the combined range of motion to 120 degree, producing muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, or producing comparable impairment. 9. From July 31, 2015, the Veteran's lumbar strain and intervertebral disc syndrome limited motion and produced pain on motion and diminished endurance without limiting forward flexion to 30 degrees or less, producing ankylosis, or producing comparable impairment. 10. The Veteran's left knee patellofemoral pain syndrome has produced limitation of flexion, diminished endurance, painful motion with and without weightbearing, and weakened motion, without limiting flexion to 30 degrees or producing comparable impairment. 11. The Veteran's right knee patellofemoral pain syndrome and strain has produced limitation of flexion, diminished endurance, painful motion with and without weightbearing, and weakened motion, without limiting flexion to 30 degrees or producing comparable impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a gynecological disorder including cervical dysplasia have not been met. 38 U.S.C. §§ 1110, 1117, 5107 (2012); 38 C.F.R. § 3.303 (2020). 2. The criteria for service connection for right wrist disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.310 (2020). 3. The criteria for a disability rating higher than 30 percent for anxiety disorder and PTSD from November 25, 2014, to May 13, 2019, were not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Codes 9411, 9413 (2020). 4. The criteria for a 50 percent disability rating for anxiety disorder and PTSD from May 14, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Codes 9411, 9413. 5. The criteria for a disability rating higher than 50 percent for anxiety disorder and PTSD from December 18, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Codes 9411, 9413. 6. The criteria for an initial (from November 25, 2014,) 30 percent disability rating for migraine headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.124A, Diagnostic Code 8100 (2020). 7. The criteria for a disability rating higher than 30 percent for migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.124A, Diagnostic Code 8100. 8. The criteria for a disability rating higher than 10 percent for lumbar strain from November 25, 2014, to July 30, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 9. The criteria for a disability rating higher than 20 percent for lumbar strain and intervertebral disc syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5243 (2020). 10. The criteria for a disability rating higher than 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 11. The criteria for a disability rating higher than 10 percent for right knee patellofemoral pain syndrome and strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1992 to September 2006, from October to December 2007, from March to April 2008, from July to August 2008, from March 2010 to April 2011, and from October 2011 to October 2014. She is a Persian Gulf veteran. In November 2014 the Veteran sought service connection for decreased sense of smell, PTSD, migraine headaches, lower back problems, and left knee problems. In January 2015 she also sought service connection for a gynecological disorder manifested by abnormal Pap smear results, right wrist disability, anxiety, and problems in both knees. In a July 2015 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for loss of sense of smell, for PTSD, for dysplasia claimed as gynecological and Pap smear problems, and for right wrist disability. The RO granted service connection, effective November 25, 2014, for anxiety disorder, and assigned a disability rating of 30 percent. The RO granted service connection for migraine headaches and assigned a rating of 0 percent. The RO granted service connection for lumbar strain and assigned a rating of 10 percent. The RO granted service connection for left knee patellofemoral pain syndrome and assigned a rating of 0 percent. The RO granted service connection for right knee patellofemoral pain syndrome and strain and assigned a 0 percent rating. The Veteran appealed to the Board the denial of service connection for decreased sense of smell, PTSD, dysplasia, and right wrist disability, and the ratings assigned for anxiety disorder, migraine headaches, lumbar strain, and disabilities of the left and right knees. In September 2015 the Veteran had a hearing before an RO Decision Review Officer (DRO). In a May 2016 rating decision, the RO increased the rating for lumbar strain to 20 percent from July 31, 2015. The RO increased from 0 to 10 percent each the initial ratings for the migraine headaches and left and right knee disabilities. On May 14, 2019, the Veteran had a Board videoconference hearing before the undersigned Veterans Law Judge. In a November 2019 decision, the Board denied service connection for decreased sense of smell. The Board found that the Veteran withdrew her appeal for service connection for PTSD and consequently dismissed that appeal. The Board granted reopening of a previously denied claim for service connection for a gynecological disorder and remanded the reopened claim to the RO for additional action. The Board remanded to the RO for additional action the claim for service connection for right wrist disability and the appeals of the ratings for anxiety disorder, lumbar strain, and left and right knee disabilities. The Board increased the rating for migraine headaches to 30 percent from May 14, 2019. The Veteran appealed some of the Board's decisions to the United States Court of Appeals for Veterans Claims (Court). In an August 2020 rating decision, the RO changed the description of the Veteran's service-connected psychiatric disability to include anxiety disorder and PTSD. The RO increased the rating for that disability to 50 percent from December 18, 2019. The RO effectuated the Board's grant of a 30 percent rating for migraine headaches from May 14, 2019. In October 2020 the Veteran and VA (the parties) submitted to the Court a Joint Motion for Partial Remand, asking the Court to vacate, and to remand for additional action, the Board's November 2019 actions denying service connection for decreased sense of smell and denying ratings for migraine headaches higher than 10 percent before May 14, 2019, and higher than 30 percent from May 14, 2019. In a November 2020 order the Court granted the JMPR. Service Connection Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. 