Citation Nr: 23047985 Decision Date: 08/31/23 Archive Date: 08/31/23 DOCKET NO. 18-25 560 DATE: August 31, 2023 ORDER An initial rating in excess of 40 percent for lumbar spine degenerative disc disease (DDD) is denied. Prior to February 26, 2021, an initial rating in excess of 10 percent for right lower extremity radiculopathy is denied. From February 26, 2021, a rating of 20 percent, but not higher, for right lower extremity radiculopathy is granted. An initial rating in excess of 10 percent for left lower extremity radiculopathy is denied. Prior to February 26, 2021, an initial rating in excess of 10 percent for a right knee disorder is denied. From February 26, 2021, a rating of 20 percent, but not higher, for a right knee disorder is granted. Prior to February 26, 2021, an initial compensable rating for right eye macular degeneration is denied. From February 26, 2021, a 10 percent rating, but not higher, for right eye macular degeneration is granted. An initial compensable rating for left ear hearing loss is denied. Service connection for right ear hearing loss is granted. Effective January 14, 2014, a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Service connection for a right foot disorder. Service connection for a left foot disorder. Service connection for temporomandibular joint (TMJ). FINDINGS OF FACT 1. The Veteran's back disorder caused forward flexion to 30 degrees or less during flare-ups, with pain, difficulty bending, fatigability, tenderness, muscle spasm and guarding. There is no ankylosis. 2. Prior to February 26, 2021, the Veteran's right lower extremity radiculopathy approximated no worse than mild incomplete paralysis. 3. From February 26, 2021, the Veteran's right lower extremity radiculopathy approximated moderate incomplete paralysis. 4. The Veteran's left lower extremity radiculopathy approximated no worse than mild incomplete paralysis. 5. Prior to February 26, 2021, the Veteran's right knee disorder was not manifested by limitation of flexion to 30 degrees or less, even with consideration of painful motion and flare-ups. 6. From February 26, 2021, the Veteran's right knee disorder approximated limitation of flexion to 30 degrees, when considering her flare-ups. 7. Prior to February 26, 2021, the Veteran's eye condition manifested visual acuity of 20/40 or better for corrected distance and near vision and there were no incapacitating episodes. 8. From February 26, 2021, the Veteran's eye condition manifested visual acuity of 20/50 for corrected distance and near vision, with no incapacitating episodes. 9. The Veteran's left ear hearing loss has been manifested by no worse than level II hearing impairment. 10. The Veteran's right ear hearing loss is related to service. 11. From January 14, 2014, the Veteran's service-connected disabilities precluded her from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial 40 percent rating for lumbar spine DDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5237. 2. Prior to February 26, 2021, the criteria for an initial rating in excess of 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8520. 3. From February 26, 2021, the criteria for a rating of 20 percent, but not higher, for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8520. 4. The criteria for an initial rating in excess of 10 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8520. 5. Prior to February 26, 2021, the criteria for an initial rating in excess of 10 percent for a right knee disorder, based on limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 6. From February 26, 2021, the criteria for a rating of 20 percent, but not higher, for a right knee disorder, based on limitation of motion, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 7. Prior to February 26, 2021, the criteria for an initial compensable rating for eye condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.79, DC 6006. 8. From February 26, 2021, the criteria for a rating of 10 percent, but not higher, for eye condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.79, DC 6006. 9. The criteria for an initial compensable rating for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, DC 6100. 10. The criteria for service connection for right ear hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 11. Effective January 14, 2014, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1978 to April 1987 and from April 1999 to August 1999. She had additional service in the Air Force Reserve. The case is on appeal from an April 2015 rating decision. In February 2021, the Veteran testified at a Board hearing. In a February 2023 decision, the Board denied seven earlier effective date claims, denied a clear and unmistakable (CUE) issue and dismissed a CUE issue. At that time, the Board also remanded the claims remaining on appeal for further development and consideration. While the case was in remand status, in a June 2023 rating decision, the RO granted service connection for migraine headaches, status post left breast biopsy with scars, uterine leiomyoma with anemia, female sexual arousal disorder, left eye macular degeneration and special monthly compensation (SMC) for loss of use of a creative organ. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran, her representative and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Staged ratings are appropriate for an increased-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). An effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings-is predicated on when the increase in the level of disability can be ascertained. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). 1. An initial rating in excess of 40 percent for lumbar spine DDD. Specific Legal Criteria The General Rating Formula for evaluating the spine provides for a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; 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. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; 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. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, DC 5237. The Board notes the rating criteria for evaluating spine disorders was revised, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020, as corrected). Generally, a change in rating criteria during the pendency of the appeal applies prospectively, if more favorable. Here, the changes to the rating criteria evaluating disorders of the spine have no impact on the Veteran's rating. Analysis The Veteran contends that an increased rating is warranted for her back disability in excess of 40 percent. Following the July 2014 claim, the Veteran was afforded a March 2015 VA examination in which the examiner diagnosed her with DDD of the lumbar spine. The Veteran reported flare-ups, including when she exerts herself. Range of motion testing revealed forward flexion limited to 25 degrees. No additional loss in flexion was indicated following repetitive testing. The examiner noted the Veteran experiences less movement than normal, pain during motion, interference with sitting, standing and/or weight-bearing and disturbance of locomotion. He indicated the Veteran is unable to stand for prolonged periods of time and has limited range of motion of her back. During the February 2021 Board hearing, the Veteran reported worsening back symptoms, including significant pain and trouble getting out of bed every morning. The claim came before the Board in February 2023 and was remanded for further development, to include a VA examination to determine the severity of the back disorder. The Veteran was afforded a June 2023 VA examination in which she reported flare-ups, including severe pain, which is continuous and chronic. She stated this pain is "extreme" and is precipitated by prolonged sitting and standing. Range of motion testing revealed forward flexion limited to 50 degrees and extension to 10 degrees with pain throughout testing. With repetitive testing, additional reduction in flexion to 40 degrees was found. Further, with flare-ups, the Veteran's forward flexion was limited to 30 degrees. The examiner noted she has tenderness, muscle spasm and guarding. He indicated the Veteran has no spinal ankylosis. He noted the Veteran requires the constant use of a cane for support and her back disability causes functional impairment on her ability to work, to include difficulty sitting and standing for prolonged periods, and trouble walking due to pain. The Board finds the Veteran's service-connected back disorder most closely approximates the current 40 percent rating and an increased rating is not warranted. Her forward flexion has approximated 30 degrees or less, and she experiences severe back pain, along with other symptoms. However, the Board notes ankylosis has not been found in the medical evidence of record, or even functional ankylosis, and the Veteran has not asserted that she experiences ankylosis. The Board determines the VA examinations during the appeal period, including dated March 2015 and June 2023 do not support the presence of ankylosis or even functional ankylosis. While the Board acknowledges the severity of the Veteran's low back symptoms, including pain, weakness, and limited range of motion, these symptoms are contemplated by the assigned rating. The Board finds there is no basis to assign a disability rating higher than 40 percent for the service-connected back disability, absent ankylosis, functional ankylosis or intervertebral disc syndrome (IVDS) requiring bed rest of at least 6 weeks within any 12 months during the rating period. Thus, a 40 percent rating is the maximum rating for limitation of motion. To the extent that any of the range of motion findings do not comport with the holdings in Correia v. McDonald, 28 Vet. App. 158 (2016), Sharp v. Shulkin, 29 Vet. App. 26 (2017) and the mandates of 38 C.F.R. § 4.59, the Board finds it is harmless error. Here, such findings could not result in a higher rating for the Veteran's spine disability as the Veteran has been awarded the maximum rating for limitation of motion for that disability for the entirety of the period on appeal, absent ankylosis. In sum, the Board finds an initial rating in excess of 40 percent for the Veteran's back disorder is not warranted. The evidence of record is persuasively against a back rating in excess of 40 percent at any time during the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. ? 2. An initial rating in excess of 10 percent for right lower extremity radiculopathy. 3. An initial rating in excess of 10 percent for left lower extremity radiculopathy. Specific Legal Criteria The Veteran's right and left lower extremity radiculopathy for the sciatic nerve are rated under the peripheral nerve impairment provisions of 38 C.F.R. § 4.124a, DC 8520. A 10 percent rating is warranted where there is mild incomplete paralysis of the sciatic nerve. A 20 percent rating is warranted where there is moderate incomplete paralysis of the sciatic nerve. A 40 percent rating is warranted where there is moderately severe incomplete paralysis of the sciatic nerve. A rating of 60 percent is warranted for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy. The highest rating of 80 percent is warranted with complete paralysis of the sciatic nerve (where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or lost). For rating disease of the peripheral nerves, the term "incomplete paralysis," indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. For the purposes of evaluating these disabilities, moderate is "tending toward the mean or average amount or dimension" and "severe" is "of a great degree." See www.merriam-webster.com/dictionary/moderate; www.merriam-webster.com/dictionary/severe. ? Analysis The Veteran contends that increased ratings are warranted for her service-connected bilateral lower extremity radiculopathy disabilities. The Veteran was afforded a March 2015 VA examination in which the examiner indicated the Veteran has bilateral lower extremity radiculopathy. He stated the Veteran's bilateral lower extremity radiculopathy resulted in mild paresthesias and/or dysesthesias and mild numbness. He further indicated the Veteran's overall level of severity is mild for both lower extremities. During the February 2021 Board hearing, the Veteran reported worsening bilateral lower extremity symptoms. She testified that her right lower extremity has resulted in total numbness, and she has had falls due to lower extremity pain and weakness. The claims came before the Board in February 2023 and were remanded for further development, to include a VA examination to determine the severity of the lower extremity conditions. The Veteran was afforded a June 2023 VA examination in which the examiner indicated her right lower extremity has moderate intermittent pain and her left lower extremity suffers mild intermittent pain. He stated the Veteran's right lower extremity has moderate numbness and her left lower extremity experiences mild numbness. The examiner further indicated the Veteran has sciatic nerve involvement in both lower extremities. After a careful review of the evidence, the Board determines the Veteran's right lower extremity radiculopathy approximates moderate incomplete paralysis from February 26, 2021, the date of the Board hearing. As such, an increased rating to 20 percent for the Veteran's right lower extremity radiculopathy is warranted from February 26, 2021. The Board finds her right lower extremity radiculopathy approximated no worse than mild incomplete paralysis prior to February 26, 2021, and her left lower extremity radiculopathy approximated no worse than mild incomplete paralysis during the appeal period. Accordingly, a right lower extremity rating in excess of 10 percent is not warranted prior to February 26, 2021, and a rating in excess of 10 percent for left lower extremity radiculopathy is not supported. With regard to the right lower extremity radiculopathy disability, the Board finds prior to the February 2021 Board hearing, a rating in excess of 10 percent is not supported. In this regard, the March 2015 VA examination report indicated the Veteran's right lower extremity radiculopathy resulted in mild paresthesias and/or dysesthesias and mild numbness. The examiner further indicated the Veteran's overall level of severity is mild for the right lower extremity. However, from the February 2021 Board hearing, an increased rating to 20 percent for the right lower extremity disorder is warranted. At the February 2021 Board hearing, the Veteran testified that her lower extremity symptoms have worsened. Subsequently, the June 2023 VA examiner reported she experiences right lower extremity moderate intermittent pain and moderate numbness. The Board finds that the evidence supports a factually ascertainable increase in disability to 20 percent as of February 26, 2021, rather than the specific date of the June 2023 VA examination. See Swain, 27 Vet. App. at 219. Moreover, the June 2023 VA examination confirmed a worsening in the Veteran's right lower extremity radiculopathy which was asserted during the Board hearing. As such, a 20 percent right lower extremity radiculopathy rating is supported from February 26, 2021. While an increased rating to 20 percent for the right lower extremity is supported from February 26, 2021, a further increased rating is not supported. In this regard, the evidence has not suggested the Veteran's right lower extremity radiculopathy approximates moderately severe impairment and 40 percent rating. With regard to the left lower extremity radiculopathy disability, the Board finds a rating in excess of 10 percent is not warranted. The March 2015 examiner indicated her left lower extremity radiculopathy resulted in mild paresthesias and/or dysesthesias and mild numbness, along with an overall level of severity of mild. Further, the June 2023 examiner indicated she has left lower extremity mild intermittent pain and mild numbness. As such, a rating in excess of 10 percent for left lower extremity radiculopathy is not warranted. In sum, after resolving reasonable doubt in the Veteran's favor, the Board finds her right lower extremity radiculopathy disorder is increased to 20 percent from February 26, 2021. However, prior to that date, an initial rating in excess of 10 percent is not warranted for the right lower extremity and additionally, a rating in excess of 10 percent for left lower extremity radiculopathy is not supported. The evidence of record is persuasively against increased bilateral lower extremity radiculopathy ratings in excess of that awarded herein. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. A rating in excess of 10 percent for a right knee disorder. Specific Legal Criteria The Veteran's right knee disorder has been rated under DC 5260, pertaining to limitation of flexion of the knee. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees. A 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees. A 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees. A 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Limitation of motion may also be rated under DC 5261 for limitation of extension of the knee. Limitation of extension of a leg to 5 degrees warrants a zero percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. A 50 percent rating requires that extension be limited to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261. Normal range of motion of the knee is zero to 140 degrees. See 38 C.F.R. § 4.71, Plate II. From February 7, 2021, The Board notes the rating criteria for evaluating knee disorders was revised, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020, as corrected). However, the rating criteria for DC 5260 were unchanged. Analysis The Veteran contends that her right knee disorder is more severe than the currently assigned 10 percent rating. The Veteran was afforded a March 2015 VA examination for her right knee disability in which she was diagnosed with degenerative osteoarthritis of the knee. She reported flare-ups almost every day which causes her knee to lock up. Range of motion testing revealed flexion limited to 135 degrees. The examiner noted she has less movement than normal, weakened movement, pain during motion, instability, disturbance of locomotion and interference with sitting, standing and weight-bearing. He indicated the Veteran is unable to stand or walk for prolonged periods of time. The Veteran was afforded a February 2021 Board hearing, in which she reported worsening right knee symptoms. She stated she has difficulty standing and walking, as well as diminished balance due to the right knee disorder. The claim came before the Board in February 2023 and was remanded for further development, to include a VA examination to determine the severity of the disability. The Veteran was afforded a June 2023 VA examination in which she reported severe flare-ups, to include falling down unexpectedly. She stated the flare-ups are precipitated by walking, extension, climbing stairs and other daily activities. The functional impairment was noted as trouble stooping, crawling, jumping, with coordination and poor balance. Range of motion testing revealed flexion limited to 60 degrees with pain during testing. The examiner noted crepitus and localized tenderness or pain on palpation. After repetitive testing, no additional loss in range of motion was found. However, with flare-ups, the examiner indicated her right knee flexion was further limited to 40 degrees. The examiner reported there is no ankylosis of the right knee. He noted there is recurrent subluxation and instability and that the Veteran requires the constant use of a cane for support. The examiner stated the right knee disorder impairs the Veteran's ability to work, including with difficulty with walking and climbing stairs. The Board determines an increased rating to 20 percent is warranted for the right knee disorder from February 26, 2021, the date of the Board hearing. The Board finds the subsequent