Citation Nr: 18145315 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 13-09 286A DATE: October 26, 2018 ORDER Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 40 percent prior to April 28, 2016, and in excess of 30 percent from June 1, 2017, to the present for a left knee disability is denied. Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 30 percent prior to November 19, 2015, and in excess of 30 percent from January 1, 2017, to the present for a right knee disability is denied. Entitlement to disability rating in excess of 10 percent for residuals of right elbow fracture is denied. Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, and in excess of 20 percent thereafter for a back disability is denied. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability prior to June 5, 2012, is denied. Entitlement to a rating of 20 percent, but no higher, for a cervical spine disability is granted effective June 5, 2012, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating in excess of 10 percent for residuals of fracture of the left femur (DC 5253) is denied. Entitlement to a compensable disability rating for residuals of fracture left femur (limitation of motion; DC 5252) is denied. Entitlement to a disability rating in excess of 10 percent for a right ankle disability is denied. Entitlement to a disability rating in excess of 30 percent for residuals of right femur fracture (to include shortening of the leg) is denied. Entitlement to a compensable disability rating prior to July 13, 2011, for residuals of a fracture of the right navicular bone is denied. Entitlement to a 10 percent rating, but no higher, for residuals of a fracture of the right navicular bone is granted effective July 13, 2011, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating in excess of 10 percent rating for residuals of a fracture of the right navicular bone for any time period after July 13, 2011, is denied. Entitlement to a compensable rating for service-connected scars of the low back and knees is denied. Entitlement to a disability rating in excess of 10 percent for residuals of a laceration and contusion of the right hand with ulnar neuropathy is denied. FINDINGS OF FACT 1. Prior to June 5, 2012, the Veteran’s left knee disability was characterized by arthritis, full extension, and limitation of flexion to 100 degrees; from June 5, 2012, to April 28, 2016, the left knee disability was characterized by arthritis, limitation of extension to 30 degrees, and limitation of flexion to 120 degrees; from June 1, 2017, the Veteran’s left knee was status post knee replacement surgery with full extension and limitation of flexion to 130 degrees, but without chronic residuals of severe painful motion or weakness or intermediate residuals of weakness, pain, or limitation of motion. 2. Prior to June 5, 2012, the Veteran’s right knee disability was characterized by arthritis, full extension, and limitation of flexion to 130 degrees; from June 5, 2012, to November 19, 2015, the right knee disability was characterized by arthritis, limitation of extension to 20 degrees, and limitation of flexion to 110 degrees; from January 1, 2017, the Veteran’s left knee was status post knee replacement surgery with full extension and limitation of flexion to 140 degrees, but without chronic residuals of severe painful motion or weakness or intermediate residuals of weakness, pain, or limitation of motion. 3. The Veteran’s residuals of right elbow fracture have been characterized by arthritis and limitation of flexion to, at minimum, 145 degrees with full extension. 4. Prior to June 5, 2012, the Veteran’s back disability was characterized by flexion limited to 70 degrees after repetitive use and 200 degrees combined range of motion with spams and guarding, which did not cause abnormal gait or abnormal spinal curvature; beginning June 5, 2012, the back disability was characterized by flexion of at least 70 degrees, 125 degrees combined range of motion, and guarding or muscle spasm of the thoracolumbar spine that resulted in abnormal gait and abnormal spinal contour; the Veteran did not have IVDS and there were no other associated neurologic abnormalities at any point during the appeal period. 5. Prior to June 5, 2012, the Veteran’s forward flexion of the cervical spine exceeded 30 degrees, combined range of motion of the cervical spine exceeded 170 degrees, and there was no muscle spasm, guarding, or localized tenderness that resulted in abnormal gait or abnormal spinal contour; as of June 5, 2012, the Veteran had forward flexion of the cervical spine of 30 degrees, but not ankylosis of the cervical spine.   6. The Veteran’s residuals of fracture of left femur were characterized by arthritis of the hip, flexion of at least 110 degrees, abduction of at least 15 degrees, but also an inability to cross left leg over right and an inability to toe-out more than 15 degrees. 7. The Veteran’s right ankle disability has been characterized by limited motion of the ankle that is moderate. 8. During the appeal period, the residuals of right femur fracture (to include shortening of the leg) have been characterized by a leg length discrepancy of two (2) centimeters, marked disability due to arthritis and malunion of the prior fracture, flexion of at least 100 degrees, 20 degrees extension, 20 degrees abduction, 25 degrees adduction, inability to cross left leg over right, inability to toe-out more than 15 degrees, functional loss including decreased mobility due to pain, weakness that affects ambulation, leg length discrepancy that affects ambulation, and limitation of range of motion that affects ambulation and pivoting, with functional loss increased during flare-ups. 9. Prior to July 13, 2011, the Veteran’s residuals of a fracture of the right navicular bone included only minimal symptomatology and no reported pain or measured limitation of motion; it is first ascertainable on July 13, 2011, that the residuals of a fracture of the right navicular bone included arthritis and flexion limited to 40 degrees, dorsiflexion limited to 55 degrees, 30 degrees of ulnar deviation, and no range of motion on radial deviation. 10. The Veteran’s service-connected scars did not involve the head, face, or neck, they were superficial, stable, and not painful, they involved an area of less than 929 square centimeters, and they did not result in any functional loss. 11. The Veteran’s residuals of a laceration and contusion of the right hand with ulnar neuropathy were characterized by mild, incomplete paralysis of the ulnar nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 40 percent prior to April 28, 2016, and in excess of 30 percent from June 1, 2017, to the present for a left knee disability have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003 and 5256-5263 (2017). 2. The criteria for entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 30 percent prior to November 19, 2015, and in excess of 30 percent from January 1, 2017, to the present for a right knee disability have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003 and 5256-5263 (2017). 3. The criteria for entitlement to disability rating in excess of 10 percent for residuals of right elbow fracture have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5010, and 5205-5213 (2017). 4. The criteria for entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, and in excess of 20 percent thereafter for a back disability have not been met. See 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 5. The criteria for entitlement to an initial rating in excess of 10 percent for a cervical spine disability have not been met prior to June 5, 2012. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5235 (2017). 6. The criteria for entitlement to a rating of 20 percent for a cervical spine disability have been met as of June 5, 2012. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5235 (2017). 7. The criteria for entitlement to a disability rating in excess of 10 percent for residuals of fracture of the left femur have not been met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5253 (2017). 8. The criteria for entitlement to a compensable disability rating for residuals of fracture left femur (limitation of motion) have not been met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5252 (2017). 9. The criteria for entitlement to a disability rating in excess of 10 percent for a right ankle disability have not been met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5270-5274 (2017). 10. The criteria for entitlement to a disability rating in excess of 30 percent for residuals of right femur fracture (to include shortening of the leg) have not been met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5250-5255 (2017). 11. The criteria for entitlement to a compensable disability rating prior to July 13, 2011, for residuals of a fracture of the right navicular bone have not been met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5215 (2017). 12. As of July 13, 2011, and continuing through the remainder of the appeal period, the criteria for entitlement to a 10 percent disability rating, but no higher, for residuals of a fracture of the right navicular bone were met. 38 U.S.C. §§ 1155 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5215 (2017). 13. The criteria for entitlement to a compensable rating for service-connected scars of the low back and knees have not been met. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7806 (2017). 14. The criteria for entitlement to a disability rating in excess of 10 percent for residuals of a laceration and contusion of the right hand with ulnar neuropathy have not been met. See 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.124a, Diagnostic Codes 8516, 8616, 8716 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1971 to February 1976. The Veteran testified before the undersigned Veterans Law Judge at a Board hearing held in February 2015 via videoconference. The claims file contains a transcript of the hearing. The Veteran filed an explicit claim for entitlement to a total disability rating based on individual unemployability (TDIU) in 2017. That claim was granted by the Regional Office in a May 2017 rating decision and the Veteran has not appealed the effective date of that grant. He indicated on his claim form he became disabled in April 2016, and he has a total schedular rating beginning with the knee replacement surgery in April 2016 and unemployability thereafter. Since he indicated on his claim he worked for this employer from 1984 until 2016, there is no inferred claim for unemployability for any time period on appeal prior to 2016, as he was, in fact, employed. This was confirmed by the Veteran at his 2015 Board hearing, where he indicated he did not intend to file a claim for unemployability since, at that time, he was still working. Therefore, no issues pertaining to the award of TDIU are currently before the Board or otherwise a part of the current appeal. The above claim pertaining to residuals of fracture of right femur has been recharacterized. The RO characterized the claim as “entitlement to a disability rating in excess of 10 percent prior to March 8, 2010, and in excess of 30 percent thereafter for residuals of right femur fracture (to include shortening of the leg)”. However, the issue originated from a March 8, 2010 claim of entitlement to an increased rating. Therefore, under 38 C.F.R. § 3.400, ratings cannot be assigned prior to the claim of entitlement to an increase in cases, such as this one, where it is first ascertainable after the date of claim that an increase in disability occurred. Here, the increase from 10 percent to 30 percent was based on a June 2010 VA examination and later medical evidence. Thus, the period prior to March 8, 2010, is not under consideration in this matter. The claim has been recharacterized as entitlement to a rating in excess of 30 percent to more accurately reflect the scope of the increased rating claim on appeal. In May 2015, the Board remanded the above-listed matters for further development, including obtaining treatment records and providing updated VA examinations. The RO completed the requested development and issued a June 2016 Supplemental Statement of the Case (SSOC). The Department of Veterans Affairs (VA) Regional Office (RO) has substantially complied with the Board’s remand instructions, so the Board may proceed to the merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The claims file contains evidence not yet considered by the agency of original jurisdiction (AOJ), but the Veteran waived AOJ consideration of that evidence in an August 2018 submission. The Board may proceed to the merits without remand. 38 C.F.R. § 20.1304(c). Increased Rating Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, VA must evaluate the veteran’s condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. VA has considered the level of the veteran’s impairment throughout the entire period on appeal, including the propriety of staged ratings. O’Connell v. Nicholson, 21 Vet. App. 89 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 innervations, or other pathology, or it 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The factors involved in evaluating and rating disabilities of the joints include weakness, fatigability, incoordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45; see also 38 C.F.R. § 4.59.   In assigning disability ratings, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also VA Gen. Coun. Prec. 9–2004 (Sep. 17, 2004) (“[T]he key consideration in determining whether rating under more than one diagnostic code is in order is whether the ratings under different diagnostic codes would be based on the same manifestation of disability or whether none of the symptomatology upon which the separate ratings would be based is duplicative or overlapping.”). While the Veteran is competent to report (1) symptoms observable to a layperson (i.e. pain, swelling); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding the clinical significance of observable symptoms. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). This Veteran, who lacks medical training, is not competent to opine on the clinical significance of the symptoms of his service-connected disabilities. See, e.g., Jandreau, 492 F.3d at 1377. Therefore, in evaluating the Veteran’s claims, the Board will rely on the medical evidence of record. The Board, however, has considered the Veteran’s subjective reports of symptoms, particularly as they illuminate or underscore the medical opinions of record. The relevant time period for each of the claims begins, unless otherwise indicated below, as of March 8, 2010, the date of his claim of entitlement to increased ratings currently on appeal. However, the Board will also consider whether an increase in severity was factually shown within the year prior to the claim. 1. Left knee disability The RO has assigned staged ratings for the Veteran’s left knee condition. He is currently assigned a disability rating of 10 percent prior to June 5, 2012, a rating of 40 percent from June 5, 2012 to April 27, 2016, and a rating of 30 percent from June 1, 2017, to the present. He had a total left knee replacement in April 2016, so he was assigned a total rating from April 28, 2016 to May 31, 2017. Disabilities of the knee joint, generally, are rated under Diagnostic Codes 5256 through 5263. See 38 C.F.R. § 4.71a. In addition, there are special provisions for rating degenerative arthritis (to include osteoarthritis) under Diagnostic Code 5003. When there is painful motion of a major joint caused by degenerative arthritis (rated under Diagnostic Code 5003) that is detected on x-ray, such painful motion will be considered limited motion pursuant to 38 C.F.R. § 4.59. Painful motion is entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even if there is no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Ankylosis (i.e. immobility) is rated under DC 5256. DC 5257 provides for 10, 20, or 30 percent ratings for recurrent subluxation or lateral instability that is, respectively, slight, moderate, or severe. Under DC 5258, a 20 percent evaluation is assigned for semilunar, dislocated cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5260, a noncompensable evaluation is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Under DC 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Impairment of the tibia and fibula is rated under DC 5262 and genu recurvatum is rated under DC 5263. Due to the Veteran’s total left knee replacement in April 2016, the Board finds that the left knee disability is more accurately rated under 38 C.F.R. § 4.71a, DC 5055, applicable to knee replacement (prosthesis), for the period beginning after the temporary 100 percent rating under 38 C.F.R. § 4.30 ended (June 1, 2017). DC 5055 provides criteria for rating knee disabilities that require knee replacement surgery. Under those criteria, a 100 percent disability rating is assigned for one year following the surgery. Thereafter, the disability is to be rated as being no less than 30 percent disabling, but may be assigned a higher disability rating on the basis of demonstrated residual weakness, pain, or loss of motion consistent with the criteria under DCs 5256, 5261, or 5262. A 60 percent disability rating may also be assigned where the post-surgery evidence shows chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to DCs 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a, DC 5055. The words "severe" referencing painful motion or weakness and "intermediate" degrees of disability as used in Diagnostic Code 5055 are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." Here, for the following reasons, the Board finds the severity of the Veteran's painful motion or weakness is not "severe" such as warranted by a 60 percent rating. Entitlement to a rating in excess of 10 percent prior to June 5, 2012 The Veteran underwent a VA examination in connection with his March 2010 claim of entitlement to an increased rating for his left knee. The VA examiner diagnosed osteoarthritis of the knees. He did not have deformity, giving way, instability, incoordination, episodes of dislocation or subluxation, locking episodes, symptoms of inflammation, or effusion. He did have pain, stiffness, weakness, decreased speed of joint motion, and flare-ups of moderate severity occurring every 2 to 3 weeks and lasting “hours”. During flare-ups, the Veteran had increased pain and functional limitations. The Veteran also had crepitation. The Veteran had no other symptoms (to include clicks or snaps, grinding, instability, or any ligament/tendon abnormalities). His range of motion was measured from full extension (0 degrees) to 110 degrees of flexion. There was no additional limitation with repetitive motion and no objective evidence of pain following repetitive motion. See June 2010 VA Examination. The Veteran was next examined for rating purposes on June 5, 2012. That exam will be discussed below as pertinent to the period beginning on that date. VA treatment and other medical records from March 2010 to June 2012 document complaints of knee pain and associated functional limitations. The records do not document symptoms inconsistent with those found at the June 2010 VA examination or limitations of motion greater than those found at the June 2010 VA examination. Under the pertinent rating criteria, the Veteran’s limitation of motion did not meet the criteria for any compensable rating, much less a rating in excess of 10 percent (flexion limited to 30 degrees). The Veteran did not meet the criteria for any rating under DCs 5256-5259, or 5261-5263. However, osteoarthritis with painful motion warrants a minimum 10 percent rating. 38 C.F.R. § 4.71a, DC 5003. The evidence supports the award of a 10 percent rating during this period, but no higher rating for the left knee prior to June 5, 2012. The evidence is not in equipoise, but is against the Veteran’s claim of entitlement to a rating in excess of 10 percent prior to June 5, 2012. Entitlement to a rating in excess of 40 percent from June 5, 2012, to April 27, 2016 The Veteran was granted a rating of 40 percent based on a June 5, 2012, VA examination. The Veteran contends he is entitled to a higher rating. The June 5, 2012, VA examination found x-ray evidence of bilateral knee osteoarthritis, not significantly changed since prior (February 2011) comparison study. X-rays contained a suggestion of left knee chondrocalcinosis. The Veteran reported flare-ups that impacted walking, working, bending, and sitting. Ranges of motion were measured at 120 degrees flexion with objective evidence of painful motion at 120 degrees and limitation of extension to 30 degrees. The measurements were the same after repetitive use testing. The examiner noted less movement than normal, weakened movement, excess fatigability, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran had pain on palpation for joint line or soft tissues. Muscle strength was reduced (3/5). Joint stability tests were normal. The Veteran did have a meniscal tear with frequent episodes of joint “locking” and pain. The Veteran had undergone a meniscectomy. He did have residuals of the surgery including pain, problem with walking, and problem with work. There was no evidence of patellar subluxation. The examiner opined that the Veteran’s knee and right femur conditions affect his work because his work involved standing in an assembly line and remaining on his feet most of the time. See June 2012 VA Examination. The Veteran underwent another VA examination with respect to his knees in August 2015. The examiner noted the Veteran’s reports of daily flare-ups that last as long as he stands. Rest improved the flare-ups but would not completely resolve his pain. Ranges of motion were measured as normal (flexion to 140 degrees, extension to 0 degrees). The examiner noted pain that did not result in or cause functional loss. There was evidence of pain with weight-bearing. There was no objective evidence of localized tenderness, pain on palpation, or crepitus. Repetitive use testing did not result in additional functional loss or reduced ranges of motion. The examiner was unable to say without resort to speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. The examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during flare-ups. Muscle strength was measured at 4/5 for flexion and extension. There was no joint instability, no history of recurrent effusion, and no meniscal condition. The Veteran’s knee and leg conditions prevented or made difficult work that requires prolonged standing, walking, lifting, bending, or kneeling. See August 2015 VA Examination. VA treatment and other medical records during this period are consistent with the above examinations in that they do document knee complaints, but do not indicate ranges of motions limited more than indicated above or other signs or symptoms of knee problems pertinent to other rating criteria. See, e.g., March 2016 Private Progress Note (“his [left] knee is getting worse”; “Knee: no tenderness, swelling, or deformities…Range of Motion: full and painless in all planes, no crepitance, no pain or instability”). The above medical findings support the award of a 40 percent rating under DC 5261 beginning June 5, 2012. Specifically, the Veteran’s left knee extension was limited to 30 degrees which meets the criteria for a 40 percent rating under DC 5261. The limitation of flexion did not warrant any compensable rating. The 2012 VA examiner noted symptoms associated with a meniscal condition including frequent episodes of joint “locking” and pain. These symptoms could support a 10 percent rating under DC 5259 or a 20 percent rating under DC 5258. However, the Board finds that, in the particular circumstances of this case, the identified symptoms of joint “locking” and pain result in the same functional limitations (particularly limitation of motion and difficulty standing, walking, bending, etc.) as the pain and limitation of extension currently compensated at a 40 percent rating under DC 5261. In particular, the 2012 VA examiner’s report suggests that the significant limitation of extension was due to pain and/or locking. The difference in the 2012 and 2015 VA examinations provides further support for this finding. In particular, the limitation of extension found in 2012 coincided with the frequent episodes of locking and knee pain found in that same examination, while the 2015 VA examiner found neither “locking” nor limitation of extension. The fact that the limitation of extension coincided with locking episodes and the full extension returned in the absence of such locking episodes, suggests that the range of motion findings and the symptoms attributed to a meniscal condition were different descriptions of the same symptom and associated functional limitations. A rating under DC 5258 or 5259 in addition to the 40 percent rating under DC 5261 is not warranted on this record as it would constitute impermissible pyramiding. The Veteran cannot benefit from a rating under DC 5258 or 5259 instead of the 40 percent rating under DC 5261. The Board has also considered the impact of flare-ups. Neither examiner provided any medical evidence to support finding that limitations of motion were measurably different during flare-ups than the significant limitation found at the 2012 VA examination (but not at the 2010 or 2015 VA examinations). The Veteran’s descriptions are consistent with the sort of limitations (pain reduced with rest) to be expected of knee extension limited to 30 degrees as measured at the 2012 VA examination. The Board concludes that the 40 percent rating under DC 5261 is adequate considering the DeLuca factors. The evidence does not support the award of any other rating of the knee under any other diagnostic code applicable to the knees. The Board does note that the available evidence other than the 2012 VA examination tends to suggest a rating less than 40 percent would be appropriate. However, the assigned rating cannot be reduced on appeal. Moreover, the interest in stability of ratings and the evidence (e.g., flare-ups), supports continuing the 40 percent rating throughout this period until worsening symptoms required knee replacement on April 28, 2016. The greater weight of the evidence is against awarding any rating in excess of 40 percent for the Veteran’s left knee disability during the period June 5, 2012 to April 27, 2016. Pursuant to 38 C.F.R. § 4.30, the RO awarded a temporary total rating for one year from the date of his April 28, 2016, left knee surgery. The temporary total rating ended May 31, 2017. Entitlement to a rating in excess of 30 percent from June 1, 2017, to the present In March 2017, the Veteran underwent another VA examination in anticipation of the end of the total temporary rating for the left knee. At that time, the examiner indicated intermittent flare-ups that vary in duration. The Veteran stated that his knees would occasionally “blow out” during flare-ups and he would have to rest. The Veteran’s functional limitations were described as an inability to kneel. Ranges of motion were measured as having reduced flexion but normal extension (0 to 130 degrees) with evidence of pain on weight-bearing. Pain caused the reduced range of motion. There was no objective evidence of localized tenderness, pain on palpation, or crepitus. Repetitive use testing did not result in additional functional loss or reduction in range of motion. The examination was neither medically consistent nor inconsistent with the Veteran’s reports of functional loss during flare-ups or after repetitive use and the examiner could not state whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over time or during flare-ups. The examiner noted that the left knee had some swelling that contributed to disability. Muscle strength on the left was 4/5. Stability testing was normal. The Veteran did not have any meniscus condition, recurrent patellar dislocation, “shin splints”, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had residuals of surgery including pain, spasms, and swelling. The examiner noted no evidence of pain when the joint was used in non-weight bearing. The examiner opined that the Veteran was unable to perform work that would require lifting, bending, twisting, prolonged walking/standing, prolonged sitting, manual dexterity, fine motor skills, grasping, or holding. The Veteran’s gait instability affected his balance, so the Veteran should avoid working in high elevations and walking on uneven surfaces. See March 2017 VA Examination. VA treatment and other medical records during this period are consistent with the above examination in that they do document knee complaints, but do not indicate ranges of motions limited more than indicated above or other signs or symptoms of knee problems pertinent to other rating criteria. Because this period involves evaluation of the Veteran’s knee subsequent to knee replacement surgery, the provisions of DC 5055 apply. 38 C.F.R. § 4.71a, DC 5055. Under those provisions, the Veteran’s symptoms and functional limitations do not warrant more than the minimum 30 percent rating. The medical evidence does not warrant any rating in excess of 30 percent under DCs 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a, DC 5055. Although the Veteran has pain and some swelling, those symptoms are not severe as contemplated by the higher rating under DC 5055, nor are they of such intermediate severity to warrant ratings under DCs 5256, 5261, or 5262. In fact, the painful (and slightly limited) motion would warrant only a 10 percent rating under DC 5262. The currently assigned 30 percent rating under DC 5055 is the most appropriate rating for the Veteran’s left knee disability during this period. Conclusion: Left Knee Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 40 percent prior to April 28, 2016, and in excess of 30 percent from June 1, 2017, to the present for a left knee disability is denied. 2. Right knee disability The RO has also assigned staged ratings for the Veteran’s right knee condition. He is currently assigned a disability rating of 10 percent prior to June 5, 2012, a rating of 30 percent from June 5, 2012 to November 18, 2015, and a rating of 30 percent from January 1, 2017, to the present. He had a total right knee replacement in November 2015, so he was assigned a total rating from November 19, 2015, to December 31, 2016. Entitlement to a rating in excess of 10 percent prior to June 5, 2012 The Veteran underwent a VA examination in connection with his March 2010 claim of entitlement to an increased rating for his right knee. The VA examiner diagnosed osteoarthritis of the knees. He did not have deformity, giving way, instability, incoordination, episodes of dislocation or subluxation, locking episodes, symptoms of inflammation, or effusion. He did have pain, stiffness, weakness, decreased speed of joint motion, and flare-ups of moderate severity occurring every 2 to 3 weeks and lasting “hours”. During flare-ups, the Veteran had increased pain and functional limitations. The Veteran also had crepitation. The Veteran had no other symptoms (to include clicks or snaps, grinding, instability, or any ligament/tendon abnormalities). His range of motion was measured from full extension (0 degrees) to 130 degrees of flexion. There was no additional limitation with repetitive motion and no objective evidence of pain following repetitive motion. See June 2010 VA Examination. The Veteran was next examined for rating purposes on June 5, 2012. That exam will be discussed below as pertinent to the period beginning on that date. VA treatment and other medical records from March 2010 to June 2012 document complaints of knee pain and associated functional limitations. The records do not document symptoms inconsistent with those found at the June 2010 VA examination or limitations of motion greater than those found at the June 2010 VA examination. Under the pertinent rating criteria, the Veteran’s limitation of motion did not meet the criteria for any compensable rating, much less a rating in excess of 10 percent (flexion limited to 30 degrees). The Veteran did not meet the criteria for any rating under DCs 5256-5259, or 5261-5263. However, osteoarthritis with painful motion warrants a minimum 10 percent rating. 38 C.F.R. § 4.71a, DC 5003. The evidence supports the award of a 10 percent rating during this period, but no higher rating for the right knee prior to June 5, 2012. The evidence is not in equipoise, but is against the Veteran’s claim of entitlement to a rating in excess of 10 percent prior to June 5, 2012. Entitlement to a rating in excess of 30 percent from June 5, 2012 to November 18, 2015 The Veteran was granted a rating of 30 percent based on a June 5, 2012, VA examination. That examination found x-ray evidence of bilateral knee osteoarthritis, not significantly changed since prior (February 2011) comparison study. The Veteran reported flare-ups that impacted walking, working, bending, and sitting. Ranges of motion were measured at 110 degrees flexion with objective evidence of painful motion at 110 degrees and limitation of extension to 20 degrees. The measurements were the same after repetitive use testing. The examiner noted less movement than normal, weakened movement, excess fatigability, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran had pain on palpation for joint line or soft tissues. Muscle strength was reduced (4/5). Joint stability tests were normal. The Veteran did have a meniscal tear with frequent episodes of joint “locking” and pain. The Veteran had undergone a meniscectomy. He did have residuals of the surgery including pain, problems with walking, and problems with work. There was no evidence of patellar subluxation. The examiner opined that the Veteran’s knee and right femur conditions affect his work because his work involved standing in an assembly line and remaining on his feet most of the time. See June 2012 VA Examination. The Veteran underwent another VA examination with respect to his knees in August 2015. The examiner noted the Veteran’s reports of daily flare-ups that last as long as he stands. Rest improved the flare-ups but would not completely resolve his pain. Ranges of motion were measured as flexion to 130 degrees and extension to 0 degrees. The examiner noted pain that did not result in or cause functional loss. There was evidence of pain with weight-bearing. There was no objective evidence of localized tenderness, pain on palpation, or crepitus. Repetitive use testing did not result in additional functional loss or reduced ranges of motion. The examiner was unable to say without resort to speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. The examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during flare-ups. Muscle strength was measured at 4/5 for flexion and extension. There was no joint instability, no history of recurrent effusion, and no meniscal condition. The Veteran’s knee and leg conditions prevented or made difficult work that requires prolonged standing, walking, lifting, bending, or kneeling. See August 2015 VA Examination. VA treatment and other medical records during this period are consistent with the above examinations in that they do document knee complaints, but do not indicate ranges of motions limited more than indicated above or other signs or symptoms of knee problems pertinent to other rating criteria. The above medical findings support the award of a 30 percent rating under DC 5261 beginning June 5, 2012. Specifically, the Veteran’s right knee extension was limited to 20 degrees which meets the criteria for a 30 percent rating under DC 5261. The limitation of flexion did not warrant any compensable rating. The 2012 VA examiner noted symptoms associated with a meniscal condition including frequent episodes of joint “locking” and pain. These symptoms could support a 10 percent rating under DC 5259 or a 20 percent rating under DC 5258. However, the Board finds that, in the particular circumstances of this case, the identified symptoms of joint “locking” and pain result in the same functional limitations (particularly limitation of motion and difficulty standing, walking, bending, etc.) as the pain and limitation of extension currently compensated at a 30 percent rating under DC 5261. In particular, the 2012 VA examiner’s report suggests that the significant limitation of extension was due to pain and/or locking. The difference in the 2012 and 2015 VA examinations provides further support for this finding. In particular, the limitation of extension found in 2012 coincided with the frequent episodes of locking and knee pain found in that same examination, while the 2015 VA examiner found neither “locking” nor limitation of extension. The fact that the limitation of extension coincided with locking episodes and the full extension returned in the absence of such locking episodes, suggests that the range of motion findings and the symptoms attributed to a meniscal condition were different descriptions of the same symptom and associated functional limitations. A rating under DC 5258 or 5259 in addition to the 30 percent rating under DC 5261 is not warranted on this record as it would constitute impermissible pyramiding. The Veteran cannot benefit from a rating under DC 5258 or 5259 instead of the 30 percent rating under DC 5261. The Board has also considered the impact of flare-ups. Neither examiner provided any medical evidence to support finding that limitations of motion were measurably different during flare-ups than the significant limitation found at the 2012 VA examination (but not at the 2010 or 2015 VA examinations). The Veteran’s descriptions are consistent with the sort of limitations (pain reduced with rest) to be expected of knee extension limited to 20 degrees as measured at the 2012 VA examination. The Board concludes that the 30 percent rating under DC 5261 is adequate considering the DeLuca factors. The evidence does not support the award of any other rating of the knee under any other diagnostic code applicable to the knees. The available evidence other than the 2012 VA examination tends to suggest a rating less than 30 percent would be appropriate. However, the assigned rating cannot be reduced on appeal. Moreover, the interest in stability or ratings and the evidence (e.g., flare-ups), supports continuing the 30 percent rating throughout this period until knee replacement surgery in November 2015. The greater weight of the evidence is against awarding any rating in excess of 30 percent for the Veteran’s left knee disability during the period June 5, 2012 to November 18, 2015. Pursuant to 38 C.F.R. § 4.30, the RO awarded a temporary total rating for one year from the date of his November 19, 2015, left knee surgery. The temporary total rating ended December 31, 2016. Entitlement to a rating in excess of 30 percent from January 1, 2017, to the present In March 2017, the Veteran underwent another VA examination. At that time, the examiner indicated intermittent flare-ups that vary in duration. The Veteran stated that his knees would occasionally “blow out” during flare-ups and he would have to rest. The Veteran’s functional limitations were described as an inability to kneel. Ranges of motion were normal for flexion and extension (0 to 140 degrees) with evidence of pain on weight-bearing. There was no objective evidence of localized tenderness, pain on palpation, or crepitus. Repetitive use testing did not result in additional functional loss or reduction in range of motion. The examination was neither medically consistent nor inconsistent with the Veteran’s reports of functional loss during flare-ups or after repetitive use and the examiner could not state whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over time or during flare-ups. Muscle strength on the right was 5/5. Stability testing was normal. The Veteran did not have any meniscus condition, recurrent patellar dislocation, “shin splints”, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had residuals of surgery including pain and spasms. The examiner opined that the Veteran was unable to perform work that would require lifting, bending, twisting, prolonged walking/standing, prolonged sitting, manual dexterity, fine motor skills, grasping, or holding. The Veteran’s gait instability affected his balance, so the Veteran should avoid working in high elevations and walking on uneven surfaces. March 2017 VA Examination. VA treatment and other medical records during this period are consistent with the above examination in that they do document knee complaints, but do not indicate ranges of motions limited more than indicated above or other signs or symptoms of knee problems pertinent to other rating criteria. Because this period involves evaluation of the Veteran’s knee subsequent to knee replacement surgery, the provisions of DC 5055 apply. 38 C.F.R. § 4.71a, DC 5055. Under those provisions, the Veteran’s symptoms and functional limitations do not warrant more than the minimum 30 percent rating. The medical evidence does not warrant any rating in excess of 30 percent under DCs 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a, DC 5055. Although the Veteran has pain, the examiner opined that the pain does not result in functional loss. His symptoms are not severe as contemplated by the higher rating under DC 5055, nor are they of such intermediate severity to warrant ratings under DCs 5256, 5261, or 5262. In fact, the painful motion would warrant only a 10 percent rating under DC 5262. The currently assigned 30 percent rating under DC 5055 is the most appropriate rating for the Veteran’s left knee disability during this period.   Conclusion: Right Knee Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, in excess of 30 percent prior to November 19, 2015, and in excess of 30 percent from January 1, 2017, to the present for a right knee disability is denied. 3. Entitlement to disability rating in excess of 10 percent for residuals of right elbow fracture Disabilities of the elbow generally are rated under DCs 5205-5213. The Veteran’s residuals of elbow fracture are currently rated under DC 5206. Under DC 5206 (dominant, right arm), a 10 percent rating is warranted for flexion limited to 100 degrees. A 20 percent rating is warranted for flexion limited to 90 degrees. A 30 percent rating is warranted for flexion limited to 70 degrees. A 40 percent rating is warranted for flexion limited to 55 degrees. A 50 percent rating is warranted for flexion limited to 45 degrees. Under DC 5207 (dominant, right arm), a 10 percent rating is warranted for extension limited to 60 degrees. A 20 percent rating is warranted for extension limited to 75 degrees. A 30 percent rating is warranted for extension limited to 90 degrees. A 40 percent rating is warranted for extension limited to 100 degrees. A 50 percent rating is warranted for extension limited to 110 degrees. Under DC 5208, a 20 percent rating is assigned for flexion limited to 100 degrees and extension limited to 45 degrees. At the June 2010 VA Examination, the Veteran did not report pain or functional limitation associated with the right elbow, but did report that he has discomfort with repetitive motions and when lifting heavy objects with his right upper extremity. Examination did not reveal deformity, giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion, other symptoms, episodes of dislocation or subluxation, locking episodes, effusions, symptoms of inflammation, any limitation of motion, or flare-ups of joint disease. Range of motion testing revealed flexion of 145 degrees and full extension. Right pronation was 80 degrees and supination was 70 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions. X-ray imaging revealed “stable mild osteoarthritis and ulnar collateral ligament calcification.” The condition had no significant effects on the Veteran’s usual occupation and no effects on his usual daily activities. In August 2015, the Veteran’s right elbow was again examined for rating purposes. The examiner noted right elbow pain and a diagnosis of degenerative arthritis. The Veteran reported a decrease in range of motion, pain in lateral epicondyle, sharp intermittent pain, throbbing pain when the weather changes, stiffness in cold/wet weather, decreased strength, and difficulty lifting. The Veteran did not report flare-ups of the elbow or functional loss or functional impairment of the right elbow. Ranges of motion were all normal (0 to 145 degrees of extension to flexion). There was no pain on examination, no pain on weight-bearing, no objective evidence of localized tenderness or pain on palpation, but evidence of crepitus. The Veteran was able to complete repetitive use testing with no additional loss of range of motion. There were no additional symptoms resulting in functional loss. Muscle strength was normal. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the right elbow condition. The examiner opined that the condition did affect occupational functioning, explaining that the Veteran has difficulty/pain with repetitive flexion of the right elbow, that lifting, pushing, and pulling also cause pain, and, because the Veteran’s employment required those activities, his right elbow pain is aggravated by the physical requirements of his job. See August 2015 VA Examination. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of elbow problems pertinent to other rating criteria. The available medical evidence establishes that the Veteran has elbow pain, but his range of motion of the elbow is not limited to a degree that warrants a compensable rating under the rating criteria. However, painful motion of a joint due to arthritis merits a minimum 10 percent rating. 38 C.F.R. § 4.71a, DCs 5003, 5010, 5206-5208. The Veteran is currently assigned a 10 percent rating for his elbow. The evidence is against awarding any higher rating. The claim of entitlement to a rating in excess of 10 percent for the service-connected right elbow condition is denied. 4. Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, and in excess of 20 percent thereafter for a back disability The Veteran’s back disability is currently rated under DC 5237. Disabilities of the thoracolumbar spine are to be rated under the General Rating Formula for Diseases and Injuries of the Spine (the “Formula”). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2016). The Formula provides, in relevant part, the following ratings: A 10 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, 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 evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. Id. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent evaluation is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. Id. Finally, a maximum 100 percent evaluation is warranted where there is unfavorable ankylosis of the entire spine. Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Id., Note (2). The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. Ranges of motion are to be rounded to the nearest five degrees. Id., Note (4). The rating criteria are to be applied irrespective of symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. See 38 C.F.R. § 4.71a, Introductory Note to General Rating Formula for Diseases and Injuries of the Spine; see also 68 Fed. Reg. at 51,455 (Supplementary Information). Notes appended to the new General Rating Formula for Diseases and Injuries of the Spine specify that associated objective neurologic abnormalities are to be evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1). Intervertebral Disc Syndrome (IVDS) is evaluated other criteria. A 10 percent rating is assigned for 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 assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. As explained below, the Veteran has not had IVDS, so those rating criteria are not directly applicable. A June 2010 VA examination resulted in a diagnosis of chronic lumbosacral spine strain. X-rays did not reveal abnormalities. The Veteran reported increased pain with bending or if he carries objects weighing over 30 pounds. He reported weekly flare-ups of moderate severity lasting for hours, precipitated by prolonged standing or weight-bearing activities, and alleviated by limitation of activities and rest. The Veteran had urinary frequency of daytime voiding every 1 to 2 hours and nocturia resulting in voiding twice per night. There was erectile dysfunction. The Veteran had no numbness, paresthesias, leg or foot weakness, falls, or unsteadiness. The examiner noted the urinary and erectile dysfunction conditions were unrelated to the back disability. Instead, those symptoms were related to colon cancer and surgery for the colon cancer. With respect to the spine, the examiner noted a history of fatigue, decreased motion, stiffness, no weakness, no spasm, and aching pain of moderate severity lasting hours occurring weekly to monthly after bending or lifting objects weighing more than 30 pounds. There was no radiation of the pain. The Veteran had an antalgic gait. He had no abnormal spinal curvatures. The only objective abnormality of the thoracolumbar sacrospinalis was pain with motion (to both the left and right). Ranges of motion were 70 degrees flexion (80 degrees initially and 70 degrees after repetitive use testing due to fatigue), 10 degrees extension, 30 degrees left and right lateral flexion, and 30 degrees left and right lateral rotation. There was no objective evidence of pain on range of motion testing. There was no additional limitation of motion or objective pain on motion following repetitive use testing. The condition resulted in decreased mobility and problems with lifting and carrying due to pain. The examiner who conducted a May 2011 VA examination indicated that the Veteran had incapacitating episodes of the thoracolumbar spine 4-5 times in the past 12 months last from six (6) hours up to three (3) days. (This indicates a total duration of between 4 days and 2 weeks.) The examiner did not diagnose IVDS. The Veteran’s pelvis was tilted left, but he had a normal gait and no abnormal spinal curvatures. The Veteran had left and right spasm, guarding, pain with motion, tenderness, and weakness of the thoracolumbar spine. The VA examiner did not test range of motion of the thoracolumbar spine. A June 2012 VA examination resulted in a diagnosis of lumbar and thoracic spine degenerative joint disease. The Veteran reported flare-ups that resulted in the Veteran “barely” being able to bend, lift, or carry. Ranges of motion were measured as 70 degrees flexion, 15 degrees extension, and 10 degrees of left and right lateral flexion and lateral rotation (after repetitive use testing and objective evidence of pain began at each of those measured ranges of motion). The examiner noted functional loss, impairment, and/or additional limitation of motion including less movement than normal, weakened movement, excess fatigability, pain on movement, instability of station, disturbance of locomotion, interference with sitting, standing and/or weight-bearing. The Veteran did exhibit pain on palpation of the low back. The Veteran had guarding or muscle spasm of the thoracolumbar spine that resulted in abnormal gait and abnormal spinal contour. The Veteran had no signs or symptoms of radiculopathy. The Veteran had no other neurologic abnormalities or findings related to the thoracolumbar spine condition. The Veteran had functional impairments due to his pain that limited walking, bending, twisting, and carrying. At an August 2015 VA examination, the Veteran was diagnosed with a lumbosacral strain. He reported chronic throbbing/piercing pain that increases with prolonged standing/walking and repetitive twisting/bending. Prolonged sitting caused stiffness. The Veteran reported flare-ups that could last an entire day and that rendered him unable to work. Ranges of motion were measured as 70 degrees flexion, 20 degrees extension, and 20 degrees left and right lateral flexion and rotation. There was objective evidence of pain on range of motion and with weight-bearing, but no additional loss of range of motion after repetitive use testing. The examiner opined that pain and incoordination significantly limited functional ability with repeated use over a period of time, although the examiner could not describe the additional limitation in terms of range of motion. The exam was consistent with the Veteran’s description of functional loss during flare-ups. Pain significantly limited functioning ability with flare-ups, though it could not be described in terms of range of motion. There was no guarding or muscle spasm. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. He did not have any other neurologic abnormalities or findings related to his thoracolumbar spine condition. He did not have intervertebral disc syndrome (IVDS). He constantly wore shoe inserts for leg length discrepancy. The Veteran had an abnormal gait and difficulty rising from a sitting position. X-ray studies documented arthritis. The Veteran’s back condition affected his occupational functioning because his job required prolonged standing, lifting, bending, twisting, and repetitive pushing/pulling. He had to miss work and be reassigned due to his back pain. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of back problems pertinent to other rating criteria. The Veteran’s ranges of motion and symptoms prior to June 5, 2012, do not warrant a rating in excess of 10 percent. Ranges of motion met, but did not exceed, the criteria for a 10 percent rating. At the 2011 VA examination the Veteran had guarding, but not guarding that caused an abnormal gait or abnormal spinal curvature. This would warrant a 10 percent, but not higher, rating. The Veteran did not have IVDS or any other neurologic abnormalities associated with the spine condition. See June 2010 VA Examination. To the extent the criteria for IVDS should be applied for incapacitating episodes not due to IVDS, the incapacitating episodes described at the 2011 VA examination would warrant a 10 percent rating, but no higher rating. The flare-ups as described by the Veteran did not indicate sufficient severity (e.g., additional limitation of range of motion to 60 degrees or less) that would warrant a higher rating. A rating in excess of 10 percent for the period prior to June 5, 2012, is denied. The June 5, 2012 VA examination again revealed ranges of motion that met, but did not exceed, the criteria for a 10 percent rating. However, the Veteran did have muscle spasm and/or guarding that resulted in an abnormal gait and abnormal curvature of the spine. The Veteran’s symptoms met the 20 percent criteria as of June 5, 2012. However, the 2012 VA examination did not reveal symptoms warranting any rating in excess of 20 percent. The ranges of motion, as noted, met only the 20 percent criteria. The Veteran did not have IVDS, did not have other neurologic abnormalities associated with his thoracolumbar spine condition that would warrant a separate or higher rating, and did not have other signs or symptoms that would warrant any higher rating. His flare-ups and limitations due to pain, weakened movement, excess fatigability, instability of station, disturbance of locomotion, and interference with standing, walking, bending, and lifting. These functional limitations are consistent with the 20 percent criteria (including the limitation on range of motion after repetitive use and the muscle spasms / guarding that caused abnormal gait and abnormal curvature of the spine). Moreover, the August 2015 VA examination produced similar results (though not the muscle spasm or guarding. Again, VA treatment and other medical records provide reports consistent with the symptoms and functional limitations described on the June 2012 and August 2015 VA Examinations. The medical evidence weighs against granting any rating in excess of 20 percent for the Veteran’s back condition for the period June 5, 2012 to the present. Entitlement to a disability rating in excess of 10 percent prior to June 5, 2012, and in excess of 20 percent thereafter for a back disability is denied. 5. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability The rating criteria for the cervical spine are found in 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, the pertinent provisions of have already been set forth above. The June 2010 VA examiner indicated that there were no objective abnormalities of the cervical spine (i.e., spasm, atrophy, guarding, pain with motion, tenderness, or weakness). Ranges of motion were 0 to 45 degrees flexion, 0 to 40 degrees extension, 40 degrees left and right lateral flexion, and 70 degrees left and right lateral rotation. There was no objective evidence of pain on range of motion testing. There was no additional limitation of motion or objective pain on motion following repetitive use testing. The examiner did not diagnose a neck condition and did not identify any neurologic abnormalities of the neck. The May 2011 VA examiner noted moderate, daily flare-ups lasting hours and characterized by neck stiffness and pain. The flare-ups were precipitated by prolonged neck positioning and alleviated by moving and physical therapy. The Veteran has fatigue, decreased motion, stiffness, weakness, no spasm, and pain. Pain was aching, of moderate intensity (6-7/10), with onset when holding head stationary occurring daily and lasting minutes. There was no radiation of the pain. The Veteran had no incapacitating episodes due to his cervical spine condition during the prior 12 months. The examiner noted spasm, guarding, pain with motion, tenderness, and weakness on both left and right sides of the cervical spine. Ranges of motion were measured as 45 degrees flexion, 35 degrees extension, 30 degrees left and right lateral flexion, 40 degrees left lateral rotation, and 45 degrees of right lateral rotation. There was objective evidence of pain on active motion and following repetitive motion. There were no additional limitations after three repetitions of range of motion. Upper extremity reflexes were normal as was sensation. The examiner diagnosed degenerative disc disease of the cervical spine. The condition caused problems with lifting and carrying, difficulty reaching, weakness and fatigue, decreased strength, and pain. The condition made it difficult to do chores at home due to generalized joint pain, but the Veteran was able to perform the usual activities of daily living. At a June 2012 VA examination, the Veteran was diagnosed with degenerative joint disease of the cervical spine. The Veteran reported flare-ups. He described the impact as: “I deal with it.” Ranges of motion were measured as 30 degrees forward flexion, 35 degrees extension, 30 degrees of right and left lateral flexion, and 65 degrees of right and left lateral rotation (all ranges involved objective evidence of painful motion at the limit of range of motion and the ranges were the same after three repetitions). The examiner noted no additional limitation of range of motion after repetitive-use testing. The examiner described the factors contributing to disability as less movement than normal, weakened movement, and pain on movement. The Veteran had localized tenderness or pain to palpation. He exhibited guarding or muscle spasm of the cervical spine that did not result in abnormal gait or spinal contour. The Veteran did not have radiculopathy associated with the neck condition. He also did not have IVDS of the cervical spine. There were no other pertinent physical findings, complications, conditions, signs or symptoms. The examiner opined that the Veteran’s cervical spine condition impacts his ability to work including because the nature of his work requires repetitive neck movement (involving lifting and holding objects weighing 25 pounds) that increases neck pain. At the August 2015 VA examination, the Veteran did not report flare-ups. The examiner measured ranges of motion as 40 degrees forward flexion, 45 degrees extension, 20 degrees of right lateral flexion, 30 degrees of left lateral flexion, 80 degrees of right lateral rotation, and 70 degrees of left lateral rotation (all ranges involved objective evidence of painful motion at the limit of range of motion and the ranges were the same after three repetitions). The examiner noted no additional limitation of range of motion after repetitive-use testing. The examiner indicated that there were no additional contributing factors of disability. The Veteran did not have localized tenderness or pain to palpation. He did not exhibit guarding or muscle spasm of the cervical spine. The examiner opined that the Veteran did have radiculopathy associated with the neck condition that involved the middle radicular group on the right. The examiner indicated that the severity was “not affected” rather than mild, moderate or severe. This statement is consistent with prior examinations. The only symptom the examiner noted indicative of radiculopathy were the Veteran’s subject reports of moderate paresthesias and/or dysesthesias of the right upper extremity. See August 2015 VA Examination (explaining, in section 13.a. that there were “no objective findings to correlate with subjective radicular complaints”). He also did not have IVDS of the cervical spine. There were no other pertinent physical findings, complications, conditions, signs or symptoms. The examiner opined that the Veteran’s cervical spine condition impacts his ability to work including pain with crossing arms, reaching, heavy lifting, pulling, pushing, overhead work, repetitive bending of the elbow, and numbness in the right hand affecting manual dexterity. (Again, the impact on the upper right extremity reflect subjective reports by the Veteran without objective findings to correlate with those complaints.) VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of neck problems pertinent to other rating criteria. The Veteran did not meet any of the criteria for a rating in excess of 10 percent prior to the June 5, 2012 VA examination. His ranges of motion did not meet the criteria for a compensable rating, though the findings of spasm and guarding as well as the presence of arthritis with painful motion did warrant a 10 percent rating. See 38 C.F.R. § 4.71a, DC 5003. The June 2012 VA examination contained a single finding that met the criteria for a 20 percent rating. Specifically, a 20 percent rating is warranted for “forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees.” The Veteran’s forward flexion was measured as 30 degrees on June 5, 2012. This meets the criteria for a 20 percent rating. Later measurements of forward flexion exceed 30 degrees. However, in the interest of stability of ratings, giving the Veteran the benefit of the doubt, and considering the functional limitations, the Board finds a 20 percent rating for the cervical spine from June 5, 2012, to the present is appropriate. An initial rating in excess of 10 percent for a cervical spine disability is denied for the period prior to June 5, 2012. A 20 percent rating is awarded effective June 5, 2012. 6. Residuals of fracture of the left femur Diagnostic codes applying to the hip and thigh include DCs 5250-5255. The Veteran’s residuals for fracture of the left femur (other than limitation of flexion) are rated under DC 5253, with a 10 percent rating in effect since 2006. The Veteran is also rated under DC 5252 based on limitation of flexion motion, which is noncompensable (zero percent) from March 2010. Under DC 5253, a 10 percent rating is warranted for limitation of rotation such that the Veteran cannot toe-out more than 15 degrees; or, limitation of adduction such that cannot cross legs. A 20 percent rating is warranted for limitation of abduction such that motion is lost beyond 10 degrees. Under DC 5252, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 20 degrees. A 40 percent rating is warranted for flexion limited to 10 degrees. The Veteran does not have ankylosis (DC 5250), limitation of extension (DC 5251), a flail joint of the hip (DC 5254), impairment of the femur due to fracture with malunion, a false joint, or nonunion (DC 5255). Those diagnostic codes will not be further discussed. With respect to the residuals of the left femur fracture, the June 2010 VA examiner opined that there were no significant occupational effects and no effects on the Veteran’s usual activities of daily living. Hip flexion and extension were both normal. Ranges of motion of the hip were not otherwise noted as reduced. A July 2011 VA examination revealed pain, stiffness, weakness, decreased speed of joint motion, and tenderness of the left hip. No other symptoms were noted. The Veteran had weekly flare-ups of moderate severity lasting for hours. The flare-ups are precipitated by sitting in one spot for a prolonged period of time and are characterized by pain. Walking around and/or changing position alleviates the symptoms. The Veteran reported being “unable to do anything” during a flare-up. The examiner noted guarding of movement of the left hip. There was objective evidence of pain on active motion. Range of motion testing showed left hip flexion was 110 degrees, extension of 110 to 0, abduction to 15 degrees, inability to cross left leg over right, could not toe-out more than 15 degrees. There was no additional limitation of range of motion after repetitive use testing. An August 2015 VA examination revealed degenerative arthritis of both the right and left hips. The Veteran described sharp, intermittent pain of the bilateral hips, also with chronic achy pain with right worse than left. He reported 4-5 flare-ups per week that last 30-45 minutes. During flare-ups, he has to rest and is unable to stand. Ranges of motion were measured as 110 degrees flexion, 20 degrees extension, 20 degrees abduction, and 25 degrees adduction. The Veteran’s adduction was not so limited as to prevent crossing his legs. External rotation was 0 to 60 degrees and internal rotation was 0-30 degrees. The Veteran’s range of motion contributed to functional loss as it affected ambulation and pivoting. There was pain on examination that caused functional loss. There was objective evidence of crepitus. There was evidence of pain with weight-bearing and there was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissues. The Veteran was able to perform repetitive use testing with no additional limitation of range of motion. Pain and weakness significantly limit functional ability with repeated use over time, but the examiner was unable to describe the limitation in terms of range of motion. The factors contributing to disability associated with the left hip included decreased range of motion and mobility due to pain, weakness that affects ambulation and standing, leg length discrepancy which affects ambulation, stiffness after sitting, difficulty with rising from sitting position, difficulty with propulsion/initiation in walking causing gait to appear unsteady. Muscle strength was reduced with 3/5 on flexion, 4/5 on extension, and 4/5 on abduction. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms pertinent to other rating criteria. The July 2011 VA examination provides evidence supporting the current 10 percent rating under DC 5253 for limitation of rotation such that the Veteran cannot toe-out more than 15 degrees or for limitation of adduction such that he cannot cross legs. However, the medical evidence does not support awarding any higher ratings. He does not meet the criteria for a 20 percent rating under DC 5253 as he does not have limitation of abduction such that motion is lost beyond 10 degrees. The ranges of motion and other symptoms do not meet the criteria for any schedular rating under any potentially applicable diagnostic codes, to include DCs 5250-5256. The Veteran also has a separate rating under DC 5252 for limitation of flexion. While he has some limitations, the evidence does not establish a limitation of flexion that meets the criteria for any compensable rating. The evidence would have to show limitation of flexion to 45 degrees to warrant a compensable rating, and he is capable of flexion far greater than that. 7. Entitlement to a disability rating in excess of 10 percent for a right ankle disability Disabilities of the ankle are rated under DCs 5270 to 5274. 38 C.F.R. § 4.71a. Under DC 5271, a 10 percent rating is warranted for limited motion of the ankle that is moderate. A 20 percent rating is warranted for limited motion of the ankle that is marked. Normal range of ankle motion is dorsiflexion to 20 degrees and plantar flexion to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Veteran does not have ankylosis of any of his ankle joints, a malunion of the os calcis or astragalus, and has not had an astragalectomy, so DCs 5270 and 5272-5274 are not applicable in this matter. At the June 2010 VA examination, the Veteran reported that he was not having pain at the ankle area, but that pain is more pronounced with prolonged weight-bearing activities on concrete floors and during inclement or humid weather. He stated that he often sprains his ankle while walking. The Veteran had a deformity of the ankle, stiffness, weakness, decreased speed of joint motion, but no other symptoms. There was abnormal wear on the right shoe. The Veteran had 15 degrees of valgus angulation with weight-bearing. The examiner measured range of motion of the right ankle as limited to 10 degrees dorsiflexion, 35 degrees of plantar flexion with no objective evidence of pain on motion and no additional limitations after three repetitions. The June 2012 VA examiner measured ranges of motion as 35 degrees plantar flexion and 10 degrees of dorsiflexion with objective evidence of painful motion at the end of the ranges of motion. There was no additional limitation of range of motion after repetitive use testing. The Veteran had functional loss and/or functional impairment of the ankle consisting of less movement than normal, pain on movement, instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing. There was pain on palpation. Muscle strength was 4/5 for both plantar flexion and plantar dorsiflexion. Stability testing was normal and there was no ankylosis. The Veteran’s ankle condition affects his standing and walking while working on the assembly line. The August 2015 VA examiner noted x-ray confirmation of arthritis and chronic throbbing, burning pain that could become sharp. The Veteran reported that the ankle was unstable and would “give out” after prolonged walking or standing. He did not report flare-ups, but did report functional loss or functional impairment after repetitive use including the aforementioned instability which affects ambulation. Range of motion was measured as 0-20 degrees dorsiflexion and 0 to 30 degrees of plantar flexion. The decreases in range of motion affected the Veteran’s propulsion and gait. There was pain that contributed to the functional loss. There was evidence of pain with weight-bearing. Pain and weakness significantly limit functional ability with repeated use over time, but the examiner was not able to describe the loss in terms of range of motion. The Veteran’s right ankle has decreased range of motion, bony deformity secondary to fracture that affects his ability to propel, ability to stand, and affects his gait, and weakness that affects his standing and locomotion. The Veteran’s right ankle affects his work due to limitations on prolonged standing, lifting, bending, twisting, pushing/pulling repetitively, climbing, and walking on uneven surfaces. A February 2012 letter from the Veteran’s private treatment physician primarily discusses the left leg and foot. However, the general descriptions contained in the letter are consistent with the VA examinations summarized above. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of ankle problems pertinent to other rating criteria. The Veteran has significant impairments of his right ankle, particularly after prolonged walking or standing. The ranges of motion are reduced on some examinations, but not on others. Moreover, at worst, dorsiflexion is limited to 10 degrees with normal dorsiflexion being 20 degrees. (Most recently, dorsiflexion was normal.) Plantar flexion has been measured at 30 or 35 degrees on all VA examinations with normal being 45 degrees. While these are moderate limitations, they are not marked limitations. Dorsiflexion ranges from half to full dorsiflexion and plantar flexion is consistently well over half of normal findings. The Board acknowledges that the Veteran has problems of pain and weakness that increase with prolonged use. The terms “moderate” and “marked” are not defined, but, given two rating categories, the Board finds “moderate” is the better description of ranges of motion of, at worst, half of normal dorsiflexion and well over half of flexion. The medical evidence warrants assigning a 10 percent rating based on “moderate” limitation of motion. The Veteran is currently assigned a 10 percent rating, so no higher rating is warranted. The Veteran’s claim of entitlement to a rating in excess of 10 percent for his right ankle is denied. 8. Entitlement to a disability rating in excess of 30 percent for residuals of right femur fracture (to include shortening of the leg) The diagnostic codes pertinent to rating residuals of a fracture to the femur were set forth and discussed above in connection with the left leg. In addition, the Veteran’s residuals with respect to the right leg include a shortening of the leg. Under DC 5275, a 10 percent rating is warranted for a shortening of a lower extremity of 1.25 inches to 2 inches (3.2 cms to 5.1 cms). A 20 percent rating is warranted for a shortening of 2 inches to 2.5 inches (5.1 cms to 6.4 cms). Higher ratings are available for shortening over 2.5 inches (6.4 cms), but the evidence does not support any such ratings in this case as the maximum measured leg length discrepancy in this case has been 1.25 inches. The June 2010 VA examination revealed a shorter right lower extremity compared with the left lower extremity which required the use of orthotic inserts, but caused no effects on usual daily activities. The right leg was measured as one and a quarter inches (1-1/4”) shorter than the left leg (also described as 2 cm difference with the right leg being 101.0 cm and the left being 103.0 cm). Diagnostic imaging showed evidence of mild right hip joint narrowing with evidence of a remote posttraumatic deformity of the proximal of the right femur. A July 2011 VA examination revealed objective evidence of pain on active motion. Range of motion testing showed right hip flexion was 100 degrees, extension of 100 to 0, abduction to 20 degrees, inability to cross left leg over right, could not toe-out more than 15 degrees. There was no additional limitation of range of motion after repetitive use testing. An August 2015 VA examination revealed degenerative arthritis of both the right and left hips. The Veteran described sharp, intermittent pain of the bilateral hips, also with chronic achy pain with right worse than left. He reported 4-5 flare-ups per week that last 30-45 minutes. During flare-ups, he has to rest and is unable to stand. Ranges of motion were measured as 100 degrees flexion, 20 degrees extension, 20 degrees abduction, and 25 degrees adduction. The Veteran’s adduction was not so limited as to prevent crossing his legs. External rotation was 0 to 60 degrees and internal rotation was 0-40 degrees. The Veteran’s range of motion contributed to functional loss as it affected ambulation and pivoting. There was pain on examination that caused functional loss. There was objective evidence of crepitus. There was evidence of pain with weight-bearing and there was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissues. The Veteran was able to perform repetitive use testing with no additional limitation of range of motion. Pain and weakness significantly limit functional ability with repeated use over time, but the examiner was unable to describe the limitation in terms of range of motion. The factors contributing to disability associated with the right hip were decreased range of motion and decreased mobility due to pain, weakness that affects ambulation and standing, leg length discrepancy which affects ambulation, stiffness after sitting, difficulty with rising from sitting position, difficulty with propulsion/initiation in walking causing gait to appear unsteady. Muscle strength was reduced with 4/5 on flexion, 4/5 on extension, and 4/5 on abduction. With respect to the leg length discrepancy, the right leg was measured as two centimeters (2 cm) shorter than the left leg. A February 2012 letter from the Veteran’s private treatment physician indicates “a difference of at least 1.5 inches between his left and right legs.” However, the physician’s measurement appears to be an estimate (“at least”) rather than a precise measurement and conflicts with the multiple measurements noted above indicating a 2 cm discrepancy. The Board finds that multiple consistent measurements by the VA examiners to be the best evidence of the Veteran’s actual leg length discrepancy. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms pertinent to other rating criteria. The Veteran’s current 30 percent rating is based on the June 2010 x-ray evidence of a malunion combined with the RO’s finding of “marked” disability due to the arthritis and malunion. The Board finds this is appropriate. Although the Veteran seeks a higher rating, his ranges of motion do not warrant higher ratings. He has interference with gait, pain, limitation of motion, and associated functional impairments, which support a finding of “marked” disability under DC 5255. The Veteran does not meet the criteria for any separate rating under DC 5275 due to shortening of the extremity. Although the June 2010 VA examiner described the difference as 1.25 inches, other measurements in his report indicate leg lengths of 101.0 cm and 103.0 cm which is a 2 cm difference (less than 1 inch difference). If these were the only statements, the Veteran would be entitled to the benefit of the doubt. However, measurements by other physicians, including the August 2015 VA examiner, have indicated the true measurement is 101.0 cm for the right leg and 103.0 cm for the left leg, i.e., a 2 cm difference. Due to these other measurements, the Board concludes that the measurement given in inches was due to error, whether due to a conversion mistake or otherwise. In any case, even if the criteria for a 10 percent rating under DC 5275 were met, the 30 percent rating under DC 5255 encompasses the pain, interference with gait, and functional limitations associated with the leg length discrepancy. For all of these reasons, an additional, separate rating under DC 5275 in addition to the currently assigned 30 percent rating under DC 5255 is not warranted. All of the disabling symptoms and effects of the fracture of right femur are encompassed by the currently assigned 30 percent rating. The Veteran’s claim of entitlement to a disability rating in excess of 30 percent for residuals of right femur fracture (to include shortening of the leg) is denied. 9. Entitlement to a compensable disability rating prior to July 30, 2015, and in excess of 10 percent thereafter for residuals of a fracture of the right navicular bone The Veteran’s residuals of a fracture of the right navicular bone are rated as noncompensable prior to July 30, 2015, and as 10 percent disabling thereafter under DC 5215. Under DC 5215, a 10 percent rating is warranted for palmar flexion limited in line with the forearm or for dorsiflexion less than 15 degrees. DC 5214 also applies to the wrist, but only in the case of ankylosis. The Veteran does not have ankylosis, so DC 5214 is not applicable. At the June 2010 VA Examination, the Veteran indicated that he was unaware of a right navicular bone fracture, that he was having no pain, functional limitations, or residual deficits related to a history of fracture. There was no pain or tenderness elicited with palpation of the area and no pain at the site with weight-bearing. There were no residual deficits of a right navicular fracture that caused any occupational impairments or that had any effect on usual activities of daily living. At a July 2011 VA examination, the Veteran denied any knowledge of a fracture of the right wrist, but noted a sharp pain in his wrist that comes and goes. Diagnostic imaging showed a deformity of the right wrist and the Veteran had stiffness and pain in the wrist, but no other symptoms. Range of motion of the right wrist was 0 to 60 degrees dorsiflexion, 0 to 40 degrees palmar flexion, 0 to 20 degrees radial deviation, and 0 to 30 degrees ulnar deviation. There was no objective evidence of pain following repetitive motion and no additional limitations after repetitive use testing. An October 2015 VA examination revealed palmar flexion of 0 to 65 degrees (80 degrees normal), 0 to 55 degrees of dorsiflexion (70 degrees normal), 0 to 45 degrees ulnar deviation (45 degrees normal), and no range of motion on radial deviation (20 degrees normal). The examiner noted the Veteran was unable to perform radial deviation with either the left or right wrist which may be a normal anatomic variant. His ulnar deviation was normal. The examiner noted decreased palmar flexion and dorsiflexion, likely due to the degenerative changes. There was not objective evidence of pain or of localized tenderness or pain on palpation. Strength was normal. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of neck problems pertinent to other rating criteria. The medical evidence prior to July 13, 2011, does not reveal limitation of motion that meets the criteria for any compensable rating. The June 2010 VA examination found essentially no symptoms or disability, so does not support any compensable rating. However, the July 2011 VA examination does indicate the presence of osteoarthritis, some limitation of motion, and flare-ups with worsened pain and reduced functionality (including reduced range of motion). These findings support the award of a 10 percent rating under DC 5003 and DC 5215. Notably, these are the same findings upon which the RO awarded a 10 percent rating effective July 30, 2015. See June 2016 Rating Decision. The examination was performed on July 13, 2011, so that is the effective date for the award of a 10 percent rating. The evidence does not warrant any higher rating as the Veteran does not have limitation of motion meeting the minimum criteria, much less for a higher rating. Therefore, a rating of 10 percent, but no higher, will be granted effective July 13, 2011, for residuals of a fracture of the right navicular bone. A compensable rating prior to July 13, 2011, is denied. A rating in excess of 10 percent for any time period on appeal after July 13, 2011, is also denied. 10. Entitlement to a compensable rating for service-connected scars of the low back and knees The Veteran seeks a compensable rating for his scars. Scars are evaluated under 38 C.F.R. § 4.118, DC 7800-7805 (2017). Diagnostic Code 7800 requires involvement of the head, face, or neck. Diagnostic Code 7801 applies to scars, other than head, face, or neck, that are deep and nonlinear and provides for a 10 percent rating where the scars have an area of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Diagnostic Code 7802 provides for no more than a 10 percent rating and requires involvement of an area or areas of 144 square inches (929 sq. cm.). The Rating Schedule no longer includes a Diagnostic Code 7803. Diagnostic Code 7804 applies to scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four such scars. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Diagnostic Code 7805 applies to limitation of function of the affected part and specifically provides: “Evaluate any disabling effect(s) not considered in rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code.” Id. The June 2010 VA examiner noted scars on the lower left extremity (0.5 cm x 0.5 cm), right lower extremity (0.5 cm x 0.5 cm), lumbar spine region (6 cm x 7 cm), and right upper extremity (0.1 cm x 7 cm). None of the scars were painful or showed signs of skin breakdown. All were superficial with no inflammation, no edema, no keloid formation, and no other disabling effects. The June 2012 VA examiner noted scars on the lower left extremity (four superficial, nonlinear scars with three measuring 1.0 cm x 0.5 cm and one 0.5 cm x 0.5 cm), right lower extremity (four superficial, nonlinear scars with three measuring 2.0 cm x 0.5 cm and one 2.0 cm x 0.3 cm), and lumbar spine region (one superficial, nonlinear scars measuring 12 cm x 9 cm). None of the scars were painful or unstable, none were unstable, and none were due to burns. All were superficial with no inflammation, no edema, no keloid formation, and no other disabling effects. The July 2015 VA examiner noted scars on the lower left extremity (one linear scar measuring 1 cm; two nonlinear scars measuring 0.5 cm x 0.5 cm), right lower extremity (two linear scars measuring 1 cm x 1.5 cm), lumbar spine region (6 cm x 7 cm), and right upper extremity (0.1 cm x 7 cm). None of the scars were painful or showed signs of skin breakdown. All were superficial with no other disabling effects. The Veteran’s scars do not meet the criteria for any compensable rating. They are superficial, non-linear, do not affect the head, face, or neck, and are not otherwise disabling (e.g., unstable, etc.). The total affected area, adding all of the scars together do not meet the criteria for a compensable rating for stable, non-painful, superficial scars under DC 7802 (which requires affected area of 929 sq. cm.). Entitlement to a compensable rating for service-connected scars of the low back and knees is denied. 11. Entitlement to a disability rating in excess of 10 percent for residuals of a laceration and contusion of the right hand with ulnar neuropathy The Veteran seeks a rating in excess of 10 percent for residuals of a laceration and contusion of the right hand with ulnar neuropathy. Diseases of the peripheral nerves are evaluated under the Schedule of Ratings for Diseases of the Peripheral Nerves. See 38 C.F.R. § 4.124a, DCs 8510-8540, 8610-8630, and 8710-8730. His condition is currently rated under DC 8516 which applies to paralysis of the ulnar nerve. The Veteran’s right hand is his dominant hand, so the criteria for the major extremity apply. Under DC 8516, a 10 percent rating is warranted for mild, incomplete paralysis. A 30 percent rating is warranted for moderate, incomplete paralysis. A 40 percent rating is warranted for severe, incomplete paralysis. A 60 percent rating is warranted for complete paralysis of the ulnar nerve. Under DC 8516, complete paralysis is characterized by the “griffin claw” deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. In addition, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. A Note at the beginning of 38 C.F.R. § 4.124a indicates that disability from neurological disorders is rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function, and that with partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The words mild, moderate, moderately severe, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration and that, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a; see also 38 C.F.R. § 4.123 (indicating neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated with a maximum equal to severe, incomplete paralysis); 38 C.F.R. § 4.124 (indicating neuralgia characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated with a maximum equal to moderate incomplete paralysis). A June 2010 VA examination revealed decrease in hand dexterity due to ulnar neuropathy, but not an overall decrease in hand strength. There were no flare-ups. Sensory, motor, and reflex examination of the right upper extremity were normal. There was no evidence of ulnar neuropathy affecting the right hand at the time of the clinical examination. The right ulnar nerve at the elbow segment had conduction velocity changes likely of demyelinating nature occurring at the elbow segment and axonal loss at forearm segment. There was prolonged dorsal ulnar cutaneous on the right side possibly due to local compression or injury to nerve from more proximal changes at elbow. There was nerve dysfunction, but not neuritis or neuralgia. The only symptoms identified were pain and stiffness. A June 2012 VA examination diagnosed right ulnar neuropathy. The EMG and NCV of the right upper extremity were normal. There was no evidence of radiculopathy or nerve entrapment. A prior EMG did show possible ulnar nerve entrapment at the elbow, but there were no clinical symptoms at that time. The examiner indicated that there was mild constant pain, mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the right upper extremity. Muscle strength was reduced at elbow flexion (3/5), elbow extension (3/5), wrist flexion (3/5), wrist extension (3/5), grip (3/5), and pinch (3/5). Reflexes were normal. There was decreased sensation at the hand and fingers. The examiner opined that the Veteran had mild incomplete paralysis of the ulnar nerve. A July 2015 VA examination revealed ulnar neuropathy characterized by moderate intermittent pain, moderate paresthesias/dysesthesias, and severe numbness. Muscle strength was normal except grip (4/5). Reflexes were normal. Sensation was normal. There were no trophic changes. All nerves were normal except the ulnar nerve which was affected by mild, incomplete paralysis. There were no other pertinent physical findings, complications, conditions, signs or symptoms. EMG of the right upper extremity was normal. VA treatment and other medical records during this period are consistent with the above examinations in that they do not indicate ranges of motions limited more than indicated above or other signs or symptoms of ulnar neuropathy pertinent to other rating criteria. All medical professionals who have assessed the Veteran’s ulnar neuropathy have opined that, at most, it is characterized by mild, incomplete paralysis. Mild, incomplete paralysis warrants a 10 percent rating under DC 8516. The Veteran does not have neuritis or neuralgia, so evaluation under alternative criteria for those conditions is not warranted. Entitlement to a disability rating in excess of 10 percent for residuals of a laceration and contusion of the right hand with ulnar neuropathy is denied. Duties to Notify and Assist The Veteran has not raised any specific 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). Therefore, the Board needs to discuss VA’s compliance with the duties to notify and assist. Finally, the Veteran has not alleged any deficiency with the conduct of his hearing before the undersigned with respect to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Kerry Hubers, Counsel