Citation Nr: 18146240
Decision Date: 10/31/18	Archive Date: 10/30/18

DOCKET NO. 16-03 950
DATE:	October 31, 2018
ORDER
The claim of entitlement to service connection for a right wrist disability is denied.
The claim of entitlement to service connection for tinnitus is denied.
The claim of entitlement to service connection for a sleep impairment, to include sleep apnea, is granted.
The claim of entitlement to an initial evaluation in excess of 10 percent for a right knee disability prior to March 23, 2016, is denied.
The claim of entitlement to a temporary total evaluation for a right knee replacement on March 23, 2016, is granted.
The claim of entitlement to an evaluation in excess of 10 percent for a left wrist disability is denied.
The claim of entitlement to an initial evaluation in excess of 10 percent for a back disability is denied.
The claim of entitlement to a compensable evaluation for a left ankle disability is granted.
The claim of entitlement to an initial evaluation in excess of 50 percent for major depressive disorder prior to January 12, 2017, is denied.
The claim of entitlement to an evaluation in excess of 50 percent for major depressive disorder since January 12, 2017, is granted.
The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of service connection for a back disability is denied.
The claim of entitlement to an effective date earlier than March 29, 2012, for the grant of an increased evaluation for a left ankle disability is denied.
The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of a 10 percent evaluation for a left wrist disability is denied.
The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of service connection for major depressive disorder is denied.
The claim of entitlement to an effective date earlier than May 30, 2012, for the grant of service connection for a right knee disability is denied.
REMANDED
The claim of entitlement to service connection for a neck disability is remanded.
The claim of entitlement to service connection for a left knee disability is remanded.
The claim of entitlement to service connection for a penile condition, to include erectile dysfunction, is remanded.
The claim of entitlement to service connection for headaches is remanded.
The claim of entitlement to an evaluation in excess of 30 percent for a right knee disability since March 24, 2017, is granted.
The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.
FINDINGS OF FACT
1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a right wrist disability.
2. The preponderance of the evidence is against finding that the Veteran has tinnitus due to a disease or injury in service, to include specific in-service event, injury, or disease.
3. The Veteran’s sleep impairment, claimed as sleep apnea, is etiologically related to his service-connected major depressive disorder.
4. Prior to March 23, 2016, the evidence of record does not demonstrate that the Veteran’s right knee flexion was more limited than to 45 degrees. 
5. On March 23, 2016, the Veteran underwent a total right knee replacement. 
6. The Veteran’s left wrist disability did not include a finding of favorable or unfavorable ankylosis throughout the period on appeal. 
7. Throughout the period on appeal, the Veteran’s back disability manifested with no more than forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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.
8. The evidence of record reflects that the Veteran’s left ankle disability caused recurring pain but had full range of motion in the ankle with 0 to 20 degrees dorsiflexion and 0 to 45 degrees plantar flexion.  
9. Prior to January 12, 2017, the Veteran’s major depressive disorder manifested with, at worst, occupational and social impairment with reduced reliability and productivity.
10. Since January 12, 2017, the Veteran’s major depressive disorder manifested with, at worst, occupational and social impairment in most areas.
11. The Veteran’s entitlement to a grant of service connection for a back disability arose as of January 24, 2014, the date of receipt of the claim. 
12. The Veteran’s entitlement to a grant of an increased evaluation for a left ankle disability arose as of March 29, 2012, the date of receipt of the claim.
13. The Veteran’s entitlement to a grant of an increased evaluation for a left wrist disability arose as of January 24, 2014, the date of receipt of the claim.
14. The Veteran’s entitlement to a grant of service connection for major depressive disorder arose as of January 24, 2014, the date of receipt of the claim.
15. The Veteran’s entitlement to a grant of service connection for a right knee disability arose as of May 30, 2012, the date of receipt of the claim.
CONCLUSIONS OF LAW
1. The criteria for service connection for a right wrist disability are not met.  38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 
2. The criteria for service connection for tinnitus are not met.  38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018).
3. The criteria for service connection for a sleep impairment have been met.  38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018).
4. Prior to March 23, 2016, the criteria for an initial rating in excess of 10 percent for a right knee disability have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321(b), 3.951, 4.1, 4.3, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024-5060 (2018). 