June 2023 VA examination showed a worsening right knee disability suggestive of imitation of flexion to 30 degrees, and a 20 percent rating, per DC 5260. The Board determines prior to February 26, 2021, an initial rating in excess of 10 percent is not warranted for the right knee disorder. Thus, the Board finds an increased right knee rating to 20 percent, based on limitation of motion, is warranted effective February 26, 2021, but not earlier. For the initial rating period, prior to February 26, 2021, the Board finds the Veteran's right knee disorder exhibited pain and limited motion but did not approximate flexion limited to 30 degrees or extension limited to 15 degrees. The March 2015 VA examination report indicated the Veteran has flare-ups almost every day which causes her knee to lock up. However, range of motion testing revealed flexion limited to 135 degrees with reduced movement and weakness. While pain and other symptoms were found, the evidence does not support flexion limited to 30 degrees and an initial rating in excess of 10 percent is not warranted. From the February 2021 Board hearing, the Board determines a right knee rating of 20 percent is supported. In this regard, the June 2023 VA examiner indicated the Veteran has severe flare-ups, to include causing her to fall down unexpectedly and which are precipitated by walking, extension, climbing stairs and other daily activities. Range of motion testing revealed flexion limited to 60 degrees with pain during testing. During flare-ups, the examiner indicated her flexion was further limited to 40 degrees. He further reported recurrent subluxation and instability and that the Veteran requires the constant use of a cane for support. Therefore, the June 2023 VA examination report supports that the Veteran's right knee worsened and that her flexion approximates limitation to 30 degrees. The Board finds from the February 2021 Board hearing, an increased rating to 20 percent for the right knee is supported. At the February 2021 Board hearing, the Veteran testified that her right knee symptoms have worsened. Subsequently, the June 2023 VA examiner indicated worsening right knee symptoms and the Board finds that the evidence supports a factually ascertainable increase in disability to 20 percent as of February 26, 2021, rather than the specific date of the June 2023 VA examination. See Swain, 27 Vet. App. at 219. Moreover, the June 2023 VA examination confirmed a worsening in the Veteran's right knee disorder which was asserted during the Board hearing. As such, a 20 percent right knee disorder rating is supported from February 26, 2021. While an increased rating to 20 percent for the right knee disorder is supported from February 26, 2021, a further increased rating is not supported. In this regard, the evidence has not suggested that the Veteran's right knee is limited in flexion to 15 degrees or limited in extension to 20 degrees. Thus, from February 26, 2021, a further increased rating in excess of 20 percent is not supported. In sum, the evidence supports an increased rating to 20 percent for the Veteran's right knee disorder, based on limitation of motion, from February 26, 2021. However, the evidence is persuasively against a rating in excess of 20 percent from February 26, 2021, and in excess of 10 percent prior to that date. Reasonable doubt has been resolved in the Veteran's favor and a further increased rating, aside from that awarded herein, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 5. An initial compensable rating for bilateral eye condition. Specific Legal Criteria The Veteran's eye disability has been rated under DC 6006. During the pendency of this appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Prior to May13, 2018, DC 6006 provided an evaluation pursuant to the General Rating Formula. The General Rating Formula instructed to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Prior to May 2018, DC 6006 also provides a rating where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in both eyes is 20/40, a zero percent rating is warranted. Where the visual acuity in the poorer eye is 20/50, a 10 percent rating is warranted where vision in the other eye is either 20/50 or 20/40. Where the visual acuity in the poorer eye is 20/70, the following ratings apply; a 30 percent rating is warranted where vision in the other eye is also 20/70; a 20 percent rating is warranted where vision in the other eye is 20/50. A 10 percent rating is warranted where vision in the other eye is 20/40. Under the current regulations for DC 6006, where documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent disability rating is warranted. Where documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent disability rating is warranted. Where documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent disability rating is warranted. Where documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent disability rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. 38 C.F.R. § 4.79. Analysis After the grant for the left eye after the Board's remand, the issue is now one for bilateral eye macular degeneration. The Veteran contends that a compensable rating is warranted for her service-connected eye disability. The Veteran was afforded a February 2018 VA examination in which she was diagnosed with bilateral age-related combination cataract and right eye macular degeneration, non-specific. The examiner indicated right eye uncorrected distance vision of 20/40 or better and uncorrected near vision of 20/200. However, he reported right eye corrected distance vision of 20/40 or better and corrected near vision of 20/40 or better. He stated the Veteran has dry eye in her corneas and age-related combination cataract in both eyes. The examiner indicated there are no incapacitating episodes due to the right eye disorder. He noted the Veteran experiences right macular RPE mottling. He stated the Veteran has stable ocular health, bilateral age-related combination cataract and correctable visual acuity in both eyes. He indicated the Veteran's right eye macular changes were found to be stable without change in acuity and without visual distortion. The Veteran was afforded an April 2018 VA examination in which similar findings and symptoms were indicated as the prior February 2018 examination, including bilateral dry eye, cataract and left eye macular RPE mottling. The April 2018 visual acuity testing for the right eye was similar, as the examiner indicated right eye corrected distance vision of 20/40 or better and corrected near vision of 20/40 or better, and he found no incapacitating episodes due to the right eye disability. During the February 2021 Board hearing, the Veteran reported worsening right eye symptoms. She stated her vision and other eye symptoms have worsened since the last VA examination and an additional VA examination as to the severity of the service-connected right eye disorder was requested. The claim was remanded by the Board in February 2023 for further development, to include a VA examination to determine the severity of the right eye disorder. The Veteran was afforded a March 2023 VA examination in which she was diagnosed with dry macular degeneration, cortical cataract and dry eye syndrome. Vision testing showed uncorrected distance vision of 20/70 in both eyes and uncorrected near vision of 20/100 in the right eye and 5/200 in the left eye. Corrected vision results include distance vision of 20/50 in the right eye and 20/40 in the left eye, as well as near vision of 20/50 in the right eye and 20/40 in the left eye. Treatment for the Veteran's eye includes over the counter artificial tear drops and no incapacitating episodes were noted by the examiner. Moreover, the examiner indicated there are no medical visits documented related to the right eye disorder. The Board determines an increased rating to 10 percent is warranted for the Veteran's eye condition from February 26, 2021, the date of the Board hearing. The Board finds subsequent to the hearing, the March 2023 VA examination confirmed worsening eye vision, suggestive of a 10 percent rating per the rating criteria for DC 6006, prior to May 2018. As noted, when there is a change in the rating criteria during the appeal period, as here, the Board will consider the claim in light of both the former and revised schedular rating criteria and apply whichever is more favorable. Here the pre-May 2018 rating criteria allow for a 10 percent right eye rating based on the Veteran's corrected eye vision found to be 20/50 for both distance and near testing. The Board finds prior to February 26, 2021, a compensable right eye rating is not supported. For the initial rating period, prior to February 26, 2021, the evidence includes the February 2018 and April 2018 VA examination reports which indicated corrected distance vision of 20/40 or better and corrected near vision of 20/40 or better in the eye. The examiner further indicated there are no incapacitating episodes due to the eye disorder. He stated the Veteran has stable ocular health, bilateral age-related combination cataract and correctable visual acuity in both eyes. As such, prior to February 2021, an initial compensable rating is not supported, as the Veteran's corrected vision was 20/40 or better in the eye and she had no incapacitating episodes. From the February 2021 Board hearing, a worsening was shown suggestive of a 10 percent right eye rating. In this regard, while incapacitating episodes were still not indicated by the medical evidence of record, the Veteran's eye vision has worsened. The March 2023 examiner indicated the Veteran has corrected eye distance vision of 20/50 and near vision of 20/50. As such, a 10 percent rating is warranted per the pre-May 2018 rating criteria. With regard to the effective date, from the February 2021 Board hearing, an increased rating is supported. In this regard, the March 2023 VA examiner indicated the Veteran has worse vision results upon testing, including distance and near vision of 20/50. Therefore, the March 2023 VA examination report supports that the Veteran's eye disorder worsened, which was asserted by the Veteran during the February 2021 hearing. See Swain, 27 Vet. App. at 219. While an increased rating to 10 percent for the eye disorder is supported from February 26, 2021, a further increased rating is not supported based on the Veteran's visual acuity or lack of incapacitating episodes, as noted above. In sum, the evidence supports an increased rating to 10 percent for the Veteran's eye condition from February 26, 2021. However, the evidence is persuasively against a rating in excess of 10 percent from that date, and an initial compensable rating for the eye condition prior to February 26, 2021, is not warranted. Reasonable doubt has been resolved in the Veteran's favor and a further increased rating, aside from that awarded herein, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 6. An initial compensable rating for left ear hearing loss. Specific Legal Criteria Disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Examinations are conducted using the controlled speech discrimination tests together with the results of the pure tone audiometry test. See 38 C.F.R. § 4.85. The results are analyzed using tables contained in 38 C.F.R. § 4.85, DC 6100. The rating schedule for hearing loss provides that evaluations of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000 and 4000 cycles per second (Hertz). To evaluate the degree of disability from defective hearing, the rating schedule established eleven auditory acuity levels designated from level I for essentially normal acuity through level XI for profound deafness. Id. In cases of exceptional hearing impairment, i.e., when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the Roman numeral designation will be determined, separately for each ear, from either Table VI or Table VIA ("Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average"), whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Additionally, when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, either Table VI or VIA will be used, whichever results in the higher numeral. The numeral will then be elevated to the next higher Roman numeral. 38 C.F.R. § 4.86(b). If impaired hearing is service connected in only one ear, as here, the nonservice-connected ear will be assigned level I hearing impairment subject to the provisions of 38 C.F.R. § 3.383 for special considerations for paired organs. See 38 C.F.R. § 4.85(f). Analysis The Veteran contends that a compensable left ear hearing loss rating is warranted. She was afforded a February 2015 VA audiological examination in which the examiner reported the following pure tone thresholds, in decibels: HERTZ CNC 1000 2000 3000 4000 % LEFT 20 25 25 30 88 The average pure tone threshold was 25 decibels in the left ear with a speech discrimination score of 88 percent. The Veteran also reported missing information due to her hearing loss and that she is unable to hear certain voices and tones. The results of the examination correspond to level II hearing loss in the left ear and reflect a noncompensable rating for the Veteran's left ear hearing loss. 38 C.F.R. § 4.85. The Veteran was afforded a February 2021 Board hearing, in which she reported worsening left ear hearing loss symptoms. She stated her hearing has declined since the previous VA examination nearly 8 years prior. The claim was remanded by the Board in February 2023 for an additional VA audiological examination to determine the etiology of her service-connected left ear hearing loss. The Veteran was afforded a March 2023 VA audiological examination in which the examiner reported the following pure tone thresholds, in decibels: HERTZ CNC 1000 2000 3000 4000 % LEFT 30 35 35 35 100 The average pure tone threshold was 33.75 decibels in the left ear with a speech discrimination score of 100 percent. The Veteran also reported she does not hear well in her day to day life and frequently needs people to repeat themselves. The results of the examination correspond to level I hearing loss in the left ear and reflect a noncompensable rating for the Veteran's left ear hearing loss. 38 C.F.R. § 4.85. The Board finds a compensable rating for the Veteran's left ear hearing loss disability is not warranted at any point during the appeal. In this regard, the mechanical hearing testing of record shows that the Veteran's left ear hearing loss is correctly rated as noncompensable because she experiences no worse than level II hearing loss in her left ear and is not service connected for right ear hearing loss at the time of appeal. See 38 C.F.R. §§ 3.383(a)(3); 38 C.F.R. § 4.85(f). The Board notes that the current decision grants service connection for right ear hearing loss, as discussed below. However, such grant does not support an increased rating for her service-connected left ear hearing loss. In addition, the findings do not show an exceptional pattern of hearing impairment and, thus, 38 C.F.R. § 4.86 is not applicable. 38 C.F.R. §§ 4.85, 4.86, DC 6100. Thus, in applying the rating criteria under DC 6100 to the audiological results, an increased rating is not warranted for the Veteran's left ear hearing loss. In sum, the Board finds that the evidence is persuasively against the increased rating claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and an initial compensable rating for left ear hearing loss is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 7. Service connection for right ear hearing loss. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Analysis The Veteran contends that she has right ear hearing loss which is directly related to service. The Board notes the Veteran is already service connected for left ear hearing loss and tinnitus. Further, the Veteran was exposed to hazardous noise from aircrafts in service. As such, in-service noise exposure is established. Thus, the Board must determine whether the Veteran has current right ear hearing loss, and if so, whether such is related to her in-service noise exposure. The Veteran's service treatment records (STRs) show that in July 1988, shortly after her first service period, she reported during a VA examination that her hearing problems started in service. The examiner noted the presence of hearing loss, although audiological testing revealed no right ear hearing loss at that time. Following the Veteran's July 2014 claim, she was afforded a February 2015 VA audiological examination in which right ear hearing loss was not found by the examiner. See 38 C.F.R. § 3.385. However, the examiner provided a positive nexus opinion. She stated the Veteran's hearing loss is at least as likely as not caused by service. She indicated the Veteran's enlistment examination showed normal hearing and subsequent hearing examinations revealed a significant threshold shift and documented hearing loss complaints. The examiner indicated this is consistent with the findings on examination, as well as the Veteran's known military noise exposure. Therefore, she opined a nexus has been established and the Veteran's hearing loss is causally related to service. During the February 2021 Board hearing, the Veteran testified that she currently has right ear hearing impairment and that such is causally related to service, similar to her service-connected left ear. The claim was remanded by the Board in February 2023 for a VA examination to determine whether the Veteran has current right ear hearing loss, and if so, the etiology of such. The Veteran was afforded a March 2023 VA examination in which current right ear hearing loss was documented. See 38 C.F.R. § 3.385. However, the examiner provided a negative nexus opinion. She indicated the Veteran's military occupational specialty (MOS) in personnel has a low probability for hazardous noise exposure. She stated the Veteran's hearing was within normal limits during her 1988 separation from service with no significant threshold shift noted. She indicated during service the Veteran did not report changes in hearing in the right ear, as opposed to the left ear where worsening was found. Further, the examiner found the Veteran's hearing in 2014 was normal and although noise exposure has been conceded, service connection cannot be granted for the right ear due to noise exposure alone. Thus, she opined the Veteran's right ear hearing loss is not causally related to service. After review of the evidence, and despite the recent March 2023 VA examiner's negative nexus opinion, the Board finds that the Veteran's right ear hearing loss is related to service. The Board determines that the Veteran had in-service complaints for hearing loss and her in-service exposure to hazardous noise has been established. Further, current right ear hearing loss has been confirmed and there are adequate VA opinions in favor of and against the claim. Therefore, when affording her all reasonable doubt, the Board finds the Veteran's right ear hearing loss is causally related to service. As noted, current right ear hearing loss was established per the March 2023 VA examination report. The February 2015 examiner provided a positive nexus opinion and stated the Veteran had a threshold shift and documented hearing loss complaints in service. She concluded the Veteran had known military noise exposure and her right ear hearing loss is causally related to service. In contrast, the March 2023 VA examiner provided a negative nexus opinion. She indicated the Veteran's MOS had a low probability for hazardous noise exposure and hearing loss in the right ear was not documented at separation. As such, she opined the Veteran's right ear hearing loss is not causally related to service. While the Board acknowledges the March 2023 VA opinion, it finds the claim for service connection can still be granted. Moreover, there are medical opinions in favor of and against the claim and the Board determines the evidence has reached a level of equipoise. Therefore, based on the evidence overall, and when resolving reasonable doubt in the Veteran's favor, the Board finds that her current right ear hearing loss is related to service. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection for right ear hearing loss is warranted. ? 8. A TDIU. Legal Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: " The veteran's history, education, skill, and training; " Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and " Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Analysis The Veteran contends that her service-connected disabilities have prevent all substantially gainful employment. The Veteran's July 2014 TDIU application indicated that she became too disabled to work in January 2013 and that she last worked full-time for the Department of State as a human resources specialist in October 2013. The Veteran indicated she is a college graduate and has a master's degree in special education. The relevant medical evidence includes a March 2015 VA examination for the Veteran's service-connected back and bilateral lower extremity disorders which indicated she is unable to stand for prolonged periods of time and she has limited range of motion for her back. With regard to her right knee, the March 2015 examiner opined the Veteran is prohibited from standing or walking for prolonged periods of time due to right knee symptoms. The Veteran was afforded a May 2018 VA examination related to her migraines which indicated she experiences severe migraine symptoms, including pain in her head which radiates, nausea, sensitivity to light and sound, and changes in vision, including blurry and cloudy vision. The examiner noted she has characteristic prostrating attacks and that her ability to work is impaired by her migraines, including that her concentration is affected along with the ability to drive a car due to impaired vision. Following the Board remand in February 2023, the Veteran was afforded June 2023 VA examinations related to her service-connected back, bilateral lower extremity radiculopathy and right knee. With regard to the right knee, the examiner indicated the Veteran reported severe flare-ups, to include falling down unexpectedly. The examiner indicated she has trouble stooping, crawling, jumping, increased coordination and poor balance. The examiner stated the right knee disorder impairs the Veteran's ability to work. He noted when the Veteran was still working, she had trouble walking and climbing stairs due to increasing right knee pain. With regard to the back and lower extremity disorders, the June 2023 examiner indicated she reported flare-ups, including severe pain, which is continuous and chronic. She stated this pain is "extreme" and is precipitated by prolonged sitting and standing. The examiner noted tenderness, muscle spasm and guarding, along with the required constant use of a cane for support. The examiner reported while the Veteran was working, she had trouble sitting for prolonged periods and standing during meetings. He noted the Veteran had significant low back pain, including while walking in long hallways which caused shooting pain to both legs. Additionally, the Veteran was afforded a June 2023 VA migraines examination in which the examiner indicated symptoms of nausea, sensitivity to light and sound, along with changes in vision. He noted the Veteran has characteristic prostrating attacks monthly and that when she was working, her migraines caused constant daily headaches which made it difficult for her to concentrate and increased her irritability during work. After a careful review of the evidence, the Board finds the Veteran's service-connected disabilities have prevented all substantially gainful employment from January 14, 2014. As such, the evidence shows a TDIU is warranted from January 14, 2014. This is a full grant of the benefit sough. The evidence shows the Veteran has not worked during the appeal period and her service-connected disabilities, to include her back, lower extremity radiculopathy, right knee and migraines have caused severe impairment. As noted, the Veteran's back, bilateral lower extremity radiculopathy and right knee conditions have led to severe trouble sitting, and with prolonged periods of walking and standing. Further, her migraines have caused symptoms of pain in her head which radiates, nausea, sensitivity to light and sound, and changes in vision, including blurry and cloudy vision. She has been found to have characteristic prostrating migraine attacks on a monthly basis and her concentration is impacted, along with her ability to drive. The June 2023 examiner indicated the Veteran had daily headaches when she was still working which made it difficult for her to concentrate and increased her irritability during work. Thus, the severity of the symptoms overall supports that the Veteran's service-connected disabilities prevent all substantially gainful employment. Accordingly, a TDIU is warranted from January 14, 2014, the entire appeal period. The Board notes that the Veteran contends in her TDIU application that she became too disabled to work in January 2013; however, her service-connected disabilities are effective from January 14, 2014. Thus, the grant of a TDIU cannot be effective earlier than the initial date of service connection. Furthermore, the schedular criteria for a TDIU have been met since January 14, 2014. From that date, the Veteran's back disability as rated at 40 percent and her overall rating is 90 percent. Thus, from January 14, 2014, the schedular criteria per 38 C.F.R. § 4.16(a) have been met. In sum, after resolving any reasonable doubt in the Veteran's favor, the Board finds that her service-connected disabilities prevented her from securing and following substantially gainful employment from January 14, 2014. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, a TDIU is warranted from January 14, 2014. Based on the noted contentions, the Board considers this grant of a TDIU a full grant of the benefit sought on appeal. Although the Board is remanding other claims for additional development, remand is not necessary for the issues decided herein, as there is no reasonable possibility that further assistance would substantiate the claims. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND 1. Service connection for a right foot disorder. 2. Service connection for a left foot disorder. The Veteran contends that her bilateral foot disorders are causally related to service. Alternatively, she asserts that the conditions are related to her service-connected disabilities. The Board remanded the claims in February 2023 for further development, to include a VA examination to determine the etiology of the disorders. As noted in the prior remand, the Veteran had complaints and treatment throughout service related to her feet. Such records included a June 1981 STR which indicated the Veteran received treatment for her left ankle and foot. She reported pain to the distal portion of her anterior tibia and over the tarsal bones. A later June 1981 STR showed the Veteran had a left foot strain or sprain, and she required crutches for 25 days. A July 1981 STR noted reports of left foot tenderness to the anterior portion of her left foot. Thereafter, a July 1986 STR indicated the Veteran sought treatment for right foot swelling and pain. Following the February 2023 Board remand, the Veteran was afforded a June 2023 VA examination in which the examiner opined the Veteran's feet disorders are not causally related to service or her service-connected disabilities. With regard to direct service connection, the examiner noted that the Veteran had in-service treatment, to include a 1981 sprained left foot and right foot swelling in 1986. However, he stated the remainder of her service records are silent for foot pain or diagnosis. He stated the first record related to left foot treatment following service is in 2005, six years following the Veteran's separation from service. As such, he opined there is no chronicity of care, and a nexus between the current foot disorders and service is not established. With regard to secondary service connection, the examiner indicated there are no records to support that the Veteran has falls or that her back disorder has caused her foot conditions. He indicated the Veteran's foot disorders and her back disability are not medically related. The Board finds the June 2023 VA examination report is not fully adequate with regard to the etiology of the Veteran's foot disorders. While the examiner addressed the Veteran's contentions, he did not adequately discuss the Veteran's in-service treatment. As noted, the Veteran had several treatment records from service which exhibited foot complaints and treatment, to include a June 1981 STR which showed the Veteran had a left foot strain or sprain, and that she required crutches for 25 days. Further, discussion of the lay evidence is required, to include such provided in the February 2021 Board hearing. Thus, an additional VA opinion is required to determine if the Veteran's bilateral foot disorders are causally related to service or her service-connected disabilities. 3. Service connection for TMJ. The Veteran contends that her TMJ had its onset during or is otherwise related to service. Alternatively, she asserts that the disorder preexisted service and was aggravated by such. The claim was remanded by the Board in February 2023 for a VA examination to determine the etiology of the Veteran's TMJ, if diagnosed. The Board took note of the service records which support a pre-service injury to the Veteran's jaw, to include a 1977 accident in which a gunshot wound severely injured her jaw. A December 1990 STR noted the Veteran suffered a prior shattered left jaw due to an inadvertent gunshot wound and that she had her jaw reconstructed. Additionally, in a November 1995 STR and report of medical history, prior to the Veteran's second service period, she reported TMJ symptoms and that the disorder began in service. The Veteran was afforded a March 2023 VA examination in which she was diagnosed with TMJ. The examiner opined the Veteran's jaw disorder preexisted service and was not aggravated during service. He found there was no evidence showing the Veteran's TMJ was permanently worsened during her active service. He indicated the records show the Veteran shattered her jawbone in approximately 1976 and was subsequently diagnosed with TMJ in 1990. The examiner stated there is no evidence showing complications regarding this condition during her active duty and no evidence suggesting permanent worsening of her TMJ. The Board finds the March 2023 VA examination report is not adequate with regard to the etiology of the Veteran's TMJ. While the examiner's opinion is clear that the Veteran's jaw disorder, to include TMJ, preexisted service, he did not adequately address the evidence of record which supports a potential worsening of the Veteran's TMJ during her over nine years of service. In this regard, a November 1995 STR between the Veteran's two service periods contains reports that her TMJ began during service. At the very least, this record supports that the Veteran had symptoms during service related to her jaw and the associated TMJ. Thus, the November 1995 STR is highly relevant and must be considered and addressed by the examiner. Further, the Veteran testified in the February 2021 Board hearing that she had TMJ and bruxism in service. Thus, an additional VA opinion is required to determine if the Veteran's TMJ which preexisted service was aggravated or worsened during service. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate medical professional to determine the nature and etiology of the Veteran's bilateral foot disorders. The examiner should opine as to whether it is at least as likely as not that the Veteran's foot conditions had their onset during, or are otherwise related to, service. The examiner must thoroughly review and discuss the Veteran's foot treatment during service, addressed above. If not related to service, the examiner should opine as to whether it is at least as likely as not that the foot conditions were caused or aggravated by her service-connected disabilities, to include the back disability and associated falls. The examiner should consider the lay evidence in support, to include the February 2021 Board hearing testimony. Aggravation is an increase in severity beyond the natural progress of the disease. 2. Obtain a VA medical opinion from an appropriate medical professional to determine if the Veteran's preexisting TMJ worsened during service. The examiner must opine whether it is clear and unmistakable (i.e., undebatable from a medical standpoint) that the Veteran's preexisting jaw condition, to include TMJ, was not aggravated by service? (Continued on the next page) ? Aggravation is an increase in severity beyond a temporary flare-up or natural progress of the disease. The Veteran's STRs related to a pre-service jaw injury and in-service symptoms, addressed above, should be considered and discussed by the examiner. The examiner should also consider the February 2021 Board hearing testimony in support. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Isaacs, Brandon 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.