Citation Nr: 1750140 Decision Date: 11/06/17 Archive Date: 11/17/17 DOCKET NO. 09-43 748 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased disability rating in excess of 30 percent from June 1, 2007 to July 17, 2012, and in excess of 60 percent thereafter for service-connected status post-total left knee replacement. 2. Entitlement to an initial disability rating in excess of 10 percent for service-connected degenerative arthritis of the right knee. 3. Entitlement to an initial disability rating in excess of 10 percent from June 1, 2007 to July 17, 2012, and in excess of 20 percent thereafter for service-connected degenerative arthritis of the lumbar spine. 4. Entitlement to an initial compensable disability rating for service-connected dermatitis. 5. Entitlement to an initial compensable disability rating for service-connected left knee scar. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. F. Brandau, Associate Counsel INTRODUCTION The Veteran has active duty service in the United States Army from August 1981 to August 1984 and from May 1986 to May 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran has filed a notice of disagreement (NOD) at the RO concerning earlier effective dates for: major depressive disorder to include a traumatic brain injury, scars on the right forehead and left nasal dorsum, visual field loss with glaucoma, and bilateral pes planus with plantar fasciitis and hallux valgus as shown in the electronic claims file (VBMS). Such appeal is contained in the VACOLS appeals tracking system as an active appeal at the RO. While the Board is cognizant of the United States Court of Appeals for Veterans Claims (Court)'s decision in Manlincon v. West, 12 Vet. App. 238 (1999), the Board notes that in this case, unlike in Manlincon, the RO has fully acknowledged the NOD and is currently in the process of adjudicating the appeal. Action by the Board at this time may serve to actually delay the RO's action on that appeal. As such, no action will be taken by the Board at this time, and the issues presently before the RO will be the subject of a later Board decision, if ultimately necessary. FINDINGS OF FACT 1. For the period on appeal prior to July 17, 2012, the Veteran's left knee disability has been manifested at worst by chronic pain that varies in severity, mild weakness, mild instability, periodic swelling and flexion to 100 degrees with extension to zero degrees without severe painful motion or weakness. 2. For the period on appeal from July 17, 2012, the Veteran was more than one year removed from total left knee replacement, and was in receipt of the maximum 60 percent disability rating for knee replacement (prosthesis) more than one year after knee replacement surgery. 3. Throughout the period on appeal, the Veteran's degenerative joint disease of the right knee was manifested by painful motion, stiffness, occasional locking, flexion to at least 110 degrees, and extension to zero degrees. 4. Prior to July 17, 2012, the Veteran's spinal disability manifested with, at worst, forward flexion to 80 degrees a combined range of motion in the thoracolumbar spine to 230 degrees. 5. Beginning July 17, 2012, Veteran's spinal disability manifested with, at worst, forward flexion to 60 degrees. 6. Prior to May 9, 2012, the Veteran's dermatitis manifested with a skin rash that spread over less than five percent of the entire body, and less than five percent of the exposed areas affected, and did not require systemic therapy. 7. Beginning May 9, 2012, the Veteran's dermatitis manifested with a skin rash that spread between 20 to 40 percent of the entire which did not require near-constant systemic therapy. 8. Throughout the period on appeal, the Veteran's left knee scar was not objectively painful, and was not unstable, deep, or more than six square inches in area. CONCLUSIONS OF LAW 1. For the period on appeal prior to July 17, 2012, the criteria for a disability rating in excess of 30 percent for status post left knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2016). 2. For the period on appeal from July 17, 2012, the criteria for an increased disability rating in excess of 60 percent for the service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.71a, Diagnostic Code 5055. 3. The criteria for entitlement to an initial disability rating in excess of 10 percent for service-connected degenerative joint disease of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5017; 38 C.F.R. §§ 4.3, 4.71a, Diagnostic Code 5010 (2016). 4. Prior to July 17, 2012, the criteria for an initial disability rating in excess of 10 percent for service-connected degenerative arthritis of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2016). 5. Beginning July 17, 2012, the criteria for an initial disability rating in excess of 20 percent for service-connected degenerative arthritis of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5242. 6. The criteria for a compensable initial disability rating for service-connected dermatitis have not been met prior to May 9, 2012. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7806 (2016). 7. Beginning May 9, 2012, the criteria for an initial disability rating of 30 percent, but no higher, for service-connected dermatitis have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7806. 8. The criteria for a compensable initial disability rating for the left knee scar have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008); 38 C.F.R. §§ 4.3, 4.118, Diagnostic Code 7804 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2016). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2016); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2016); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2016). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2016); see also 38 C.F.R. §§ 4.45, 4.59 (2016). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran is service connected for a number of impairments, but those presently on appeal to the Board include the left knee, right knee, lumbar spine, dermatitis, and left knee scarring. With the exception of the left knee, the Veteran was granted entitlement to service connection for these impairments in a November 2007 rating decision, which is the basis of these appeals. Each impairment will be discussed in the following sections. A. Knees The Veteran's status post total left knee replacement with instability is rated under Diagnostic Code 5055, and his right knee disability is rated under Diagnostic Code 5010. 38 C.F.R. § 4.27 (2016). Under VA's Rating Schedule, Diagnostic Code 5010 addresses traumatic arthritis and Diagnostic Code 5055 provides the rating criteria for the prosthetic replacement of a knee joint. Under Diagnostic Code 5055, for one year following implantation, the knee joint warrants an evaluation of 100 percent. 38 C.F.R. § 4.71. Thereafter, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation is warranted. Where there are intermediate degrees of residual weakness, pain, or limitation of motion, Diagnostic Code 5055 instructs that they are to be rated by analogy to Diagnostic Code 5256, 5261, or 5262. The minimum evaluation for the residuals of the prosthetic replacement of a knee joint is 30 percent. Under Diagnostic Codes 5256, 5258, 5259, 5262, and 5263, ratings are assigned for ankylosis of the knee, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia and fibula, and genu recurvatum, respectively. 38 C.F.R. § 4.71a. As noted below, the evidence of record does not reflect the presence of any of these disabilities. As such, ratings under these criteria would not be appropriate in this case. Diagnostic Code 5260 addresses limitation of flexion of the leg and provides a noncompensable rating if flexion is limited to 60 degrees, a 10 percent rating where flexion is limited to 45 degrees, a 20 percent rating where flexion is limited to 30 degrees, and a maximum 30 percent rating where flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Related to Diagnostic Code 5260 is Diagnostic Code 5261 which addresses limitation of extension. Extension limited to 10 degrees warrants a 10 percent disability rating, extension limited to 15 degrees warrants a 20 percent disability rating, extension limited to 20 degrees warrants a 30 percent disability rating, extension limited to 30 degrees warrants a 40 percent disability rating, and extension limited to 45 degrees warrants a 50 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Other diagnostic codes which may apply to the knees include Diagnostic Code 5257, which addresses recurrent subluxation or lateral instability of the knee. Slight impairment warrants a 10 percent disability rating, moderate impairment warrants a 20 percent disability rating, and severe impairment warrants a 30 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Normal ranges of motion of the knee are to zero degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. By way of history, the Veteran was granted entitlement to service connection for the left knee disability in November 1984 and was assigned a noncompensable disability rating until 1986, when he returned to active duty. He was assigned a 30 percent disability rating as of June 1, 2007. In July 2012, that disability rating rose to 60 percent. As for the service-connected right knee, the Veteran was granted entitlement to service connection in June 2007, and has been in receipt of a 10 percent disability rating since that time. At all times during the appeal period, the Veteran has asserted that he is entitled to a higher disability rating. Each knee will be discussed separately. Left knee As noted, the Veteran is in receipt of a 30 percent disability rating prior to July 17, 2012, and his disability rating was raised to 60 percent thereafter. i. Prior to July 17, 2012 In September 2007 the Veteran underwent VA examination in connection with his claim, at which time he reported that he injured his knee in 1991. He reported that his left knee caused weakness, stiffness, swelling, heat, giving way, lack of endurance, and fatigability. The Veteran asserted that his left knee pain was constant, sharp, and aching; he reported that his pain was an eight on a pain scale of one to ten, but that he could function with medication. The Veteran noted that he had two incidents of incapacitation for a total of eight days in the year prior. On physical examination the Veteran had an antalgic gait, but there was no evidence of edema, effusion, weakness, tenderness, redness, heat, guarding of movement, locking pain, or crepitus. During the range of motion testing the Veteran had left knee flexion to 100 degrees with pain at 70 degrees and extension to zero degrees. On repetition the Veteran had functional limitation of fatigue, weakness, lack of endurance, and incoordination, but there was no change of range of motion on repetition. The stability testing was normal, and the left knee x-ray showed only post-surgical changes. A few months later the Veteran sought treatment at VA, and during the physical examination the Veteran had tenderness in the left knee, with no evidence of effusion, erythema, warmth, or deformity. The Veteran had a reduced range of motion but there was no evidence of instability. In January 2008 the Veteran again sought treatment and during the range of motion testing he had a full extension of the knees but his flexion