38 C.F.R. § 3.310(b). Service connection may also be established for a Persian Gulf veteran who exhibited objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A "Persian Gulf veteran" is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317. A "qualifying chronic disability" includes: (A) an undiagnosed illness; (B) the following medically unexplained chronic multi-symptoms illnesses: chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary of VA determines is medically unexplained chronic multi-symptom illness; and (C) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense, of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2), (5). Compensation shall not be paid under 38 C.F.R. § 3.317 if: (1) the undiagnosed illness was not incurred during active service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) the undiagnosed illness was caused by a supervening condition or event that occurred between your most recent departure from service in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) the illness is the result of willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The Court has indicated that the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons 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); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Gynecological disorder including cervical dysplasia The Veteran reports that on several occasions during active service Pap smears and biopsies of the cells of her uterine cervix showed dysplasia. She contends that the dysplasia continued after service. During the Veteran's active service from March 1992 to October 2006, a March 1997 Pap smear was negative for cell abnormalities. A March 2002 Pap smear showed atypical squamous cells. High-grade squamous intraepithelial lesion (HGSIL) could not be excluded. A May 2002 biopsy of her cervix showed cervicitis, with no evidence of malignancy. In June 2002 a Pap smear showed mild dysplasia. In November 2002 she had follow-up for dysplasia. Testing in December 2002 detected human papilloma virus (HPV). In May 2003 biopsies of the Veteran's cervix showed dysplasia. In August 2004 biopsies of her cervix showed dysplasia. In November 2004 she had treatment for a urinary tract infection. On testing in March 2005 HPV was not detected. In August 2005 and November 2005 Pap smears showed abnormal results. In March 2006 biopsies of her cervix showed mild dysplasia. In September 2006 a Pap smear was normal. She was instructed to follow up in a dysplasia clinic in four to six months. After the 1992 to 2006 service period, a Pap smear in August 2007 mild dysplasia. The Veteran's assembled service treatment records do not reflect any Pap smears during her active service periods from October to December 2007, March to April 2008, and July to August 2008. In December 2008 biopsies of her cervix showed squamous metaplasia and benign squamous epithelium. There is no record of cervical cell testing during her March 2010 to April 2011 service period. In September 2011 cervicovaginal cytology was negative for intraepithelial lesion and malignancy. During the Veteran's October 2011 to October 2014 active service period, she had treatment in October 2013 for vaginal bleeding and lower pelvic cramping. Pelvic ultrasound showed an IUD in place but did not show any abnormality. In the September 2015 DRO hearing, the Veteran reported that during service she was found to have cervical dysplasia. She stated that the findings continued over several years, and that follow-up testing continued. She indicated that the most recent testing did not show dysplasia. In VA treatment in January 2016, the Veteran's reported that in recent years she had an IUD and had no menstruation. She reported new onset of vaginal bleeding and of pain in the left side of her lower abdomen. Ultrasound showed a simple cyst. Pap and HPV tests were negative. In March 2016 the Veteran reported that a non-VA provider removed and replaced her IUD. In VA treatment in February 2017, it was noted that the Veteran had an abnormal Pap test ten to eleven years earlier. The treating clinician found that the Veteran's cervix presently had no tenderness or visible abnormality. The clinician found vaginitis consistent with bacterial infection and prescribed medication. In September 2017 testing showed bacterial vaginosis. A clinician prescribed medication. In October 2017 the Veteran reported vaginal itching. In December 2017 testing showed bacterial vaginosis. Medication was prescribed. In September 2018 the Veteran reported that she took a probiotic to help prevent recurrent bacterial vaginosis. She stated that she had no current vaginal issues. Treatment notes from 2017 through 2020 reflect plans to perform the Veteran's next Pap and HPV tests in 2021. In the May 2019 Board hearing, the Veteran indicated that she had onset of gynecological problems in service. In August 2019, physiology professor D. J. H., Ph. D., reviewed the Veteran's medical history. Dr. H. found that the Veteran's health issues included "general dysplasia." Dr. H. expressed the opinion that the Veteran's physical conditions were at least as likely as not a result of physically demanding duties and physical injuries during service. In VA treatment in September 2019, the Veteran reported that recently she stopped taking a probiotic. She reported no current vaginal complaints. In the November 2019 remand, the Board instructed the RO to provide a medical file review and opinion as to whether the dysplasia noted in service continued after service. In December 2019 a VA clinician completed a VA disability benefits questionnaire (DBQ) regarding the Veteran's gynecological conditions. The Veteran reported that in service in 2002 testing showed HPV and dysplasia. She stated that subsequent testing showed increased dysplasia. She reported that in 2005 she underwent a biopsy and a loop electrosurgical excision procedure (LEEP). The examiner found that the Veteran did not presently have pain or other symptoms related to the dysplasia and its treatment. The examiner expressed the opinion that any current gynecological disorder was less likely than not related to her dysplasia during service. The examiner explained that the dysplasia found in service was acute only, and that treatment during service cured the dysplasia. The examiner stated that presently all testing showed normal findings. Testing showed cervical dysplasia multiple times during the Veteran's 1992 