Back to BVA DecisionsMIXEDSpecial Benefit NO SPECIAL BENEFIT Diagnostic Code 5271 Docket No. 250319-525919
LUMBOSACRAL OR CERVICAL STRAIN
R. FEINBERG · 2026 · Case ID: A26036139
Summary
The veteran, who served, appeals the denial of service connection for left and right hip conditions and a left knee condition, as well as a reduction in his rating for left ankle strain. The Board found the reduction in the left ankle strain rating improper, restoring the prior 10 percent rating. The Board determined that the VA examination in November 2024 was inadequate because it did not address the ameliorative effects of Tylenol on the veteran's reported ankle pain and range of motion limitations, which contrasted with an earlier October 2024 examination. Therefore, the reduction was voided. For the hip and knee claims, the Board found no current disability. While the veteran reported vague symptoms like being a "mess" and experiencing pain and stiffness, the Board found the evidence persuasive against a current disability, citing normal physical examination findings from a November 2024 VA examination and a lack of complaints or treatment for these conditions to his providers. The Board also noted the veteran's lay statements were too vague to support functional limitations. The claim for high blood pressure was remanded due to a duty to assist error, as the veteran's toxic exposure risk activity (TERA) was not developed prior to the initial denial, and conflicting TERA memos exist in the file.
Rationale
Reduction in rating improper; November 2024 VA exam inadequate; Restoration of prior 10 percent rating warranted
Full Decision Text
Citation Nr: A26036139 Decision Date: 04/17/26 Archive Date: 04/17/26 DOCKET NO. 250319-525919 DATE: April 17, 2026 ORDER The reduction in rating for left ankle strain from 10 to zero percent, effective November 14, 2024, was improper and restoration of the prior 10 percent rating is granted. Entitlement to service connection for left hip condition is denied. Entitlement to service connection for right hip condition is denied. Entitlement to service connection for a left knee condition is granted. REMANDED Issue of entitlement to service connection for high blood pressure is remanded. FINDINGS OF FACT 1. The evidence of record does not show actual improvement in the Veteran's left ankle strain under the ordinary conditions of life and work. 2. The evidence of record does not show a current right or left hip condition 3. The evidence of record does not show a current left knee condition. CONCLUSIONS OF LAW 1. The criteria for restoration of the 10 percent rating for left ankle strain during the period from November 14, 2024, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.105(e), 3.344, 3.655(c). 2. The criteria for entitlement to service connection for left hip condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for right hip condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for a left knee condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The October 2024, November 2024, and March 2025 rating decisions on appeal were issued under the modernized review system, also known as the Appeals Modernization Act (AMA). In the March 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, for the issue of entitlement to service connection for high blood pressure, the Board may only consider the evidence of record at the time of the October 2024 rating decision on appeal. 38 C.F.R. § 20.301. For the issues of entitlement to service connection for a left or right hip condition and a left knee condition, the Board may only consider the evidence of record at the time of the November 2024 rating decision on appeal. Id. For the reduction in rating from 10 to zero percent for left ankle strain, the Board may only consider the evidence of record at the time of the March 2025 rating decision. Any evidence submitted for an issue after the rating decision on appeal that adjudicated it cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 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 claim(s), considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claims of entitlement to service connection for high blood pressure, any evidence the Board could not consider will be considered by the agency of original jurisdiction (AOJ) in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). Rating Reduction 1. The reduction in rating for left ankle strain from 10 to zero percent, effective November 14, 2024 The criteria for a rating reduction based on improvement in the disability level are provided in 38 C.F.R. § 3.105(e). Heightened notification and procedural safeguards apply where the reduction results in a decrease in the compensation payments. If the special procedural prerequisites for a rating reduction have not been followed, the reduction is void ab initio, and reinstatement of the prior rating is required consider will be considered by the agency of original jurisdiction (AOJ) in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). Rating Reduction 1. The reduction in rating for left ankle strain from 10 to zero percent, effective November 14, 2024 The criteria for a rating reduction based on improvement in the disability level are provided in 38 C.F.R. § 3.105(e). Heightened notification and procedural safeguards apply where the reduction results in a decrease in the compensation payments. If the special procedural prerequisites for a rating reduction have not been followed, the reduction is void ab initio, and reinstatement of the prior rating is required. Schafrath v. Derwinski, 1 Vet. App. 589, 595-96 (1991). A reduction will not be based on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. 38 C.F.R. § 3.344(a). There must have 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. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993). There must also be actual improvement in the veteran's ability to function under the ordinary conditions of life and work. See 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13; Brown, 5 Vet App at 420-421. In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. Hohol v. Derwinski, 2 Vet. App. 169 (1992). But VA rating reductions, as with all VA rating decisions, are based upon review of the entire history of a veteran's disability. See Schafrath, 1 Vet. App. at 594. The reduction generally must have been supported by the evidence on file at the time of reduction; pertinent post-reduction evidence favorable to restoring the rating must also be considered, but negative evidence may not be considered. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The Veteran asserts that the reduction of his rating for left ankle strain from 10 to zero percent was improper because he still has left ankle pain and his use of over the counter Tylenol was not considered. April 2025 VA Form 10182. His left ankle strain is currently evaluated under Diagnostic Code 5271. Under Diagnostic Code 5271, a 10 percent is warranted for moderate limitation in motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion); and a 20 percent rating is warranted for marked limitation in motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating musculoskeletal disabilities, VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca, 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. The Veteran's left ankle strain was mostly continued at a 10 percent rating based on an October 2024 VA examination for ankle conditions finding that his left ankle plantar flexion is limited 1 (2011). Pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. The Veteran's left ankle strain was mostly continued at a 10 percent rating based on an October 2024 VA examination for ankle conditions finding that his left ankle plantar flexion is limited to 20 degrees, dorsiflexion limited to 10 degrees, and painful motion. October 2024 Rating Decision. His left ankle strain was then reduced to a zero percent rating by the March 2025 rating decision on appeal based on a November 2024 VA examination for ankle conditions showing only a diagnosed disability with no compensable symptoms. A review of the November 2024 VA examination reports shows normal range of motion finding in the Veteran's left ankle. But the VA examiner does not discuss the Veteran's report of using Tylenol for his left ankle symptoms and whether its ameliorative effects explain the difference in range of motion findings in the October 2024 and November 2024 VA examination, which would just one month apart. The Board notes that Diagnostic Code 5271 does not consider the ameliorative effects of medication so any effects should, if possible, be discounted. The Board finds the November 2024 VA examination for ankle condition was inadequate and, thus, the evidence of record is insufficient to show actual improvement in the Veteran's left ankle strain. Accordingly, the reduction of his left ankle strain rating was improper and restoration of its 10 percent rating is warranted. Service Connection Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection is established when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service connection may also 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). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See, e.g., Degmetich v. Brown, 104 F.3d 1328 (1997). Congress has specifically limited entitlement to service connection for a disease or injury where such instances have resulted in a disability. 38 U.S.C. §§ 1110, 1131. Hence, where the evidence does not support a finding of a current disability upon which to predicate the grant of service connection, there can be no valid claim for this benefit. See Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for left hip condition 2. Entitlement to service connection for right hip condition After careful and thorough review of the evidence of record, the Board finds no current left or right hip disability. The medical treatment evidence shows no complaint or treatment for a hip condition. The Veteran was afforded a November 2024 VA examination for hip and thigh conditions. The VA examiner found normal left and right hip findings, including range of motion and muscle strength. Id. The VA examiner opined that the Veteran did not ); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for left hip condition 2. Entitlement to service connection for right hip condition After careful and thorough review of the evidence of record, the Board finds no current left or right hip disability. The medical treatment evidence shows no complaint or treatment for a hip condition. The Veteran was afforded a November 2024 VA examination for hip and thigh conditions. The VA examiner found normal left and right hip findings, including range of motion and muscle strength. Id. The VA examiner opined that the Veteran did not have a current diagnosis associated with his left or right hip. See id. The VA examiner is a medical professional who had the opportunity to examine the Veteran and provided a detailed report with relevant findings. The Board finds the VA examiner's findings and opinion to be probative for these reasons and persuasive against finding that he has a current left or right hip disability. The Board recognizes that the VA examiner did not specifically discuss the Veteran's reported "dull and aching" pain and stiffness with activity, or his use of Tylenol for his symptoms. See id. But the Board finds the normal physical examination findings by the VA examiner in combination with the lack of treatment by, or even complaints to, his treatment providers still persuasively support finding no current right or left hip disability. Lastly, the Board considered whether the Veteran's complaints reflects symptoms that amount to a disability based on functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran has only indicated to being a "mess" after separation and having dull and aching pain with stiffness with prolonged sitting, standing, or walking. November 2024 VA Examination for Hip and Thigh Conditions. The Board finds the statements too vague to support functional limitations. It is unclear what functional limitations are from being a "mess." It is also unclear what limitations, if any, result from his reported pain and stiffness, particularly given the normal VA examination findings. The Board finds the Veteran's lay statements about his hips to not be probative to establish a current disability for these reasons. The Board finds the more probative evidence of record to be against finding that the Veteran has a current right or left hip disability. Because the first element of service connection, i.e., a current disability, has not been met, service connection for a right or left hip condition must be denied. 3. Entitlement to service connection for a left knee condition After careful and thorough consideration of the evidence, the Board finds the evidence persuasive against finding a current left knee disability. A review of the medical treatment evidence shows the Veteran has made numerous complaints about his right knee pain but not his left knee. See, e.g., September 2024 VA treatment evidence; November 2024 VA treatment evidence. The Veteran was afforded a November 2024 VA examination for knee and lower leg conditions. Like with his hips, the Veteran reported being a "mess" after separation and having dull and aching pain with stiffness after prolonged sitting, standing, or walking. Id. He also reported that his knees would buckle when walking and his left knee feels swollen and heavy. Id. But an examination of the Veteran showed normal left knee findings, including his range of motion and joint stability. See id. The VA examiner found no evidence of a current left knee disability. Id. The Board recognizes that the VA examiner did not specifically discuss his reported pain, stiffness, and knees giving out and feeling swollen and heavy, or that he uses Tylenol. But the VA examiner is a medical professional who had the opportunity to examine the Veteran and the Board finds the normal physical examination findings in combination with the lack of complaint about his left knee to treatment providers still persuasively support finding no current left knee disability. The Board finds the Veteran statements about being a mess or having pain and stiffness in his knee to be too vague to support functional limitations. His report about his knees giving out is not credible as to his left knee as he has never reported such a problem when seeking treatment from his right knee. The Board finds the Veteran's lay statements to not be probative in establishing a current left knee disability. Because the first element of service connection, i.e., a current disability, has not been met, service connection for a left knee condition must be denied. REASONS FOR REMAND Issue of entitlement to service connection for high blood pressure is remanded The Board finds a remand is needed for a duty to assist error that occurred prior to the October 2024 rating decision on remand pain and stiffness in his knee to be too vague to support functional limitations. His report about his knees giving out is not credible as to his left knee as he has never reported such a problem when seeking treatment from his right knee. The Board finds the Veteran's lay statements to not be probative in establishing a current left knee disability. Because the first element of service connection, i.e., a current disability, has not been met, service connection for a left knee condition must be denied. REASONS FOR REMAND Issue of entitlement to service connection for high blood pressure is remanded The Board finds a remand is needed for a duty to assist error that occurred prior to the October 2024 rating decision on remand. The AOJ found the evidence supports a current hypertension disability. October 2024 Rating Decision. With his September 2024 claim for entitlement to service connection for high blood pressure, the Veteran reported having being exposed to diesel fuel and oil during service. But the evidence of record does not show that his toxic exposure risk activity (TERA) was developed prior to the denial of his claim by the October 2024 rating decision on appeal. The Board finds development of the Veteran's TERA is needed. The Board notes that the claims file now contains several TERA memos with the March 2025 and March 2026 memos finding no TERA and the November 2025 memorandum finding that he has TERA. Clarification may be needed on remand. The matters are REMANDED for the following action: Develop the Veteran's TERA, including obtaining a VA examination about his hypertension and TERA if deemed warranted by the AOJ. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lin, M 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.