was reduced. He showed no evidence of instability. The Veteran was prescribed a knee brace for the left knee. In August 2009 the Veteran again underwent VA examination in connection with his claim wherein he described his prior surgical treatment and indicated that he still had pain and instability with a giving way sensation. He reported that his treatment modalities include home exercises, pain medication, and bracing the knees. On physical examination the Veteran had tenderness in the left knee with some instability in the anterior and posterior but there was no evidence of crepitation. The Veteran had left knee flexion to 120 degrees with normal extension, and his left knee flexion was to 110 degrees on repetition. His left knee x-ray showed post-surgical changes. In light of the evidence of record, the Board concludes that the evidence is consistent with a 30 percent disability rating. While the record evidences chronic pain in the knee, severe painful motion has not been demonstrated. Although the Veteran had a painful range of motion in the September 2007 VA examination, there is nothing to suggest that he had severe pain. His range of motion was only slightly reduced, and there was minimal change on repetition. In addition, severe weakness has not been shown. Although the Veteran asserted that he had weakness, there were no objective findings of weakness on physical examination. No other records are in significant conflict with the examination findings. Of note, the Veteran's x-ray findings showed only post-surgical changes with no residuals. The findings on examination are given more probative weight than the Veteran's lay statements about the severity of his pain and weakness. Given the above, a higher rating is not warranted when considering Diagnostic Code 5055. See 38 C.F.R. § 4.71a. The Board has considered whether a higher rating, through a single rating or combination of ratings, could be assigned by using the rating criteria specific to the knee rather than Diagnostic Code 5055, but finds that this would not result in a higher rating at any time during the course of the appeal. Of note, in this case separate ratings for the knee under Diagnostic Codes 5256 through 5263 cannot be assigned in conjunction with a rating under Diagnostic Code 5055 as that would constitute impermissible pyramiding. 38 C.F.R. § 4.14 (2016). As noted by the VA examiners, the Veteran does not have left knee ankylosis, semilunar cartilage removal or dislocation, impairment of the tibia or fibula, or genu recurvatum. Thus, ratings based on these diagnostic codes are not appropriate. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. While mild instability was shown at the August 2009 examination, this would only amount to a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Recurrent subluxation is also not shown. Id. The evidence of record shows left knee flexion limited at worst to 100 degrees and extension to zero degrees. This results in a noncompensable rating for limitation of flexion and for limitation of extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Even if a 10 percent rating was assigned based on painful motion in addition to a 10 percent rating for slight instability, this would not entitle the Veteran to a rating greater than that assigned currently under Diagnostic Code 5055. Based on these findings, the Board finds that the 30 percent disability rating is adequate. There are no evidence findings to the contrary. In making this determination the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against a higher disability rating during this period, that doctrine is not for application. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ii. Beginning July 17, 2012 In July 2012 the Veteran underwent VA examination in connection with his claim. At the time he reported having knee replacement surgery in 2005, and that he had knee manipulation later that year. He reported that his left knee still buckled and caused severe popping that caused sharp pain which weakened his motion. He asserted that he used a knee brace to stabilize the left knee from strain and buckling. During the range of motion testing the Veteran had left knee flexion to 95 degrees and extension to five degrees. On repetition testing he had decreased function as evidenced by weakened movement. He had full strength and reflexes, however. The Veteran continued to have knee pain and was prescribed a knee brace and later leg orthotics. He reported continued pain in the left knee in September 2016. As noted, the Veteran underwent left knee replacement in 2005. Diagnostic Code 5055 provides for temporary total ratings for the year following a total knee replacement. A higher rating is not warranted from July 17, 2012, because these periods were not in the year following replacement of a knee joint. There is nothing to suggest that additional periods of convalescence beyond one year were necessary. The RO assigned a 60 percent disability rating for this period, which is the next highest rating under Diagnostic Code 5055. This code applies to chronic residuals of knee replacement consisting of severe painful motion or weakness in the affected extremity. Under Diagnostic Code 5055 no higher rating is available for periods more than a year after knee replacement, and thus the Board concludes that no higher rating is warranted for any period on appeal under Diagnostic Code 5055. The Board has considered whether a higher rating, through a single rating or combination of ratings, could be assigned by using the rating criteria specific to the knee rather than Diagnostic Code 5055, but finds that this would not result in a higher rating at any time during the course of the appeal. Of note, in this case separate ratings for the knee under Diagnostic Codes 5256 through 5263 cannot be assigned in conjunction with a rating under Diagnostic Code 5055 as that would constitute impermissible pyramiding. 38 C.F.R. § 4.14. During this period, limitation of flexion and extension are not to a compensable degree, and there is no ankylosis of the knee, tibia or fibula impairment or genu recurvatum. Instability was not found on the most recent examination, and cartilage problems can only be assigned ratings far less than the current 60 percent rating. Thus, it is most beneficial to rate the Veteran under Diagnostic Code 5055. Based on the evidence above, an increased disability rating in excess of 60 percent for the left knee disability is not warranted from July 17, 2012. 38 C.F.R. §§ 4.3, 4.7. In making this determination the Board has considered the applicability of the benefit of the doubt doctrine. However as the preponderance of the evidence is against a higher disability rating during this period, that doctrine is not applicable. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. 49. Right knee The Veteran began experiencing right knee pain secondary to his left knee disability. In October 2006 his right knee x-ray showed mild degenerative changes. When he underwent VA examination in connection with his claim in September 2007 he was diagnosed with Grade III chondromalacia of the patella with arthritis. He reported that his knee pain was an eight on a pain scale of one to ten. During the range of motion testing the Veteran had flexion to 140 degrees and extension to zero degrees. There was no additional limitation by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. His stability testing was normal. A few months later the Veteran sought treatment at VA, and on physical examination the Veteran exhibited tenderness but had a full range of motion with pain. His stability testing was normal, and there was no tenderness with ambulation. In January 2008 the Veteran followed up with treatment had he had full extension in the knees with some crepitus, but no instability. In August 2009 the Veteran again underwent VA examination in connection with his claim. At the time the VA examiner noted that the Veteran had tenderness in the right knee with no crepitation, grinding, or instability. During range of motion testing, the Veteran had flexion to 130 degrees with normal extension with pain on repetition. Approximately three years later in July 2012 the Veteran again underwent VA examination in connection with his claim, and he asserted that he might need a right knee replacement but that he carried a diagnosis of Grade III to IV chondromalacia of the patella. During range of motion testing the Veteran had right knee flexion to 110 degrees with pain at 100, with normal extension. On repetition the Veteran's right knee flexion was to 100 with additional functional loss of weakened lesser movement, although he had full strength and reflexes. He was diagnosed with degenerative arthritis of the right knee. The Veteran continued to seek treatment for knee pain, and he was given orthotics and braces for the knee. Upon review, the Board finds that increased ratings are not warranted at any point during the period on appeal. With respect to limitation of flexion, the Veteran's current 10 percent disability rating is based on painful motion. At no point during the period on appeal does the evidence reflect that his flexion approached compensable levels, let alone the 30 degrees required for a higher disability rating. Accordingly, a disability rating in excess of 10 percent for limitation of flexion is not warranted at any point during the period on appeal. With respect to right knee extension, the Veteran's extension testing has consistently been normal or zero degrees. Accordingly, a compensable disability rating for limitation of extension is not warranted at any point during the period on appeal. With respect to right knee instability, the Veteran has asserted that his knees buckle and that he requires a cane to ambulate. Nonetheless, his physical examination findings have never shown objective evidence of instability. His September 2007 VA examination was normal for instability, as was his VA treatment note from December 2007. The August 2009 VA examination and July 2012 VA examination likewise showed no objective evidence of instability. Although the Veteran's lay statements describe instability, the objective evidence is insufficient to find even a slight instability impairment which would be necessary for a separate disability rating under Diagnostic Code 5257. The objective medical evidence and testing is more probative than the Veteran's lay reports of a feeling of instability. Additionally, as noted, the record also does not show that the Veteran has ankylosis, dislocated semilunar cartilage with frequent locking and effusion into the joint, or nonunion or malunion of either tibia or fibula. Accordingly, Diagnostic Codes 5256, 5258, and 5262 are not for application. 38 C.F.R. § 4.71a. While the Veteran has had meniscectomies, the residuals of such are pain and decreased motion. As such, a separate rating for "cartilage, semilunar, removal of, symptomatic" under Diagnostic Code 5259 cannot be assigned as these symptoms are fully contemplated by the already assigned ratings. Id. An additional rating would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, as required by Schafrath, 1 Vet. App. 589. The Board finds there are no other symptoms which should be addressed by a separately-assigned disability rating. In making this determination the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against assignment of a higher disability rating, this doctrine is not for application. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. 49. B. Lumbar spine Spinal disabilities are rated under the General Rating Formula for Diseases and Injuries of the Spine, 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. In relevant part, a 10 percent rating requires forward flexion of the thoracolumbar spine to 85 degrees or less; a combined range of motion of the thoracolumbar spine of 235 degrees or less; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). Intervertebral Disc Syndrome (IVDS) is rated using the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Evaluations range from 10 to 60 percent based on the number of incapacitating episodes (period of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician). 38 C.F.R. § 4.71a, Diagnostic Code 5243. A 10 percent rating is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. Higher ratings are assignable with 4 weeks or more of incapacitating episodes in a year. Painful motion with joint or periarticular pathology is to be treated as productive of disability and entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Likewise, with a finding of arthritis, a 10 percent rating is for application for each major joint affected by limitation of motion when there is objective evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. By way of history, the Veteran was granted entitlement to service connection for degenerative arthritis of the lumbar spine in November 2007, and was granted a 10 percent disability rating as of June 1, 2007. A May 2017 rating decision raised the disability rating to 20 percent as of July 17, 2012. At all times during the appeal the Veteran has asserted that he is entitled to a higher disability rating. The Board will discuss each period in turn. i. Prior to July 17, 2012 In September 2007 the Veteran underwent VA examination in connection with his claim, and at the time he reported that he had stiffness in the spine and back spasms that made the legs go numb and weakness that traveled to the legs. He reported having pain flare-ups once per month that lasted for three weeks. He asserted that at worst his pain was a ten on a pain scale of one to ten and that his pain was elicited by physical activity and relieved by rest and medication. The Veteran noted that his spinal condition did not cause any incapacitation, although it limited his ability to walk, stand, or sit for prolonged periods. On physical examination the Veteran had normal posture but an antalgic gait; he did not require an assistive device for ambulation. The spine had no pain or muscle spasms during movement, and no tenderness was noted; his straight leg raise was negative bilaterally and there was no evidence of ankylosis of the lumbar spine. He had lumbar spine flexion to 90 degrees with pain, and extension to 30 degrees with pain at 30 degrees. His lateral flexion was to 30 degrees with pain, and his lateral rotation was to 30 degrees with pain at 20 degrees. He had no change in range of motion on repetition, but there was functional loss due to pain and weakness. Intervertebral disc syndrome was not noted. The lumbar spine x-ray showed degenerative arthritis and joint narrowing. When the Veteran followed up with VA for treatment in October 2008 he had spinal tenderness and muscle spasm, as well as a full range of motion. In July 2009 he reported having back spasms and losing sleep, but his physical examination showed a normal spine with no tenderness and no loss of motion. His straight leg raise was negative bilaterally and he was diagnosed with intervertebral disc syndrome. The following month the Veteran again underwent VA examination in connection with his claims, and he reported having continued back pain despite physical therapy and occupational therapy. He asserted that his pain ranged from a five to a ten on a pain scale of one to ten. The Veteran's lumbar flexion was to 80 degrees and his extension was to 30 degrees. His bilateral rotation and flexion was to 30 degrees, although there was evidence of pain during range of motion testing; there was no change in range of motion on repetition. Gait was normal and there were no abnormal spinal curvatures. His spinal x-ray showed degenerative changes in the lumbar spine. The Veteran continued treatment with VA, and in May 2012 he reported that he had tightness in the spine with decreased range of motion; he reported that he was considering steroid injections for his pain management. In this case, the evidence is consistent with a 10 percent disability rating. During the September 2007 VA examination the Veteran had forward flexion to 90 degrees and a combined range of motion to 240 degrees, and during the August 2009 VA examination the Veteran had forward flexion to 80 degrees and a combined disability rating of 230 degrees, which is within the parameters of the 10 percent disability rating based on forward flexion and a combined range of motion. These findings are consistent with a 10 percent disability rating, but no higher. The evidence does not suggest a higher disability rating would be applicable. The Veteran has a reduced range of motion but not to the extent required for a higher disability rating. While muscle spasm was reported in 2009 and 2009, there is no indication this resulted in an abnormal gait or spinal contour. Of note, both gait and spinal contour were normal on examination in 2009. Moreover, while he has been diagnosed with IVDS during the appeal period, there is no evidence of a period of incapacitation as defined by VA, which would be necessary for a higher disability rating. Given the evidence during this period, the Board finds that a 10 percent disability rating is warranted. The Board has considered the applicability of the benefit of the doubt doctrine, but the VA examination findings suggest that a higher disability rating is not warranted therefore this doctrine is not for application. Gilbert, 1 Vet. App. 49. ii. Beginning July 17, 2012 In July 2012 the Veteran underwent VA examination in connection with his claim. At the time he reported having back pain flare-ups and that he had been prescribed a TENS unit to help with his symptoms. During his range of motion testing, he had forward flexion to 60 degrees with pain, and extension to 25 degrees with pain. His bilateral flexion and rotation was to 20 degrees with pain. There was no change on repetition, but he did have noted functional loss to include less movement, pain, incoordination, and excess fatigability. He exhibited spinal tenderness but no guarding or muscle spasms; his straight leg raise was normal and he had no evidence of IVDS. The Veteran reported that he used a back brace regularly. The Veteran continued treatment with VA and he seemed to improve in that he reported that he was able to go to the gym three times per week in May 2015. There were no symptom flare-ups that required treatment beyond conservative modalities. In viewing the totality of the evidence, the Board finds that the evidence is consistent with a 20 percent disability rating. During the physical examination the Veteran's forward flexion was from zero to 60 degrees with pain, which is consistent with a 20 percent disability rating. The Veteran's combined range of motion was to 165 degrees, which is less than the requirements for a 20 percent disability rating, but in viewing the evidence in the light most favorable to the Veteran, the Board finds that it is consistent with a 20 percent disability rating. The evidence does not show that the Veteran meets the criteria for a 40 percent disability rating during this period. The Veteran's forward flexion of the spine would need to be 30 degrees or less, or he would have to have unfavorable anklylosis of the spine; as noted, the Veteran's forward flexion is to 60 degrees and no physician has ever indicated that the Veteran has ankylosis in the spine. The requisite amount of incapacitating episodes for a higher rating to be assigned were not shown or alleged during this period; he has never suggested that he has had periods of incapacitation and the July 2012 VA examiner found that he did not have IVDS. Overall the Board notes that the Veteran has reported having back pain and that he has needed a cane to ambulate. He has also reported having muscle spasms before receiving inserts. Nonetheless, he has not reported any loss of range of motion in the spine, and based on the physical examination findings, no loss of motion is documented that would be consistent with a higher disability rating during either period. The Board has considered the applicability of the benefit of the doubt doctrine but given the physical findings showing a 20 percent disability rating, the Board finds this doctrine is not for application. Gilbert, 1 Vet. App. 49. C. Dermatitis The Veteran's dermatitis is rated under the criteria of 38 C.F.R. § 4.118, Diagnostic Code 7806 (dermatitis or eczema). The rating criteria are as follows. A noncompensable rating is assigned with less than 5 percent of the entire body affected; or, less than 5 percent of exposed areas affected; and, no more than topical therapy required during the past 12-month period. A rating of 10 percent is assigned with at least 5 percent, but less than 20 percent, of the entire body affected; or, at least 5 percent, but less than 20 percent, of the exposed areas affected; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than 6 weeks during the past 12-month period. A rating of 30 percent is assigned with 20 to 40 percent of the entire body or exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constant, during the past 12-month period. A rating of 60 percent is assigned with more than 40 percent of the entire body or exposed areas affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Alternatively, the disability may be rated as disfigurement of the head, face or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804 or 7805) depending on the predominant disability. In this case, there is no evidence of disfigurement due to dermatitis, and the Veteran is already in receipt of separate ratings for scars. Therefore, the Board will only evaluate this disability under Diagnostic Code 7806. By way of history, the Veteran filed a claim for entitlement to service connection for dermatitis in January 2007, and he was granted entitlement to service connection in a November 2007 rating decision, and was assigned a noncompensable disability rating. At all times during the appeal the Veteran has argued that he is entitled to a higher disability rating. For the reasons that follow, the Board finds that the Veteran is entitled to a 30 percent disability rating as of May 9, 2012. Each period will be discussed separately. i. Prior to May 9, 2012 In September 2007 the Veteran underwent VA examination in connection with his claim. At the time he reported having dermatitis since 1987 and that he had itching, shedding, and crusting of the skin. He asserted that his symptoms occurred intermittently, up to six times per year with each time lasting 30 days. Although the skin rash was not on the face, neck, hands, or head, it was noted to occur in areas exposed to the sun, to include the back of arms. On physical examination the Veteran was noted to have dermatitis without any ulceration, crusting, tissue loss, induration, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. The skin lesion/condition was noted to occur on zero percent of the exposed area, with a total coverage of one percent. In August 2009 the Veteran again underwent VA examination in connection with his claim. At the time he was diagnosed with eczema with a gradual onset with visible bumps on the back of the left knee and dark patches with scaling. The Veteran described having a burning itch and scaling with occasional scab formation. The Veteran described taking topical over the counter Eucerin lotion daily and as needed. This treatment was not classified as a corticosteroid or immunosuppressive. The VA examiner noted that the condition had zero percent of exposed areas, and affected less than five percent of the total body area. The Veteran was diagnosed with eczematous dermatitis that was asymptomatic at the time of the examination. Upon review, the Board finds that the Veteran's disability is consistent with a noncompensable rating. The VA examiner detected a skin rash that manifested on the arms and legs, but there was no evidence of a rash on the face or neck. The VA examiners specifically opined that the Veteran's skin disability manifested in less than five percent of the total body surface and at zero percent of the exposed body surface, which is consistent with a non-compensable rating. Moreover, the Veteran denied requiring medication for this disability other than over the counter Eucerin lotion which is neither an immunosuppressive nor a corticosteroid. Given the minimal prevalence of the skin rash on the body combined with the lack of medication, the Board finds that the evidence is consistent with a noncompensable disability rating. There is no evidence to the contrary. In making this determination, the Board has considered the benefit of the doubt rule; however, since a preponderance of the evidence is against a higher disability rating during this period, the benefit of the doubt rule is not for further application. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3. ii. Beginning May 9, 2012 In May 2017 the Board received a disability questionnaire from the Veteran's physician which was dated May 9, 2012. The Veteran was diagnosed with dermatitis or eczema, without evidence of disfigurement in the face or neck, or malignant skin neoplasms or systemic manifestations due to skin disease. The Veteran was noted to be using ammonium lactate medication for his symptoms constantly or near-constantly. The examiner noted no evidence of debilitating episodes, but noted that the Veteran had non-debilitating episodes of urticaria which occurred four or more times per year despite engaging in immunosuppressive therapy. The examiner opined that the Veteran's dermatitis affected between 20 to 40 percent of the total body area. In July 2012 the Veteran underwent VA examination in connection with his claim. At the time he was diagnosed with dermatitis, and he admitted that he was using topical medication to include hydrocortisone ointment. The VA examiner noted that the Veteran had debilitating episodes despite immunosuppressive therapy. The VA examiner found that the Veteran's dermatitis was in remission. Upon review, the Board finds that the Veteran's disability is consistent with a 30 percent disability rating during this period. This is based primarily on the Veteran's physician's statement that the Veteran's dermatitis affected between 20 to 40 percent of the total body area. Moreover, both physicians found that the Veteran required immunosuppressive therapy but that he continued to have debilitating episodes despite treatment. Neither examiner found that the Veteran's skin disability manifested in more than 40 percent of the entire body, and the Veteran has not suggested this. Based on the total body exposure between 20 to 40 percent the Board finds that this evidence is consistent with a 30 percent disability rating. While immunosuppressive therapy was noted during this period at no point was near-constant systemic therapy described. In making this determination, the Board has considered the benefit of the doubt rule; however, since a preponderance of the evidence is against a higher disability rating during this period, the benefit of the doubt rule is not for further application. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3. D. Left knee scar The Veteran filed for entitlement to service connection for a left knee scar in June 2007. He was granted entitlement to service connection in a November 2007 rating decision and was assigned a noncompensable disability rating. Effective October 23, 2008, VA revised the criteria for the evaluation of scars to allow for separate evaluations for scars that are both disfiguring and painful. 73 Fed. Reg. 54,710-12 (Sept. 23, 2008). Here, the Board will consider both the old and new regulations. Prior to October 23, 2008, scars (other than those involving the head, face, or neck) that are deep or that cause limited motion warranted a 10 percent rating for an area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent rating was warranted for an area or areas of such scars exceeding 12 square inches (77 sq.cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, were separately rated and combined in accordance with 38 C.F.R. § 4.25 (2008). 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1) (2008). A deep scar was one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2) (2008). A 10 percent rating was also warranted for scars (other than those on the head, face, or neck) that were superficial and that did not cause limited motion, provided that they covered an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). A 10 percent rating was warranted for scars which were superficial and unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). An unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). A 10 percent rating was warranted for a superficial scar which was painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Other scars were rated based on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). Under the newer criteria, Diagnostic Code 7804 pertains to evaluation of scars that are unstable or painful, with the assignment of a 10 percent rating for one or two such scars, a 20 percent rating for three or four scars, and a 30 percent rating for five or more scars. Note 1 defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that where one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Note 3 states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under 7804 when applicable. 38 C.F.R. § 4.118 (2016). Diagnostic Codes 7801 and 7802 continue to provide for assignment of disability evaluations on the basis of surface area of the affected scars. The revised Diagnostic Code 7805 applies to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. A rating is to be assigned on the basis of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under another appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2016). In September 2007 the Veteran underwent VA examination in connection with his claim, and on physical examination the VA examiner noted that the Veteran had an elevated scar on the left knee that had a midline measuring 21 centimeters by one centimeter with keloid formation of less than six square inches. There was no evidence of tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, or hypopigmentation. The VA examiner also noted that the Veteran had a scar on the left lateral knee that measured seven centimeters by 0.7 centimeters with hyperpigmentation of less than six square inches. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, abnormal texture, inflammation, or edema. In July 2012 the Veteran again underwent VA examination in connection with his claim, and at the time he reported having a scar on the left knee with burning and itching pain that was numb to the touch. The left knee scarring was not identified as unstable or painful, and the surgical scar was noted to be 22 centimeters by 1.5 centimeters. More recently in July 2016 the Veteran reported having two scars on the left knee from prior knee surgeries. He asserted that the left knee scars were painful, tender, numb, and itched constantly. However, the VA examiner indicated that none of the scars were painful on examination. With respect to the Veteran's left knee scar, the Board finds that a compensable disability is not warranted at any point during the period on appeal. For the time period prior to October 23, 2008, only the older rating criteria described above apply. The evidence during that period that does not reflect that the scar was ever painful, unstable, deep, or greater than 6 square inches in area. In fact, his larger scar was 21 centimeters long by one centimeter wide, and there was no evidence of tenderness or instability during the September 2007 VA examination. On and after October 23, 2008, the new rating criteria apply, unless the old rating criteria are more favorable to the Veteran. The Veteran reported experiencing pain in the scar at times, but at no time during the pendency of the appeal was the Veteran's scar noted to be objectively painful, unstable, or deep, or to cover an area of 6 square inches or more. There is also no evidence that the scar was noted to cause limitation of motion, and the Veteran has not alleged this. Accordingly, the Board finds that the Veteran does not meet the criteria for a higher disability rating at any time under either version of the Diagnostic Code, as the scar was not shown to be objectively painful, unstable, deep, or greater than 6 square inches in area. Accordingly, a compensable disability rating for a left knee scar is not warranted at any time during the period on appeal. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Other Considerations Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). The Board notes that the Veteran has at times suggested that his disabilities impact his ability to work, but he has never asserted that he is incapable of working due to his disabilities. It is noteworthy that the Veteran has instituted many claims since separating from service in 2007, but he has never made a claim for a total disability rating based on individual unemployability due to service-connected disability. ORDER Entitlement to an increased disability rating in excess of 30 percent from June 1, 2007 to July 17, 2012, and in excess of 60 percent thereafter for service-connected status post-total left knee replacement is denied. Entitlement to an initial disability rating in excess of 10 percent for service-connected degenerative arthritis of the right knee is denied. Entitlement to an initial disability rating in excess of 10 percent from June 1, 2007 to July 17, 2012, and in excess of 20 percent thereafter for service-connected degenerative arthritis of the lumbar spine is denied. Entitlement to an initial compensable disability rating prior to May 9, 2012, for service-connected dermatitis is denied. Entitlement to an initial compensable disability rating of 30 percent, but no higher, from May 9, 2012, for service-connected dermatitis is granted. Entitlement to an initial compensable disability rating for service-connected left knee scar is denied. ____________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs