MALIGNANT NEOPLASMS OF THE CENTRAL NERVOUS SYSTEM

Summary

The Veteran served from March 1984 to January 2012, with combat service noted for periods after June 1991, for which he received the Combat Action Ribbon. The Veteran appeals the denial of service connection for meningioma, headaches, Grover's disease (transient acantholytic dermatosis), actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus, as well as a traumatic brain injury (TBI). The Veteran also appeals the denial of an earlier effective date for his left knee disability claims, including flexion disability, instability, and scar, for which the RO had granted service connection with 10 percent ratings for flexion and instability, and a noncompensable rating for the scar. The Board found the evidence evenly balanced for the neurological and dermatological conditions, resolving doubt in the Veteran's favor to grant service connection for meningioma, headaches, Grover's disease, actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus. The Board denied service connection for TBI, finding the criteria were not met. For the left knee claims, the Board granted the earlier effective date of September 17, 2018, and assigned 30 percent ratings for both flexion disability and instability, and a 10 percent rating for the scar, finding the criteria for these ratings were met.

Rationale

Evidence evenly balanced; Benefit of doubt resolved in Veteran's favor

Full Decision Text

Citation Nr: A26031276
Decision Date: 04/06/26	Archive Date: 04/06/26

DOCKET NO. 210427-155656
DATE: April 6, 2026

ORDER

Entitlement to service connection for meningioma is granted.

Entitlement to service connection for headaches is granted.

Entitlement to service connection for transient acantholytic dermatosis (Grover's disease) is granted.

Entitlement to service connection for actinic keratosis is granted.

Entitlement to service connection for seborrheic keratosis is granted.

Entitlement to service connection for nail pterygium in lichen planus is granted.

Entitlement to service connection for traumatic brain injury (TBI) is denied.

Entitlement to an effective date of September 17, 2018, for the grant of service connection for status post left knee open reduction internal fixation medial and lateral tibial plateau fracture with bone grafting (left knee flexion disability), is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to an effective date of September 17, 2018, for the grant of service connection for status post left knee open reduction internal fixation medial and lateral tibial plateau fracture with bone grafting instability (left knee instability), is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to an effective date of September 17, 2018, for the grant of service connection for left knee scar is granted, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to an initial rating of 30 percent, the maximum schedular rating, for left knee flexion disability, from September 17, 2018, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to an initial rating of 30 percent, the maximum schedular rating, for left knee instability, from September 17, 2018, is granted, subject to the laws and regulations governing the award of monetary benefits.

Entitlement to an initial rating of 10 percent, but no higher, for left knee scar, from September 17, 2018, is granted, subject to controlling regulations governing the payment of monetary awards.

FINDINGS OF FACT

1. The evidence is at least evenly balanced as to whether the Veteran's meningioma is related to service.

2. The evidence is at least evenly balanced as to whether the Veteran's headaches are related to service.

3. The evidence is at least evenly balanced as to whether the Veteran's Grover's disease is related to service.

4. The evidence is at least evenly balanced as to whether the Veteran's actinic keratosis is related to service.

5. The evidence is at least evenly balanced as to whether the Veteran's seborrheic keratosis is related to service.

6. The evidence is at least evenly balanced as to whether the Veteran's nail pterygium in lichen planus is related to service.

7. Prior to and during the appeal period, the Veteran has not been diagnosed with a TBI. 

8. The Veteran continuously pursued his initial claim for compensation for left knee disability, including limitation of flexion, instability, and scar, from the September 17, 2018, date of the initial claim.

9. Throughout the appeal period beginning September 17, 2018, the Veteran's left knee flexion disability more nearly approximated flexion limited to 15 degrees, but did not more nearly approximate any other symptoms (other than instability) warranting a higher rating.

10. Throughout the appeal period beginning September 17, 2018, symptoms of the Veteran's left knee instability more nearly approximated severe lateral instability or recurrent subluxation.

11. Throughout the appeal period beginning September 17, 2018, symptoms of the Veteran's left knee scar have more nearly approximated a single painful scar but have not at any time more nearly approximated three or more painful or unstable scars.

CONCLUSIONS OF LAW

1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for meningioma have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for headaches have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for Grover's disease have been met.  38 U.S.C. §§ 
 the Veteran, the criteria for service connection for meningioma have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for headaches have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for Grover's disease have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for actinic keratosis have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

5. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for seborrheic keratosis have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

6. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for nail pterygium in lichen planus have been met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for service connection for TBI have not been met.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303.

8. The criteria for an effective date of September 17, 2018, for the grants of service connection for left knee flexion disability, left knee instability, and left knee scar, have been met.  38 U.S.C. § 5110; 38 C.F.R. § 3.2500.

9. The criteria for an initial 30 percent rating, the maximum schedular rating, for left knee flexion disability, from September 17, 2018, have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.71a, Diagnostic Code (DC) 5260.

10. The criteria for an initial 30 percent rating, the maximum schedular rating, for left knee instability, from September 17, 2018, have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.71a, DC 5257.

11. The criteria for an initial rating of 10 percent, but no higher, for left knee scar, from September 17, 2018, have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.118, DC 7804.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1984 to June 1991, from May 2003 to February 2004, from March 2007 to December 2007 and from December 2007 to January 2012, with combat service noted for the three periods of service following June 1991, for which he received the Combat Action Ribbon.

This case comes before the Board of Veterans' Appeals (Board) from an April 2021 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).  Prior to that decision, in March 2018, the RO denied entitlement to service connection for meningioma, previously referred to as brain cancer or brain condition, headaches, skin condition, and a TBI.  Following a September 17, 2018 claim, in a December 2018 rating decision, the RO denied entitlement to service connection for left knee arthritis, and continued the denials of entitlement to service connection for headaches, a skin condition, and a TBI.  The Veteran filed a supplemental claim in November 2019 and in the rating decision on appeal, the RO granted entitlement to service connection for the Veteran's left knee flexion disability and left knee instability, and assigned separate
VA) Regional Office (RO).  Prior to that decision, in March 2018, the RO denied entitlement to service connection for meningioma, previously referred to as brain cancer or brain condition, headaches, skin condition, and a TBI.  Following a September 17, 2018 claim, in a December 2018 rating decision, the RO denied entitlement to service connection for left knee arthritis, and continued the denials of entitlement to service connection for headaches, a skin condition, and a TBI.  The Veteran filed a supplemental claim in November 2019 and in the rating decision on appeal, the RO granted entitlement to service connection for the Veteran's left knee flexion disability and left knee instability, and assigned separate 10 percent ratings for both disabilities.  The RO granted entitlement to service connection for the Veteran's left knee scar, and assigned a noncompensable rating.  Finally, the RO continued the denial of service connection for a TBI, meningioma, skin condition, and headaches.  

In the April 2021 rating decision on appeal, the RO considered the merits and evidence for each appealed claim and determined that new and relevant evidence had not been submitted with respect to only the TBI claim.  However, given that the Veteran's evidence provided in his November 2024 Board hearing and submitted within the 90-day evidentiary window tends to prove an element of the claim, new and relevant evidence has been received and the Board will adjudicate the TBI claim on the merits.  38 U.S.C. § 101(35) (defining relevant evidence as "evidence that tends to prove or disprove a matter in issue"); VA Adjudication Procedures Manual, M21-1, X.ii,2.A.2.d ("New evidence that affirms findings previously deemed favorable to the claimant is still relevant").

In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  A Board hearing was held on November 5, 2024.

Therefore, the Board may only consider the evidence of record at the time of the April 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing.  38 C.F.R.  § 20.302(a).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision. 

As for characterization of the issues on appeal, the Veteran's claim for service connection for skin condition has been recharacterized as Grover's disease, actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus based on the medical evidence of record. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (a claim should not be limited to the disorder as characterized by the Veteran but must be characterized and addressed based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim).

Service Connection

Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Entitlement to service connection for
1110; 38 C.F.R. § 3.303(a).  Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a relationship between the current disability and the in-service disease or injury.  Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018).  Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Entitlement to service connection for meningioma is granted. 

As favorably found by the AOJ, the December 2020 VA examination report contains a diagnosis of meningioma.  The Board is bound by this favorable finding, 38 C.F.R. § 3.104(c), and the current disability requirement has thus been met.

With respect to meningioma, in its April 2021 rating decision, the AOJ favorably found that the evidence shows that the Veteran was exposed to environmental hazards during military service in Southwest Asia.  Regarding additional in-service exposures, during his November 2024 Board hearing, the Veteran explained that while a midshipman at the United States Naval Academy from 1980 to 1984, he spent a summer on a submarine, and was required to wear a dosimeter given the levels of radiation exposure from the nuclear-powered engines, as well as from radar equipment and signals, radios and weapons control systems.  In addition, an October 1987 letter from the medical department of the U.S.S. Kitty Hawk states that the Veteran was exposed to ionizing radiation while at that command from May to July 1987.  During his Board hearing, the Veteran testified that he was required to stand on signal and navigational bridges onboard the U.S.S. Kitty Hawk for 8 hours per day, exposing him to radiation from the surface radars, air acquisition radars, air search radars, and weapons acquisition radars; he also worked in the steam plan engine room of the ship.  

In a private opinion submitted in February 2025, the physician further explained that the Veteran spent countless hours in and around the naval command operation systems radar, which created direct contact with various levels of radar equipment, communications equipment, radio consoles and radio wave antenna.  In addition to his time onboard the U.S.S. Kitty Hawk, a July 2005 Fitness Report Evaluation shows the Veteran's service as part of the reserve diving and salvage unit in response to Hurricane Katrina and that the Veteran provided analytical support during the recent Russian mini-sub rescue operation, further exposing the Veteran to radiation and electromagnetic fields during service.  Finally, during his Board hearing, and as reflected in service treatment records, the Veteran experienced transient changes in vision and headaches, with the Veteran ultimately being disqualified from flight because he was unable to consistently test as having 20/20 vision.  The Veteran stated that he had not experienced either prior to service.  Based on the favorable finding, the lay and medical evidence of record, and the Veteran's service records, the in-service injury or disease requirement for meningioma have been met. 

The remaining issue is thus whether there is a relationship between the Veteran's meningioma and his service.  There are conflicting medical opinions on this question.

All opining physicians indicated that the Veteran was diagnosed in 1998 with a right frontal benign tumor after complaints of a persistent headache.  At the time of diagnosis, the mass measured 5 centimeters by 3.8 centimeters by 5 centimeters, largely located in the frontal lobe and extending into the parietal lobe, compressing the right lateral ventricle with significant midline structures to the left.  The private opining physician, as well as the Veteran, describe the tumor as goose egg in size and the submitted MRI imaging shows a very large mass at the front of the Veteran's brain.  All physicians understand that the Veteran underwent a surgical craniotomy, with not all of the tumor removed during the 1998 procedure because of potential vascular involvement.  All physicians agree that the tumor returned, and that the Veteran underwent a gamma knife procedure in 2004 to remove the tumor and to prevent future growth through radiation; however, the procedure was not effective, and caused the tumor to mutate and regrow.  By 2012, the tumor had returned and the Veteran underwent a second craniotomy in 2014, after gamma knife treatment was discontinued due to the size of the tumor.  The deep tissue margins around the tumor were also removed.  While the tumor has not been shown to return, the 2014 craniotomy caused brain injury in the surrounding
 surgical craniotomy, with not all of the tumor removed during the 1998 procedure because of potential vascular involvement.  All physicians agree that the tumor returned, and that the Veteran underwent a gamma knife procedure in 2004 to remove the tumor and to prevent future growth through radiation; however, the procedure was not effective, and caused the tumor to mutate and regrow.  By 2012, the tumor had returned and the Veteran underwent a second craniotomy in 2014, after gamma knife treatment was discontinued due to the size of the tumor.  The deep tissue margins around the tumor were also removed.  While the tumor has not been shown to return, the 2014 craniotomy caused brain injury in the surrounding areas, affecting the Veteran's memory, thought processing, organizational abilities, reasoning skills, and emotional and mental stamina.

In January 2018, the Veteran attended a cranial nerves VA examination.  The physician recorded the history above, including that the diagnosis occurred in 1998 in between two periods of active duty service.  Based only on the date of diagnosis, the physician opined that it is less as likely as not that the Veteran's meningioma was incurred or caused by an in-service event, injury, or illness during military service.

The Veteran attended a central nervous system (CNS) and neuromuscular diseases VA examination in December 2020, with the physician recording the above history.  The physician marked that the Veteran's tumor was a disease with clear and specific etiology and diagnosis that is less likely than not related to a specific exposure event experienced by the Veteran during service in southwest Asia.  When asked to provide a rationale to support that opinion, the physician wrote that the Veteran's tumor is a recognized benign brain tumor that is not known to be caused by any specific environmental exposures. 

The physician providing the February 2025 opinion explained that the Veteran's tumor is considered slow growing, taking many years to reach sizable proportions.  Based on the size of the tumor in 1998, the physician stated that it can be determined to a reasonable degree of accuracy that the tumor began growing a decade or more previously.  This finding is supported by the regrowth of the tumor by 2004; after six years, the tumor had not reached its original size from 1998.  Due to its significantly smaller size, it was thought to be a candidate for the gamma knife.  Based on this growth picture, the physician stated that the onset of the tumor occurred around ten to fifteen years prior to the original diagnosis, during the Veteran's first period of active duty service.  The physician noted, as well as the Veteran testified, that the neurologist performing the 1998 craniometry stated that the tumor likely began a decade prior to his diagnosis.  The opining physician further explained that the Veteran's transient fluctuation in vision testing and headaches during his first period of active service were likely due to the original growth of the tumor, displacing structures in his brain.  Finally, the physician explained that while medical science does not know why tumors form, the widely accepted consensus of identified risk factors include gender (with females more common), hormone replacement therapy or use of oral contraceptive pills, breast cancer, genetic conditions, race, older age, obesity, head injury, radiation exposure, and exposure to other toxins and chemicals.  The physician stated that the Veteran has only the last three risk factors, all of which are tied to his first period of military service.  In further support, the physician provided research showing that radiation causes brain tumors that are not cancerous, including studies that determined that radar induced electromagnetic fields in ships generally exceed the limits, including exposure to those working on flight bridges for extended periods, and increased the likelihood of adverse health outcomes, including benign tumors. Further, with respect to chemicals and toxin exposure, the physician stated that while brain cancer is a presumptive disability recognized under the Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act, from a medical viewpoint, the mutagenic agent that alters the normal cell structure is the same regardless of how the cell behaves after the change, e.g., whether it is cancerous or benign growth. 

The private physician providing the positive nexus opinion considered the Veteran's type and circumstances of service, including multiple types of in-service exposures, the lay and medical evidence regarding the onset of the meningioma during his first period of active service, such as the size and location of the tumor when it was diagnosed in 1998, and provided relevant medical literature in support of his conclusion.  As this physician "applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion," the opinion is adequate and entitled to significant probative weight in determining a relationship between the Veteran's meningioma and service.  Nieves-Rodriguez v
., whether it is cancerous or benign growth. 

The private physician providing the positive nexus opinion considered the Veteran's type and circumstances of service, including multiple types of in-service exposures, the lay and medical evidence regarding the onset of the meningioma during his first period of active service, such as the size and location of the tumor when it was diagnosed in 1998, and provided relevant medical literature in support of his conclusion.  As this physician "applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion," the opinion is adequate and entitled to significant probative weight in determining a relationship between the Veteran's meningioma and service.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning").  In contrast, the VA physicians providing negative opinions relied solely on the date of diagnosis of the Veteran's meningioma, without considering any other lay or medical evidence of record, and without providing any citations or evidence in support of the conclusion that benign brain tumors are not known to be caused by any specific environmental exposures.  Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (stating that a medical opinion must support its conclusion with an analysis that the Board can weigh, and a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision).  These opinions are therefore inadequate and not entitled to any probative weight in making a determination as to whether direct service connection is warranted. 

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's meningioma is related to service.  As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for meningioma, and all residuals, is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Entitlement to service connection for headaches is granted. 

As favorably found by the AOJ, the March 2020 VA examination report contains a diagnosis of headaches.  The Board is bound by this favorable finding, 38 C.F.R. § 3.104(c), and the current disability requirement has thus been met.

During the Veteran's Board hearing, he stated that he began to experience headaches while a midshipman at the United States Naval Academy.  Service as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy, is active duty.  38 U.S.C. § 101 (21)(D).  The Veteran believed his headaches were from associated stress and also recalled an incident during which a member of the USNA boxing team knocked him unconscious.  As the Veteran is competent and credible to report the observable symptoms of a headache that developed in service, Layno v. Brown, 6 Vet. App. 465, 470 (1994) (lay testimony is competent to prove that a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared), and his disorder is consistent with the "places, types, and circumstances of service as shown by service records," 38 C.F.R. § 3.303(a), the in-service injury element has been met.

During his January 2018 headaches VA examination, the Veteran reported first experiencing a significant headache in 1998, when it felt as though his head was pressure filled and going to burst; this ultimately led to the diagnosis of his meningioma.  The Veteran reported continuing to experience headaches since that time, with the VA physician opining that the Veteran's headaches are correlated to the meningioma and its treatment.  

The Veteran attended a VA headaches examination in March 2020.  The physician provided the same opinion that the Veteran's headaches are at least as likely as not proximately due to or the result of the Veteran's meningioma, and the multiple rescissions following that diagnosis.  

In the private opinion submitted in February 2025, the physician acknowledged it is common for people who have meningioma and/or have undergone craniotomies to experience chronic headaches, especially in the Veteran's case, as deeper tissue margins around the meningioma were removed.  In addition, the Veteran's biochemical and radiation exposure could independently cause chronic headaches.  As the Veteran has compounded military-related etiology for his headaches, which began in service and have continued since that time, the physician opined that the Veteran's headaches are most likely related to his military service. 

The VA physicians providing the positive secondary service connection opinions considered only the Veteran's headaches in relation to his meningioma
 the multiple rescissions following that diagnosis.  

In the private opinion submitted in February 2025, the physician acknowledged it is common for people who have meningioma and/or have undergone craniotomies to experience chronic headaches, especially in the Veteran's case, as deeper tissue margins around the meningioma were removed.  In addition, the Veteran's biochemical and radiation exposure could independently cause chronic headaches.  As the Veteran has compounded military-related etiology for his headaches, which began in service and have continued since that time, the physician opined that the Veteran's headaches are most likely related to his military service. 

The VA physicians providing the positive secondary service connection opinions considered only the Veteran's headaches in relation to his meningioma, and did not consider his statements that his headaches occurred during his first period of active service or any in-service injuries or exposures that may have caused his headaches to begin during service.  For this reason, the opinions are inadequate as to direct service connection.  See Buchanan v. Nicholson,451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (stating that an examiner's opinion failed to consider whether lay statements presented sufficient evidence of the etiology of the Veteran's disability such that his claim could be proven without contemporaneous medical evidence).

The private physician considered the Veteran's statements regarding his in-service injuries and exposure, and the Veteran experiencing headaches during his first period of active service, as the basis for his positive direct service connection opinion.  For this reason, the opinion is adequate and entitled to significant probative weight in determining that direct service connection for the Veteran's headaches is warranted.  See Nieves-Rodriguez, 22 Vet. App. at 304. 

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's headaches are related to service.  As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for headaches is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Entitlement to service connection for Grover's disease, actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus, is granted. 

Additional laws and regulations need to be considered in connection with this claim.  In the April 2021 rating decision, the AOJ found that with respect to the Veteran's claim for entitlement to service connection for a skin condition, that the claimed existed prior to military service, with medical evidence showing treatment for skin.  The AOJ did not clarify the type of skin condition or the period of service.  However, as this finding facially relates to the presumption of soundness, the Board will address it. 

A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service.  38 U.S.C. § 1111; 38 C.F.R. § 3.304(b).  The term "noted," in 38 U.S.C.A. § 1111, refers to "[o]nly such conditions as are recorded in examination reports."  38 C.F.R. § 3.304(b). A "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions."  38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994).

Here, on the February 1979 enlistment examination report, the Veteran was noted to have mild acne.  The physician marked "no" for skin diseases.  This constitutes notation of a preexisting defect of mild acne, but does not constitute notation of skin diseases preexisting service.  Amezquita v. McDonough, 135 F.4th 1369, 1372 (Fed. Cir. 2023) ("an asymptomatic condition can be noted as a preexisting defect under section 1111"); Verdon v. Brown, 8 Vet. App. 529, 535 (1996) ("even though the veteran's bunions may have been asymptomatic at the time of his induction, they were 'noted' on the Navy induction medical examination report and the accompanying orthopedic examination report.  The Board therefore was not in error in determining that the bunion disorder was a preexisting condition").  

To this point, during his November 2024 Board hearing, the Veteran
 Amezquita v. McDonough, 135 F.4th 1369, 1372 (Fed. Cir. 2023) ("an asymptomatic condition can be noted as a preexisting defect under section 1111"); Verdon v. Brown, 8 Vet. App. 529, 535 (1996) ("even though the veteran's bunions may have been asymptomatic at the time of his induction, they were 'noted' on the Navy induction medical examination report and the accompanying orthopedic examination report.  The Board therefore was not in error in determining that the bunion disorder was a preexisting condition").  

To this point, during his November 2024 Board hearing, the Veteran testified that he had mild acne prior to service but did not experience recurrent rashes or dry and scaley skin until service, as documented in the below service treatment records.  The skin diseases for which he seeks service connection do not include acne.  Those skin disorders include Grover's disease, also known as transient acantholytic dermatosis, a skin disorder characterized by a rash of small, raised pink spots, which are usually itchy and generally located on the trunk and torso; nail pterygium in lichen planus, a disorder involving the nails and surrounding skin; actinic keratosis, a precancerous, rough-feeling patch or spot on the skin; and seborrheic keratosis, a benign skin growth, often appearing as brown, black, or tan "stuck-on" waxy and scaly patches. 

To the extent that acne and a rash from Grover's disease may resemble each other, the VA physician completing the January 2018 skins condition examination recorded that after examining the Veteran, there were no present signs of acne valgus.  In contrast, the examination showed the presence of Grover's disease with the Veteran's torso and the upper bilateral extremities, estimated to be 20 to 40 percent of his body, covered in semi-raised papules that are annular with dry and pruritic base.  As the physician captured that the skin disorders of acne valgus and Grover's disease are different diagnoses with different and identifiable manifestations, the Veteran's pre-service notation of acne valgus does not extend to claims related to all skin disorders, which were specifically not noted at entry.  See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b) (referring to notation of specific "defects, infirmities, or disorders" noted at service entry rather than general disability or parts of the anatomy or body systems).

Therefore, the presumption of soundness applies to all skin disorders, with the exception of acne valgus.  As the Veteran has not claimed entitlement to service connection for acne valgus, a further discussion of the presumption of soundness is not warranted. 

As favorably found by the AOJ, the September 2020 VA examination report contains a diagnosis of Grover's disease.  The Board is bound by this favorable finding, 38 C.F.R. § 3.104(c), and the current disability requirement has thus been met with respect to Grover's disease.  VA treatment records from 2018 show that the Veteran's 20 nails were discolored and thickened; he was diagnosed with nail pterygium in lichen planus following an unsuccessful antifungal treatment.  Finally, VA treatment records show that the Veteran was diagnosed with actinic keratosis in October 2011, with later records from February 2017 showing actinic keratosis scattered with 18 lesions.  Finally, a VA treatment record from January 2019 shows a diagnosis of seborrheic keratosis.  Based on VA treatment records, the current disability requirement for actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus has been met. 

With respect to an in-service disease or injury, in April 1982, the Veteran reported a rash on his trunk area, with dry patches on his abdomen for one month; the physician observed multiple dry patches on his torso and arms.  He complained of a rash on his groin and bumps on his left foot in October 1982.  In September 1984, the Veteran was assessed with tinea cruris, a fungal infection.  The Veteran was treated again for a rash around his groin in October 1985 and July 1986, diagnosed as tinea cruris.  His separation report of medical examination from April 1991 notes multiple serous filled pinpoint papules over the soles of his feet, thickened nails, and dyshidrotic eczema.  In the Veteran's May 1991 physical
 area, with dry patches on his abdomen for one month; the physician observed multiple dry patches on his torso and arms.  He complained of a rash on his groin and bumps on his left foot in October 1982.  In September 1984, the Veteran was assessed with tinea cruris, a fungal infection.  The Veteran was treated again for a rash around his groin in October 1985 and July 1986, diagnosed as tinea cruris.  His separation report of medical examination from April 1991 notes multiple serous filled pinpoint papules over the soles of his feet, thickened nails, and dyshidrotic eczema.  In the Veteran's May 1991 physical examination questionnaire, the Veteran recorded small pink skin patches on the right side of his nose, cracked and peeling toenails and chronic athlete's foot.  The physician completing his separation medical report recorded dyshidrotic eczema.  In his January 2004 post-deployment health assessment after his deployment to Bahrain and Kuwait during his second period of active service, the Veteran reporting experiencing rashes on his face, chest and back and reporting possible exposures during that deployment.  He was assessed at that time as potentially having Grover's disease.  The Veteran was diagnosed as having actinic keratosis on his face in October 2011, during his last period of active service.  Based on the foregoing, the in-service injury or disease element has been met.

Following service, as noted above in the diagnosis section, the Veteran continued to receive treatment for his skin.  In April 2016, a dermatologist noted that the etiology of his rash was unclear with the rash distribution fitting for Grover's disease but that the rash was not itchy, and had been present for years.  A biopsy confirmed a diagnosis of Grover's disease.

The Veteran attended a VA skin condition examination in January 2018 for his Grover's disease.  The physician recorded that presenting symptoms included diffused, semi-raised papules that are annular with dry, pruritic base, sensitive to touch, and since initial presentation at the torso, has since spread to the bilateral upper extremities.  The Veteran follows a dermatologist who prescribed a topical medication, to which the skin condition is not responding, with the rash still actively spreading.  The Veteran denied the presence of any systemic conditions associated with integument disorder.  The physician opined that the Veteran's skin condition is less as likely as not (50 percent or lesser probability) incurred in or caused by an in service event, injury, or illness that occurred during military service.  They reasoned that the Veteran's skin disorders that were diagnosed in service must have resolved because they were not seen on that day's examination.  Regarding Grover's disease, the Veteran was diagnosed with this condition in 2016 after service, with no further findings indicating that this condition was present or started while in service.  

In the Veteran's August 2018 statement, he explained he was not experiencing a flare-up of skin conditions during his examination, and that he has been seen and treated throughout his military career for several skin conditions and rashes. 

In September 2020, a VA physician provided a negative service connection opinion for Grover's disease.  The physician stated that while there was an earlier in service diagnosis of Grover's disease in 2004, it was not confirmed with a biopsy until 2016.  The physician also stated that it could be theorized that heat, sweating, mechanical irritation, sunlight, all of which can be considered possible military related factors, are risk factors for Grover's disease, as stated in the included medical research.  However, because a rash caused by Grover's disease typically resolves, with asymptomatic periods between eruptions, and do not often involve the face, the physician stated that it cannot be concluded that military service aggravated the condition beyond its usual condition without resorting to speculation.  The physician did not consider the VA dermatologist's notation of the abnormal persistence and presentation of Grover's disease prior to the 2016 biopsy. 

In the February 2025 private opinion, the physician considered the above evidence, including the Veteran's in-service recurrent disease of his nails, his recurrent rashes over his trunk and groin, his diagnosed acidic keratosis on his face, that was previously described as a rash on the side of his nose and diagnosed as dyshidrotic eczema, and finally, his Grover's disease, initially assessed in 2004 following the Veteran's deployment, and confirmed by biopsy in 2016.  The physician explained that these fungal, viral and bacteria dermatological disorders, that only appeared during and following service, worsened over time, have not resolved and continued intermittently to present, and are consistent with immune modulation as shown in
In the February 2025 private opinion, the physician considered the above evidence, including the Veteran's in-service recurrent disease of his nails, his recurrent rashes over his trunk and groin, his diagnosed acidic keratosis on his face, that was previously described as a rash on the side of his nose and diagnosed as dyshidrotic eczema, and finally, his Grover's disease, initially assessed in 2004 following the Veteran's deployment, and confirmed by biopsy in 2016.  The physician explained that these fungal, viral and bacteria dermatological disorders, that only appeared during and following service, worsened over time, have not resolved and continued intermittently to present, and are consistent with immune modulation as shown in the cited medical research related to toxin exposure (discussed above).  For this reason, the physician opined that it is at least as likely as not that the Veteran's diagnosed skin conditions were caused by repeated and prolonged exposures to hazardous chemical agents and radiation during his military service.

Despite service treatment records reflecting the Veteran experiencing a recurrent rash on his trunk and groin since 1982 and the 2004 in-service assessment of Grover's disease, the VA physician providing the January 2018 opinion based the negative opinion on the lack of an in-service diagnosis and no further findings indicating that this condition was present or started while in service.  While the VA physician providing the opinion in September 2020 considered these relevant facts, along with providing a list of in-service risk factors affecting the Veteran, the physician opined, without explanation, that making any determination as to the cause without an in-service biopsy confirming diagnosis of Grover's disease would be speculative.  As both physicians failed to address the relevant facts of the case in rendering their opinions, the opinions are inadequate and not entitled to any probative value.  See Nieves-Rodriguez, 22 Vet. App. at 304; see also Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (stating that before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion, or the basis must otherwise be apparent).

The physician providing the private opinion considered the lay and medical evidence of record, including the in-service exposures and recurring conditions and evolving diagnoses regarding the rash on his trunk and groin since 1982, the thickening and discoloration of nails, and the types of keratoses diagnosed following deployments.  For this reason, the opinion is adequate and entitled to substantial probative weight.  

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's Grover's disease, actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus are related to service.  As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for Grover's disease, actinic keratosis, seborrheic keratosis, and nail pterygium in lichen planus is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Entitlement to service connection for a TBI is denied. 

The current disability requirement is satisfied when a Veteran "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim," McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or "when the record contains a recent diagnosis of disability prior to... filing a claim for benefits based on that disability."  Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013).

The existence of a current disability is the cornerstone of a claim for VA disability compensation.  See Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997).  In the absence of evidence of a current disability, there can be no valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Board has considered whether the Veteran experienced a TBI-related disability at any time during the pendency of this appeal or in close proximity to the appeal, even if the disorder has resolved.  McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowski v. Shinseki, 26 Vet. App. 289 (2013).

The VA and private medical records, examinations and reports do not contain a TBI diagnosis.  While the private orthopedist providing the opinion in February 2025 references a TBI, the orthopedist does not identify any
 valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Board has considered whether the Veteran experienced a TBI-related disability at any time during the pendency of this appeal or in close proximity to the appeal, even if the disorder has resolved.  McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowski v. Shinseki, 26 Vet. App. 289 (2013).

The VA and private medical records, examinations and reports do not contain a TBI diagnosis.  While the private orthopedist providing the opinion in February 2025 references a TBI, the orthopedist does not identify any supporting TBI evaluations and did not complete an in-person examination of the Veteran.  In addition, the VA's Adjudication Procedures Manual, M21-1, states that an initial diagnosis of TBI must be made by one of the following specialists: physiatrists; psychiatrists; neurosurgeons; or neurologists.  While the Adjudication Manual is not binding on the Board, DAV v. Sec'y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) ("The M21-1 Manual is binding on neither the agency nor tribunals"), it "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases." Overton v. Wilkie, 30 Vet. App. 257, 264 (2018).  

Moreover, while pain alone can serve as a disability for VA compensation purposes if it rises to the level of functional impairment that affects earning capacity, see Saunders v. Wilkie, 886 F.3d 1356 (2018), a TBI disability requires a specific diagnosis.  The Board has also considered whether it can recharacterize the claim for service connection for a TBI as a claim for a disability manifesting in memory loss or noted symptoms, in view of the Veteran's assertions and the medical evidence of record, as described above.  See Clemons v. Shinseki, 23 Vet. App. 1 (2009).  However, the symptoms that the Veteran attributes to a TBI directly overlap with those attributed to his meningioma and subsequent craniotomies, including memory loss, thought processing, organizational abilities, reasoning skills, and emotional and mental stamina, with the Board granting entitlement to service connection for meningioma and all residuals in this instant decision, as well as having granted service connection for headaches.    

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a TBI is warranted.  Rather, the evidence persuasively weighs against entitlement to service connection for a TBI.  The benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), 38 C.F.R. § 3.102, is therefore not for application as to this claim.  Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Entitlement to an earlier effective date of November 17, 2018, for the grant of service connection for left knee flexion disability, left knee instability, and left knee scar, is granted.

In his NOD, the Veteran listed as issues service connection for the left knee disability (as characterized by the AOJ) "is granted with an evaluation of 10 percent effective November 27, 2019."  Given that the Board must "construe [arguments identifying the specific decision and issue or issues therein with which the claimant disagrees] in a liberal manner for purposes of determining whether they raise issues on appeal," 38 C.F.R. § 20.202(a), the Board infers that the Veteran sought to challenge both the initial ratings assigned and the effective dates for the grants of service connection for left knee flexion disability and left knee instability.  

Pursuant to 38 C.F.R. § 3.2500(h)(1), "the effective date will be fixed in accordance with the date of receipt of the initial claim or date entitlement arose, whichever is later, if a claimant continuously pursues an issue by timely filing in succession any of the available review options as specified in paragraph (c) of this section within one year of the issuance of the decision."  Pursuant to 38 C.F.R. § 3.2500(c), a claimant may continuously pursue a claim by timely filing one of the specified administrative review options after any
 initial ratings assigned and the effective dates for the grants of service connection for left knee flexion disability and left knee instability.  

Pursuant to 38 C.F.R. § 3.2500(h)(1), "the effective date will be fixed in accordance with the date of receipt of the initial claim or date entitlement arose, whichever is later, if a claimant continuously pursues an issue by timely filing in succession any of the available review options as specified in paragraph (c) of this section within one year of the issuance of the decision."  Pursuant to 38 C.F.R. § 3.2500(c), a claimant may continuously pursue a claim by timely filing one of the specified administrative review options after any decision by the AOJ, Board, or Court.  The available review options in 38 C.F.R. § 3.2500(c) include filing a supplemental claim, request a higher-level review, or appeal to the Board of Veterans' Appeals following notice of a decision on an initial claim or supplemental claim.

In this case, the Veteran filed his initial claim for service connection for left knee arthritis on September 17, 2018.  The RO denied entitlement to service connection for left knee arthritis in a December 2018 rating decision.  Within one year of the December 2018 rating decision, on November 27, 2019, the Veteran filed a supplemental claim challenging the denial of service connection for left knee arthritis.  In the April 2021 rating decision on appeal, the RO adjudicated the November 2019 supplemental claim, and granted entitlement to service connection for the left knee disability, assigning an initial 10 percent rating for left knee instability, a separate 10 percent rating for limitation of flexion of the knee, and a noncompensable rating for left knee scar, with an effective date of November 27, 2019 for all disabilities.  As the Veteran continuously pursued his initial claim for compensation for left knee disability filed on September 17, 2018, and entitlement arose prior to the date of claim, the proper effective date is the date of the initial claim, September 17, 2018.

Higher Initial Ratings

Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology and impairment with the criteria set forth in VA's Rating Schedule.  38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.  If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned.  38 C.F.R. § 4.7.

Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged.  Fenderson v. West, 12 Vet. App. 119 (1999).  Here, however, as shown below, the evidence warrants uniform and separate 30 percent ratings for left knee flexion disability and left knee instability, and a uniform 10 percent rating for left knee scar.

Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.

Entitlement to an initial rating of 30 percent for left knee flexion disability, from September 17, 2018, is granted.

Disabilities of the knee and leg are generally rated under 38 C.F.R. § 4.71a, DCs 5256 through 5263.  

The Veteran's left knee disability is separately rated under 38 C.F.R. § 4.71a, DC 5257, applicable to recurrent subluxation or instability, and DC 5260 applicable to limitation of flexion of the leg.   

Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion.  38 C.F.R. § 4.71, Plate II.  When there is limitation of motion of the specific joint or joints that is 10 percent or higher under the appropriate diagnostic code, the compensable limitation of motion should be rated under the appropriate diagnostic code for the specific joint or joints involved.  38 C.F.R. § 4.71A

DC 5260 applies to limitation of flexion of a leg.  Under DC 5260, flexion
5257, applicable to recurrent subluxation or instability, and DC 5260 applicable to limitation of flexion of the leg.   

Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion.  38 C.F.R. § 4.71, Plate II.  When there is limitation of motion of the specific joint or joints that is 10 percent or higher under the appropriate diagnostic code, the compensable limitation of motion should be rated under the appropriate diagnostic code for the specific joint or joints involved.  38 C.F.R. § 4.71A

DC 5260 applies to limitation of flexion of a leg.  Under DC 5260, flexion limited to 60 degrees is noncompensable; flexion limited to 45 degrees is 10 percent disabling; flexion limited to 30 degrees is 20 percent disabling; and flexion limited to 15 degrees is 30 percent disabling.  38 C.F.R. § 4.71A, DC 5260.

VA's General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion.  VAOPGCPREC 9-04, published at 69 Fed. Reg. 59,990 2004); see 38 C.F.R. § 4.14.

DC 5261 is applicable to the limitation of extension of a leg.  DC provides a noncompensable disability rating when extension is limited to 5 degrees, a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees.  Id.

Other Diagnostic Codes apply to disabilities of the knees.  

Degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved.  38 C.F.R. § 4.71, DC 5003.  If the limitation of motion is noncompensable, a rating of 10 percent applies for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  In the absence of limitation of motion, a 20 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.  A 10 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups.  38 C.F.R. § 4.71A, DC 5003.  

There are additional DCs that pertain to the knee, with the DC applicable to knee instability or recurrent subluxation discussed below.  Except for instability, the evidence of record shows that the symptoms of the left knee disability in this case have neither manifested as or been attributed to ankylosis or its functional equivalent, see Chavis v. McDonough, 34 Vet. App. 1, 23-24 (2021) (the ankylosis criterion in VA's General Rating Formula for Diseases and Injuries of the Spine can be met with evidence of the functional equivalent of ankylosis during a flare), symptomatic removal of semilunar cartilage, impairment of the tibia or fibula, traumatic arthritis or genu recurvatum.  Therefore, separate, or higher disability ratings under these knee DCs do not require further discussion.  38 C.F.R. §§ 4.14, 4.71a; DCs 5010, 5256, 5259, 5262, 5263. 

When assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flareups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time, functional loss due to flareups, fatigability, incoordination, and pain on movement.  DeLuca v. Brown, 8 Vet. App. 28 Vet. App. 202, 206-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011).  Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4
ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time, functional loss due to flareups, fatigability, incoordination, and pain on movement.  DeLuca v. Brown, 8 Vet. App. 28 Vet. App. 202, 206-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011).  Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40 ), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45 ).  See Mitchell, 25 Vet. App. at 44.  

Joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.  38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016).

A VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given.  Sharp v. Shulkin, 29 Vet. App. 26 (2017).  Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner.  Id. 

Private treatment records show that in August 2010, during active service, the Veteran sustained a left knee tibial plateau compression fracture, requiring surgical repair with plates and screws.

The Veteran attended a knee and lower leg VA examination in October 2018.  The physician recorded a diagnosis of tibia and/or fibula fracture, and left knee instability.  The Veteran's current symptoms included achiness on both sides of the front of the knee that he rated a four or six out of 10 in severity, which he experiences a couple of times a week with the pain lasting most of the day.  The Veteran also experiences occasional swelling after using stairs, prolonged walking, high impact activities, repetitive squatting, and kneeling.  The Veteran avoids these activities and takes NSAID as needed.  The Veteran described flare-ups of his left knee as severe pain lasting around 5 hours, with the Veteran requiring rest and avoiding bearing weight on his left leg.  The Veteran then experiences a day or two of moderate pain, and being unable to walk normally, described as "hobbling."  The physician measured a flexion endpoint of 120 degrees and an extension endpoint of 0 degrees, with pain noted on flexion and weight bearing, and objective evidence of localized tenderness or pain on palpitation.  The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional loss of range of motion in the left knee.  The Veteran was being examined immediately after repetitive use over time but not during a flare-up.  For both, the physician declined to provide an estimate in terms of range of motion, and referred to Section 2 of the examination report, which recorded the Veteran's statement that he must avoid weight bearing during a flare-up and "hobbles."  The physician recorded normal strength in the left knee, with no evidence of ankylosis, crepitus, medial tibial stress syndrome or meniscal conditions, and no history of recurrent sublation; however, the Veteran showed anterior instability during the Lachman test, and the physician remarked that his left knee demonstrates a mild degree of instability anteriorly and medially.  

A January 2019 VA telephone encounter note records the Veteran describing his chronic left pain, rated as seven out of 10, as a generalized ache.  While he can walk with the chronic pain, it "keeps [him] from doing other things that [he] want[s] to do." 

A January 2019 VA primary care note shows the Veteran reporting increased pain in his left knee after hiking or walking for long periods of time that lasts for a few days and is relieved with Motrin.  The physician assessed some crepitus, with the knee stable and the varus and valgus stress neurovascular examination intact.

The Veteran attended a knee and lower leg VA examination in March 2021.  The physician recorded that the Veteran experienced pain when using the
 records the Veteran describing his chronic left pain, rated as seven out of 10, as a generalized ache.  While he can walk with the chronic pain, it "keeps [him] from doing other things that [he] want[s] to do." 

A January 2019 VA primary care note shows the Veteran reporting increased pain in his left knee after hiking or walking for long periods of time that lasts for a few days and is relieved with Motrin.  The physician assessed some crepitus, with the knee stable and the varus and valgus stress neurovascular examination intact.

The Veteran attended a knee and lower leg VA examination in March 2021.  The physician recorded that the Veteran experienced pain when using the knee, and can have severe soreness following any moderate use, as well as a sharp pain if he moves it incorrectly.  The Veteran restricts the use of his knee, and does not run, and avoids standing for long periods of time, significant walking, and weight bearing activity, if possible, to avoid flare-ups.  The Veteran reported that he incurs flare-ups of his left knee that are moderate to severe, depend on the activity, last several hours to a day, and are precipitated by activity.  Normal treatment, as well as during a flare-up, includes restricted use and ibuprofen.  The physician further recorded that the Veteran has a positive test for instability, with the Veteran reporting a history of instability or recurrent subluxation and feeling a sharp pain at those times.  The physician measured the Veteran's flexion endpoint of 130 degrees, and an extension endpoint of 0 degrees for passive and active ranges of motion.  Pain was exhibited on flexion, as well as with weight bearing, causing functional loss.  There was no objective evidence of crepitus or localized tenderness or pain on palpitation of the joint.  The Veteran was able to perform three repetitive use testing with at least three repetitions, with no additional loss of function or range of motion after these repetitions.  The Veteran was not being examined immediately after repeated use overtime or during a flare-up, and the physician selected that the Veteran would experience pain during both.  To account for the additional pain experienced after repeated use overtime or a flare-up, the physician reduced the flexion endpoint by 10 degrees, estimating a flexion endpoint of 120 degrees.  The physician recorded that the Veteran did not have muscle atrophy, ankylosis of the knee and/or lower leg, or a meniscal condition.  Despite the physician recording a positive test showing instability, the physician marked that the Veteran did not have recurrent subluxation or persistent instability, that there has not been a ligament tear or sprain, and that the Veteran does not require a device to help ambulate.  However, the physician reported that the Veteran experiences pain and instability following his August 2010 surgical repair.  The physician performed the same testing on the Veteran's right knee.

During his November 2024 Board hearing, the Veteran stated that he avoids any downhill movement with his left knee, as his knee feels as though it will buckle.  He fears this and avoids the movement because at times, his left knee has given out entirely, also causing pain, but he has been able to avoid a fall.  The Veteran also testified that he experiences increased pain after using his left knee and that he limits full extension and use of the knee, and restricts natural movement because of increased pain and instability.  

The Veteran submitted an opinion by a private orthopedist in February 2025 to evaluate the severity of the Veteran's left knee disability including instability, weakness, and decreased function after repetitive use.  The physician explained that the Veteran's fractured tibia damaged the Veteran's surrounding muscles and ligaments.  Additional trauma was sustained with the surgery installing metallic hardware in the joint, which over time creates additional tissue damage with the metal rubbing against the surrounding soft structures.  Based on a review of the record, the orthopedist determined that the Veteran was not provided with sufficient physical therapy following the surgery, encouraged to return to full functioning as soon as he was able, and provided with medication to mask the pain.  Therefore, the physician opined that it is highly expected that the Veteran's knee would suffer faster progression of disease given the injury, poor recovery, and instability.  Regarding instability, the Veteran stated that he experiences instability daily, has to think about every step or movement he makes with the left leg / knee, and must assess every surface for unevenness.  The Veteran explained that he tries not to bend his knee, place too much pressure on it, or overuse it because of fear of the pain.  Despite these restrictions, his left knee feels tired all day.  The Veteran rated his constant pain as a three to four out of 10, that increases to a 7 out of 
 provided with medication to mask the pain.  Therefore, the physician opined that it is highly expected that the Veteran's knee would suffer faster progression of disease given the injury, poor recovery, and instability.  Regarding instability, the Veteran stated that he experiences instability daily, has to think about every step or movement he makes with the left leg / knee, and must assess every surface for unevenness.  The Veteran explained that he tries not to bend his knee, place too much pressure on it, or overuse it because of fear of the pain.  Despite these restrictions, his left knee feels tired all day.  The Veteran rated his constant pain as a three to four out of 10, that increases to a 7 out of 10 with minimum movement, such as walking on a flat hard top surface.  Around three to 4 times a week, he experiences severe exacerbations of the pain rated 10 out of 10, and that he must stop and do nothing until the symptoms subside, which could take hours.  The orthopedist recorded that the Veteran guards his left knee, creating more locking in the joint, and also muscle fatigue from the muscles forced to compensate.  The physician did not provide flexion or extension endpoints, but stated that he would expect the Veteran to have greater limitations during exacerbation with greatly restricted motion and muscular fatigue.

For the following reasons, the Board finds that entitlement to an initial 30 percent rating is warranted for the Veteran's left knee flexion disability for the entire appellate period.  

The October 2018 VA examiner only provided an active range of motion for left knee flexion of 120 degrees; the examiner recorded that the passive range of motion was the same as active, and that the Veteran did not lose range of motion after three repetitions.  The March 2021 VA examiner only provided an active range of motion for left knee flexion of 130 degrees.  These findings do not more nearly approximate limitation to 15 degrees, indicative of a 30 percent rating.  The Board must, however, also consider additional functional loss due to symptoms such as pain and painful motion, weakness, premature or excess fatigability, and incoordination.  To this end, the Veteran reported that his chronic left knee pain is constant and moderate to severe, rating the pain he experiences each day as a four to six out of ten.  Functionally, this constant pain significantly limits his ability to stand, sit, ambulate, walk down an incline, use stairs, squat and kneel.  The pain was observed by the examiners, with the October 2018 recording moderate peripatellar tenderness or pain on palpitation, and both examiners recording pain with weight bearing and with active and passive motion.  For this reason, the Veteran has consistently reported altering his gait and avoiding any activities that place additional weight or strain on his left knee, which as the private orthopedist determined, creates additional muscle fatigue and strain.

In addition to this constant left knee pain, if the Veteran is unable to guard his left knee or must engage in an activity with his left knee that he would otherwise avoid, such as prolonged standing or walking, or any climbing, the Veteran experiences a flare-up.  The flare-ups involve severe pain, rated as 10 out of ten, and require the Veteran to rest and avoid bearing weight on the knee.  Because the increased pain from a flare-up can last for several days, during this period, the Veteran described his walking as "hobbling," indicating a near immobile knee that can only bear enough weight while the right leg ambulates.  Because his constant knee pain is aggravated by basic and prolonged movements, such as walking, he would be significantly limited in his excursion, strength, speed, coordination, and endurance after repetitive use over time and during a flare-up.  As factors to consider in determining functional impairment include "disturbance of locomotion, interference with sitting, standing and weight-bearing," 38 C.F.R. § 4.45(f), these factors may be the basis for a higher rating.  

The VA examiner in March 2021 accounted for the Veteran's report of flare-ups by decreasing the flexion endpoint by 10 degrees.  In contrast, the October 2018 VA examiner did not provide estimates for ranges of motion after repetitive use or during a flare-up, and instead referred to the Veteran's description of not being able to bear weight on the knee, requiring bedrest and hobbling for days following the flare-up.  That examiner's notation indicates that the Veteran's left knee flexion during a flare-up is greatly reduced because of the severe pain the Veteran experiences and his inability to use the knee.  Similarly, the private orthopedist did not estimate a flexion endpoint during flare-ups, but stated that he would expect the Veteran to have greatly restricted motion and muscular fatigue.
 Veteran's report of flare-ups by decreasing the flexion endpoint by 10 degrees.  In contrast, the October 2018 VA examiner did not provide estimates for ranges of motion after repetitive use or during a flare-up, and instead referred to the Veteran's description of not being able to bear weight on the knee, requiring bedrest and hobbling for days following the flare-up.  That examiner's notation indicates that the Veteran's left knee flexion during a flare-up is greatly reduced because of the severe pain the Veteran experiences and his inability to use the knee.  Similarly, the private orthopedist did not estimate a flexion endpoint during flare-ups, but stated that he would expect the Veteran to have greatly restricted motion and muscular fatigue.  

Based on the above, the symptoms of the Veteran's left knee flexion disability more nearly approximate significant functional loss after repeated use over time and during flare-ups.  Although range of motion testing conducted during the VA examinations do not reflect flexion limited to 15 degrees, as the Veteran has consistently reported significant aggravated pain that requires him to rest the knee, it is reasonable to conclude that the Veteran's range of motion was much more limited as the VA examinations did not take place after walking or standing for more than 20 minutes.  Based on this evidence, a 30 percent rating under DC 5260 for his left knee disability, based on estimated losses in range of motion and considering factors such as pain and interference with standing and ambulation, is warranted.

Regardless of the competent and credible reports of pain and other functional impairments, and despite the fact that painful motion has been documented, the evidence is neither evenly balanced nor approximately so with regard to whether a rating in excess of 30 percent for this disability is warranted.  Rather, the evidence weighs persuasively against approximation of the symptoms required for a rating in excess of 30 percent for left knee disability.  The evidence of record fails to indicate that the Veteran had limitation in extension to warrant a compensable disability rating under DC 5261.  Extension was normal, to 0 degrees, and painful motion under 38 C.F.R. § 4.59 is contemplated in the 30 percent rating being granted for left knee flexion.  See Frazier v. McDonough, 66 F.4th 1353, 1358 (Fed. Cir. 2023) (finding that VA's "interpretation of section 4.59" as allowing for only a single compensable rating for the joint based on pain "is not only reasonable but is consistent with the interpretation of section 4.59 applied by the DVA both prior to and since the Veterans Court's decision in Sowers").  

For the above reasons, entitlement to a 30 percent rating for the Veteran's left knee flexion disability is warranted.  The probative evidence of record weighs persuasively against a rating in excess of 30 percent or any separate rating other than for instability as discussed below, for the Veteran's left knee flexion disability.  Therefore, the benefit of the doubt doctrine is not for application in this regard.  Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Entitlement to an initial rating of 30 percent for left knee instability, from September 17, 2018, is granted. 

DC 5257 applies to lateral instability or recurrent subluxation of the knee.  During the pendency of this appeal, the rating criteria pertaining to DC 5257 were revised effective February 7, 2021.  If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question.  38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003).  If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change.  If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change.  38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327.  Therefore, the Board will consider the Veteran's claim under the former and amended criteria.

Under the prior version of DC 5257, a 10 percent rating is available for slight recurrent subluxation or lateral instability.  A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability.  A 30 percent rating is assigned for severe recurrent subluxation or lateral
 no earlier than the effective date of that change.  If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change.  38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327.  Therefore, the Board will consider the Veteran's claim under the former and amended criteria.

Under the prior version of DC 5257, a 10 percent rating is available for slight recurrent subluxation or lateral instability.  A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability.  A 30 percent rating is assigned for severe recurrent subluxation or lateral instability.  38 C.F.R. § 4.71a, DC 5257.

Slight, moderate, and severe are not defined in the regulation.  

"Slight," as an adjective, is defined as "small of its kind or in amount."  Slight, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/slight, Definition 2.  "Moderate," as an adjective, is defined to include as "not violent, severe, or intense"; "limited in scope or effect."  Moderate, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/moderate, Definitions 3 and 5.  "Severe," as an adjective, is defined as "causing discomfort or hardship"; "very painful or harmful"; "of a great degree."  Severe, Merriam-Webster Dictionary Online, Definitions 6a, 6b, and 8.

Under the amended criteria, DC 5257 provides for recurrent subluxation or instability with a 30 percent rating that is unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation.  A 20 percent rating is warranted for one of the following: (a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (b) an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation.  A 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation.  DC 5257 also provides for patellar instability with a 30 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker; a 20 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker.  A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker.  Note (1) of the rating provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon, and Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration).

As explained above, during the appeal period, the Veteran reported instability in his left knee.     

The Veteran does not have a diagnosed condition involving the patellofemoral complex of his left knee that is necessary to satisfy the criterion under amended DC 5257. 

However, his competent, credible, and consistent lay statements indicating recurrent instability indicate severe recurrent subluxation or lateral instability under prior version of DC 5257, warranting a 30 percent rating.

The Veteran was assigned an initial rating of 10 percent for slight instability of his left knee, indicating a small amount of impairment.  However, throughout the appeal period, the Veteran consistently reported that his left knee is
 to, arthroscopy to remove loose bodies and joint aspiration).

As explained above, during the appeal period, the Veteran reported instability in his left knee.     

The Veteran does not have a diagnosed condition involving the patellofemoral complex of his left knee that is necessary to satisfy the criterion under amended DC 5257. 

However, his competent, credible, and consistent lay statements indicating recurrent instability indicate severe recurrent subluxation or lateral instability under prior version of DC 5257, warranting a 30 percent rating.

The Veteran was assigned an initial rating of 10 percent for slight instability of his left knee, indicating a small amount of impairment.  However, throughout the appeal period, the Veteran consistently reported that his left knee is unable to walk at a downhill incline without locking or feeling as though it will buckle, sometimes accompanied by a very sharp pain.  The Veteran has further consistently reported, as explained by the private orthopedist, that he alters and restricts his movements to protect the left knee, including from buckling, which places additional strain on the stabilizing muscles during the day.  For this reason, the Veteran explained that even when he does not use his left knee or greatly limits movement, that his knee feels tired.  Further, the Veteran reported that his fear of falling after his knee locks or buckles is not unfounded, as his knee has given out multiple times, but he has been able to avoid a fall.  Given that the Veteran constantly guards and protects his left knee, including during all downhill movements that cause locking and buckling, with sometimes severe pain, the Veteran's left knee instability more nearly approximates severe instability in that it causes discomfort or hardship, is of a great degree, and is very harmful.  This description does not more nearly approximate an impairment of the left knee that is limited in scope or effect, which would warrant a lower rating for moderate instability. 

For the above reasons, the evidence is at least evenly balanced as to whether the symptoms and impairment caused by the Veteran's left knee instability more nearly approximate the criteria for a 30 percent rating.  As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to an initial rating of 30 percent for left knee instability is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.

Entitlement to an initial rating of 10 percent for left knee scar, from September 17, 2018, is granted. 

The Veteran's left elbow scar is rated under 38 C.F.R. § 4.118, DC 7802, applicable to burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 

Under DC 7802, a 10 percent rating is warranted if the scar has an area or areas of 144 square inches (929 sq. cm.) or greater.

Although the Veteran's appealed rating is under DC 7802, the Board has a duty to acknowledge and consider all regulations that are potentially applicable, Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), and discretion in determining the appropriate diagnostic code, which "is a determination that is completely dependent upon the facts of a particular case," Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (applying the more deferential "arbitrary, capricious" standard, rather than de novo review, to the Board's determination of the appropriate diagnostic code).

To this end, DC 7804 applies to unstable or painful scars.  Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating.  38 C.F.R. § 4.118, DC 7804.  Three or four scars that are unstable or painful warrant a 20 percent rating.  Id.  DC 7804, Note (1) defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar.  DC 7804, Note (2) provides that if one or more scars are both painful and unstable, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.

In the report for the October 2018 knee and lower leg conditions VA examination, the examiner recorded that over the left lateral knee, the Veteran has a scar measuring 8 centimeters in length and 0.3 centimeters wide.  

In March 2021, the physician completing the knee VA examination also completed the report for a scars and disfigurement VA examination.  The physician recorded the same measurement of 8 centimeters in length and
 for any reason, there is frequent loss of covering of skin over the scar.  DC 7804, Note (2) provides that if one or more scars are both painful and unstable, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.

In the report for the October 2018 knee and lower leg conditions VA examination, the examiner recorded that over the left lateral knee, the Veteran has a scar measuring 8 centimeters in length and 0.3 centimeters wide.  

In March 2021, the physician completing the knee VA examination also completed the report for a scars and disfigurement VA examination.  The physician recorded the same measurement of 8 centimeters in length and 0.3 centimeters wide, noting that the scar was not painful or unstable.

During his November 2024 Board hearing, the Veteran testified that when he uses his left knee, he can feel pulling in the scar, questioning whether it may be an issue of adhesion.

A 10 percent rating is warranted under DC 7804 for a single scar that is either stable or painful.  While the VA physician completing the examination report in March 2021 marked that the Veteran's scar was not painful, the Veteran testified that he experiences a pulling feeling in the scar, indicating discomfort and that the Veteran may restrict movement to avoid additional discomfort or pain.  Therefore, the evidence is approximately evenly balanced as to whether his left knee scar more nearly approximates pain.  The Board resolves the reasonable doubt created by this relative equipoise in the evidence in favor of the Veteran, and finds that a 10 percent rating under DC 7804 for a single painful scar is warranted.  See 38?C.F.R. § 3.102 (the benefit of the doubt doctrine applies to each point within a claim as well as its ultimate disposition).

For the above reasons, the evidence is at least evenly balanced as to whether the Veteran's left knee scar more nearly approximates the criteria for a 10 percent rating under DC 7804.  As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to an initial rating of 10 percent for his left knee scar is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.

Conclusion

The Board has considered the Veteran's claims and decided entitlement based on the evidence.  Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims.  Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  

 

 

Jonathan Hager

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	H. T. Mowell, 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.