5. From March 23, 2016, to March 23, 2017, the criteria for a temporary total disability rating for a right knee replacement have been met.  38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2018).
6. The criteria for an evaluation in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321 (b)(1), 4.1, 4.10, 4.40, 4,.45, 4.59, 4.71a, Diagnostic Codes 5214-5215 (2018). 
7. The criteria for an initial evaluation in excess of 10 percent for a back disability have not been met.  38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242 (2018).
8. The criteria for a 10 percent rating, but no higher, for a left ankle disability are met.  38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5271 (2018). 
9. Prior to January 12, 2017, the criteria for an initial evaluation in excess of 50 percent for major depressive disorder have not been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9434 (2018).
10. Since January 12, 2017, the criteria for an evaluation of 70 percent, but no higher, for major depressive disorder have been met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9434 (2018).
11. The criteria for an effective date prior to January 24, 2014, for the grant of service connection for a back disability have not been met.  38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.157, 3.159, 3.340, 3.341, 3.400 (2018). 
12. The criteria for an effective date prior to April 2, 2012, for the grant of an increased evaluation for a left ankle disability have not been met.  38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.157, 3.159, 3.340, 3.341, 3.400 (2018).
13. The criteria for an effective date prior to January 24, 2012, for the grant of an increased evaluation for a left ankle disability have not been met.  38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.157, 3.159, 3.340, 3.341, 3.400 (2018). 
14. The criteria for an effective date prior to January 24, 2014, for the grant of service connection for major depressive disorder have not been met.  38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.157, 3.159, 3.340, 3.341, 3.400 (2018).  
15. The criteria for an effective date prior to January 24, 2014, for the grant of service connection for a right knee disability have not been met.  38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.157, 3.159, 3.340, 3.341, 3.400 (2018). 
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran had active duty service with the United States Air Force from March 1986 to January 1989 and was discharged under honorable conditions.
At the outset, after reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as reflected in the issues section above.  The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled.  See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing symptoms of the disability); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record).  Therefore, in consideration of the holdings in Brokowski and Clemons, the Board has recharacterized the Veteran’s claim for sleep apnea as a claim of entitlement to service connection for a sleep impairment.
Additionally, the Veteran asserts that he is entitled to a temporary total evaluation following his March 2016 right knee replacement surgery.  See February 2018 Fully Developed Claim.  In a subsequent March 2018 rating decision, the RO acknowledged the Veteran’s right knee replacement by assigning a new Diagnostic Code and affording a 30 percent minimum evaluation for its residuals.  The RO did not address the Veteran’s claim for a total evaluation in connection with the right knee replacement.  Given that the claim for entitlement to an increased evaluation for the Veteran’s right knee is before the Board, the Board has included the intertwined issue of entitlement to a temporary total evaluation based on a right knee replacement in this appeal, as reflected above.
Service Connection
Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service.  38 U.S.C. §§ 1131 (2012).  A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (“nexus”) between the present disability and the in-service event, injury, or disease.  38 C.F.R. § 3.303 (2018); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).
In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury.  38 C.F.R. § 3.310.  Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated.  Allen v. Brown, 7 Vet. App. 439 (1995).  When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability.
In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran.  See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence.  Layno v. Brown, 6 Vet. App. 465, 469 (1994).
Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465.  Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation.  38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).
When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.
Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record.  Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence.  Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal.
1. The claim of entitlement to service connection for a right wrist disability
The Veteran contends that he is entitled to service connection for a right wrist disability.
The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.
The Board concludes that the Veteran does not have a current diagnosis of a right wrist disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim.  38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d).
The Veteran’s service treatment records do not note injuries or complaints pertaining to his right wrist.  The Veteran’s post-service VA treatment records similarly are silent with respect to his right wrist.
In August 2014, the Veteran underwent a VA examination to assess the severity of his service-connected left wrist disability.  At the time of examination, the Veteran’s right wrist had full range of motion with no objective evidence of pain on examination.  The Veteran did not voice complaints pertaining to his right wrist in this examination.  In August 2015, a second VA examination assessed the Veteran’s bilateral wrists.  Again, the Veteran did not voice complaints pertaining to his right wrist, and specifically denied flare ups of the right wrist.  The right wrist had full range of motion and no objective evidence of pain on examination.
Based on the evidence of record, the Board concludes that the Veteran does not have a diagnosis for a right wrist disability.  As such, the first element of a service connection claim is not met.  In the absence of proof of a present disability, there can be no valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992).
The Board is cognizant of the recent holding in Saunders v. Wilkie which stated that, where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis.  Saunders v. Wilkie, No. 17-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018).  In sum, pain alone resulting in functional impairment is in fact a disability, and should not be summarily discounted as a bar to benefits based on a finding of no current diagnosis.  However, even in light of Saunders, the Veteran still does not have a present disability pertaining to the right wrist as he does not have a diagnosis, and the VA examiner noted that his pain did not result in any functional loss or functional impairment.  Furthermore, his VA treatment records do not reflect complaints pertaining to his right wrist.  Based on such evidence, the Board finds that this case is distinguished from Saunders.
While the Veteran believes he has a current right wrist disability, he is not competent to provide a diagnosis in this case.  The issue is medically complex, as it requires specialized medical education to diagnose physical disabilities.  Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  Consequently, the Board gives more probative weight to the competent medical evidence.
In sum, the preponderance of the evidence is against the claim for service connection for a right wrist disability.  Because the preponderance of the evidence is against the Veteran’s appeal, the benefit-of-the-doubt doctrine is not applicable.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.
2. The claim of entitlement to service connection for tinnitus
The Veteran contends that he is entitled to service connection for tinnitus.
The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.
The Board concludes that, while the Veteran has a current diagnosis of tinnitus, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of tinnitus began during service or is otherwise related to an in-service injury, event, or disease.  38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d).
Tinnitus is a chronic disease listed under 38 C.F.R. § 3.309 (a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303 (b) based on “chronic” symptoms in service and “continuous” symptoms since service are applicable to this service connection claim.  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes.  For the showing of a chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time.  If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection.  38 C.F.R. § 3.303 (b).
The Veteran underwent a September 2014 audiology examination in order to determine the etiology of his tinnitus.  In the examination, the Veteran reported the onset of tinnitus approximately two years prior to the examination, which was over 30 years after any exposure to military noise while on active duty.  Given such a delayed onset, the examiner opined that the Veteran’s tinnitus was less likely than not related to active duty service.
Post-service VA treatment records do not indicate reports of tinnitus during active duty service.  Similarly, the Veteran’s service treatment records do not note complaints relating to tinnitus.  While tinnitus is a disorder that may be identified through lay observation alone, the Veteran does not identify that related symptoms occurred during active duty service.  To the contrary, he specifically reported tinnitus beginning around 2012, many decades after service.  The Board will generally accept the date of onset of tinnitus without further examination, and this remains the case in the Veteran’s present appeal.  The preponderance of the evidence of record, including a medical opinion and the Veteran’s own lay statements, weigh against a nexus between his reported tinnitus and active duty service.
In sum, the preponderance of the evidence is against the claim for service connection for tinnitus.  Because the preponderance of the evidence is against the Veteran’s appeal, the benefit-of-the-doubt doctrine is not applicable.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102.
3. The claim of entitlement to service connection for a sleep impairment, to include sleep apnea
The Veteran contends that he suffers a sleep impairment related to his active duty service.
The Board concludes that the Veteran has a current diagnosis of a sleep impairment that is caused by his service-connected major depressive disorder.  38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).
Multiple medical records and lay statements associate the Veteran’s claimed sleep impairment with his service-connected major depressive disorder.  In August 2015, a VA examination assessing his major depressive disorder noted that he experienced poor sleep patterns and chronic sleep impairment associated with his major depressive disorder.  In his wife’s January 2017 statement, she reported ongoing sleep problems.  The Veteran’s VA treatment records also note repeated complaints of difficulty sleeping.  In an April 2018 VA examination, the examiner opined that the Veteran’s sleep disturbances were at least as likely as not proximately due to or the result of the Veteran’s major depressive disorder.  In fact, the Veteran’s sleep disturbances were a significant contributor to his major depressive disorder.
