Citation Nr: 1605008 Decision Date: 02/09/16 Archive Date: 02/18/16 DOCKET NO. 09-08 871 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a higher initial rating for service-connected status-post residuals of left anterior cruciate ligament (ACL) reconstruction with degenerative joint disease (DJD), currently at 10 percent for the period from October 1, 2006, to December 9, 2009, and at 30 percent for the period beginning December 10, 2009. 2. Entitlement to a higher initial rating for service-connected chorioretinal scar of the left eye, currently noncompensable. 3. Entitlement to a higher initial rating for service-connected bilateral onychomycosis, currently noncompensable. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Becker, Counsel INTRODUCTION The Veteran served on active duty from May 1986 to September 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision in which the Benefits Delivery at Discharge (BDD) unit of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina granted service connection and assigned initial noncompensable (0 percent) ratings for status-post left ACL reconstruction, left eye chorioretinal scar, and onychomycosis. The Veteran appealed each of these initial ratings. Jurisdiction subsequently was transferred to the RO in Atlanta, Georgia. In a July 2010 rating decision, the Atlanta RO found clear and unmistakable error (CUE) in the assignment of a noncompensable initial rating for status-post left ACL reconstruction residuals with DJD. Specifically, the rating was retroactively increased to 10 percent for the period from October 1, 2006 (the day after the Veteran's discharge), to December 9, 2009, and to 30 percent for the period beginning December 10, 2009. Both periods remain on appeal because an even higher initial rating is possible for each. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified before the undersigned regarding this matter at a hearing at the Atlanta RO in September 2012. In May 2013, the Board decided many issues appealed from the December 2006 rating decision-and also remanded the claims comprising this current matter for additional development. Review of the claims file shows that the Board can proceed by making a decision concerning them all at this time. FINDINGS OF FACT 1. The Veteran's status-post residuals of left ACL reconstruction with DJD never has manifested recurrent subluxation or lateral instability, did not manifest flexion limited to at least 45 degrees or extension limited to 10 degrees or more through December 9, 2009, and has not manifested flexion limited to at least 45 degrees or extension limited to 30 degrees or more beginning December 10, 2009. 2. The chorioretinal scar of the Veteran's left eye is not centrally located. Since December 10, 2008, his visual acuity has been better than 20/50 in this eye, he has not had any diplopia, and the scar was not the cause of his left eye visual field impairment. 3. The Veteran bilateral onychomycosis affects zero percent of his exposed areas, less than five percent of his entire body, and has not been treated with systemic therapy such as corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 10 percent for the period from October 1, 2006, to December 9, 2009, and higher than 30 percent for the period beginning December 10, 2009, for service-connected status-post residuals of left ACL reconstruction with DJD have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.340, 3.400, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.15, 4.16, 4.19, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2015). 2. The criteria for an initial compensable rating for service-connected chorioretinal scar of the left eye have not been met. 38 U.S.C.A. §§ 110, 1155, 1159, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. § 4.84a, Diagnostic Code 6011 (2008); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.340, 3.383, 3.400, 3.951, 3.957, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.15, 4.16, 4.19, 4.20, 4.27, 4.75, 4.76, 4.77, 4.78, 4.79, Diagnostic Codes 6011, 6066, 6080, 6090 (2015). 3. The criteria for an initial compensable rating for service-connected bilateral onychomycosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.321, 3.340, 3.400, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.15, 4.16, 4.19, 4.118, Diagnostic Codes 7806, 7813 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters VA has a duty to notify a claimant seeking VA benefits. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. Notice must be provided prior to initial adjudication of the evidence necessary to substantiate the benefit(s) sought, that VA will seek to obtain, and that the claimant should submit. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notice of how a rating and an effective date will be assigned if the benefit(s) sought is/are granted also must be provided. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not alleged any notice error. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). He was notified in April 2006, prior to his discharge given his participation in the BDD program, of the criteria for establishing service connection, the evidence required, and his and VA's respective duties for obtaining evidence. Initial adjudication followed in which service connection for the relevant disorders were granted. See December 2006 rating action. As such, no further notice to include of how ratings and effective dates are assigned was required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). An October 2013 letter nevertheless reiterated the April 2006 information and provided notice of how ratings and effective dates are assigned. VA has a duty to assist a claimant seeking VA benefits. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), which includes aiding the claimant in the procurement of relevant records whether they are in government custody or the custody of a private entity. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). A VA medical examination also must be provided and/or a VA medical opinion procured when necessary in order to render a decision. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service treatment records and a few military treatment records dated just after the Veteran's discharge have been obtained by VA. No other VA or private treatment records have been obtained by VA because none have been identified by him. Indeed, he failed to respond to the October 2013 letter requesting such identification sent pursuant to the Board's remand. In May 2006, December 2009, January 2014, and March 2014, the Veteran underwent VA medical examinations. Those in 2014 were as directed in the Board's remand. To the extent there was no review the claims file, the examiner otherwise was aware of the Veteran's medical history by interviewing him. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). Each examiner also performed a relevant assessment. This decision is fully informed because of these actions. As such, the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Significantly, the Veteran has not identified any necessary assistance development that as of yet has not been completed. No such uncompleted necessary assistance development otherwise is apparent. VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio, 16 Vet. App. at 183. Also, there has been at least substantial compliance with the Board's remand, as required. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). Adjudication therefore may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). The issues on appeal must be explained and the submission of outstanding evidence must be suggested at a hearing. 38 C.F.R. § 3.103(c)(2); Bryant, 23 Vet. App. at 488. The undersigned identified all issues of the Veteran's appeal at the start of the September 2012 hearing. Next, the undersigned stated that the current severity of each service-connected disability was of primary import-and asked the Veteran questions in this regard. He was also asked questions about where he receives treatment for the relevant disorders. No outstanding evidence was identified as a result, however. The undersigned thus did not suggest the submission of any. II. Higher Initial Ratings Several rules govern the Board in making determinations on the merits. Only the most salient evidence must be discussed even though all the evidence must be and thus has been reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Persuasive or unpersuasive evidence must be identified, however, and reasons must be provided for rejecting favorable evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Wilson v. Derwinski, 2 Vet. App. 614 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay or non-medical evidence may be discounted in light of its inherent characteristics and relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence, the claimant must be afforded the benefit of the doubt. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. The Veteran is a lay person because there is no indication he has a medical background. His reports about his symptoms and their effects are competent because they are personally experienced by him. Layno v. Brown, 6 Vet. App. 465 (1994). The credibility of competent lay reports is assessed by factors such as interest, bias, inconsistency, implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). The Veteran is interested since a higher initial rating equates to potential monetary gain, but his demeanor at the hearing did not reveal dishonesty. Further, no inconsistency, implausibility, or malingering is found. As such, his lay reports are credible as well as competent. A. Schedular Ratings represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. A rating is assigned under the Rating Schedule by comparing the extent to which a claimant's disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by symptoms, with the rating criteria for the disability. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). For an equitable and just rating, the disability's history must be taken into account with all other relevant evidence. 38 C.F.R. §§ 4.1, 4.6. Examinations must be interpreted and reconciled to form a consistent picture of the disability. 38 C.F.R. § 4.2. If two ratings are potentially applicable, the higher rating is assigned if the disability more nearly approximates the criteria required for it. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Different ratings may be assigned for different periods of time for the same disability, a practice known as staging the rating. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). If a disability has increased in severity, consideration therefore must be given to when the increase occurred. The period in question for an increased rating, as opposed to an initial increased rating, begins one year prior to the claim. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). 1. Status-Post Residuals of Left ACL Reconstruction with DJD A musculoskeletal disability involves the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss in the form of limitation of motion may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion, or weakness. 38 C.F.R. §§ 4.40, 4.59. It also may be due to excess fatigability or incoordination. 38 C.F.R. § 4.45. An increased rating for functional loss, to include during flare ups, due to those factors accordingly may be assigned under Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). 38 C.F.R. § 4.71a addresses musculoskeletal disabilities. According to the December 2006 rating decision, the Veteran's service-connected residuals of left ACL reconstruction with DJD was rated pursuant to Diagnostic Code 5299-5258 thereunder. It is reiterated, however, that the July 2010 rating decision found CUE in the December 2006 rating decision. The Veteran's aforementioned disability was rated under Diagnostic Code 5261 therein, with an indication that it previously was rated under Diagnostic Code 5010. Yet all potentially applicable Diagnostic Codes will be considered. Indeed, the Diagnostic Code utilized is fact dependent. Butts v. Brown, 5 Vet. App. 532 (1993). A disability that has its own Diagnostic Code may not be rated under another Diagnostic Code. Copeland v. McDonald, 27 Vet. App. 333 (2015). A change in Diagnostic Code otherwise is permissible as long as it is explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Diagnostic Code 5010 is for arthritis due to trauma. It calls for establishment by X-rays findings and rating as degenerative arthritis (hypertrophic or osteoarthritis), which is the subject of Diagnostic Code 5003. This Diagnostic Code also calls for establishment by X-ray findings. Rating is to be made on the basis of limitation of motion under the appropriate Diagnostic Code(s) for the specific joint(s) involved. If this results in a noncompensable rating, a 10 percent rating is assigned for each major joint or group of minor joints affected by limitation of motion. Such limitation must be objective confirmation by findings such as swelling, spasm, or painful motion. Absent any limited motion, involvement of two or more major joints or two or more minor joint groups warrants a 10 percent rating. The same with occasional incapacitating exacerbations warrants a 20 percent rating. Diagnostic Code 5260 addresses limitation of flexion of the leg. Under it, flexion limited to 60 degrees warrants a noncompensable rating. Flexion limited to 45 degrees warrants a 10 percent rating. A 20 percent rating is assigned for flexion limited to 30 degrees. The maximum rating of 30 percent is reserved for flexion limited to 15 degrees. Diagnostic Code 5261 concerns limitation of extension of the leg. Extension limited to 5 degrees merits a noncompensable rating. A 10 percent rating is assigned for extension limited to 10 degrees, and a 20 percent rating for extension limited to 15 degrees. Extension limited to 20 degrees calls for a 30 percent rating. A 40 percent rating requires extension limited to 30 degrees. The maximum 50 percent rating is reserved for extension limited to 45 degrees. Normally, flexion is to 140 degrees and extension to zero degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5256 pertains to ankylosis of the knee. A 30 percent rating is warranted for a favorable angle in full extension or in slight flexion between 0 and 10 degrees. In flexion between 10 and 20 degrees warrants a rating of 40 percent, while in flexion between 20 and 45 degrees warrants a 50 percent rating. The maximum 60 percent rating is reserved for an extremely unfavorable angle in flexion at 45 degrees or more. Diagnostic Code 5257 addresses other knee impairment due to recurrent subluxation or lateral instability. It provides for a 10 percent rating for slight impairment, a 20 percent rating for moderate impairment, and a maximum 30 percent rating for severe impairment. A 20 percent rating is assigned under Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of semilunar cartilage. Diagnostic Code 5262 is for impairment of the tibia and fibula. A 10 percent rating requires malunion with slight knee or ankle disability. Malunion with moderate knee or ankle disability merits a 20 percent rating, and malunion with marked knee or ankle disability is assigned a 30 percent rating. The maximum rating of 40 percent is reserved for nonunion of the tibia and fibula with loose motion requiring a brace. Lastly, Diagnostic Code 5263 establishes a 10 percent rating for genu recurvatum. Pyramiding, rating the same symptom of a disability under different Diagnostic Codes, is prohibited. 38 C.F.R. § 4.14. Yet ratings under different Diagnostic Codes are warranted for separate and distinct symptoms. Symptoms cannot overlap, in other words. Esteban v. Brown, 6 Vet. App. 259 (1994). Separate ratings are assigned, for example, where there is limitation of flexion and of extension. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59,990 (2004). Separate ratings also are assigned for arthritis and for instability. VAOPGCPREC 09-98 (August 14, 1998), 63 Fed. Reg. 56,704 (1998); VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997); Esteban, 6 Vet. App. at 259; Licthenfels v. Derwinski, 1 Vet. App. 484 (1991). Given the evidence, the Board finds that several Diagnostic Codes are inapplicable to the Veteran's service-connected residuals of left ACL reconstruction with DJD, including Diagnostic Codes 5256, 5258, 5259, 5262, and 5263. There is no indication of left knee ankylosis, dislocated or removed left semilunar cartilage, impairment of the left tibia and fibula, or left genu recurvatum. Nothing reported by the Veteran in statements or his hearing testimony suggests the existence of any of these conditions. The service and military treatment records are silent as to them, as are the VA medical examinations. Detection, and mention of, the aforementioned conditions would be expected if they existed. Buczynski v. Shinseki, 24 Vet. App. 221 (2011). This follows from the fact that the purpose of the VA medical examinations, and to a lesser though still significant extent the service and military treatment records, was to assess the current state of the Veteran's left knee. Accompanying this lack of affirmative evidence is the presence of some negative evidence. It was found that the Veteran had no tibia and fibula impairment at the January 2014 VA medical examination. He further was not found to have a meniscal condition or surgery for such a condition. The meniscus is semilunar cartilage. Dorland's Illustrated Medical Dictionary 1151 (31st ed. 2007). There was no semilunar cartilage dislocation or removal, in other words. Genu recurvatum and ankylosis were not found at the December 2009 VA medical examination. Ankylosis also implicitly was ruled out at the May 2006 and January 2014 VA medical examinations because movement to varying degrees was measured. Indeed, ankylosis is immobility, consolidation, or fixation of a joint. Dorland's at 94; Dinsay v. Brown, 9 Vet. App. 79 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). Next, the Board finds that an initial rating in excess of 10 percent for the period from October 1, 2006, to December 9, 2009, and in excess of 30 percent for the period beginning October 10, 2009, is not warranted for the Veteran's service-connected residuals of left ACL reconstruction with DJD based on limitation of motion. No separate compensable rating is warranted on this basis either. Service treatment records document that the Veteran had very close to full extension in August 2005 and full range of motion, both extension and flexion, in December 2005. At the May 2006 VA medical examination, his range of motion was from zero to 140 degrees with pain at the endpoints. Repetition caused pain but no change in range of motion. The Veteran reported in a March 2009 statement that full extension causes him discomfort. The December 2009 VA medical examination, which specifically took place on the 10th, reflects that the Veteran's range of motion was from 20 to 90 degrees with pain at the endpoints. Repetition caused weakness, lack of endurance, incoordination, and primarily pain. However, there was no change in range of motion. The Veteran testified at the hearing that he has range of motion problems. His range of motion at the January 2014 VA medical examination was from zero to 140 degrees with pain at the endpoints. Repetition caused pain but no change in range of motion. In sum, the Veteran's flexion was normal initially and upon repetition during the period from October 1, 2006, to December 9, 2009. It has been reduced by only to 90 degrees at worst, both initially and upon repetition, during the period beginning December 10, 2009. A noncompensable rating therefore is warranted under Diagnostic Code 5260 with respect to both periods. During the period from October 1, 2006, to December 9, 2009, the Veteran's extension was normal both initially and upon repetition the one occasion it was measured. While it was reduced on another occasion, an exact measurement was not taken. It therefore would be purely speculative to conclude that it was limited to at least 10 degrees, the requirement for even the lowest compensable rating of 10 percent under Diagnostic Code 5261. Pure speculation is an insufficient basis for determining the degree of disability present. 38 C.F.R. § 3.102. A noncompensable rating accordingly is warranted. During the period beginning December 10, 2009, the Veteran's extension has been normal initially and upon repetition as well as reduced to 20 degrees at worst initially and upon repetition. This limitation corresponds to a 30 percent rating under Diagnostic Code 5261. Pain, to the extent it was present during range of motion, does not alter any of the aforementioned findings. Indeed, painful motion does not by itself constitute limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The pain must prevent some portion of the normal range of motion in order for there to be limited motion. The Veteran experienced and experiences pain with movement, but it is not significant enough to limit his flexion or extension to the required degree. Since pain must prevent some portion of the normal range of motion in order for there to be limited motion, so must other factors. The Veteran has reported weakness, fatigability, stiffness, swelling, and grinding. Weakness, lack of endurance, incoordination, and possibly crepitus (it was noted as found once and not found once in the report of the December 2009 VA medical examination) have been found at one or more VA medical examinations. It is reiterated that these factors were and are not significant enough to limit his flexion or extension to the required degree. Like motion affected by pain or other factors, flare-ups do not alter any of the aforementioned findings. Flare-ups were not referenced at the May 2006 VA medical examination. The Veteran reported them with physical activity at the December 2009 VA medical examination. He indicated that his pain increased during them and that he could not stand, walk, or run for prolonged periods. Attempts to reach him thereafter to provide more information failed. At the January 2014 VA medical examination the Veteran reported flare-ups characterized by swelling and a warming sensation. He indicated that they limited his standing and walking. It appears, in sum, that the Veteran's flare-ups are characterized by pain and other factors. Nothing suggests that they limit his range of motion more than normal during a flare-up, and it has not been approximated. It also has not been measured. To find that the Veteran's flexion or extension is limited to the required degree thus would be impermissible pure speculation. 38 C.F.R. § 3.102. In sum, the Veteran had limitation of motion in terms of extension only that is not compensable under Diagnostic Code 5261 during the period from October 1, 2006, to December 9, 2009. He had limitation of motion in terms of extension only that is compensable under Diagnostic Code 5261 during the period beginning December 10, 2009. Diagnostic Codes 5010 and 5003 thus must be considered only for the former period. X-rays taken as part of the December 2009 VA medical examination showed degenerative arthritic changes. While this examination occurred on the first day of the latter of the aforementioned periods, the Board recognizes that degenerative arthritis does not develop overnight. It accordingly was present in the former period too. Confirmation of the extension limitation of motion is clear given the Veteran's painful motion as well as swelling. Yet the knee constitutes one major joint. 38 C.F.R. § 4.45(f). As such, only a 10 percent rating is allowable. A higher initial rating on this basis is not warranted, in other words. The Board lastly finds that a separate initial rating is not warranted for the Veteran's service-connected residuals of left ACL reconstruction with DJD under Diagnostic Code 5257. Subluxation is an incomplete or partial dislocation. Rykhus v. Brown, 6 Vet. App. 354 (1994). The Veteran has not reported subluxation or dislocation. With respect to lateral instability, he has reported some giving way, locking, and feeling that his knee is loose, is unstable, or would snap. However, August and December 2005 service treatment records reflect that no subluxation or laxity was found. Stability tests were negative then and at each VA medical examination. The December 2009 examination further found no instability or subluxation. The Veteran's reports, though competent and credible, are outweighed by these findings. Indeed, his reports were noted by each examiner. They have the background necessary to determine the degree of impairment, if any, associated with his reports. In finding that Diagnostic Code 5258 is inapplicable and that Diagnostic Code 5257 cannot serve as a basis for a separate initial rating, the Board acknowledges the opinions made at the January 2014 VA medical examination. The examiner was directed to opine as to whether or not the Veteran has recurrent subluxation or lateral instability, the degree of impairment present if so, and whether or not he has frequent episodes of locking, pain, and joint effusion. In response, the examiner indicated that the claimed condition was at least as likely as not related to the claimed in-service event. This opinion, while seemingly favorable, addresses service connection and not an increased initial rating. The rationale was that the Veteran's knee pain and weakness are moderately impairing and cause limited prolonged standing, walking, and bending. None of the symptoms the opinion was to address except pain were found, in other words. This corresponds with the findings already discussed herein, to include from the examination itself. Consideration has been given by the Board to the benefit of the doubt and reasonable doubt as well as to the assignment of a staged rating. However, there is no doubt or reasonable doubt to resolve to the Veteran's benefit or in his favor regarding the findings that an initial rating in excess of 10 percent for the period from October 1, 2006, to December 9, 2009, and in excess of 30 percent for the period beginning October 10, 2009, is not warranted for his service-connected residuals of left ACL reconstruction with DJD. Indeed, each is based on the preponderance of the evidence. So was the finding that a separate initial rating is not warranted. The previously assigned stage in the Veteran's ratings, which separates it into the period from October 1, 2006, to December 9, 2009, and the period beginning December 10, 2009, is retained. No other staging of the rating is warranted because the aforementioned findings apply to these entire periods. The Veteran's claim, in sum, is denied regarding this issue. 2. Chorioretinal Scar of the Left Eye The criteria for rating eye disabilities changed effective December 10, 2008, but the changes apply only to claims received on or after this date. 73 Fed. Reg. 66,543 (Nov. 10, 2008). Since the Veteran filed his claim in April 2006, the initial rating assigned to his service-connected chorioretinal scar of the left eye was under the old criteria. Supplemental statements of the case dated in May 2009, July 2010, and December 2014 utilized the new criteria to continue his initial rating. Doing so was erroneous, but not considering the new criteria now after they have been previously may be prejudicial. Both the old and new criteria thus will be taken into account. While the new criteria can be applied only to the period beginning on the effective date of the criteria change, the old criteria can be applied even after this change if doing so is more favorable to the Veteran. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overturning Karnas v. Derwinski, 1 Vet. App. 308 (1991)); VAOPGCPREC 7-03 (Nov. 19, 2003); VAOPGCPREC 3-00 (Apr. 10, 2000). Under the old criteria, 38 C.F.R. § 4.84a addressed eye disabilities. The Veteran's service-connected chorioretinal scar of the left eye was rated pursuant to Diagnostic Code 6099-6006 thereunder. Hyphenated Diagnostic Codes signify that the rating for a service-connected disability is based upon how another disability would be rated. 38 C.F.R. § 4.27. The Diagnostic Code for the service-connected disability is before the hyphen, and the Diagnostic Code for the other disability is after the hyphen. Id. Diagnostic Code 6099 conveys that the Veteran's aforementioned service-connected disability was not listed in the Schedule for Rating Disabilities. Id. Diagnostic Code 6066, which was for retinitis, was deemed most analogous for rating purposes. 38 C.F.R. § 4.20. The Board finds at the outset that the use of Diagnostic Code 6099-6006 was erroneous. Doing so was premised on there being no Diagnostic Code specifically for chorioretinal scars. Yet, Diagnostic Code 6011 addressed localized retina scars. It is reiterated that a disability that has its own Diagnostic Code may not be rated under another Diagnostic Code. Copeland, 27 Vet. App. at 333. Caution is required in changing Diagnostic Codes, however. Indeed, service connection that has been in effect for 10 or more years generally cannot be severed absent fraud. 38 U.S.C.A. § 1159; 38 C.F.R. § 3.957; Read v. Shinseki, 651 F. 3d 1296 (Fed. Cir. 2011). A rating that has been in effect for 20 or more years further cannot be reduced absent fraud. 38 U.S.C.A. § 110; 38 C.F.R. § 3.951(b); Murray v. Shinseki, 24 Vet. App. 420 (2011). The Veteran has been in receipt of service connection for less than 10 years, and he never has been in receipt of a compensable rating. In sum, a change in Diagnostic Code from 6099-6006 to 6011 under the old criteria accordingly is warranted. A 10 percent rating was assigned pursuant to Diagnostic Code 6011 when unilateral or bilateral localized scars, atrophy, or irregularities of the retina were centrally located with irregular, duplicated, enlarged, or diminished image. Under the new criteria, 38 C.F.R. § 4.79 concerns eye disabilities. Retinal scars once again has its own Diagnostic Code thereunder, and once again it is Diagnostic Code 6011. It establishes a 10 percent rating for unilateral or bilateral localized scars, atrophy, or irregularities of the retina that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image. Rating alternatively is based on visual impairment due to such scars, atrophy, or irregularities, if doing so would result in a higher rating. Visual impairment includes impairment of visual acuity excluding developmental errors of refraction, visual field, and muscle function. 38 C.F.R. § 4.75(a). When only one eye is service-connected, the visual acuity of the other eye is considered to be 20/40. 38 C.F.R. § 4.75(c). This is subject to 38 C.F.R. § 3.383(a), which provides that compensation benefits are payable for the combination of visual impairment of one eye as a result of a service-connected disability and visual impairment in the other eye as a result of a nonservice-connected disability if certain requirements are met. They include that the nonservice-connected disability is not the result of the Veteran's own willful misconduct and either the visual acuity in each eye is 20/200 or less or the field of vision for each eye is 20 degrees or less. 38 C.F.R. § 3.383(a)(1). Finally, the maximum rating for visual impairment of one eye is 30 percent unless there is anatomical loss of that eye. 38 C.F.R. § 4.75(d). To determine the rating for visual acuity, corrected distance vision is used. 38 C.F.R. § 4.76(b). 20/40 vision or better in both eyes warrants a zero percent rating. 38 C.F.R. § 4.79, Diagnostic Code 6066. The lowest compensable rating of 10 percent requires 20/50 vision or worse in one eye and 20/40 vision or worse in the other eye. Id. Diplopia is used to assess muscle function, which is rated as an equivalent visual acuity based on its location. 38 C.F.R. §§ 4.78, 4.79, Diagnostic Code 6090. Separate ratings for visual acuity and visual field impairment are permissible. 38 C.F.R. § 4.77(c). A 10 percent rating for visual field impairment calls for a remaining field of 46 to 60 degrees bilaterally or unilaterally, a remaining field of 31 to 45 degrees or of 16 to 30 degrees unilaterally, loss of the superior or nasal half of the field bilaterally or unilaterally, or loss of the inferior half temporal half of the field unilaterally. 38 C.F.R. § 4.79, Diagnostic Code 6080. The Board finds, given the evidence, that an initial compensable rating for the Veteran's service-connected chorioretinal scar of the left eye is not warranted under the old criteria. The Board also finds that an initial compensable rating is not warranted under the new criteria. Both the old and the new criteria require that the retinal scar be centrally located. A March 2006 service treatment record notes only that the Veteran's scar is in the inferior retina. However, the May 2006 VA medical examination clarifies that it is mid periphery in the lower temporal quadrant. This is confirmed by the March 2014 VA medical examination, which indicated simply that it was peripheral. There is, in sum, agreement that the Veteran's scar is not centrally located. It follows that the disagreement as to its impact, with the May 2006 examination finding it is of no visual significance and the March 2014 examination finding it causes diminished image, need not be resolved. Regarding an alternative initial rating under the new criteria for visual impairment, only the evidence dated on or after the December 10, 2008, effective date can be considered. The Veteran's corrected distance vision was 20/30 in the right eye and 20/25 in the left eye at the December 2009 VA medical examination. It was 20/40 or better in both eyes at the March 2014 VA medical examination. Decreased visual acuity accordingly was not found in the left eye. Payment thus is not warranted for a combination of service-connected and nonservice-connected visual acuity impairment. Only the Veteran's left eye is service-connected, so his right eye visual acuity is deemed 20/40 notwithstanding the aforementioned. His left eye visual acuity, in sum, has measured 20/40 or better. A noncompensable rating accordingly is warranted under Diagnostic Code 6066, even assuming any left eye visual acuity impairment is due to his retinal scar. Diplopia was not found at either the December 2009 or the March 2014 VA medical examinations. An initial rating for muscle function impairment under Diagnostic Code 6090 accordingly is not warranted. Also, an initial rating is not warranted under Diagnostic Code 6080 for visual field impairment. No such impairment was mentioned at the December 2009 VA medical examination. Detection, and mention of, it would be expected if it existed. Buczynski, 24 Vet. App. at 221. This once again follows from the fact that the purpose of the examination was to assess the current state of the Veteran's eyes. At the March 2014 VA medical examination, there was peripheral contraction of his visual field in the left eye. This also was described as a full field constriction. Repeat measurement in this regard was suggested because of a discrepancy with other findings. In any event, the Veteran's retinal scar was eliminated as the cause of this visual field impairment. Payment for a combination of such service-connected and nonservice-connected impairment finally is not warranted since both eyes are not affected. Consideration has been given to the Veteran's competent and credible reports that his vision is distorted, blurred, he sees dots, floaters, and lines, has discharge, pain, redness, irritation, and a feeling that something is always in his eyes, is sensitive to light and glare, sometimes gets headaches, and has episodes of incapacitation. Medical professionals have the background necessary to determine whether they are related to his retinal scar. At no point has such a determination been made. However, other conditions were diagnosed which account for some of the Veteran's reports. Pinguecula was diagnosed in the March 2006 service treatment record. Pterygium of the right eye, associated with irritation, and chronic conjunctivitis, associated with secretions, were diagnosed at the December 2009 examination. Pterygium also was diagnosed at the March 2014 examination. Consideration has been given by the Board to the benefit of the doubt and reasonable doubt as well as to the assignment of a staged rating. However, there is no doubt or reasonable doubt to resolve to the Veteran's benefit or in his favor regarding the finding that a compensable initial rating is not warranted for his service-connected chorioretinal scar of the left eye. Indeed, it is based on the preponderance of the evidence. No staged rating is warranted because the aforementioned finding applies to the entire period on appeal. The Veteran's claim, in sum, is denied regarding this issue. 3. Bilateral Onychomycosis The Veteran's service-connected onychomycosis has been rated under Diagnostic Code 7813, which concerns dermatophytosis (ringworm to include of the nails, known as tinea unguium). 38 C.F.R. § 4.118. Onychomycosis is another term for tinea unguium. Dorland's at 1955-56. Since it has its own Diagnostic Code, no other Diagnostic Code can be used for rating purposes. Copeland, 27 Vet. App. at 333. Diagnostic Code 7813 calls for rating as disfigurement of the head, face, or neck under Diagnostic Code 7800, scars under Diagnostic Codes 7801-7805, or dermatitis under Diagnostic Code 7806, depending on the predominant disability. Since the aforementioned disability is not of the Veteran's head, face, or neck and has not produced disfigurement or scars, Diagnostic Codes 7800 and 7801-7805 are not his predominant disability. That leaves Diagnostic Code 7806, which addresses eczema in addition to dermatitis. A noncompensable rating is warranted under Diagnostic Code 7806 if less than five percent of the entire body is or exposed areas are affected or no more than topical therapy is required during the past 12-month period. A 10 percent rating requires at least five percent but less than 20 percent of the entire body or exposed areas being affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs being required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body is or exposed areas are affected or systemic therapy is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The maximum rating of 60 percent is reserved for when more than 40 percent of the entire body is or exposed areas are affected or constant or near-constant systemic therapy is required during the past 12-month period. Based on the evidence, the Board finds that an initial compensable rating for the Veteran's service-connected bilateral onychomycosis is not warranted. He has reported exudation, itching, crusting, shedding, scaling, and irritation with respect to his feet. Only the face, neck, and hands are considered exposed areas for VA compensation purposes. VA Skin Diseases Disability Benefits Questionnaire, Section 5A. It follows that zero percent of the Veteran's exposed areas are affected, as found at VA medical examinations in May 2006 and December 2009. No estimate of the amount of his entire body affected was made at the May 2006 examination, at a VA medical examination in January 2014, or in service and military treatment records. The estimate was only 1/4 of a percent (.25 percent) at the December 2009 examination, far less than the five percent requirement. This estimate corresponds with the sole finding made at the time of exfoliation, crusting, and abnormal texture with respect only to the Veteran's toenails. Similarly, thick great toenails with debris in the nailbeds were the sole finding at the May 2006 VA medical examination. The Veteran's feet were seen by the undersigned to be affected at the September 2012 hearing, but no estimate of the total body area was made at that time. His disability finally was described as quiescent at the January 2014 VA medical examination. All of the aforementioned sources reference topical medication exclusively. The Veteran has reported that his feet are still problematic notwithstanding these creams. There is, in sum, no indication whatsoever of systemic therapy such as corticosteroids or other immunosuppressive drugs for any duration. The Veteran has reported foot pain, particularly when walking, and sensitivity for which he wears special shoes. The Board acknowledges the opinion made at the January 2014 VA medical examination in this regard. The examiner was directed to opine as to whether or not the Veteran's reports were related to his service-connected onychomycosis and if so whether he has functional impairment when he stands or walks. In response, the examiner indicated that the claimed condition was at least as likely as not related to the Veteran's service-connected disability. The rationale was that his foot pain and weakness are moderately impairing and result in limited prolonged standing and walking. A discussion of the evidence used reveals that the Veteran's left knee was the major reason for the opinion. That it essentially is the same as the opinion provided for his service-connected status-post residuals of left ACL reconstruction with DJD also is notable. It therefore is quite suspect. To the extent the Veteran's foot pain and sensitivity are attributable to his service-connected onychomycosis and not his left knee, they are not significant enough to warrant an initial compensable rating. His feet comprise less than five percent of his entire body. He routinely takes over the counter pain medication for both his left knee and his feet. These are administered orally instead of topically and thus are systemic. Dorland's at 1888. Yet, they are not the kind of systemic therapy contemplated by Diagnostic Code 7806. The examples provided, corticosteroids and immunosuppressive drugs, suppress immune responses [Id. at 429, 935] and generally require a prescription. Pain medications suppress pain and, as indicated by the description of over the counter, are available without a prescription. Consideration has been given by the Board to the benefit of the doubt and reasonable doubt as well as to the assignment of a staged rating. However, there is no doubt or reasonable doubt to resolve to the Veteran's benefit or in his favor regarding the finding that a compensable initial rating is not warranted for his service-connected onychomycosis. Indeed, it is based on the preponderance of the evidence. No staged rating is warranted because the aforementioned finding applies to the entire period on appeal. The Veteran's claim is denied regarding this issue. B. Extraschedular As an alternative to assigning a rating under the Rating Schedule, one may be assigned on an extraschedular basis. 38 C.F.R. § 3.321(b); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). First, it must be determined that the service-connected disability picture is so unusual or exceptional that the schedular rating criteria are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). This includes the impact of each such disability as well as the combined impact of them all. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). It then must be determined whether there are related factors such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 111. Referral finally must be made for extraschedular rating consideration. Id. The Veteran has not argued specifically for an extraschedular rating. Neither his service-connected status-post residuals of left ACL reconstruction with DJD nor his chorioretinal scar of the left eye or bilateral onychomycosis is unusual or exceptional. These disabilities combined also are not unusual or exceptional. Indeed, each is reasonably described by the schedular rating criteria set forth above. These criteria also reasonably describe them in combination. For the Veteran's left knee, the ratings assigned based on them have taken into account his loss of motion factoring in a wide variety of ways in which functional loss may be manifested (pain, weakness, fatigability, lack of endurance, etc.) as well as his stiffness, swelling, grinding, and possibly crepitus. They also have taken into account his perception of instability, giving way, locking, and feeling as if his knee would snap. For the chorioretinal scar of the Veteran's left eye, the ratings assigned based on the them have taken into account its location and effect in terms of image and visual impairment. For the Veteran's bilateral onychomycosis, the ratings assigned based on them have taken into account the amount of his entire body and exposed areas affected by exudation, crusting, shedding, scaling, itch, irritation, and pain as well as the treatment required. His symptoms, in sum, are contemplated by the schedular rating criteria. Some of his symptoms are not set forth in them, but it is reiterated that many (in particular with respect to his eyes) have not been attributed to his service-connected disability. To the extent some of his symptoms are attributable to his service-connected disability but are not set forth in them, this does not automatically render them inadequate. That the Veteran uses a left knee brace and a cane was reflected at the December 2009 VA medical examination. As discussed, he is limited in terms of prolonged bending, standing, walking, and running. Some restriction of movement is typical, not unusual or exceptional, of an individual with a knee disability. It is typical, not unusual or exceptional, of an individual with a peripheral retinal scar like the Veteran to have no resulting visual impairment. Finally, it is typical as opposed to unusual or exceptional of an individual with bilateral onychomycosis like the Veteran to require topical medication for a host of skin symptoms limited to a small portion of the entire body. Having to wear special shoes is somewhat atypical, but it alone is not significant enough to qualify his disability picture as unusual or exceptional. Referral for consideration of the assignment of an extraschedular rating, in sum, is not warranted because the schedular rating criteria are adequate. Even if the schedular rating criteria were inadequate, referral still would not be warranted because the related factors do not exist. There is no indication that the Veteran ever, much less frequently, has been hospitalized because of his left ACL reconstruction with DJD, chorioretinal scar of the left eye, or bilateral onychomycosis. There also is no indication of marked interference, interference beyond that contemplated by the initial rating assigned herein, with employment due to these disabilities. Whether or not the Veteran has worked since his discharge is unknown. However, VA medical examinations either found no functional impact or did not mention such an impact due to his chorioretinal scar or his bilateral onychomycosis. Restricted movement on the job due to his left ACL reconstruction with DJD was found. Yet, only minimal time off work, three days a month, was reported by the Veteran at the May 2006 examination. No other reports about time lost from work were made by him. C. Total Disability Based on Individual Unemployability (TDIU) When a higher initial rating is sought, entitlement to a TDIU due to the service-connected disability or disabilities involved must be considered as a component of the matter if the issue is either expressly raised by the Veteran or his representative or reasonably raised by the evidence. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). A TDIU is warranted when the Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disability or disabilities rated at less than 100 percent. 38 C.F.R. §§ 3.340, 4.15, 4.16. The Veteran's level of education, special training, and previous work experience may be considered, but her age and the effect of disabilities that are not service-connected may not be taken into account. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Veteran is service-connected for several disabilities. However, only his left ACL reconstruction with DJD, chorioretinal scar of the left eye, and bilateral onychomycosis are for consideration. He has not argued that he is unable to secure or follow a substantially gainful occupation because of any one of these disabilities or all of them in combination. There additionally is no indication from the evidence that this may be the case. While the January 2014 VA medical examination included a determination that the Veteran's restriction of movement may limit his activities of physical as well as sedentary employment, such activities were not determined to be impossible. That he is not prevented from working altogether because of the aforementioned disabilities further follows from the aforementioned finding of not even marked interference with his ability to work due to them. Consideration of a TDIU as a component of this matter, in sum, is not warranted. ORDER Initial ratings for service-connected status-post residuals of left ACL reconstruction with DJD, greater than 10 percent for the period from October 1, 2006, to December 9, 2009, and greater than 30 percent for the period beginning December 10, 2009, are denied. An initial compensable rating for service-connected chorioretinal scar of the left eye is denied. An initial compensable rating for service-connected bilateral onychomycosis is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs