Citation Nr: 18140222 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 06-39 244 DATE: October 2, 2018 ORDER 1. Entitlement to a rating in excess of 30 percent for retropatellar pain syndrome (RPPS) of the right knee from November 1, 2005 until April 9, 2010 is denied. 2. Entitlement to a rating in excess of 10 percent for RPPS of the right knee after April 9, 2010 is denied. 3. Entitlement to a rating in excess of 10 percent for RPPS of the left knee is denied. 4. Entitlement to a rating in excess of 30 percent for spontaneous pneumothorax, postoperative, with restrictive lung disease for the period from November 1, 2005 to September 13, 2017 is denied. FINDINGS OF FACT 1. From November 1, 2005 until April 9, 2010, RPPS of the Veteran’s right knee has been manifested by pain and range of motion from 20 degrees to 125 degrees of flexion, at worst, without recurrent subluxation, lateral instability or other impairment with no reports of flare-ups. 2. From April 9, 2010 to the present, RPPS of the Veteran’s right knee has been manifested by pain and range of motion from 125 degrees of flexion, at worst, without recurrent subluxation, lateral instability or other impairment with no current reports of flare-ups. 3. Throughout the entire period on appeal, RPPS of the left knee has been manifested by pain and range of motion to 125 degrees of flexion, at worst, without recurrent subluxation, lateral instability or other impairment with no current complaints of flare-ups. 4. For the period ranging from November 1, 2005 to September 13, 2017, the Veteran’s spontaneous pneumothorax with restrictive lung disease resulted in pulmonary function tests (PFTs) that documented no worse than Forced Expiratory Volume in one second (FEV-1) of 56 to 70 percent predicted, or; a ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 56 to 70 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 56 to 66 percent predicted. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 30 percent for RPPS of the right knee have not been met for the period from November 1, 2005 until April 9, 2010. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5260, 5261. 2. The criteria for an increased rating in excess of 10 percent for RPPS of the right knee have not been met for the period from April 9, 2010 to the present. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DCs 5260, 5261. 3. The criteria for an increased rating in excess of 10 percent for RPPS of the left knee have not been met for any period on appeal. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DCs 5260, 5261. 4. The criteria for an increased disability rating in excess of 30 percent for spontaneous pneumothorax with restrictive lung disease have not been met for the period from November 1, 2005 until September 13, 2017. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.21, 4.97, DC 6843. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from October 1985 until October 2005. This matter comes before the Board of Veterans’ Appeals (Board) from a December 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran filed a notice of disagreement in March 2006 and was provided with a statement of the case in September 2006. The Veteran perfected his appeal with a December 2006 VA Form 9. The Veteran declined a hearing in this case. Subsequently, the Veteran’s claims discussed in this case were remanded by the Board in both June 2009 and March 2013. Increased Ratings – Generally Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is prohibited. 38 C.F.R. § 4.14. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Generally, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 1. Entitlement to a rating in excess of 30 percent for RPPS of the right knee from November 1, 2005 until April 9, 2010 The Veteran seeks entitlement to an increased disability rating in excess of 30 percent for RPPS of the right knee from November 1, 2005 until April 9, 2010. For judicial brevity, a description of code sections relevant to the Veteran’s claims for an increased rating in excess of 30 percent for RPPS of the right knee from November 1, 2005 until April 9, 2010, for an increased rating in excess of 10 percent for RPPS of the right knee from April 9, 2010 to the present, and for an increased rating in excess of 10 percent of the left knee from November 1, 2005 are included only once, below. Under DC 5261, a 10 percent disability rating is warranted for limitation of extension to 10 degrees; a 20 percent disability rating is warranted for limitation of extension to 15 degrees; a 30 percent disability rating is warranted for limitation of extension to 20 degrees; a 40 percent disability rating is warranted for limitation of extension to 30 degrees; and a maximum schedular 50 percent disability rating is warranted for limitation of extension to 45 degrees. Under DC 5260, a 10 percent disability rating is warranted for limitation of flexion to 45 degrees; a 20 percent disability rating is warranted for limitation of flexion to 30 degrees, and a maximum schedular 30 percent disability rating is warranted for limitation of flexion to 15 degrees. The Veteran was afforded a VA examination in March 2005. The examiner noted that the Veteran’s right knee lacked 20 degrees of extension on active movement, and had a full range of motion on passive movement. The examiner also noted that flexion of both knees was limited secondary to stiffness, and that a March 2005 x-ray of the right knee showed old post-traumatic changes but was otherwise normal. The examiner diagnosed the Veteran with bilateral knee pain, with etiology “probably due to old trauma causing changes,” and noted that repetitive use caused decreased function due to stiffness. The examiner noted that the Veteran’s condition was currently stable. The Veteran was afforded another examination in March 2010. The medical professional conducting the examination noted that the Veteran’s active right knee extension was to 0 degrees, and active right knee flexion was to 121 degrees. The medical professional noted that the Veteran’s passive right knee extension was to 0 degrees and his passive right knee flexion was to 128 degrees. The Veteran was able to complete three repetitions without significant reduction in function or worsening of pain. The medical professional noted that sonography of the right knee joint revealed signs of synovitis with capsule proliferation, with no inflammatory changes visible. The medical professional further noted that an x-ray of the right knee-joint in two planes revealed a narrowing of the medial joint space by approximately 2/3. Finally, the medical professional diagnosed the Veteran with grade II medial gonarthrosis and grade I retropatellar arthrosis in the right knee. Following a review of the evidence of record, the Board finds that the preponderance of evidence is against the Veteran’s claims of entitlement to an increased disability rating in excess of 30 percent for RPPS of the right knee from November 1, 2005 until April 9, 2010. In order to warrant an increased 40 percent disability rating for his right knee under DC 5261, the Veteran must have displayed limitation of extension to 30 degrees. The probative evidence of record does not document that the Veteran’s knee extension was limited to this extent. Rather, it was limited only to 20 degrees. Separate ratings are assigned for limitation of extension and limitation of flexion if both are compensable in degree. In order to warrant a 10 percent rating for limitation of flexion, the Veteran must have displayed limitation of flexion to 45 degrees. The probative evidence of record does not document that the Veteran’s knee flexion was limited to this extent. The Board has also considered whether any other applicable rating criteria may support a higher evaluation. However, after review, the Board finds that no other diagnostic code provides for a higher rating. There was no evidence of ankylosis of the right knee. Therefore, Diagnostic Code 5256 is not for application. There are no findings of instability or recurrent subluxation in the right knee. Thus, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257. The Board also finds that a higher disability rating or a separate disability rating is not warranted under either Diagnostic Code 5258 or 5259. Diagnostic Codes 5258 and 5259 address cartilage injuries and symptoms. The weight of the competent and credible evidence shows that there is no cartilage disability or pathology in the right knee. There is no evidence of nonunion of the tibia and fibula or genu recurvatum in the right knee. Thus, a higher or separate rating is not warranted under Diagnostic Codes 5262 or 5263. In assessing the severity of the Veteran’s right knee disability, the Board has also considered the lay evidence of record, including statements of the Veteran, which describe symptoms such as stiffness in the morning hours that lessens over the course of the day and knee pain that is made worse by running, jumping, and biking. Such lay statements are considered competent insofar as they describe observable symptomatology. The Veteran’s history and reported symptoms have been considered, including as presented in the evidence discussed above, and have been contemplated by the disability ratings that have been assigned. As such, while the Board accepts the lay evidence of record insofar as it is competent, the Board relies upon the competent medical evidence of record regarding the specialized evaluation of the Veteran’s service-connected right knee disability. Thus, the Board finds that the preponderance of the evidence is against the assignment of disability ratings in excess of 30 percent for right knee RPPS from November 1, 2005 until April 9, 2010. There is no reasonable doubt to be resolved, and the claim for an increased rating is denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 2. Entitlement to a rating in excess of 10 percent for RPPS of the right knee from April 9, 2010 to the present In the March 2010 examination report, the medical professional conducting the examination noted that the Veteran’s active right knee extension was to 0 degrees, and active right knee flexion was to 121 degrees. The medical professional noted that the Veteran’s passive right knee extension was to 0 degrees and his passive right knee flexion was to 128 degrees. The Veteran was able to complete three repetitions without significant reduction in function or worsening of pain. The medical professional noted that sonography of the right knee joint revealed signs of synovitis with capsule proliferation, with no inflammatory changes visible. The medical professional further noted that an x-ray of the right knee-joint in two planes revealed a narrowing of the medial joint space by approximately 2/3. Finally, the medical professional diagnosed the Veteran with grade II medial gonarthrosis and grade I retropatellar arthrosis in the right knee. The Veteran was afforded another examination in August 2017. The examiner reviewed the Veteran’s service treatment records and noted that the Veteran received treatment during service for RPPS. The examiner noted that the Veteran was experiencing bilateral knee pain at a 4-5 intensity on a scale of 1-10 with 10 being the worst. The Veteran described his functional loss by stating that his knees are constantly painful when running, jumping, or biking, with the left knee being more painful than the right knee. There were no additional factors causing functional loss. The examiner noted that the condition had progressed, and that the Veteran currently suffered from grade 1 retropatellar arthrosis. Finally, on range of motion testing, the examiner noted that both the Veteran’s right knee flexion was to 140 degrees, with his right knee extension to 0 degrees. There was evidence of pain with weightbearing or on extension, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time, but the examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over time. The examination was not conducted during a flare up. The examiner noted that muscle strength was normal in the right knee and that no muscle atrophy, ankylosis, or history of recurrent subluxation, lateral instability, or effusion was present. The examiner noted that the Veteran did not have nor had ever had recurrent patellar dislocation, “shin splints,” stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The examiner noted traumatic arthritis in the right knee, confirmed by imaging studies. The examiner noted that the Veteran’s diagnosis impacts his ability to perform occupational tasks, as he is unable to run, jog, jump, or bike due to increased pain in both knees. The examiner noted that there was objective evidence of pain when each knee was used in non-weightbearing exercises, and that the range of motion for each knee was the same for both active and passive motion. Finally, the examiner noted that the findings of the examination were consistent with gonarthrosis, that there was no loss of range of motion, and that “the disability is just moderate pain on passive and active motion.” Given the evidence of record, as discussed above, the Board finds that the preponderance of the evidence weighs against the Veteran’s claims of entitlement to an increased disability rating in excess of 10 percent for RPPS of the right knee from April 9, 2010. In order to warrant an increased 20 percent disability rating for the right knee under DC 5260 or 5261, the Veteran must have displayed limitation of flexion to 30 degrees or limitation of extension to 15 degrees, respectively. The probative evidence of record does not document that the Veteran’s right knee disability has resulted in the required severity of limitation of flexion or extension, to include warranting compensable ratings for each range of motion. Rather, the evidence indicates that there was no loss of range of motion at all at the August 2017 evaluation. As such, the application of DCs 5260-61 does not warrant increased ratings for the Veteran’s right knee disability. The Board has also considered whether any other applicable rating criteria may support a higher evaluation. However, after review, the Board finds that no other diagnostic code provides for a higher rating. There is no evidence of ankylosis of the right knee. Therefore, Diagnostic Code 5256 is not for application. There are no findings of instability or recurrent subluxation in the right knee. Thus, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257. The Board also finds that a higher disability rating or a separate disability rating is not warranted under either Diagnostic Code 5258 or 5259. Diagnostic Codes 5258 and 5259 address cartilage injuries and symptoms. The weight of the competent and credible evidence shows that there is no cartilage disability or pathology in the right knee. There is no evidence of nonunion of the tibia and fibula or genu recurvatum in the right knee. Thus, a higher or separate rating is not warranted under Diagnostic Codes 5262 or 5263. In assessing the severity of the Veteran’s right knee disability, the Board has also considered the lay evidence of record, including statements of the Veteran, which describe symptoms such as experiencing intense stiffness in his joints in the morning hours that lessens over the course of the day, and knee pain that becomes worse with running, jumping, and biking. Such lay statements are considered competent insofar as they describe observable symptomatology. The Veteran’s history and reported symptoms have been considered, including as presented in the evidence discussed above, and have been contemplated by the disability ratings that have been assigned. As such, while the Board accepts the lay evidence of record insofar as it is competent, the Board relies upon the competent medical evidence of record regarding the specialized evaluation of the Veteran’s service-connected right knee disability. Thus, the Board finds that the preponderance of the evidence is against the assignment of disability ratings in excess of 10 percent for the right knee RPPS from April 9, 2010 to the present. There is no reasonable doubt to be resolved, and the claim for an increased rating is denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 3. Entitlement to a rating in excess of 10 percent for RPPS of the left knee from November 1, 2005 to the present The Veteran was afforded a VA examination in March 2005. The examiner noted that flexion of the left knee was limited secondary to stiffness. The examiner diagnosed the Veteran with left knee pain, with etiology “probably due to old trauma causing changes,” and noted that repetitive use causes decreased function due to stiffness. The examiner further noted that the Veteran’s left knee extension lacked 11 degrees actively and extension was full passively. The examiner noted that the Veteran’s condition was currently stable. The Veteran was afforded another examination in March 2010. The medical professional conducting the examination noted that the Veteran’s active left knee extension was to 0 degrees, and active left knee flexion was to 109 degrees. The medical professional noted that the Veteran’s passive left knee extension was to 0 degrees and his passive left knee flexion was to 120 degrees. The medical professional explained that there was noticeable pain beginning at 95 degrees flexion projecting to the medial joint compartment as well as to the femoral patellar joint. The Veteran was able to complete three repetitions without significant reduction in function or worsening of pain. The medical professional noted that sonography of the left knee joint revealed signs of synovitis with capsule proliferation, with no inflammatory changes visible. The medical professional further noted that an x-ray of the left knee joint in two planes revealed a narrowing of the medial joint space by approximately 2/3. Finally, the medical professional diagnosed the Veteran with grade II medial gonarthrosis and grade I retropatellar arthrosis in the left knee. The Veteran was afforded an in-person VA examination in August 2017. The examiner reviewed the Veteran’s service treatment records and noted that the Veteran received treatment during service for RPPS. The examiner noted that the Veteran was experiencing left knee pain at a 4-5 intensity on a scale of 1-10 with 10 being the worst. The Veteran described his functional loss by stating that his knees are constantly painful when running, jumping, or biking, with the left knee being more painful than the right knee. There were no additional factors causing functional loss. The examiner noted that the condition had progressed, and that the Veteran currently suffered from grade 1 retropatellar arthrosis. Finally, on range of motion testing, the examiner noted that both the Veteran’s left knee flexion was to 140 degrees, with his left knee extension to 0 degrees. There was evidence of pain with weightbearing or on extension, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time, but the examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over time. The examination was not conducted during a flare up. The examiner noted that muscle strength was normal in the left knee and that no muscle atrophy, ankylosis, or history of recurrent subluxation, lateral instability, or effusion was present. The examiner noted that the Veteran did not have nor had ever had recurrent patellar dislocation, “shin splints,” stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The examiner noted traumatic arthritis in both knees, confirmed by imaging studies. The examiner noted that the Veteran’s diagnosis impacts his ability to perform occupational tasks, as he is unable to run, jog, jump, or bike due to increased pain in the left knee. The examiner noted that there was objective evidence of pain when the left knee was used in non-weightbearing exercises, and that the range of motion for the left knee was the same for both active and passive motion. Finally, the examiner noted that the findings of the examination were consistent with gonarthrosis, that there was no loss of range of motion, and that “the disability is just moderate pain on passive and active motion.” Given the evidence of record, as discussed above, the Board finds that the preponderance of the evidence weighs against the Veteran’s claims of entitlement to an increased disability rating in excess of 10 percent for RPPS of the left knee from November 1, 2005 to the present. In order to warrant an increased 20 percent disability rating for the left knee under DC 5260 or 5261, the Veteran must have displayed limitation of flexion to 30 degrees or limitation of extension to 15 degrees, respectively. The probative evidence of record does not document that the Veteran’s left knee disability has resulted in the required severity of limitation of flexion or extension. Rather, the evidence indicates that there was no loss of range of motion at all at the August 2017 evaluation, and a limitation of extension of the left knee of only 11 degrees in March 2005. As such, the application of DCs 5260-61 does not warrant increased ratings for the Veteran’s left knee disability, to include entitlement to separate ratings for limitation of flexion and limitation of extension. The Board has also considered whether any other applicable rating criteria may support a higher evaluation. However, after review, the Board finds that no other diagnostic code provides for a higher rating. There is no evidence of ankylosis of the left knee. Therefore, Diagnostic Code 5256 is not for application. There are no findings of instability or recurrent subluxation in the left knee. Thus, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257. The Board also finds that a higher disability rating or a separate disability rating is not warranted under either Diagnostic Code 5258 or 5259. Diagnostic Codes 5258 and 5259 address cartilage injuries and symptoms. The weight of the competent and credible evidence shows that there is no cartilage disability or pathology in the left knee. There is no evidence of nonunion of the tibia and fibula or genu recurvatum in the left knee. Thus, a higher or separate rating is not warranted under Diagnostic Codes 5262 or 5263. In assessing the severity of the Veteran’s left knee disability, the Board has also considered the lay evidence of record, including statements of the Veteran, which describe symptoms such as experiencing intense stiffness in his joints in the morning hours that lessens over the course of the day, and knee pain that becomes worse with running, jumping, and biking. Such lay statements are considered competent insofar as they describe observable symptomatology. The Veteran’s history and reported symptoms have been considered, including as presented in the evidence discussed above, and have been contemplated by the disability ratings that have been assigned. As such, while the Board accepts the lay evidence of record insofar as it is competent, the Board relies upon the competent medical evidence of record regarding the specialized evaluation of the Veteran’s service-connected left knee disability. Thus, the Board finds that the preponderance of the evidence is against the assignment of disability ratings in excess of 10 percent for the left knee RPPS at any time during the appeal period. There is no reasonable doubt to be resolved, and the claim for increase is denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 4. Entitlement to a rating in excess of 30 percent for spontaneous pneumothorax, postoperative, with restrictive lung disease for the period from November 1, 2005 to September 13, 2017 The Veteran seeks an increased disability rating in excess of 30 percent from November 1, 2005 to September 13, 2017 for spontaneous pneumothorax. His disability is currently rated under the General Rating Formula for Restrictive Lung Disease pursuant to DC 6843. 38 C.F.R. § 4.97. As of September 13, 2017, the service-connected disability is rated at 100 percent, and as this is the highest evaluation available, the evaluation as of that date is not part of the current appeal. Thereunder, a 30 percent disability rating is warranted for Forced Expiratory Volume in one second (FEV-1) of 56 to 70 percent predicted, or; a ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 56 to 70 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 56 to 66 percent predicted. Id. A 60 percent disability rating is warranted for FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC or 40 to 55 percent, or; DLCO (SB) or 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg in (with cardiorespiratory limit). Id. A maximum 100 percent schedular disability rating is warranted for FEV-1 less than 40 percent of predicted value, or; FEV-1/FVC less than 40 percent, or; DLCO (SB) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg in oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; the requirement of outpatient oxygen therapy. Id. There are special provisions for the application of the rating criteria for certain diagnostic codes, including DC 6843. 38 C.F.R. § 4.96(d). PFTs are required to evaluate these conditions, except when the results of a maximum exercise capacity test are of record and are 20 ml/kg or less; when pulmonary hypertension cor pulmonale, or right ventricular hypertrophy has been diagnosed; or when there have been one or more episodes of acute respiratory failure. 38 C.F.R. § 4.96(d)(1). If DLCO (SB) results are not of record, such conditions are evaluated based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96(d)(2). When PFTs are not consistent with clinical findings, conditions are evaluated based on the PFTs unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. 38 C.F.R. § 4.96(d)(3). Post-bronchodilator studies are required when PFTs are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why. 38 C.F.R. § 4.96(d)(4). When evaluating based on PFTs, post-bronchodilator results are to be used unless the post-bronchodilator results were poorer than the pre-bronchodilator results, in which case, the pre-bronchodilator results are used for rating purposes. 38 C.F.R. § 4.96(d)(5). The Veteran was afforded a VA examination in March 2005. The examiner indicated that the Veteran’s pulmonary function tests (PFTs) were abnormal and showed restrictive airway problems. The exact scores of the PFTs are not noted in this exam. The examiner also indicated that a PFT performed in March 2005 showed mild restrictive ventilatory defect with no significant change after inhaled bronchodilator, while a PFT performed in April 2004 showed a mild restrictive defect. The Veteran was afforded another examination in October 2015. The examiner noted that the Veteran’s FEV-1/FVC results most accurately reflected the Veteran’s level of disability. The Veteran’s FEV-1/FVC results indicated that his pulmonary function was at 34 percent pre-bronchodilator. The Veteran’s FVC score was 16 percent of the predicted value, and his FEV-1 score was 22 percent of the predicted value pre-bronchodilator. Post-bronchodilator, the Veteran’s FEV-1/FFC percentage was 4 percent, his FVC score was 17 percent of the predicted value, his FEV-1 score was 12 percent of the predicted value. The examiner noted that the Veteran did not use any inhalers, did not take any oral medications for his lungs, and avoids physical activity due to the chance of shortness of breath, and that the Veteran “is easily winded with little activity.” The examiner further noted that the Veteran had a panic attack during this VA examination, and that the Veteran’s PFT results did not accurately reflect the Veteran’s current pulmonary function. The Veteran was afforded a VA examination in August 2017. This exam also documents a PFT performed in September 2017. The examiner noted that the Veteran developed a spontaneous pneumothorax in July 2003 without any defining injury or event. The examiner noted in an October 2017 addendum that the FEV-1 PFT findings were the most accurate measure of the Veteran’s respiratory disability. These findings indicated that the Veteran’s FEV-1 PFT percentage was 37.1 percent of the predicted value prebronchodilator. On this exam, the Veteran’s FVC score was 31.2 percent of the predicted value prebronchodilator, with an FEV-1/FVC percentage of 89.94 percent. PFTs were not administered post-bronchodilator. The examiner noted that there was a worsening of the Veteran’s symptoms, however, there was no change to the service-connected diagnosis and no additional diagnoses were rendered. The examiner also noted that the Veteran was not able to perform strenuous activities like running, jumping, climbing stairs at a fast pace, or lifting more than 15 pounds of weight due to exacerbation of the chest pain in the right hemithorax and shortness of breath. DLCO testing was not completed because it caused the Veteran pain. The examiner noted minor changes due to scarring and thickening in the right basal and apical region, with otherwise unimpaired ventilation of the lungs. A chest x-ray was also conducted and examined. Following a review of the evidence of record, the Board finds that the preponderance of evidence is against the Veteran’s claim of entitlement to an increased disability rating in excess of 30 percent for spontaneous pneumothorax with restrictive lung disease for the period from November 1, 2005 to September 13, 2017. Significantly, no valid PFTs were conducted during the period ranging from November 1, 2005 to September 13, 2017 that indicate Forced Expiratory Volume in one second (FEV-1) of less than 56 to 70 percent predicted, or; a ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of less than 56 to 70 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of less than 56 to 66 percent predicted. For example, an October 2015 VA examination indicated that the results of this exam were invalid because the Veteran had a panic attack during the procedure, and the examiner indicated that the Veteran’s PFT results did not accurately reflect the Veteran’s current pulmonary function. For this reason, the Board finds that the clinical findings cannot be relied upon in assessing the severity of the service-connected disability. The Board has also considered the Veteran’s service treatment records and VA treatment records in reaching this decision. However, these records do not contain any PFT results. In evaluating the Veteran’s increased rating claim, the Board has also considered whether the Veteran is entitled to a separate or higher rating under other potentially applicable diagnostic codes relevant to respiratory disabilities; however, the rating schedule provides that DCs 6600-6817 and 6822-6847 will not be combined with each other. 38 C.F.R. § 4.96(a). Where there is lung or pleural involvement, ratings under DCs 6819 and 6820 will not be combined with each other or with DCs 6600-6817 or 6822-6847. Id. A single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating where the severity of the overall disability warrants such rating. Id. In assessing the severity of the Veteran’s pulmonary disability, the Board has also considered the lay evidence of record, including statements of the Veteran, which describe symptoms such as becoming easily winded with small amounts of physical activity. Such lay statements are considered competent insofar as they describe observable symptomatology. The Veteran’s history and reported symptoms have been considered, including as presented in the evidence discussed above, and have been contemplated by the disability ratings that have been assigned. Specifically, while his service-connected spontaneous pneumothorax is rated based on the results of PFTs, such testing contemplates the difficulty resulting from decreased lung capability, which includes the Veteran’s reported symptoms and limitations. As such, while the Board accepts the lay evidence of record insofar as it is competent, the Board relies upon the competent medical evidence of record regarding the specialized evaluation of pulmonary functional impairment, symptom severity, and details of clinical features of the Veteran’s service-connected spontaneous pneumothorax. In conclusion, the Board has carefully considered the evidence of record; however, as the preponderance of evidence weighs against the Veteran’s claim, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Caruso, Associate Counsel