to 2006 active service period, and again in 2007 and 2008, between active service periods. Testing in 2011, between service periods, and in 2016, after the most recent service period, did not show cervical dysplasia. The Veteran had cervical dysplasia during and between active service periods but testing from 2011 forward has not shown cervical dysplasia. Dr. H.'s reference to general dysplasia, without reference to the uterine cervix, raises a question as to whether Dr. H. understood the nature of the reported dysplasia. Dr. H. also attributed all current conditions, including dysplasia, to physical demands and injuries in service, without explaining how exertion or injury caused dysplasia. Considering those factors, Dr. H.'s opinion linking dysplasia and events in service has little to no persuasive weight. The VA clinician who examined the Veteran in 2019 made accurate references to the assembled medical records in concluding that the Veteran did not have current or recent cervical dysplasia. The greater persuasive weight of the evidence is against a current cervical dysplasia disability. The recurrent bacterial vaginosis for which the Veteran was treated in 2017 and 2018 was not noted during any of the Veteran's service periods. The Veteran had diagnosed cervical dysplasia and recurrent bacterial vaginosis. The Board therefore denies service connection for claimed current cervical dysplasia or other current gynecological disorder. 2. Right wrist disability The Veteran contends that pain and weakness in her right wrist is attributable to physical demands (or injuries) in service. She also contends that her right wrist problems are secondary to (caused or aggravated by) a cervical spine disorder. In an August 2020 rating decision, VA granted service connection, effective from November 2014, for the Veteran's cervical spine strain with degenerative joint disease. The Veteran's service treatment records do not reflect complaints regarding his right wrist. In a May 2015 statement, the Veteran wrote that she had chronic wrist pain. She stated that treatment had included medications, therapy, and a splint. On VA examination in June 2015, the Veteran reported that her right wrist pain began about five years earlier. She stated that her service duties required three to four hours of typing per day. She stated that physical therapists who treated her in 2011 attributed the right wrist pain to neck problems. The examiner found evidence of right wrist pain with dorsiflexion. The right wrist appeared normal on x-rays. The examiner's diagnosis was right wrist strain. In July and August 2015, the Veteran had private physical therapy for pain in her right wrist, neck, and low back. In the September 2015 DRO hearing, the Veteran reported that during the last two years of her active service she had wrist pain that made it difficult to perform the push-ups required in physical fitness tests. In the May 2019 Board hearing, the Veteran reported that a physical therapist and a chiropractor each related her wrist problems to her neck problems. In August 2019 Dr. H. opined that injuries during the Veteran's service at least as likely as not caused her right wrist disability. In November 2019 the Board remanded the Veteran's right wrist service connection claim for the RO to reconsider after obtaining a medical opinion as to the likely etiology of the Veteran's cervical spine disability. On a VA cervical spine examination in December 2019, the examiner found degenerative arthritis of the cervical spine, and related radiculopathy of the bilateral upper extremities. On a December 2019 VA wrist examination, the Veteran reported that in service she was hit by a vehicle in 2002 and fell onto her right wrist. She stated that treatment after the accident focused on her neck and shoulder, which had more severe symptoms. She related ongoing weakness, pain, and fatigue in her right wrist. The examiner found limitation of motion, pain on motion, and muscle weakness in the Veteran's right wrist. Right wrist x-rays showed no evidence of fracture or arthritis. The examiner diagnosed C7-C8 radiculopathy affecting the Veteran's right wrist. In a June 2020 addendum, a VA clinician clarified that, in addition to radiculopathy, the Veteran's right wrist also had a diagnosis of strain. In August 2020 a VA clinician reviewed the Veteran's claims file. The reviewer expressed the opinion that it is less likely than not that the Veteran's cervical spine disorders proximate cause or result in her right wrist disorder. In explanation, the reviewer noted that in December 2019 the Veteran attributed her right wrist problems to falling on that wrist in 2002. The reviewer did not express an opinion as to the likelihood that the Veteran's cervical spine disorders aggravate her right wrist disorder. A causal relationship between the Veteran's cervical spine disability and her right wrist disorder was supported by the December 2019 VA examiner and opposed by the August 2020 VA reviewer. Each opinion was adequately explained and was reasonably persuasive. Neither opinion is clearly more persuasive than the other. The evidence for and against secondary service connection is approximately balanced. Giving the benefit of the doubt to the Veteran, the Board finds that the cervical spine disability caused the right wrist disability, and grants service connection for the right wrist disability. Increased Ratings VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Court also has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim for an increased rating was filed until a final decision is made. See Hart. v. Mansfield, 21 Vet. App. 505 (2007). The rating criteria for musculoskeletal disorders changed effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. §§ 4.71a, 4.73). Where the rating criteria affecting a disability have changed, VA will apply the earlier version before February 7, 2021, the effective date for the change. From February 7, 2021, VA will apply either the earlier version or the revised version, whichever is more favorable to the claimant. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). When evaluation of a musculoskeletal disability is based on limitation of motion, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened motion, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating joints with pain on motion, considerations include pain on both active and passive motion, pain with and without weightbearing, and comparison to the range of motion of any opposite undamaged joint. 38 C.F.R. § 4.59; see Correia v. McDonald, 28 Vet. App. 158 (2016). 3., 4., and 5. Anxiety disorder and PTSD The Veteran appealed the initial 30 percent rating that the RO assigned effective November 25, 2014, for her anxiety disorder. She appealed the 50 percent rating that the RO assigned from December 18, 2019, for her PTSD previously rated as anxiety disorder. VA evaluates anxiety disorder under Diagnostic Code 9413 and PTSD under Diagnostic Code 9411, both under a General Formula for Mental Disorders at 38 C.F.R. § 4.130, as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70 percent Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30 percent Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 10 percent A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 0 percent During service the Veteran had a mental health consultation in November 1994. She reported having stresses related to her sister and a coworker. She stated that, when she was angry, she had difficulty talking with her spouse and had difficulty calming down. The clinician called for individual and couples counseling. In a March 1997 health assessment, the Veteran reported anxiety symptoms. In mental health treatment in June 2000, the Veteran reported anger on learning that her spouse had an affair. On follow-up, the Veteran reported that she was still very angry. The clinician found that she appeared calmer. Later in June, the clinician found that the Veteran continued to cope better with her marital situation. In August 2000 the Veteran was referred for behavioral therapy related to minor physical maltreatment of her spouse. In December 2000 the Veteran reported anger and rage at her spouse. She admitted to hitting him, throwing things at him, and having homicidal ideation. She was admitted for inpatient mental health treatment. Later in December 2000 a clinician noted that the Veteran had reduced homicidal ideation, and no homicidal plan or intent, toward her spouse. In January 2001 the Veteran reported considering divorce. In February 2001 the Veteran denied any current maltreatment in her home. In April 2001 a clinician reported that the Veteran was not engaged in ongoing treatment. In July 2001 the Veteran stopped behavioral health treatment for problems related to a partner relationship and life circumstances. The Veteran had a mental health consultation in March 2006. The clinician's assessment was adjustment disorder with depression. The clinician's plan was cognitive restructuring and education. In an August 2008 health assessment, the Veteran reported difficulty sleeping. In a March 2010 service health assessment, the Veteran indicated that she felt anxious two out of the past 30 days and got insufficient sleep five out of the past 30 days. In an August 2010 health assessment, the Veteran reported a history of traumatic experiences, followed by nightmares as recently as in the past month. She indicated that, in the past month, a few or several days she had little interest or pleasure in doing things and felt down, depressed, or hopeless. In November 2010 a clinician noted that the Veteran had multiple stressors, especially assuming care for both parents who had health problems. In a March 2011 health assessment, the Veteran reported feeling anxious three out of the past 30 days and having insufficient sleep seven out of the past 30 days. In a July 2014 health assessment, the Veteran reported frequent difficulty sleeping. She indicated that she was receiving medical or mental health services. In December 2014 statements, the Veteran described stressors during her service. She stated that in 1999 she was sexually harassed and assaulted by a senior officer. She reported that after the September 2001 terrorist attacks she became afraid to fly. She reported that in 2008 she experienced attempted rape by a fellow service member, stopped by rescue by another service member. She stated that after the attempted rape she experienced panic attacks and depression. She reported that in Iraq in 2010 mortar attacks on her post scared her severely. She stated that she developed insomnia, which was treated with Ambien. She stated she helped transport service members with severe injuries and then began to have nightmares. She reported that presently she had nightmares, panic attacks, and constant tension. In a May 2015 statement, the Veteran wrote that during service she was prescribed medication to help her sleep. On VA PTSD examination in May 2015, the Veteran related that during service she experienced an unwanted sexual advance from a senior officer. She stated that later in service she was subjected to attempted rape. She reported that during service in Iraq she experienced mortar attacks. She stated that while volunteering at a hospital she saw traumatic injuries. She indicated that she reacted with horror and was treated with Ambien. She related that while she was in active service her mother and father each had a stroke and her father died. She stated that during service she had private mental health care. She stated that she had been taking Nortriptyline, an antidepressant, intermittently for twelve to eighteen months. She reported intrusive memories and physical symptoms related to traumatic events in service. She reported ongoing anxiety and chronic sleep impairment. The examiner noted the Veteran's mental health treatment in service. The examiner stated that the Veteran's reported anxiety and obsessive symptoms were similar to symptoms of generalized anxiety. The examiner concluded that presently the Veteran had anxiety disorder. The examiner concluded that the Veteran's anxiety disorder produced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In June 2015 the Veteran had a VA psychology consultation. She reported intrusive memories and nightmares about traumatic experiences during service. She related having a quick temper. She reported physical tension, with neck and shoulder pain and headaches. She related having panic attacks, presently managed with breathing and muscle relaxation exercises learned in physical therapy. She reported that she was taking courses toward a master's degree and was working part time as a bartender. She reported that she was divorced and that she lived with her son and two nephews that she was raising. The clinician observed that the Veteran was oriented, had normal speech and thought process, and had unimpaired concentration and memory. In VA treatment in September 2015, the Veteran reported a history of military sexual trauma. She stated that she took Nortriptyline as needed, less than once a week. In the September 2015 DRO hearing, the Veteran stated that two or three times a week her sleep was interrupted in the middle. She reported that about once every two weeks she woke up crying in the middle of the night or in the morning. She stated that two or three times a week her stress was manifested by clenching her hands so tightly that they swelled and had decreased coordination. She related that she had difficulty interacting with people other than her family and friends. She indicated that she had panic attacks once or twice a week. She stated that it had been a long time since she went out with friends. She reported a fixation on the numbers 9/11, such that she froze up when reminded of the numbers. She stated that her anxiety symptoms had worsened significantly over time. She stated that she was not working presently. She reported increasingly struggling to attend classes for her degree program. In a March 2019 claim for VA vocational rehabilitation, the Veteran reported having generalized anxiety disorder, with sleep disturbance, rumination, and anxiety when she left home. She related having difficulty leaving home, to an extent that varied from day to day. She reported at times having difficulty dealing with people in authority or new people. She stated that she received private mental health treatment, without medication. In the May 2019 Board hearing, the Veteran reported that for the last two years she had panic attacks about once a week. She stated that she had trouble staying asleep. She reported that two or three times a week she awakened at night with racing thoughts. She indicated that her panic attacks and anxiety caused difficulty finding and keeping jobs. She reported increased difficulty getting along with friends and family. She stated that she stayed at home more and left the house less frequently than before. She reported that over the last twelve to eighteen months her mood had become more anxious and unhappy. She related problems with concentration and task completion that in 2017 caused her to leave a job. On VA examination on December 18, 2019, the Veteran reported that in 2016 she completed a master's degree. She stated that she was self-employed as a mental health therapist. She stated that for the last three years her practice had been part time. The examiner noted that the Veteran had depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The examiner found that the Veteran had PTSD that produced occupational and social impairment with reduced reliability and productivity. From November 2014 through April 2019, the assembled evidence indicated that the Veteran had disturbed sleep and panic attacks. She sometimes struggled with school and work and interactions with people. Generally, however, she attended classes, held employment, and functioned as a parent and guardian. Through that period, her psychiatric disability picture was more consistent with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, with general satisfactory functioning and normal routine behavior, self-care, and conversation, than it was with reduced reliability and productivity. The Board denies a rating higher than 30 percent for that period. The March 2019 vocational rehabilitation report and the May 2019 Board hearing presented a picture in which her anxiety caused her to resist leaving her house. She reported that she had left a job because of impaired concentration and capacity to complete tasks. That picture is more consistent with reduced reliability and productivity. The evidence supports, and the Board grants, a 50 percent rating from May 14, 2019, the date of the Board hearing. From December 18, 2019, and through all periods through the present, the Veteran's anxiety and PTSD have produced deficiency in her work capacity. At least partly due to those disorders she left one job and later engaged in self-employment on only a part-time basis. Her functioning in school was impaired but not deficient. Anxiety about leaving her house made it difficult to attend classes, but she completed her degree. Her capacity for family relations has not been deficient. While she has more recently reported difficulty getting along with family members, she has raised her son and two nephews. Her accounts and professional observations have not indicated deficiencies in judgment or thinking. She has had impairment and sometimes deficiency in mood. As her psychiatric disability has produced deficiency in work and mood, but not in school, family relations, judgment, or thinking, it has not produced deficiencies in most of those areas. It has not produced total occupational and social impairment. As it has not met or approximated the criteria for a rating higher than 50 percent, the Board denies a rating higher than 50 percent from December 18, 2019, or for any period. 6. and 7. Migraine headaches The Veteran has appealed for ratings for migraine headaches higher than 10 percent from November 25, 2014, and 30 percent from May 14, 2019. VA evaluates migraine headaches under 38 C.F.R. § 4.124A, Diagnostic Code 8100, as follows: With very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability 50 percent With characteristic prostrating attacks occurring on an average once a month over last several months 30 percent With characteristic prostrating attacks averaging one in 2 months over last several months 10 percent With less frequent attacks 0 percent The Veteran's service treatment records reflect findings of headaches and migraine headaches from the late 1990s forward. Her service treatment records from 2011 to 2014 do not provide information about the frequency and severity of her headaches. On VA examination in June 2015, the Veteran reported that her migraine headaches were rare. She stated that she mainly had tension headaches, which occurred three to four times per week and lasted two to three hours each. She indicated that headaches caused her to miss work a couple of days per month. In VA treatment in June 2015 the Veteran reported having tension headaches and tension in her neck and shoulders. The Veteran had private physical therapy in 2013 through 2015 for problems including low back pain and neck pain. In July 2015, she reported ongoing neck pain and, currently, daily headaches. She stated that the headaches had become an issue in the last several months. In VA treatment in September 2015, the Veteran reported headaches. In the September 2015 DRO hearing, in response to statements from her representative, the Veteran affirmed that she had headaches regularly. She affirmed that the headaches maybe occurred as frequently as once a day and she affirmed that they maybe occurred as frequently as once a day. She affirmed that not necessarily all of her headaches were debilitating, but that they were debilitating regularly. She agreed with her representative's plan to submit a headache log. In VA treatment in August 2017, the Veteran reported headaches. In private chiropractic treatment in September to December 2017, the Veteran reported pain in the cervical and lumbar areas of her spine and in her upper and lower extremities. She also reported headache. Over more than ten treatment visits she described her combined musculoskeletal and headache pain as between 3 and 7 out of 10 in severity, and as present 20 to 50 percent of the time. In a March 2019 claim for VA vocational rehabilitation, the Veteran reported that her migraines were bad and that they lasted the entire day. She stated that with migraines she had nausea and needed to be in a dark, quiet area. In the May 2019 Board hearing, the Veteran reported having full-blown migraines two to four times per month, and lesser headaches three to four times per month. She stated that during the full-blown migraines she had to stay in bed, she was very sensitive to light, and she had nausea. She related that she had no capacity on those days. She stated that sometimes pain medication sometimes reduced symptoms such that she could function a little, and sometimes the medication did not. She reported that during the lesser headaches she was unable to work for a few hours. In the June 2015 VA examination, the Veteran reported that her headaches made her miss about two days of work per month. A headache severe enough to prevent working can reasonably be considered prostrating. In private treatment in July 2015, the Veteran related that her headaches had been an issue for several months. In 2015 she indicated that, for several months prior to June 2015, her headaches made her unable to work about two days a month. The disability picture for 2015 is consistent with or that least comparable to the criteria for a 30 percent rating. The Board grants a 30 percent rating from November 25, 2014, the initial date of service connection. The Veteran has provided information on the effects of her headaches from 2014 forward. She indicated in the June 2015 VA examination that headache attacks kept her from working a couple of days per month. Her responses in the September 2015 DRO hearing, that some of her possibly daily, or possibly not daily, headaches were debilitating, were not specific enough to indicate how much work her headaches caused her to miss. In the May 2019 Board hearing she reported that headache attacks incapacitated her two to four times per month. Headache episodes reported have affected her economic adaptability up to four days per month. Loss of four days of work per month does not constitute or even approach severe economic inadaptability. Her migraine headaches thus have not, at any time since separation from service, met the criteria for a rating higher than 30 percent. The Board denies a rating higher than 30 percent. 8. and 9. Lumbar strain The Veteran has appealed for ratings for lumbar strain higher than 10 percent from November 25, 2014, and 20 percent from July 21, 2015. VA evaluates lumbar strain under 38 C.F.R. § 4.71a, Diagnostic Code 5237. The rating criteria for lumbar strain did not change with the revisions effective February 7, 2021. Lumbar strain is evaluated under a General Rating Formula for Diseases and Injuries of the Spine (General Spine Formula) at 38 C.F.R. § 4.71a, as follows: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire thoracolumbar spine 50 percent Forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine 40 percent Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis 20 percent Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height 10 percent Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. In private physical therapy in February 2013, active motion of the Veteran's lumbar spine in forward flexion, extension, later flexion to each side, and rotation to each side, was to 75 percent of full. In January 2014, active motion of her lumbar spine was to 75 percent of normal for forward flexion, 50 percent for extension, 85 percent for lateral flexion to each side, and 90 percent for rotation to each side. On VA examination in June 2015, the ranges of motion of the Veteran's thoracolumbar spine were to 80 degrees of forward flexion, 25 degrees of extension, 30 degrees of lateral flexion to each side, and 30 degrees of rotation to each side. There was pain with extension that did not result in functional loss. After three repetitions the ranges of motion remained the same. There was no evidence of pain with weightbearing. Lumbar spine x-rays showed normal vertebral body alignment and stature and no disc space narrowing or significant degenerative change. In private physical therapy on July 31, 2015, forward flexion of the Veteran's lumbar spine was limited to 50 degrees. Extension was limited to 15 degrees. The treating clinician found mild limitations in lateral flexion and in rotation but did not report the remaining ranges of motion in those directions in degrees. In the September 2015 DRO hearing, the Veteran reported that she had low back pain with standing and had to sit and rest after standing for any significant time. In the May 2019 Board hearing, the Veteran stated that her lumbar strain now made standing difficult. She reported that she resigned from a childcare job because her lumbar strain made her unable to manage the physical demands. She stated that she had considerable limitation of motion of her low back. She related that her low back pain interfered with sleep. On VA examination in December 2019, the Veteran reported a gradual increase in low back pain. She related decreased ranges of motion of her low back. She stated that while she worked in childcare her back gave out and she fell with a child. She reported low back pain at 7 out of 10 in severity at rest and at 10 out of 10 when standing. She related difficulty with prolonged standing and walking. She noted that difficulty standing also caused difficulty cooking. She stated that limitation of positions due to pain caused difficulty with sex. She stated that her back problems made her unable to squat and unable to sit for long periods. She reported that she worked as a therapist. She stated that her back problems had caused her to miss up to one week of work time over the preceding twelve months. She reported treatment with ibuprofen and Tylenol. The examiner continued the diagnosis of lumbar strain and added a diagnosis of intervertebral disc syndrome (IVDS). The examiner found motion of the Veteran's thoracolumbar spine to 55 degrees of forward flexion, 20 degree of extension, 25 degrees of lateral flexion to each side, and 15 degrees of rotation to each side. There was pain on motion with all motions, and that pain caused functional loss. After three repetitions, the ranges of motion remained the same. The examiner indicated that ranges of motion tested were active and that testing of passive motion of the spine cannot be done safely. The examination was medically consistent with the Veteran's account of functional loss with repetitive use over time. There was evidence of pain with weightbearing. There was no objective evidence of pain in a non-weightbearing position at rest. Prior to February 7, 2021, VA evaluated IVDS under the General Spine Formula or under a Formula for Rating IVDS Based on Incapacitating Episodes (Incapacitating Episodes Formula), whichever resulted in a higher rating. The Incapacitating Episodes Formula provides for a 60 percent rating with incapacitating episodes having a total duration for at least 6 weeks over that past 12 months. The rating is 40 percent if, over the past 12 months, such episodes have a total duration of at least 4 weeks but less than 6 weeks, 20 percent if at least 2 weeks but less than 4 weeks, and 10 percent if at least one week but less than 2 weeks. See 38 C.F.R. § 4.71a (2020). From February 7, 2021, a back disorder is to be rated as IVDS only when there is disc herniation with compression and/or irritation of the adjacent nerve root. Disorders rated as IVDS are rated the same way as before February 7, 2021. As the earlier version of the rating criteria potentially is more favorable to the Veteran, that Board is applying the earlier version. From November 24, 2014, through July 30, 2015, the limitations of motion of the Veteran's thoracolumbar spine were consistent with the criteria for a 10 percent rating and did not meet or approach the criteria for a higher rating. Pain on motion and diminished endurance did not produce further impairment to the extent that impairment was consistent with the criteria for a rating higher than 10 percent. The strain was no manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The preponderance of the evidence is against a rating higher than 10 percent for that period. The Board denies a higher rating. From July 31, 2015, the limitations of motion of the Veteran's thoracolumbar spine have been with the criteria for a 20 percent rating and have not met or approached the criteria for a higher rating. Pain on motion and diminished endurance have not produced further impairment to the extent that impairment has been consistent with the for the General Spine Formula criteria for a rating higher than 20 percent. Considering the Incapacitating Episodes Formula, the Veteran has not reported incapacitating episodes. The time lost from work she reported was up to one week in 12 months. Even if considered incapacitating episodes, that amount of time would not warrant a rating higher than 20 percent. Under either formula then, the preponderance of the evidence is against a rating higher than 20 percent. The Board denies a higher rating. 10. Left knee disability The Veteran has appealed for an initial (effective November 15, 2014), rating higher than 10 percent for left knee patellofemoral pain syndrome. VA has evaluated that disability under 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under that code, limitation of flexion of the leg at the knee is rating at 30 percent if flexion is limited to 15 degrees, 20 percent if limited to 30 degrees, 10 percent if limited to 45 degrees, and 0 percent if limited to 60 degrees. Those rating criteria did not change with the regulation revisions effective February 2, 2021. During service the Veteran was treated for bilateral knee pain with running. After service, in a May 2015 statement, she reported chronic knee pain. In a June 2015 VA examination, the Veteran reported left knee discomfort with squatting. That knee had motion from 0 to 140 degrees. There was no evidence of pain with weight bearing. After three repetitions, the range of motion remained the same. The knee had 5/5 muscle strength in flexion and extension. On testing the knee was stable. In the September 2015 DRO hearing, the Veteran reported that occasionally her knees swelled. She stated that her knees popped and had pain, especially after walking for more than ten or fifteen minutes, standing for more than twenty minutes, or climbing more than three flights of stairs. She reported that at least three times in the last year her knees had caused her to fall when descending stairs. In the May 2019 Board hearing, the Veteran related that her left knee was swollen most of the time. She stated that left knee pain limited how long she could walk, stand, or sit. On VA examination in December 2019, the Veteran reported worsening pain in both knees. She related trouble climbing stairs. She reported weakness that had resulted in falls. She reported pain with 5 out of 10 severity at rest and 8 out of 10 severity when climbing stairs. The ranges of motion of her left knee were from 0 to 70 degrees. She could not squat. The examiner noted evidence of sharp pain on motion. After three repetitions, the ranges remained the same. There was objective evidence of pain on passive motion and without weightbearing. The knee had 3/5 muscle strength. The examiner attributed the weakness partly to an unrelated condition. On testing there was no evidence of instability. Flexion of the Veteran's left knee has not been limited to 30 degrees. Her left knee disorder has produced diminished endurance, pain with motion, painful motion with and without weightbearing, and weakened motion. Those factors have not produced impairment comparable to reduction of flexion to 30 degrees. She has attributed falls to left and right knee problems; but testing on examinations has not shown knee instability. The preponderance of the evidence is against a rating higher than 10 percent for her left knee disability. 11. Right knee disability The Veteran has appealed for an initial (effective November 15, 2014), rating higher than 10 percent for right knee patellofemoral pain syndrome and strain. VA has evaluated that disability under 38 C.F.R. § 4.71a, Diagnostic Code 5260. During service the Veteran was treated for bilateral knee pain with running. In private physical therapy in January 2014, she reported right knee pain. She stated that prolonged standing aggravated achiness, due to fatigue. A clinician noted right knee guarding and pain due to popliteus tightness. In February 2014 a clinician instructed the Veteran in exercises to strengthen her hamstring muscle. After service, in a May 2015 statement, the Veteran reported chronic knee pain. In a June 2015 VA examination, the Veteran reported pain with bending her right knee. She reported right knee swelling and weakness. That knee had motion from 0 to 140 degrees. There was no evidence of pain with weight bearing. After three repetitions, the range of motion remained the same. The knee had 5/5 muscle strength in flexion and extension. On testing the knee was stable. In the September 2015 DRO hearing, the Veteran reported that occasionally her knees swelled. She stated that her knees popped and had pain, especially after walking for more than ten or fifteen minutes, standing for more than twenty minutes, or climbing more than three flights of stairs. She reported that at least three times in the last year her knees had caused her to fall when descending stairs. In the May 2019 Board hearing, the Veteran related that her right knee was swollen most of the time. She stated that right knee pain limited how long she could walk, stand, or sit. On VA examination in December 2019, the Veteran reported worsening pain in both knees. She related trouble climbing stairs. She reported weakness that had resulted in falls. She reported pain with 5 out of 10 severity at rest and 8 out of 10 severity when climbing stairs. The ranges of motion of her right knee were from 0 to 70 degrees. She could not squat. The examiner noted evidence of sharp pain on motion. After three repetitions, the ranges remained the same. There was objective evidence of pain on passive motion and without weightbearing. The knee had 3/5 muscle strength. The examiner attributed the weakness partly to an unrelated condition. On testing there was no evidence of instability. Flexion of the Veteran's right knee has not been limited to 30 degrees. Her right knee disorder has produced diminished endurance, pain with motion, painful motion with and without weightbearing, and weakened motion. Those factors have not produced impairment comparable to reduction of flexion to 30 degrees. She has attributed falls to left and right knee problems; but testing on examinations has not shown knee instability. The preponderance of the evidence is against a rating higher than 10 percent for her right knee disability. REASONS FOR REMAND 1. Decreased sense of smell (hyposmia) The Board is remanding this issue for additional medical opinion. The Veteran reports that she lost nearly all sense of smell after her deployment to Saudi Arabia. The Veteran had treatment in service for sinusitis. In June 1994 x-rays of her sinuses report showed mucosal thickening consistent with chronic sinusitis changes. On VA examination in June 2015, the Veteran reported that over an eight year period friends told her that she does not notice the smells that other people do. She stated that in service in about 2000 she worked around jet fuel. She reported that over time she had decreasing perception of tastes, especially salty tastes. She indicated that she could distinguish all major tastes. On qualitative smell testing, she correctly identified 29 out of 40 smells. The score was in the 25th percentile. The examiner stated that the score was not evidence of anosmia or malingering. On nasal endoscopy her nasal structures appeared normal. The examiner found that the Veteran's service treatment records showed treatment for acute, non-complicated sinusitis. The examiner expressed the opinion that the Veteran's hyposmia was less likely than not related to her service, including the sinusitis treated in service. In August 2019 physiology professor D. J. H., Ph.D., wrote that she reviewed the Veteran's history and medical records. Dr. H. expressed the opinion that it is at least as likely as not that multiple disorders that the Veteran has, including olfaction loss, resulted from events during her service. In reaching an opinion regarding the likely etiology of the Veteran's hyposmia, the 2015 VA examiner relied on a finding that the Veteran's sinusitis in service was acute and non-complicated. That finding appears to be inconsistent with the sinus x-rays in service in 1994 that showed mucosal thickening consistent with chronic sinusitis changes. The Board is remanding the issue for additional medical review of the file, including careful consideration of all evidence regarding the condition and illness involving the Veteran's sinuses, and opinion as to the likelihood of a relationship between sinusitis in service and the current hyposmia. The matters are REMANDED for the following action: (Continued on the next page) 1. Provide the Veteran's claims file to an otolaryngologist or other appropriate physician for review. Ask the reviewer to consider in particular the Veteran's history of sinusitis and other sinus conditions during and after her active service periods. Ask the reviewer to provide opinion as to whether it is at least as likely as not that sinusitis and/or other sinus conditions during the Veteran's service proximately caused or resulted in her current hyposmia. Ask the reviewer to explain each conclusion and opinion. 2. Then review the expanded claims file and review the remanded claim. If the claim remains denied, satisfaction, issue a supplemental statement of the case and afford the Veteran and her representative an opportunity to respond. Then return the case to the Board for appellate review, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. J. Kunz, 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.