Case A25061319

T. V. CASEY · 2025 · Case ID: A25061319

MIXED

Summary

The veteran, who served in the U.S. Marine Corps from September 1988 to July 1990, appeals decisions regarding his right wrist, left knee, lumbosacral spine, left hip scar, and mental health conditions. The Board granted restoration of a 30 percent disability rating for right wrist fusion and degenerative joint disease (DJD), finding the prior reduction improper due to lack of demonstrated improvement. The Board also granted a 50 percent rating for the right wrist disability effective July 7, 2020, finding it functionally equivalent to unfavorable ankylosis. Service connection for a left hip surgical scar, secondary to the right wrist surgery, was granted. The Board granted service connection for depression and anxiety as secondary to the service-connected left knee, back, and right wrist disabilities, resolving doubt in the veteran's favor. However, claims for an increased rating for the right wrist prior to July 7, 2020, for left knee surgical scars, and for a somatic pain disorder were denied. The case was remanded for further development regarding right knee DJD and right shoulder DJD, as the prior VA opinions were inadequate and did not fully address secondary service connection or consider all evidence.

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Docket No.

211215-204715

Full Decision Text

Citation Nr: A25061319
Decision Date: 07/17/25 Archive Date: 07/17/25

DOCKET NO. 211215-204715
DATE: July 17, 2025

ORDER

Restoration of a 30 percent disability rating for right wrist fusion and degenerative joint disease (DJD) is granted.

Entitlement to a disability rating in excess of 30 percent prior to July 7, 2020, for right wrist fusion and DJD is denied.

Entitlement to a 50 percent disability rating, but no higher, since July 7, 2020, for right wrist fusion and DJD is granted.

Entitlement to a 20 percent disability rating since April 14, 2020, but no earlier, for left knee traumatic arthritis with atrophy status post ligament reconstruction, under Diagnostic Code (DC) 5010-5257, is granted.

Entitlement to a separate 20 percent disability rating since April 14, 2020, but no earlier or higher, for limitation of extension related to left knee traumatic arthritis with atrophy status post ligament reconstruction, under DC 5010-5261, is granted.

Entitlement to a compensable (greater than zero percent) disability rating for surgical scars associated with the left knee is denied.

Entitlement to a disability rating in excess of 20 percent for lumbosacral strain is denied.

Service connection for a left hip surgical scar as secondary to the service-connected right wrist fusion status post radial styloidectomy with a left iliac crest bone graft is granted.

Service connection for depression and anxiety, as due to the service-connected left knee traumatic arthritis with atrophy status post ligament reconstruction, lumbosacral strain, and right wrist fusion with DJD, is granted.

Service connection for a somatic pain disorder is denied.

REMANDED

Service connection for right knee DJD status post anterior cruciate ligament revision is remanded.

Service connection for right shoulder DJD is remanded.

FINDINGS OF FACT

1. The reduction of the Veteran's disability rating for the right wrist fusion and DJD was improper because the evidence of record does not persuasively show actual improvement in the Veteran's ability to function under the ordinary conditions of life and work.

2. Prior to July 7, 2020, the evidence of record persuasively weighs against finding the Veteran's right wrist disability resulted in unfavorable ankylosis or the functional equivalent of unfavorable ankylosis.

3. Since July 7, 2020, the evidence of record persuasively weighs in favor of finding the Veteran's right wrist disability resulted in the functional equivalent of unfavorable ankylosis due to diminished ulnar and radial deviation.

4. Since April 14, 2020, the evidence of record persuasively weighs in favor of finding the Veteran's left knee traumatic arthritis with atrophy status post ligament reconstruction has resulted in moderate instability requiring constant use of a knee brace.

5. Since April 14, 2020, the evidence of record persuasively weighs in favor of finding the Veteran's left knee traumatic arthritis with atrophy status post ligament reconstruction has limited his ability to extend his knee to 15 degrees in relation to repetitive use over time and/or during a flare-up.

6. The evidence of record persuasively weighs against finding the left knee surgical scars were painful or unstable; the total surface area was less than 144 in2.

7. The evidence of record persuasively weighs against finding the Veteran's lumbosacral strain resulted in forward flexion no less than 30 degrees or manifested in favorable or unfavorable ankylosis of the thoracolumbar spine, or the functional equivalent of favorable or unfavorable ankylosis.

8. The evidence of record persuasively weighs in favor of finding the left hip scar is directly due to a right wrist radial styloidectomy with a left iliac crest bone graft.

9. Resolving reasonable doubt in favor of the Veteran, his depression and anxiety are due to the service-connected left knee, back, and right wrist disabilities.

10. The record persuasively weighs against finding the Veteran has been clinically diagnosed with a somatic pain disorder.

CONCLUSIONS OF LAW

1. The criteria for restoration of the 30 percent rating under DC 5214 for right wrist fusion with DJD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105, 3.344, 4.1, 4.3, 4.7, 4.124a, DC 5214.

2. The criteria for entitlement to a disability rating in excess of 30 percent rating for right wrist fusion with DJD prior to July 7, 202
wrist disabilities.

10. The record persuasively weighs against finding the Veteran has been clinically diagnosed with a somatic pain disorder.

CONCLUSIONS OF LAW

2. The criteria for entitlement to a disability rating in excess of 30 percent rating for right wrist fusion with DJD prior to July 7, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 5214.

3. The criteria for entitlement to a 50 percent disability rating, but no higher, since July 7, 2020, for right wrist fusion with DJD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, DC 5214.

4. The criteria for a 20 percent disability rating since April 14, 2020, but no earlier, for a knee impairment resulting in instability related to left knee traumatic arthritis with atrophy status post ligament reconstruction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257.

5. The criteria for a separate 20 percent disability rating since April 14, 2020, but no higher or earlier, for limitation of extension related to left knee traumatic arthritis with atrophy status post ligament reconstruction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261.

6. The criteria for an initial disability rating in excess of 20 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5237.

7. The criteria for a compensable (greater than zero percent) disability rating for left knee surgical scars status post arthroscopic surgery have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.118, DCs 7801-7805.

8. The criteria for service connection for left hip surgical scar as secondary to the right wrist fusion status post radial styloidectomy with a left iliac crest bone graft have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

9. The criteria for service connection for acquired psychiatric disorder, to include depression and anxiety as secondary to the service-connected left knee, lumbar spine, and right wrist disabilities, have been met. 38?U.S.C. §§ 1131, 5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

10. The criteria for service connection for a somatic pain disorder have not been met. 38?U.S.C. §§ 1131, 5107; 38?C.F.R. §§?3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from September 1988 to July 1990.

This matter comes before the Board of Veterans' Appeals
bar spine, and right wrist disabilities, have been met. 38?U.S.C. §§ 1131, 5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

10. The criteria for service connection for a somatic pain disorder have not been met. 38?U.S.C. §§ 1131, 5107; 38?C.F.R. §§?3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from September 1988 to July 1990.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2020, June 2021, and August 2021 rating decisions by a Department of Veterans Affairs (VA) regional office, which is the Agency of Original Jurisdiction (AOJ).

The Veteran elected the Board's Evidence Submission docket. See December 2021 VA Form 10182. This restricts the Board's review to the evidence of record at the time of the December 2020 and June 2021 rating decisions and August 2021 Higher-Level Review (HLR) decision (following a July 2020 rating decision) for the respective claims and any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303.

The Board notes that evidence was associated with the claims file during a period that is outside the applicable evidentiary window - between the respective rating decisions and the December 2021 VA Form 10182, and more than 90 days thereafter. Therefore, the Board has not considered this evidence in its present decision. 38 C.F.R. § 20.300(a). However, as to the issues being remanded, the AOJ will consider them in light of the entire claims file upon remand.

If the Veteran would like VA to consider the additional evidence that the Board could not consider with respect to the claims decided herein, the Veteran may file a supplemental claim (VA Form 20-0995) and identify the evidence for the AOJ's consideration. 38 C.F.R. § 3.2501. Specific instructions for filing a supplemental claim are included with this decision.

Propriety of a Rating Reduction

To properly reduce a disability rating, VA must satisfy both procedural and substantive criteria. 38 C.F.R. §§ 3.105, 3.343, 3.344; see also 38 C.F.R. §§ 3.500, 3.501. However, the procedural requirements under 38 C.F.R. § 3.105(e) do not apply if the proposed rating reduction does not result in reduction in the compensation amount, i.e., section 3.105(e) is not applicable where the evaluation of a specific disability is reduced but the amount of compensation is not reduced because the combined rating remains the same or the reduction of one disability is being completed simultaneously with an increase in a rating of one or more other disabilities. VAOPGCPREC 71-91 (Nov. 1991).

The substantive criteria for rating reductions are outlined in 38 C.F.R. § 3.344. For a rating that has been in effect for more than five years, it is essential that the entire record of examination and the medical history be reviewed to ascertain whether the recent examination is full and complete, including all special (ancillary) examinations indicated as a result of general examination and the history of the disability at issue. Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction. Ratings for diseases subject to temporary or episodic improvement will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a); see also Faust v. West, 13 Vet. App. 342, 350 (2000). If doubt remains as to whether the improvement will be maintained under the ordinary conditions of life, the rating agency will continue the rating and order a reexamination in 18, 24, or 36 months. 38 C.F.R. § 3.344(b). The above considerations do not apply to disabilities which have not stabilized and are likely to improve. 38 C.F.R. § 3.344(c); see also Brown v. Brown, 5
evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a); see also Faust v. West, 13 Vet. App. 342, 350 (2000). If doubt remains as to whether the improvement will be maintained under the ordinary conditions of life, the rating agency will continue the rating and order a reexamination in 18, 24, or 36 months. 38 C.F.R. § 3.344(b). The above considerations do not apply to disabilities which have not stabilized and are likely to improve. 38 C.F.R. § 3.344(c); see also Brown v. Brown, 5 Vet. App. 413, 421 (1993); Kitchens v. Brown, 7 Vet. App. 320, 324 (1995).

The United States Court of Appeals for Veterans Claims (Court) held in Brown that there are several general VA regulations that apply to all rating reductions regardless of how long the rating has been in effect for. Brown, 7 Vet. App. at 420-421. Each disability is to be viewed in relation to its history. 38 C.F.R. § 4.1. The AOJ should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. 38 C.F.R. § 4.13. Additionally, it must be determined that improvement in a disability has actually occurred and that such improvement reflects improvement in the ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; see also 38 C.F.R. §§ 4.2, 4.10. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless the Board concludes that the approximate balance of the evidence weighs against the claim. Id.

When VA reduces a disability rating without following the applicable regulations, the reduction is vacated, void ab initio, and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); Greyzck v. West, 12 Vet. App. 288, 292 (1999).

Restoration of a 30 percent disability rating for right wrist fusion and DJD.

A September 2013 rating decision awarded service connection for a right wrist fusion with internal fixation and DJD (with scar) and assigned a 30 percent rating with an effective date of January 26, 2012.

In response to a March 2017 application for a higher rating, May 2017 and August 2017 rating decisions continued the rating. See also March 2017 VA Form 21-526EZ; May 2017 VA Forms 21-0820 & 21-2507a.

In May 2019, VA sent notice of a rating decision that proposed to decrease the disability rating for the right wrist disability from 30 percent to a noncompensable rating (zero percent). See May 2019 Rating Decision & Proposal to Reduce Service Connected Compensation. Following a July 2020 VA examination, a July 2020 rating decision reduced the disability rating for the right wrist disability to 10 percent, effective on October 1, 2020. The reduction was upheld, and 10 percent disability rating continued, in the August 2021 HLR decision.

The Board initially considered the procedural requirements. Here, the reduction of the service-connected right wrist disability from 30 percent to zero percent resulted in a reduction in the Veteran's combined rating. The Veteran was notified of the proposed rating reduction in May 2019. The notice advised he had 30 days to request a hearing and 60 days to submit new evidence. Therefore, the procedural requirements of 38 C.F.R. § 3.105(e) were satisfied.

Turning to the substantive requirements, the Board finds that the evidence does not show there was actual improvement in the Veteran's ability to function under the ordinary conditions of life and work. The provisions of 38 C.F.R. § 3.344(a) apply in this appeal because the 30 percent rating at issue was in effect for more than five years at the time of the July 2020 rating decision.

The July 2020 rating decision, and the August 2021 HLR decision, fail to address whether there was actual improvement in the Veteran's ability to function under the ordinary conditions of life and work with respect to the right wrist disability. Rather, the decisions state only that the March 2017 VA examination report showed objective evidence that the Veteran maintained some degree of motion in his right wrist. See also June 2017 C&P Exam. In an addendum opinion, the VA examiner clarified that there was no ankylosis because the Veteran had some mobility of his right wrist. See also August 2017 C&P Exam. VA continued the 30 percent rating and scheduled a routine reexamination for the future. The July 2020 VA examination report again showed objective evidence that the Veteran continued to maintain some degree of motion in his right wrist; there was no evidence of ankylosis. VA, thus, concluded that there was no longer ankylosis and reduced the disability rating to 10 percent to account for the less than 15 degrees of dorsiflexion (and painful motion with limited palmar flexion).

Though there may have been no evidence of actual ankylosis of the right wrist during the March 2017 and July 2020 VA examinations, the approximate balance of the evidence does not show there was actual improvement under the ordinary conditions of life. The claims file shows that the Veteran was initially afforded a VA wrist examination in June 2013. See August 2013 CAPRI. The diagnosis was right wrist fusion with internal fixation. The clinical examination included range of motion testing showing an endpoint of palmar flexion at 25 degrees and an endpoint of dorsiflexion at zero degrees of dorsiflexion (extension) during active and repetitive range of motion testing. The report did not document range of motion testing for ulnar or radial deviation. The examiner described the Veteran as having less movement in his right wrist with favorable ankylosis between 20 degrees and 30 degrees dorsiflexion. The Board recognizes that the examiner's opinion is inconsistent with the clinical exam that showed endpoint dorsiflexion to zero degrees.

A September 2013 rating decision awarded service connection for the right wrist disability and assigned a 30 percent disability rating with an effective date of January 26, 2012. Of note, the rating decision states that the rating was assigned based on "Favorable ankylosis in 20 degrees to 30 degrees of dorsiflexion."

The Veteran was afforded a second VA wrist examination in June 2017. The diagnosis was right wrist fusion status post scaphoid fracture. The clinical examination showed that the Veteran had "some minimal ability to rotate wrist"; he had zero to 8 degrees of palmar flexion and dorsiflexion and zero to 20 degrees of ulnar and radial deviation. The examiner found no evidence that the Veteran's range of motion would be eroded when considering repetitive use over time or flare-ups (which the Veteran reportedly denied).

The Veteran was afforded a third VA wrist examination in July 2020. The diagnosis was right wrist fusion with internal fixation and DJD (and surgical scar). He reported his current symptoms included an "inability to bend" and problems gripping. He experiences flare-ups on a daily basis; any use of his right hand causes a flare up. The clinical examination showed zero to 10 degrees of palmar flexion, zero to 20 degrees of dorsiflexion, and zero to 10 degrees of ulnar and radial deviation. After three repetitions, he had only zero to 5 degrees of ulnar and radial deviation; the remaining values did not change. The examiner opined that the pain symptoms would cause functional loss with repetitive use over time and flare-ups, which would further reduce the Veteran's dorsiflexion to 10 degrees; palmar flexion would remain at 10 degrees and ulnar and radial deviation at 5 degrees.

The Board finds the June 2013, June 2017, and July 2020 VA examination reports probative and gives them limited weight. The VA examiners sufficiently documented pertinent, objective clinical findings. The examiners appear to have considered the Veteran's description of his symptoms as reported at the time of each examination, including the July 2020 examiner documenting a loss of 5 degrees of ulnar and radial deviation following 3 repetitions and opinion that the Veteran's pain symptoms would erode the endpoint for dorsiflexion to no more than 10 degrees. Nieves-Rodriguez
iflexion to 10 degrees; palmar flexion would remain at 10 degrees and ulnar and radial deviation at 5 degrees.

The Board finds the June 2013, June 2017, and July 2020 VA examination reports probative and gives them limited weight. The VA examiners sufficiently documented pertinent, objective clinical findings. The examiners appear to have considered the Veteran's description of his symptoms as reported at the time of each examination, including the July 2020 examiner documenting a loss of 5 degrees of ulnar and radial deviation following 3 repetitions and opinion that the Veteran's pain symptoms would erode the endpoint for dorsiflexion to no more than 10 degrees. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

The question before the Board focuses not whether the assigned rating was proper but rather whether there is evidence that the disability improved to support assigning a lower rating. The Board must look at the history of the disability, considering the clinical findings consistent with findings identified in the rating criteria in general and reviewing the most current examination to ensure it is full and complete. The VA examinations as previously summarized do show that the Veteran's dorsiflexion did increase from zero degrees (2013) to between 8 and 10 degrees (2017 and 2020). However, his palmar flexion decreased from 25 degrees to somewhere between 8 and 10 degrees (when considering flare-ups). His ulnar and radial deviation fell to 5 degrees (after 3 repetitions). The Board does not find the 10-degree improvement of the endpoint dorsiflexion material evidence that the Veteran's right wrist disability as a whole improved, or that there was reason to believe that he would maintain such improvement under the original conditions of life.

Furthermore, the claims file shows that service connection was awarded and an initial disability rating assigned for the right wrist disability in a September 2013 rating decision. The rating decision suggests VA relied on the June 2013 VA examiner's notation that the Veteran had favorable ankylosis. If VA believes it made a clear and unmistakable error when it assigned the rating, it should address such error under 38 U.S.C. § 5109A, and not as a rating reduction. See also 38 C.F.R. §§ 3.104.

For the above reasons, the Board finds that the evidence of record weighs against the propriety of the rating reduction because actual material improvement has not been demonstrated. The reduction is void ab initio. The Board, thus, grants restoration of the 30 percent rating for the service-connected right wrist disability.

Increased Ratings

Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects the veteran's ability to function under the ordinary conditions of daily life, including employment, by comparing the veteran's symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R., Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. Id. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10.

VA rates unlisted conditions under a closely related disease or injury consistent with the functions affected, anatomical localization, and symptomatology. 38 C.F.R. § 4.20.

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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. "Staged ratings" are, however, 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. Hart v. Mansfield, 21 Vet. App. 505 (2007).

In every instance where a rating schedule does not identify specific rating criteria for a noncompensable rating (zero percent), a noncompensable rating will be assigned when the requirements
nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. "Staged ratings" are, however, 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. Hart v. Mansfield, 21 Vet. App. 505 (2007).

The evaluation of the same disability under several DCs, known as "pyramiding," must be avoided. 38 C.F.R. § 4.14. However, separate ratings may be assigned for distinct disabilities resulting from the same injury, so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Id.

For non-initial increased rating claims, when medical records indicate an increase in a disability, receipt of such medical records may be used to establish effective dates for retroactive benefits based on facts found of an increase in a disability only if a complete claim or intent to file a claim for an increase is received within 1 year of the date of the report of examination, hospitalization, or medical treatment. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010) (The plain language of 38 U.S.C. § 5110(b)(2) imposes a condition, permitting application of this earlier date only "if application is received within one year from such date.").

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Veteran will receive the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc).

1. Entitlement to a disability rating in excess of 30 percent prior to July 7, 2020, for right wrist fusion and DJD.

2. Entitlement to a 50 percent disability rating, but no higher, since July 7, 2020, for right wrist fusion and DJD.

The period for review in this matter is from June 29, 2020 (one year prior to the date VA received the VA Form 20-0996), to the August 2021 rating decision on appeal. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400.

A September 2013 rating decision awarded service connection for right wrist fusion with DJD and assigned a 30 percent rating under DC 5003-5214 with an effective date of January 26, 2012 (date the VA received the Veteran's VA Form 21-526). 38 C.F.R. § 4.71a. A May 2017 rating decision continued the 30 percent rating. A July 2020 rating decision reduced the rating to 10 percent with an effective date of October 1, 2020, which this decision herein above restored. The August 2021 HLR decision found the reduction proper and continued the 10 percent rating.

A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence
upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40.

Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered when determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.45. The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the DCs predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); Johnson v. Brown, 10 Vet. App. 80, 84-85 (1997).

In Chavis v. McDonough, the United States Court of Appeals for Veterans Claims discussed evaluating ankylosis and the functional equivalent to ankylosis of a musculoskeletal joint. Chavis, 34 Vet. App. 1 (2021). "Ankylosis is a medical term meaning '[i]mmobility and consolidation of a joint due to disease, injury, or surgical procedure.'" Id. at 14; citing Dorland's Illustrated Medical Dictionary 94 (33d ed. 2019); Steadman's Medical Dictionary 95 (28th ed. 2006) ("Stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint."); Churchill's Illustrated Medical Dictionary 91 (1989) ("A stiffening or immobilization of a joint as a result of injury, disease, or surgical intervention."). "Although in the past we have focused on application of the DeLuca factors in the context of limitation of motion, nothing in [38 C.F.R. §§ 4.40 and 4.45] or our caselaw suggests that those factors should not apply in the context of ankylosis, particularly as ankylosis is, in essence, a complete limitation of motion." Chavis, 34 Vet. App. at 18; citing Lyles, 29 Vet. App. 107, 118 (2017), citing DeLuca, 8 Vet. App. at 206. The assignment of a higher rating based on ankylosis is appropriate if there is evidence of functional loss that is the functional equivalent of that contemplated by ankylosis. Id. at 11.

In Johnson v. Brown, the Court found the Board did not err when it failed to consider 38 C.F.R. §§ 4.40 and 4.45 because the veteran was in receipt of the maximum evaluation under DC 5215 and the issue of ankylosis had not been explicitly raised. Johnson, 9 Vet. App. 7, 11 (1996), citing Johnston, 10 Vet. App. at 85; Spencer, 13 Vet. App. 376, 382 (2000).

Painful motion is a factor when considering functional limitations of a joint disability. 38 C.F.R. § 4.59. Because VA is permitted to award the minimum compensable rating for a joint due to painful motion, testing must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016).

Disabilities directly related to the wrist rated under the General Rating Formula for the Wrist. 38 C.F.R. § 4.71a, DCs 5214-5215. A rating is assessed based on whether the joint is a "major" joint (dominant upper extremity) or a "minor
. § 4.59. Because VA is permitted to award the minimum compensable rating for a joint due to painful motion, testing must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016).

DC 5215 addresses limitation of motion of the wrist. Id. A 10 percent rating is warranted if the dorsiflexion is less than 15 degrees, or the palmar flexion is limited in line with the forearm regardless of whether the disability involves a major or minor joint.

DC 5214 addresses ankylosis of the wrist. Id. For major joints, a 30 percent rating is warranted for favorable ankylosis of the wrist at 20 to 30 degrees of dorsiflexion. A 40 percent rating is warranted for ankylosis of the wrist in any position but favorable. A 50 percent rating is warranted for unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation.

The Note for DC 5214 directs the fact finder to consider rating a disability resulting in extremely unfavorable ankylosis as loss of use of hands under 5125.

The DC uses some terms that are not defined in the General Rating Schedule. The term "extreme" means "existing in a very high degree," "going to great or exaggerated lengths," and "exceeding the ordinary, usual, or expected." See Merriam-Webster Dictionary online, available at https://www.merriam-webster.com/dictionary/extreme. Rather than applying a mechanical formula, the Board has considered these definitions and evaluated all of the evidence so that this decision is "equitable and just." 38 C.F.R. § 4.6.

The private and VA treatment records contain no complaints related to the right wrist or that a treating provider focused on the right wrist disability just prior to or during the appeal period. See, i.e., October 2020 Medical Treatment Record; December 2020 & July 2021 CAPRI.

The Veteran was afforded a VA wrist examination on July 7, 2020. The diagnosis was right wrist fusion with internal fixation and DJD. He reported fracturing the right wrist during service and that he continued to have issues with pain with an inability to "bend" and grip items. He had a reduced range of motion in his right wrist. He experienced flare-ups daily when using his right hand. A clinical examination was performed on both wrists. With respect to the right wrist, palmar flexion was reduced to 10 degrees, dorsiflexion was reduced to 20 degrees, and ulnar and radial deviation were reduced to 10 degrees each. Pain was present during active, passive, weight-bearing and nonweight-bearing testing. Ulnar and radial deviation fell to 5 degrees each after 3 repetitions. The examiner opined that the Veteran's pain would cause some degree of functional loss with repeated use over time and during flare-ups. The examiner estimated dorsiflexion would be further reduced to 10 degrees; there would be no change to palmar flexion and ulnar and radial deviation. The examiner stated that the Veteran did not have ankylosis of the right wrist joint. The examiner opined that the Veteran's wrist disability would impact his strength and ability to grip items.

The Board finds the VA examination report of limited probative value and gives it limited weight. The examination shows that the Veteran retained active movement in his right wrist. The examiner reasonably considered the Veteran's statements and range of motion testing when estimating how repetitive use and flare-ups might reduce the Veteran's range of motion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017).

Of note, the Board finds it unnecessary to remand this matter for a new VA examination to specifically document passive range of motion testing because the record as a whole does not indicate a new examination could possibly avail the Veteran of any additional benefits - the rating criteria focuses on how much active motion remains. The evidence currently
estimating how repetitive use and flare-ups might reduce the Veteran's range of motion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017).

Of note, the Board finds it unnecessary to remand this matter for a new VA examination to specifically document passive range of motion testing because the record as a whole does not indicate a new examination could possibly avail the Veteran of any additional benefits - the rating criteria focuses on how much active motion remains. The evidence currently in the record is adequate for adjudication. 38 U.S.C. § 5103A; Correia, 28 Vet. App. at 168.

In March 2022, within 90 days of filing the appeal, the Veteran submitted an independent medical evaluation report. See March 2022 Medical Treatment Record. The report indicates that a private examination was performed on January 6, 2022, which is more than 4 months after the period on appeal. Of note, the clinical examination showed 18 degrees of palmar flexion, 38 degrees of dorsiflexion, 17 degrees of ulnar deviation, and 5 degrees of radial deviation.

The Board finds the private examination of no probative value and gives it no weight. The examination was completed months after the appeal period. The examination does not satisfy Correia; the examination appears to be limited to a single repetition of active range of motion testing. The examiner also provided no opinion or estimate about functional limitations with respect to repetitive use over time or during flare-ups to satisfy DeLuca, Mitchell, and Sharp. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

The Board has considered the Veteran's lay statements. 38 U.S.C. § 1154(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). He has reported any use of his right hand causes a flare-up and that his ability to complete tasks is limited by the "inability to move my wrist." See July 2020 C&P Exam; March 2022 VA Form 21-4138 & Medical Treatment Record. The Board finds the Veteran is competent to describe his observations of his symptoms, including limitations related to his right hand mobility in general, though the Board has afforded more weight to the range of motion values identified in the July 2020 VA examination report. Jandreau, 492 F.3d at 1377; Kahana, 24 Vet. App. at 435.

The Board finds that the right wrist disability resulted in the functional equivalent of unfavorable ankylosis with ulnar and radial deviation but no earlier than July 7, 2020. During the July 2020 clinical examination, the VA examiner estimated that the Veteran would have functional loss limiting him to no greater than 5 degrees of ulnar or radial deviation of his right wrist with repetitive use over time and during flare-ups. Though the VA examiner estimated the Veteran would retain some mobility in the right wrist, the Board finds the reduction to no more than 5 degrees of ulnar or radial deviation of the wrist to be the functional equivalent of ankylosis. Though not completely immobile, the Veteran had effectively lost his ability to move his wrist to the right or left. The Board found no subjective evidence or objective findings that show the right wrist disability worsened between June 29, 2020, and the July 2020 VA examination to support an earlier effective date. 38 C.F.R. § 3.400(o)(2); see, e.g., CAPRI.

The Board has considered but finds the reduced range of motion did not result in extreme unfavorable ankylosis to support rating the right wrist disability as loss of use of the right hand under DC 5125 during the appeal period. Here, the Veteran has maintained some amount of motion allowing him to continue to use his hand albeit causing flares of pain.

Because the Veteran is already in receipt of a rating for limitation of motion, the regulatory provisions pertaining to functional loss are not applicable. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206; Johnston, 10 Vet. App. at 85; Chavis, 34 Vet. App. at 11.

For the reasons above, the evidence of record persuasively weighs in favor of finding that the right wrist disability resulted in the equivalent to ankylosis on July 7,
period. Here, the Veteran has maintained some amount of motion allowing him to continue to use his hand albeit causing flares of pain.

For the reasons above, the evidence of record persuasively weighs in favor of finding that the right wrist disability resulted in the equivalent to ankylosis on July 7, 2020, but no earlier. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th at 781-82. Thus, the claim for a rating in excess of 30 percent prior to July 7, 2020, for the right wrist disability is denied, and a 50 percent rating thereafter is granted.

3. Entitlement to a disability rating of 20 percent since April 14, 2020, for left knee traumatic arthritis with atrophy status post ligament reconstruction, under DC 5010-5257.

4. Entitlement to a separate 20 percent disability rating, but no higher, since April 14, 2020, for limitation of extension related to left knee traumatic arthritis with atrophy status post ligament reconstruction, under DC 5010-5261.

The period for review in this matter is from October 12, 2019 (one year prior to VA receiving the Veteran's new claim for an increased rating), to the June 2021 rating decision on appeal. 38 C.F.R. § 3.400(o)(2).

The claims file shows that the Veteran twisted his left knee in April 1989 and that an arthroscopy was performed in June 1989. See March 2017 Military Personnel Record. He was diagnosed with anterior cruciate ligament deficiency and patellofemoral stress syndrome of the left knee. He was separated from service with severance pay under DC 5257 after the Medical Board found it unlikely that he would be able to return to full duty status. See January 2012 DD 214; see also December 1993 Rating Decision.

A December 1993 rating decision awarded service connection for a left knee condition status post ligament reconstruction with traumatic arthritis. The rating decision assigned a 10 percent rating under DC 5010-5257 with an effective date of April 7, 1993 (the date VA received a VA Form 21-526). 38 C.F.R. § 4.71(a). The rating decision noted that the Veteran reinjured his left knee after it gave way in November 1991 and that he had undergone ligament reconstruction in January 1992. The VA examination at the time did not show "reduced range of motion or function sufficient for a higher compensable rating."

The June 2021 rating decision increased the disability rating to 20 percent for the left knee disability with an effective date of October 12, 2020. The rating was increased to account for limitation of extension. The rating decision codesheet shows that DC 5010-5257 was replaced with DC 5010-5261.

Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered when determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.45.
pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40.

Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered when determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.45. The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the DCs predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, 8 Vet. App. at 206-08; Johnson, 10 Vet. App. at 84-85.

Disabilities directly related to the knee and leg are rated under DCs 5256 to 5263. 38 C.F.R. § 4.71a. Of note, during the pendency of this appeal, the rating criteria for DCs 5257 and 5262 were revised with an effective date of February 7, 2021. See 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes during the pendency of an appeal, the version most favorable to the veteran applies, absent congressional intent to the contrary. The original criteria are considered with respect to the entire appeal period. However, the amended criteria, if more favorable, can be applied on the effective date of the regulatory change or anytime thereafter. 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Green v. Brown, 10 Vet. App. 111, 116-119 (1997).

DC 5256 addresses ankylosis of the knee. A 30 percent rating for ankylosis is assigned when there is a favorable angle at full extension of the knee or ankylosis in slight flexion between 0 and 10 degrees. A 40 percent rating is assigned for ankylosis of the knee in flexion between 10 and 20 degrees. A 50 percent rating is assigned for ankylosis of the knee in flexion between 20 and 45 degrees. A 60 percent rating (maximum) is assigned if the knee is ankylosed in flexion at an angle of 45 or more.

Prior to February 7, 2021, DC 5257 addressed recurrent subluxation and lateral instability of the knee in general. Id. (2020). A 10 percent rating was assigned for a slight impairment. A 20 percent rating was assigned for a moderate impairment. A 30 percent rating (maximum) was assigned for a severe impairment.

Of note, the regulations do not define the words "slight," "moderate," and "severe." The definition of slight includes "small of its kind or in amount." See Merriam-Webster Dictionary online, available at https://www.merriam-webster.com/dictionary/slight. The definition of moderate includes "tending towards the mean or average amount or dimension" and "having average or less than average quality." See id., available at https://www.merriam-webster.com/dictionary/moderate. The definition of severe includes "of a great degree" and, alternatively, "causing discomfort or hardship." See id., available at https://www.merriam-webster.com/dictionary/severe. The Board has considered these definitions when evaluating all
ight," "moderate," and "severe." The definition of slight includes "small of its kind or in amount." See Merriam-Webster Dictionary online, available at https://www.merriam-webster.com/dictionary/slight. The definition of moderate includes "tending towards the mean or average amount or dimension" and "having average or less than average quality." See id., available at https://www.merriam-webster.com/dictionary/moderate. The definition of severe includes "of a great degree" and, alternatively, "causing discomfort or hardship." See id., available at https://www.merriam-webster.com/dictionary/severe. The Board has considered these definitions when evaluating all of the evidence so that this decision is "equitable and just." 38 C.F.R. § 4.6.

As of February 7, 2021, DC 5257 was amended to address subluxation and instability of the knee in general as well as patellar instability. Id. (2021). A 10 percent rating is assigned if there is evidence of a sprain, incomplete ligament tear, or complete ligament tear (regardless of surgically status) causing persistent instability and no medical provider has prescribed an assistive device or bracing for ambulation. A 20 percent rating is assigned if there is evidence that a medical provider has prescribed an assistive device or brace for the sprain or ligament tear. A 30 percent rating (maximum) is assigned if there is evidence that a medical provider has prescribed both an assistive device and brace for an unrepaired or failed repair of a complete ligament tear.

For patellar instability specifically, a 10 percent rating is assigned if the patellofemoral complex regardless of whether the condition has been surgically repaired. Id. A 20 percent rating is assigned if there is recurrent instability following surgically repair of the patellofemoral complex and a medical provider has prescribed a brace, cane, or walker. A 30 percent rating (maximum) is assigned if there is recurrent instability following surgically repair of the patellofemoral complex and a medical provider has prescribed both a brace and cane or walker.

Note 1 clarifies "patellofemoral complex" encompasses the quadriceps tendon, the patella, and the patellar tendon. Note 2 states that the surgical repair must involve a patellofemoral component that contribute to the underlying instability. For example, VA does not consider an arthroscopy to remove loose bodies and joint aspiration a qualifying surgical repair.

DCs 5258 and 5259 address issues relating to knee cartilage. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent rating is assigned for removal of symptomatic, semilunar cartilage. Under DC 5258, a 20 percent rating is assigned when there is evidence of dislocation with frequent episodes of locking, pain and effusion into the affected knee joint.

DC 5260 addresses limitation of flexion. Id. A noncompensable rating (zero percent) is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating (maximum) is assigned for flexion limited to 15 degrees.

DC 5261 addresses limitation of extension. Id. A noncompensable rating is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating (maximum) is assigned for extension limited to 45 degrees.

For comparison purposes, the normal range of motion of the knee is from zero to 140 degrees for flexion and extension. See id, Plate II.

The Board acknowledges there are additional DCs for the knee and leg (5262 - impairment of the tibia and fibula; and 5263 - genu recurvatum). There is no evidence that the Veteran has been diagnosed with a bone fracture or deformity of the left knee. The Board has reviewed but finds these DCs not relevant to this appeal, and this decision will not discuss these DCs any further.

A review of the medical evidence in the claims file shows that the Veteran contacted his VA provider to report that he had tripped and reinjured his left knee on April 14, 2020. See July 2020 CAPRI. He described his symptoms as similar to his symptoms when he tore his ACL. He was unable to flex his
are additional DCs for the knee and leg (5262 - impairment of the tibia and fibula; and 5263 - genu recurvatum). There is no evidence that the Veteran has been diagnosed with a bone fracture or deformity of the left knee. The Board has reviewed but finds these DCs not relevant to this appeal, and this decision will not discuss these DCs any further.

On April 16, 2020, the Veteran was seen at Next Care Urgent Care. See October 2020 Medical Treatment Record. The clinical examination of the knee was noted to be normal but for pain with weight bearing. In June 2020, he was seen again to complete paperwork for a Workers' Compensation Claim related to his left knee and right shoulder. He stated his knee pain prevented him from completing his work as a groundskeeper, including climbing ladders. A clinical examination of the left knee was not performed though the provider did observe a brace on the left knee. A referral to an orthopedist remained pending. See also July 2020 CAPRI. In August 2020, he was seen and requested a note restricting him to light duty/sitting-type work. He reported the left knee pain was aggravated by bending, climbing/descending stairs, lifting, movement, pushing, walking, and standing. The clinical examination showed pain with flexion and internal and external rotation. The drawer test was negative. The provider described the Veteran as walking with a significant limp.

The Veteran was afforded a VA knee and lower leg conditions examination in May 2021. See June 2021 C&P Exam. The diagnoses were left knee traumatic arthritis status post ligament reconstruction and atrophy. He stated the left knee buckled in April 2020. He had been seen in Urgent Care because he was unable to be seen in a VA facility and was still waiting to be seen by an orthopedist. He had purchased and been using a brace since his knee buckled. He reported constant left knee flare-ups due to any movement. He had a decreased range of motion and was unable to bend down or squat. He confirmed a history of left knee instability/ subluxation.

The clinical examination was abnormal. See id. He was able to flex his left knee to 110 degrees and extend it to 10 degrees during active and passive testing; pain was present at 100 degrees of flexion and 10 degrees of extension. There was no change after three repetitions. Though not examined after repetitive use over time or during a flare, the examiner opined that pain, weakness, and lack of endurance would cause additional loss of function and estimated that the Veteran's left knee flexion would be reduced to 100 degrees and extension to 15 degrees in both instances. The examiner also tested the right (damaged) knee.

The clinical examination was positive for crepitus and tenderness/pain on palpation. See id. There was muscle atrophy at 10 cm below the back of the left knee; the left leg circumference was 35 cm compared to 37.5 cm on the right. The examiner explained that knee instability/subluxation testing was limited due to extreme pain during the first maneuver. The examiner found no ankylosis of the left knee or lower leg, subluxation or instability to include a history of a ligament tear, patellar instability, or recurrent effusion of the left knee. He had a history of a left knee reconstruction in 1991. He was using a brace constantly.

The Board finds the May 2021 VA examination report of limited probative value and gives the report limited weight. The examiner was a qualified medical professional who conducted in-person examination and appears to have considered the Veteran's lay statements when providing an estimate about how the left knee pain, weakness, and lack of endurance could reduce his range of motion after repetitive use over time and during a flare. However, the examiner's finding that there was no persistent instability or a history of a ligament tear/sprain is inconsistent with evidence elsewhere in the claims file. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

Of note, the VA examiner did not check that there was evidence of pain with weight- and nonweight-bearing tasks. The Board finds no explicit statement addressing the pertinent observations elsewhere in the report, including in
-person examination and appears to have considered the Veteran's lay statements when providing an estimate about how the left knee pain, weakness, and lack of endurance could reduce his range of motion after repetitive use over time and during a flare. However, the examiner's finding that there was no persistent instability or a history of a ligament tear/sprain is inconsistent with evidence elsewhere in the claims file. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

Of note, the VA examiner did not check that there was evidence of pain with weight- and nonweight-bearing tasks. The Board finds no explicit statement addressing the pertinent observations elsewhere in the report, including in the Remarks section (where the examiner explained why joint stability testing was not completed). The Board finds it unnecessary to remand this matter for a new VA examination that clearly addresses whether pain was or was not present during weight- and nonweight-bearing. First, the August 2020 treatment notes support the presence of pain at least with weight-bearing activities. Second, a new examination would not avail the Veteran of a higher rating since the pertinent rating criteria do not specifically consider the presence of pain during weight- and nonweight-bearing movements. The evidence currently in the record, which includes the Veteran's descriptions of his symptoms as recorded in the VA examination report, VA treatment records, and private treatment records, are adequate for adjudication. 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159.

The Board recognizes that the Veteran was remotely afforded VA examinations of his knees in 1993 and 2017. See May 1993 VA Examination; June 2017 C&P Exam. Though the prior VA examination reports were reviewed, the remote findings are not probative in light of the Veteran's report of reinjuring his left knee in April 2020. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

In March 2022, within 90 days of filing the appeal, the Veteran submitted an independent medical evaluation report. See March 2022 Medical Treatment Record. A private examination was performed on January 6, 2022, which was almost 6 months after the period on appeal. The clinical examination showed the Veteran had 5 degrees of left knee flexion and 25 degrees of extension. There was evidence of medial and lateral collateral ligament laxity and subluxation. He was observed using an unloader brace on his left knee.

The Board finds the private examination of no probative value and gives it no weight. The examination was completed about 6 months after the appeal period. The examination does not satisfy Correia; the examination appears to be limited to a single repetition of active range of motion testing. The examiner also provided no opinion or estimate about functional limitations with respect to repetitive use over time and during flare-ups to satisfy DeLuca, Mitchell, and Sharp. The examiner also failed to explain how the January 2022 findings related back to the appeal period. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

Additionally, the Board has considered the lay statements. 38 U.S.C. § 1154(a); Layno, 6 Vet. App. at 470. The Veteran has reported a long history of left knee disability that was aggravated when he twisted his left knee days prior to April 14, 2020. See October 2020 CAPRI & Medical Treatment Record. He reported his left knee buckled (instability) and that he immediately purchased a knee brace. The Board finds the Veteran competent to describe his symptoms during the appeal period. He, however, does not have the requisite medical training or expertise to determine the current nature, extent, and severity of his symptoms as reflected by the applicable rating criteria. Jones, 7 Vet. App. 134, 137-38 (1994). The contentions pertaining to the severity of his left knee disability, while probative, are less so than the range of motion values and general examinations documented by the VA examiner and his providers. Jandreau, 492 F.3d at 1377; Kahana, 24 Vet. App. at 435.

Having reviewed the evidence in the record at the time of the June 2021 rating decision, the Board finds a higher rating for left knee instability is warranted under DC 5010-5257. An April 14, 2020, communication note states the Veteran reported reinjuring his left knee when it buckled several days earlier. See October 2020 CAPRI. He immediately purchased a knee brace for his left knee. He reported wearing the knee brace constantly at the May 2021 VA examination. See June 2021 C&P Exam. The Board finds the reported buckling resulting in the Veteran needing to use a knee brace constantly is more consistent with a moderate impairment, rather than slight, when considering the knee instability under DC 5257 prior to February 7, 2021. There is nothing to suggest the instability resulted in a severe impairment, such as instability resulting in recurring falls despite using a brace. There is no evidence that the Veteran was also prescribed an assistive device in addition to the knee brace to support a 30 percent disability rating under DC 5257 on or after February 7, 2021. Thus, a 20 percent disability rating under DC 5010-5257 since April 14, 2020 (the date the Veteran contacted his VA provider and reported injuring his left knee) is warranted. 38 C.F.R. § 3.400(o)(2).

The Board also finds a separate a disability rating for limitation of extension is warranted. The May 2021 VA report shows the Veteran's extension was limited to 10 degrees during active and passive testing. See June 2021 C&P Exam. The VA examiner estimated that the Veteran's symptoms would erode his ability to extend his left knee beyond 15 degrees, which is consistent with a 20 percent rating under DC 5261. The VA examiner's opinion is not inconsistent with evidence elsewhere in the claims file. Thus, a separate 20 percent disability rating under DC 5010-5261 since April 14, 2020 (the date the Veteran contacted his VA provider and reported injuring his left knee) is warranted. 38 C.F.R. § 3.400(o)(2).

The Board does not find a separate rating under DC 5260 is warranted. The April 2020 VA communication notes suggest the Veteran reported left knee flexion was limited to 90 degrees, which is well more than the 60 degrees required for a noncompensable rating. See October 2020 CAPRI. The private treatment records described the clinical examination of the left knee as essentially normal but for pain. See October 2020 Medical Treatment Record. The May 2021 VA examination report shows he was able to flex to 100 degrees before signs of pain were evident. See June 2021 C&P Exam.

Moreover, the regulations clearly state that the intent of the regulations relating to the musculoskeletal system is to recognize symptoms, such as painful motion, and provide a veteran the minimum compensable rating for that joint. 38 C.F.R. § 4.59 (emphasis added); see also 29 Fed. Reg. 6718 (May 22, 1964). While a veteran may be entitled to multiple separate ratings for a knee disability, the disability relates to a single joint. A veteran is only entitled to a rating relating to pain, including painful motion, under a single DC for a single joint. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 487-88 (1991). Since pain has been considered when evaluating the rating criterion of DC 5261, awarding a 10 rating for painful motion under DC 5260 pursuant to 38 C.F.R. § 4.59 would result in impermissible pyramiding. 38 C.F.R. § 4.14. A rating under DC 5260 is not warranted.

The Board has considered if there is another DC that could avail the Veteran of a higher or additional separate rating, specifically DC 5256. However, there is no competent or credible evidence that the left knee disability has manifested in ankylosis or the functional equivalent of ankylosis during the appeal period. 38 C.F.R. § 4.71(a), DC 5256. He has not asserted, nor does the evidence show, that his left knee range of motion was non-existent and/or that the knee remained in a fixed position. Clinical examinations showed he maintained no less than 110 degrees of active flexion and 10 degrees of active
4.14. A rating under DC 5260 is not warranted.

The Board has also considered the Veteran's use of pain medication in general and if such medication has provided him any ameliorative benefits when evaluating whether a higher rating is warranted under any DC. See Ingram v. Collins, No. 23-1798, 2025 U.S. App. Vet. Claims LEXIS 327 (Mar. 12, 2025); Jones, 26 Vet. App. at 61. However, there is no evidence in the VA treatment records, private treatment record, or the VA examination report that would suggest the knee disability would be significantly worse, such as further reduce his left knee extension, if he had not used pain medication during the appeal period.

For the reasons above, the Board finds that the evidence persuasively weighs in favor of granting a 20 percent disability rating, but no higher, under DC 5010-5257 for left knee instability and awarding a separate 20 percent disability rating, but no higher, for limitation of extension under DC 5010-5261, both with an effective date of April 14, 2020. The claim is granted to that extent.

5. Entitlement to a compensable (greater than zero percent) disability rating for surgical scars associated with the left knee.

The period for review in this matter is from October 12, 2019 (one year prior to VA receiving the Veteran's new claim for an increased rating for the left knee disability), to the June 2021 rating decision on appeal. 38 C.F.R. § 3.400(o)(2).

The June 2021 rating decision awarded service connection for surgical scars associated with the left knee and assigned a noncompensable rating under DC 7802 with an effective date of October 12, 2020. See also June 2021 Rating Decision - Codesheet.

Scars in general are rated under DCs 7800, 7801, 7802, 7804, and 7805. 38 C.F.R. §§ 4.118; 83 Fed. Reg. 32592 (July 13, 2018). DC 7801 evaluates deep and nonlinear burn scars and scars due to other causes that are not of the head, face, or neck that are associated with underlying soft tissue damage. A 10 percent rating is warranted for a scar(s) with an area or areas greater than 6 but less than 12 in2, or at least 39 but less than 77 cm2. A 20 percent rating is warranted for a scar(s) with an area or areas at least 12 but less than 72 in2, or at least 77 but less than 465 cm2. A 30 percent rating is warranted for a scar(s) with an area or areas at least 72 but less than 144 in2, or at least 465 but less than 929 cm2. A 40 percent rating is warranted for a scar(s) with an area or areas of 144 in2 or greater, or 929 cm2 of greater.

Note (1) clearly identifies six zones of the body - four extremities, the anterior trunk, and the posterior trunk - and that the anterior and posterior trunk are divided by the midaxillary line. Id. Note (2) allows the rating to be based on the higher of a combined rating under 38 C.F.R. § 4.25 after separately evaluating each affected zone of the body or a rating based on the total area of the affected zones.

DC 7802 evaluates superficial and nonlinear burn scars and scars due to other causes that are not of the head, face, or neck that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. A 10 percent rating is warranted for a scar(s) with an area or areas of 144 in2 or greater, or 929 cm2 or greater.

Note (1) to the DC identifies the six separate zones and Note (2) addresses the ability to combine the ratings
be based on the higher of a combined rating under 38 C.F.R. § 4.25 after separately evaluating each affected zone of the body or a rating based on the total area of the affected zones.

Note (1) to the DC identifies the six separate zones and Note (2) addresses the ability to combine the ratings for the separate zones under 38 C.F.R. § 4.25.

DC 7804 evaluates scars that are unstable and/or painful. 38 C.F.R. § 4.118. A 10 percent rating is warranted for 1 to 2 painful or unstable scars. A 20 percent rating is warranted for 3 to 4 painful or unstable scars. A 30 percent rating is warranted for 5 or more painful or unstable scars.

Note (1) defines an unstable scar as a scar where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if any scar is both unstable and painful, a 10 percent rating is added to the evaluation based on the total number of scars. Note (3) clarifies a veteran is entitled to a rating under 7804 as well as DCs 7800, 7801, 7802, and 7805 for the same scar, i.e., ratings under these DCs will not result in pyramiding.

DC 7805 evaluates other scars, including linear scars, and other effects of scars not addressed in DCs 7800, 7801, 7802, or 7804. The rating official is directed to evaluate any additional "disabling effects" not considered in DCs 7800, 7801, 7802, or 7804 under an appropriate DC elsewhere in Part 4.

The Board acknowledges there is an additional DC for scars, DC 7800, but it is relevant only when the issue relates to a scar present on the head, face, or neck, which is not the issue. Thus, this decision will not discuss this DC any further.

On review of the record, the evidence persuasively weighs against awarding a compensable rating for the left knee surgical scars. The private and VA treatment records show no complaints related to any surgical scars associated with the left knee. See generally CAPRI & Medical Treatment Records.

The Veteran was afforded a VA knee conditions and scar examination in May 2021. See June 2021 C&P Exams. The diagnoses included "[s]cars left knee s/p knee reconstruction." The examiner identified two scars around the left knee. The first scar was a vertical scar at mid knee, which measured 10 cm by 0.5 cm. The second scar was a vertical scar on the lateral aspect of the left knee, which measured 4 cm by 0.3 cm. The combined total area was 14 cm by 0.7 cm. There was no subjective or objective evidence that either scar was painful or unstable; both were fully healed. There was no evidence of underlying tissue damage. The examiner found no evidence that either scar limited the Veteran's left knee or right left lower extremity in general.

The Board finds the June 2021 VA examination report probative evidence and gives it great weight with respect to this issue. The VA examiner provided the Board with a thorough clinical examination of the scars. There is no evidence elsewhere in the claims file that contradicts the examiner's findings, including that either scar was painful (or unstable). Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

The Board finds the private examination of no probative value and gives it no weight. The examination was completed after the appeal period. The examiner makes no mention of the June 2021 VA scar examination nor explains what evidence the private examiner considered when concluding that a compensable rating for the left knee scars was warranted back to the date VA received the Veteran's application for a higher rating for the left knee disability. Nieves-Rodriguez,
independent medical evaluation report. See March 2022 Medical Treatment Record. A private examination was performed on January 6, 2022, which was almost 6 months after the period on appeal. The clinical examination, in part, showed "[d]ecreased sensation and pain over scars."

The Board finds the evidence of record persuasively weighs against the assignment of a compensable evaluation under DC 7802. The Veteran's left knee scars manifested in a total area well under 144 in2 (929 cm2).

The Board has also considered the other DCs pertaining to scars. The scars are associated with the left knee and not the head, face, or neck. The scars have not been described to include underlying soft tissue damage. See June 2021 C&P Exam. Moreover, there is no evidence that any scar was unstable or painful/tender during the appeal period. The Veteran did not report any skin-related problems nor pain directly associated with any scar during the May 2021 VA examination. The Board located no complaints in the private or VA medical records prior to or during the appeal period. See generally CAPRI & Medical Treatment Records. Thus, DCs 7800, 7801, and 7804 are inapplicable. There is also no evidence that either left knee scar caused other disabling effects not considered when evaluating the scars under DCs 7800, 7801, 7802, or 7804, such as limitation of motion of the left knee. 38 C.F.R. § 4.118, DC 7805.

The Board acknowledges that the Veteran may believe that the scars are more severe than the assigned rating reflects. Moreover, he is competent to report observable symptoms. Jandreau, 492 F.3d at 1377; Kahana, 24 Vet. App. at 435. However, he did not assert, and medical treatment records do not show, that his left knee scars were painful, that the skin around his left knee was unstable, or that the scars were associated with underlying soft tissue damage and covered an area of no less than 144 in2 prior to the June 2021 rating decision. See, i.e., October 2020 VA Form 21-526EZ; see also December 2021 VA Form 10182; March 2022 VA Form 21-4138.

For the reasons above, the evidence of record persuasively weighs against the Veteran's claim for a compensable rating for the service-connected left knee scars status post reconstruction surgery. The claim is denied.

6. Entitlement to a disability rating in excess of 20 percent for lumbosacral strain.

The period for review in this matter is from October 12, 2019 (one year prior to the date VA received the October 2020 VA Form 21-526EZ), to the August 2021 rating decision on appeal. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400.

The June 2021 rating decision granted service connection for lumbosacral strain (claimed as low back condition) and assigned a 20 percent disability rating under DC 5237 with an effective date of October 12, 2020. 38 C.F.R. § 4.71(a). The rating decision indicated the final assigned rating was deferred for exam clarification. The July 2021 rating decision continued the 20 percent rating.

As previously noted, a disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled.
of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40.

Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered when determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.45. The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the DCs predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, 8 Vet. App. at 206-08; Johnson, 10 Vet. App. at 84-85.

Disabilities directly related to the spine are rated under DCs 5235 to 5243. 38 C.F.R. § 4.71a. Of note, during the pendency of this appeal, 38 C.F.R. § 4.71a was amended but the amendment only changed the titles of DCs 5242 and 5243 (and added DC 5244). 85 Fed. Reg. at 76463. No changes were made to the criteria in the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula) or the General Rating Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (General Rating IVDS Formula).

DCs 5235 to 5242 direct the rating official to rate the disability under the General Rating Formula. DC 5243 provides that IVDS, pre- or post-operatively, shall be evaluated either under the General Rating Formula or under the General Rating IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined under § 4.25.

Under the General Rating Formula, in pertinent part, with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 40 percent rating is assigned if forward flexion of the thoracolumbar spine is 30 degrees or less; or there is favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine, i.e., cervical and thoracolumbar spines.

Note (1) directs the rating official to consider objective neurological abnormalities under the appropriate DC. Id. Note (2) directs the rating official to Plate V for "normal" the range of motion values and how to calculate the sum of the ranges of motion. Note (3) states that values less than those identified in Plate V can be considered normal for a specific individual so long as the examiner explains such. Note (4) directs the rating official to round each measurement to the nearest 5 degrees. Note (5) defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted
. Id. Note (2) directs the rating official to Plate V for "normal" the range of motion values and how to calculate the sum of the ranges of motion. Note (3) states that values less than those identified in Plate V can be considered normal for a specific individual so long as the examiner explains such. Note (4) directs the rating official to round each measurement to the nearest 5 degrees. Note (5) defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. The Note also states that fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. (emphasis added). Note (6) directs the rating official to consider the cervical and thoracolumbar spine segments separately unless the issue is unfavorable ankylosis of both segments.

Under the General Rating IVDS Formula, in pertinent part, a 40 percent rating is warranted with incapacitating episodes having a total duration of at least four weeks but less than 6 weeks during the past 12 months. Id. A 60 percent (maximum) rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.

Note (1) defines an incapacitating episode as a period of acute signs and symptoms that requiring treatment and bed rest prescribed by a physician. Id. Note (2) directs the rating official to evaluate the cervical and thoracolumbar spine segments separately if the effects in each segment are clearly distinct under either the General Rating or General Rating IVDS Formula.

The evidence does not support a higher rating. The VA treatment and private medical records show no complaints related to the mid- or lower-back just prior to and since October 2019. See, e.g., CAPRI & Medical Treatment Records. The private treatment notes show only that the Veteran reported issues with his right shoulder after mowing and moving furniture in February 2020, and that he requested a medical note restricting him to light duty secondary only to his right shoulder and left knee. See October 2020 Medical Treatment Record.

The Veteran was afforded a VA back conditions examination in May 2021. See June 2021 C&P Exam. The diagnosis was lumbosacral strain. He reported low back pain for more than 15 years secondary to his left knee disability. His symptoms included back spasms. He experiences daily flare-ups; the duration depends on his ability to medicate. His treatment, which provided some alleviation, included Ibuprofen and medical marijuana, heat, and a hot tub. The condition limited his functioning, including decreased mobility, sitting comfortably for 30 minutes, standing or walking more than 45 minutes, and lifting more than 20 pounds. He was on light duty at work because of his back and knees.

The clinical examination, in part, shows a reduced range of motion. See id. The Veteran's forward flexion was limited to 60 degrees, extend to 20 degrees, lateral flexion 30 degrees to each side, and lateral rotation to 30 degrees to each side during active motion testing. There was no change during passive range of motion testing. Signs of pain were present during forward flexion at 50 degrees during active and passive testing. Pain was noted during weight- and nonweight-bearing and while at rest. There was no change after three repetitions. Not examined after repetitive use over time or during a flare, the examiner opined that the Veteran's report of pain would cause additional loss of function and estimated that the pain would reduce the Veteran's forward flexion to 50 degrees; the pain would not impact extension, lateral flexion, or lateral rotation.

The clinical examination further showed tenderness, or pain, when palpating the lumbar spine. See id. Muscle spasms were noted but the examiner stated that the symptoms did not affect the Veteran's gait and/or spine contour. There was 3+ strength in the left lower extremity from the knee down with observable muscle atrophy (unrelated to the back disability); there was normal strength in the right lower extremity. Deep tendon reflexes were normal (2+) on the right and hypoactive (1+) on the left. Sensation was normal. Straight leg raise testing was positive on the left. There was no evidence of radiculopathy. There was no evidence of favorable or unfavorable
flexion, or lateral rotation.

The Board finds the May 2021 VA examination report probative and gives the report significant weight. See id. The examiner was a qualified medical professional who conducted in-person examination and considered the Veteran's description of his symptoms. The results of range of motion testing and opinion about how repetitive use over time and flares might reduce the Veteran's forward flexion are not inconsistent with evidence elsewhere in the claims file. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

In March 2022, within 90 days of filing the appeal, the Veteran submitted an independent medical evaluation report. See March 2022 Medical Treatment Record. A private examination was performed on January 6, 2022, which was almost 6 months after the period on appeal. The clinical examination showed 45 degrees of forward flexion, 20 degrees of extension, 30 degrees of left lateral bending, 18 degrees on the right lateral bending, 30 degrees of rotation to the left, and 45 degrees of rotation to the right. Ankylosis was described as "[d]ecreased ROM." He walked with a limp favoring the left lower extremity. The examiner was in agreement with the VA examiner's diagnosis but that the current findings warranted an additional rating.

The Board finds the private examination of no probative value and gives it no weight. The examination was completed months after the appeal period. The examiner failed to explain how the January 2022 findings related back to the appeal period. The examination report also does not satisfy Correia, DeLuca, Mitchell, or Sharp. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124.

The Board has considered the lay statements. 38 U.S.C. § 1154(a); Layno, 6 Vet. App. at 470. The Veteran has reported a long history of back pain that has negatively impacted his ability to complete his activities of daily living and work as a groundskeeper. See, i.e., June 2021 C&P Exam; March 2022 VA Form 21-4138 & Medical Treatment Record. Though competent to describe his symptoms during the appeal period, he does not have the requisite medical training or expertise to determine the current nature, extent, and severity of his symptoms as reflected by the applicable diagnostic criteria. Jones, 7 Vet. App. at 137-38. Though he reported to the VA examiner that he had work restrictions that considered his back, the work restriction itself and corresponding treatment notes contain references only to the right shoulder and left knee. See October 2020 Medical Treatment Record. The contentions pertaining to the severity of his back disability, while probative, are less so than the range of motion values as documented by the May 2021 VA examiner. Jandreau, 492 F.3d at 1377; Kahana, 24 Vet. App. at 435.

Having reviewed the evidence in the record at the time of the June 2021 and July 2021 rating decisions, the Board finds that the evidence weighs against a rating in excess of the currently assigned 20 percent rating. Here, the private and VA medical records contain no complaint related to the Veteran's back just prior to or during the appeal period. See generally CAPRI, Medical Treatment Record, June 2021 C&P Exam. Even the January 2022 private examination report states that the Veteran had no less than 45 degrees of forward flexion. There is no evidence that the Veteran's forward flexion was limited to 30 degrees, including when estimating his range of motion with repetitive use over time or during a flare-up, or that he was unable to move his back. See June 2021 C&P Exam; Chavis, 34 Vet. App. at 11.

The Board has also considered the General Rating IVDS Formula but finds there is no evidence that
VA medical records contain no complaint related to the Veteran's back just prior to or during the appeal period. See generally CAPRI, Medical Treatment Record, June 2021 C&P Exam. Even the January 2022 private examination report states that the Veteran had no less than 45 degrees of forward flexion. There is no evidence that the Veteran's forward flexion was limited to 30 degrees, including when estimating his range of motion with repetitive use over time or during a flare-up, or that he was unable to move his back. See June 2021 C&P Exam; Chavis, 34 Vet. App. at 11.

The Board has also considered the General Rating IVDS Formula but finds there is no evidence that the Veteran has had any incapacitating episodes during any 12-month period. 38 C.F.R. § 4.71a, DC 5243.

The Board has considered whether a higher rating would be warranted on the basis of additional functional impairment and loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The Board acknowledges the evidence indicates functional loss, which includes limitations related to prolonged exertional activities (such as sitting, standing, walking, and lifting/carrying) as well as postural activities (such as bending and squatting). However, the occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured. The Board finds that the assigned rating adequately contemplates the Veteran's disability picture, to include functional impairment and loss, throughout the appeal period.

The Board has also considered the Veteran's use of pain medication in general and if such medication has provided him any ameliorative benefits when evaluating whether a higher rating is warranted under the General Rating Formula or General Rating IVDS Formula for the spine. See Ingram v. Collins, No. 23-1798, 2025 U.S. App. Vet. Claims LEXIS 327 (Mar. 12, 2025); Jones, 26 Vet. App. at 61. However, there is no evidence in the private or VA medical records or the VA examination report that would suggest the back disability would be significantly worse, such that the Veteran's forward flexion would be further reduced by another 20 degrees, if he stopped using pain medication.

Additionally, the Board has considered but finds no evidence that would support an additional separate rating for associated conditions, such as lower extremity radiculopathy, during the appeal period. Though the Veteran may have reported the back pain radiates into his left leg during the January 2022 private examination, there is no evidence that he reported similar complaints to a VA provider, a private provider, or the VA examiner. See, i.e., June 2021 C&P Exam; March 2022 Medical Treatment Record. 38 C.F.R. § 4.71a.

For the reasons above, the Board finds that the evidence persuasively weighs against awarding a rating in excess of 20 percent for the back disability. The claim is denied.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, 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) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Notwithstanding the lack of evidence of a disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992).

Service connection may also be granted for a disability that is due to or the result of a service-connected disease or injury, including aggravation of a non-service-connected disability that results in an increase in severity of the nonservice-connected disability. 38 C.F.R. § 3.310(a), (b); see also Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023). Secondary service connection is warranted if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). A nexus is established when medical evidence shows that the current disability was either caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Veteran will receive the benefit of the doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc).

1. Service connection for a left hip surgical scar, as secondary to the right wrist fusion status post radial styloidectomy with a left iliac crest bone graft.

The Board notes that during the pendency of the appeal for an increased rating for the right wrist disability, the record reasonably raises a claim of service connection for a left hip scar that is the result of a bone graft obtained during the right wrist fusion surgery. See July 2020 C&P Exam; March 2022 Medical Treatment Record; Morgan v. Wilkie, 31 Vet. App. 162 (2019) (schedular rating concepts, including secondary service connection, are critical components of the duty to maximize benefits well before reaching an extraschedular analysis).

The first element of service connection on a secondary basis is evidence of a current disability. The clinical evidence documents that the Veteran has a current diagnosis of a surgical scar on his left hip. See July 2020 C&P Exam; March 2022 Medical Treatment Record. Therefore, the first element has been established.

The second element of service connection on a secondary basis is evidence of a service-connected disability. 38 C.F.R. § 3.310. As discussed above, the Veteran is service connected for a right wrist fracture status post fusion with a left iliac crest bone graft. Therefore, the second element has been established.

The third and final element of service connection on a secondary basis is medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. The January 2010 operative report states that bone was harvested from the left iliac wing to complete the right wrist fusion. See January 2012 Medical Treatment Record. The VA examiner and the private examiner documented the presence of a scar on the left hip and attributed the scar to a surgical procedure associated with the right wrist. See July 2020 C&P Exam; see also March 2022 Medical Treatment Record.

The Board finds that the July 2020 VA examiner, and the January 2022 private examiner, fully considered all of the pertinent evidence and provided an adequate basis for the opinions. See July 2020 C&P Exam; March 2022 Medical Treatment Record; Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. With respect to this specific issue, the Board gives the opinions significant weight.

For the above reasons, the evidence persuasively weighs in favor of granting service connection for a left hip scar as secondary to the right wrist fusion status post radial styloidectomy with a left iliac crest bone graft. Therefore, the claim is granted.

2. Service connection for depression and anxiety, as due to the service-connected left knee traumatic arthritis with atrophy status post ligament reconstruction, lumbosacral strain, and right wrist fusion with DJD.

3. Service connection for a somatic pain disorder.

The
ieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. With respect to this specific issue, the Board gives the opinions significant weight.

3. Service connection for a somatic pain disorder.

The first element of service connection is the existence of a current disability. The VA medical records show the Veteran was diagnosed with depression and anxiety as early as 2014. See October 2020 CAPRI. Specifically, he reported "anxiety about his financial future related to his pain and challenges with work." In the January 2022 private examination report, the examiner found depression and anxiety to be associated with pain symptoms related to multiple service-connected disabilities. See March 2022 Medical Treatment Record. There is, however, no evidence that the Veteran has been formally diagnosed with a somatic pain disorder or a similar disorder. Therefore, the first element of service connection has been established only as to depression and anxiety.

For service connection on a secondary basis, the second element is evidence of a service-connected disability. 38 C.F.R. § 3.310. The claims file shows that the Veteran has been awarded service connection for physical disabilities related to his left knee, back, and right wrist. See August 2021 Rating Decision - Codesheet. Therefore, the second element has been established.

The final element of service connection on a secondary basis is evidence that a service-connected disability caused or aggravated the claimed disability. Here, the Veteran provided a private medical opinion addressing his pain symptoms and the depression and anxiety. See March 2022 Medical Treatment Record. The private examiner opined that the Veteran's stress, anxiety, and depressed mood were directly related to pain symptoms related to his left knee, back, and right wrist disabilities. The examiner cited to various articles discussing a correlation between chronic pain and depression and anxiety.

The Board finds the January 2022 private medical opinion to be probative and assigns it significant weight. The private examiner completed an in-person examination. The examiner reviewed relevant the medical records and considered the Veteran's lay statements. The examiner also discussed medical literature that supports a positive nexus between physical pain and depression and anxiety. Nieves-Rodriguez, 22?Vet. App. at?304; Stefl, 21?Vet. App. at?124.

As such, the Board finds that the third and final element of service connection on a secondary basis is met.

Resolving any remaining reasonable doubt in the Veteran's favor, the evidence weighs in favor of finding the Veteran's depression and anxiety are secondary to his service-connected left knee, back, and right wrist disabilities. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th at 781-82. The claim of service connection for a somatic pain disorder is denied. However, the claim of service connection for depression and anxiety on a secondary basis is granted. 38?C.F.R. §§?3.303, 3.310.

REASONS FOR REMAND

1. Service connection for right knee DJD status post anterior cruciate ligament revision is remanded.

The Board finds it necessary to remand this matter to correct a duty to assist error that occurred prior to the issuance of the December 2020 rating decision. 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159, 20.802.

When the VA undertakes to provide a veteran with an examination or obtain a medical opinion, it must ensure that the examination and/or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

The Veteran was afforded a VA knee and lower leg examination in June 2017. The diagnoses were bilateral anterior cruciate ligament tears (left 1992, right 1996), bilateral "arthritic" conditions, and left knee internal derangement. The Veteran reported he twisted his right knee while playing "sports" in 1996 and underwent reconstruction in 1996 or 1997. The examination was abnormal, including a reduced range of motion associated with the right knee. The examiner opined that the right knee condition was less likely than not due to or the result of the service-connected left knee disability. The examiner reasoned that the right knee condition was related to
21 Vet. App. 303, 311 (2007).

The VA medical opinion is incomplete because the rationale does not fully address the criteria for service connection on a secondary basis. The examiner's reasoning that the 1996 sport injury was the proximate cause for the right knee disability addresses only the first half of the third element. The examiner failed to address whether the left knee disability could have aggravated the right knee disability. Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023).

The Board takes note that the claims file includes a private medical opinion but cannot grant service connection at this time based on the medical opinion. See March 2022 Medical Treatment Record. The private examiner opined that it was at least as likely as not that the right knee disability was proximately due to the service-connected left knee disability. However, the examiner did not acknowledge the post-service injury. The Board cannot rely on the opinion because it appears to be based on an incomplete review of all relevant medical evidence as to this issue. Therefore, the Board finds the private medical opinion inadequate for adjudication.

Upon remand, the AOJ will obtain an addendum opinion addressing whether the service-connected left knee disability aggravated the right knee disability.

2. Service connection for right shoulder DJD is remanded.

When the VA undertakes to provide a veteran with an examination or obtain a medical opinion, it must ensure that the examination and/or opinion is adequate. Barr, 21 Vet. App. at 311.

The Veteran was afforded a VA shoulder and arm examination in June 2017. The diagnoses were bilateral degenerative arthritis of the wrists and right shoulder pain with limited range of motion (acute/subacute). The Veteran reported undergoing a cervical spine fusion procedure following the onset of right-sided neck and right shoulder pain. He recalled no specific injury. The examination was abnormal, including a reduced range of motion associated with the right shoulder. The examiner opined that the right shoulder condition was less likely than not proximately due to or the result of the service-connected right wrist disability. The examiner reasoned, in part, that the right shoulder condition is not consistent with a simple strain and more consistent with an acute or subacute condition or injury.

The Board finds an addendum opinion is needed. The examiner's reasoning that the right wrist disability was not the proximate cause for the right shoulder disability addresses only the first half of the third element. The examiner failed to address whether the right wrist disability could have aggravated the right shoulder disability. Spicer, 61 F.4th at 1364. Additionally, the VA examiner clearly did not have the opportunity to review the additional medical records that were added to the claims file after 2017 opinion but before the December 2020 rating decision, to include evidence that the Veteran was treated for a right shoulder injury while playing softball in June 2008 and work-related injuries in February 2020. See October 2020 Medical Treatment Records.

The Board takes note that the claims file includes a private opinion but cannot grant service connection at this time based on this opinion. See March 2022 Medical Treatment Record. The private examiner opined that it was at least as likely as not that the right shoulder disability was proximately due to the service-connected right wrist disability. The examiner specifically points to an article discussing shoulder pain after a period of wrist immobilization and described the right wrist as "permanently immobilized." However, as noted elsewhere in the report, the Veteran has maintained some degree of movement in his wrist. The examiner also failed to acknowledge the June 2008 or February 2020 right shoulder injuries. The Board cannot rely on the opinion because the examiner failed to explain the inconsistency and did not thoroughly review of all relevant medical evidence as to this issue. Therefore, the Board finds the private medical opinion inadequate for adjudication.

Upon rem
Record. The private examiner opined that it was at least as likely as not that the right shoulder disability was proximately due to the service-connected right wrist disability. The examiner specifically points to an article discussing shoulder pain after a period of wrist immobilization and described the right wrist as "permanently immobilized." However, as noted elsewhere in the report, the Veteran has maintained some degree of movement in his wrist. The examiner also failed to acknowledge the June 2008 or February 2020 right shoulder injuries. The Board cannot rely on the opinion because the examiner failed to explain the inconsistency and did not thoroughly review of all relevant medical evidence as to this issue. Therefore, the Board finds the private medical opinion inadequate for adjudication.

Upon remand, the AOJ will obtain an addendum opinion addressing whether the service-connected right wrist disability aggravated the right shoulder disability.

The matters are REMANDED for the following action:

1. Request an addendum medical opinion from an appropriate clinician to determine the etiology of the Veteran's right knee disability. The need for an in-person examination is left to the discretion of the examiner. The examiner must review the entire claims file, including a copy of this remand, and note such in the accompanying report.

The examiner is asked to opine on whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the right knee disability is due to or aggravated by the service-connected left knee disability?

Under Spicer, 61 F.4th 1360 (Fed. Cir. 2023), when evaluating whether a condition was aggravated by another condition, the Veteran need only show that there was an incremental increase in severity of the claimed disability and that the increase in severity would not have occurred "but for" the service-connected disability.

The examiner must provide a thorough rationale for all opinions and conclusions. The rationale should address the January 2022 private opinion (see March 2022 Medical Treatment Record) and medical literature (see March 2022 Correspondence).

Because the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology, the examiner should provide a well-reasoned explanation if there is a medical basis that supports or calls into doubt the Veteran's reported history of his symptoms or if the claimed disability is more likely than not related to an intercurrent cause, such as post-service employment or injuries.

If the examiner is unable to provide an opinion, the examiner should indicate whether there is any additional evidence that would facilitate an opinion, or whether the examiner's inability to opine is based on the limits of the examiner's medical knowledge.

2. Request an addendum medical opinion from an appropriate clinician to determine the etiology of the Veteran's right shoulder disability. The need for an in-person examination is left to the discretion of the examiner. The examiner must review the entire claims file, including a copy of this remand, and note such in the accompanying report.

The examiner is asked to opine on whether it is at least as likely as not (i.e., likelihood is at least approximately balanced or nearly equal, if not higher) that the right shoulder disability is due to or aggravated by the service-connected right wrist disability?

(Continued on the next page)

T. V. Casey

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board T. Burden, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

Analyze in VA Law Explorer