Accordingly, as the competent, probative evidence of record supports a relationship between the Veteran’s service-connected major depressive disorder and his sleep impairments, secondary service connection for a sleep impairment is warranted.
Increased Rating
Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes.  38 C.F.R. § 4.27.  The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability.  38 C.F.R. § 4.1.  If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran.  38 C.F.R. § 4.3.  However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability.  38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).
In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran’s claim is to be considered.  In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings.  Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2.  VA’s determination of the “present level” of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  Hart v. Mansfield, 21 Vet. App. 505 (2007).
Disabilities must be reviewed in relation to their entire history.  38 C.F.R. § 4.1.  VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability.  38 C.F.R. § 4.2.  VA is also required to evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person’s ordinary activity.  38 C.F.R. § 4.10.  Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered.  DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995).  Functional loss may be due to pain if supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion.  Functional impairment may be due to pain, including during flare-ups, or from repetitive use.  Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011).  
In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran.  See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence.  Layno v. Brown, 6 Vet. App. 465, 469 (1994).
Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465.  Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation.  38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).
When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.
Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record.  Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence.  Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal.
4. The claim of entitlement to an evaluation in excess of 10 percent for a right knee disability prior to March 23, 2016
The Veteran contends that he is entitled to an initial rating in excess of 10 percent for his right knee disability.  After a thorough review of the evidence, the Board finds that a rating in excess of 10 percent is not warranted prior to March 23, 2016.
The Veteran’s right knee disability was initially rated under Diagnostic Code 5003-5260.  Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating.  38 C.F.R. § 4.27.  In this case, Diagnostic Code 5003 evaluates degenerative arthritis and uses limitation of motion to assess its severity.  Diagnostic Code 5260 evaluates limitation of flexion of the leg.  A noncompensable rating is warranted when flexion is limited to 60 degrees.  A 10 percent rating is warranted when flexion is limited to 45 degrees.  A 20 percent rating is warranted when flexion is limited to 30 degrees.  The highest schedular evaluation, 30 percent, is warranted when flexion is limited to 15 degrees.  38 C.F.R. § 4.71a.  Normal range of knee motion is 140 degrees of flexion and zero degrees of extension.  38 C.F.R. § 4.71, Plate II.
Other diagnostic codes relating to the knee include: Diagnostic Code 5256 (ankylosis), Diagnostic Codes 5258 and 5259 (symptomatic dislocation and/or removal of semilunar cartilage), Diagnostic Code 5262 (impairment of tibia and fibula) and Diagnostic Code 5263 (genu recurvatum).  As noted below, these conditions are not shown on examination and application of these diagnostic codes is not warranted.  38 C.F.R. § 4.71a.
In August 2010, VA treatment records reflect complaints of right knee pain, popping, locking, aching, and throbbing.  On examination, medial joint line tenderness was noted, and a medial meniscus tear was suspected.  In October 2011, the Veteran’s right knee exhibited full range of motion, but with tenderness.  McMurray’s and Lachman’s testing was positive.  
In a July 2013 VA examination, the Veteran was diagnosed with degenerative joint disease of the right knee, status post arthroscopic surgery for a meniscal tear.  The Veteran reported flare ups in which his knee would swell.  The Veteran’s right knee exhibited full range of motion with objective evidence of pain at the endpoint of his flexion.  Repetitive use testing did not additionally limit ranges of motion.  Functional loss was noted in his right knee with pain on movement and disturbance of locomotion.  Muscle strength testing was normal.  Joint instability tests were normal.  There was no patellar subluxation or dislocation. 
In August 2015, the Veteran underwent another VA examination to assess the severity of his knee disability.  The Veteran reported pain and stiffness with prolonged walking and standing.  The Veteran’s right knee maintained full range of motion with pain noted on flexion that did not result in or cause functional loss.  There was no pain on weight bearing or crepitus noted.  Repetitive use did not additionally limit range of motion.  The examination was neither consistent or inconsistent with the Veteran’s statement describing functional loss in a flare up or after repetitive use.  Such an answer would reportedly require speculation if the examiner did not assess the Veteran in those specific situations.  No ankylosis was found on examination.  There was no indication of instability or recurrent subluxation.  The examiner concluded that the Veteran’s right knee disability presented no functional impact.
With regard to limitation of motion, in order to warrant a schedular evaluation of 20 percent for the Veteran’s right knee disability under Diagnostic Code 5260, there would need to be evidence of limitation of flexion to 30 degrees.  Treatment records and the VA examination report do not indicate flexion to such a degree.  In fact, the Veteran demonstrated full range of motion with pain only noted at 140 degrees of flexion, the endpoint of the range of motion.  The Veteran has not reported limitations of flexion more severe than assessed on examination.  Accordingly, his right knee disability is not entitled to a higher evaluation based on limitation of flexion.  The Veteran has not demonstrated at any point that he experiences limitation of extension or pain with extension.
The Board further finds that there is no basis for the assignment of an increased rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7.  The Veteran’s present 10 percent evaluation was afforded in consideration of his subjective reports of painful motion and objective pain on flexion during his VA examinations.  The Court has held that “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.”  Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011).  Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.”  Id., quoting 38 C.F.R. § 4.40.  In this case, even with his complaints of pain, the Veteran had no loss of range of motion.  He also did not report additional limitations in range of motion during flare ups and after repetitive use.  He primarily reported chronic pain, particularly after prolonged sitting or standing.  As such, the 10 percent rating presently awarded in consideration of painful motion is sufficient in light of DeLuca.
The Board notes that the medical evidence of record has not found recurrent subluxation or lateral instability of the knee throughout this period on appeal.  Nor have there been any medical findings of dislocation or removal of the semilunar cartilage of the right knee, impairment of the tibia or fibula, or genu recurvatum.  In the absence of such findings, evaluating the Veteran’s right knee under Diagnostic Codes 5256, 5257, 5258, 5262 and 5263 is not appropriate.  38 C.F.R. 4.71a; see generally VAOPGCPREC 23-97.
In sum, the Veteran’s limitation of motion and symptomatology do not rise to the level of a 20 percent initial evaluation.  As the preponderance of the evidence weighs against an increased evaluation, the rule regarding benefit of the doubt is not for application.  The Board finds that a rating in excess of 10 percent is not warranted.
5. The claim of entitlement to a temporary total evaluation for a right knee replacement
The Veteran contends that he is entitled to a temporary total evaluation for his right knee replacement on March 23, 2016.
Knee replacements are evaluated under Diagnostic Code 5055.  For one year following a prosthetic knee replacement, a 100 percent rating is warranted.  Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity, warrant a 60 percent rating.  With intermediate degrees of residual weakness, pain or limitation of motion, rate by analogy to Diagnostic Codes 5256, 5261, or 5262.  The minimum rating is 30 percent.
Following the Veteran’s right knee replacement, the RO recategorized his right knee disability under Diagnostic Code 5055 and afforded the minimum evaluation.  As the present claim on appeal stems from the Veteran’s initial grant of service connection for a right knee disability and initial evaluation, the period on appeal includes the year in which he recovered from his right knee replacement.  The RO recognized this procedure, but failed to award a temporary total evaluation as specifically listed in Diagnostic Code 5055.  Accordingly, as the Veteran’s VA treatment records specifically indicate that he underwent a right knee replacement on March 23, 2016, the Veteran is entitled to a temporary total evaluation for one year following the procedure.
6. The claim of entitlement to an evaluation in excess of 10 percent for a left wrist disability
The Veteran contends that he is entitled to an evaluation in excess of 10 percent for his left wrist disability.
The Veteran’s left wrist disability is evaluated under Diagnostic Code 5215 for limitation of motion of the wrist.  A 10 percent rating, which the Veteran presently receives, is the maximum evaluation under the Diagnostic Code.  
Under Diagnostic Code 5215, a 10 percent evaluation is awarded where dorsiflexion is limited to less than 15 degrees.  A 10 percent evaluation is also provided for when the palmar flexion is limited in line with the forearm.  38 C.F.R. § 4.71a, Diagnostic Code 5215.  Normal palmar flexion of the wrist is 80 degrees and normal dorsiflexion (extension) of the wrist is 70 degrees of motion.  Normal ulnar deviation of the wrist is 45 degrees and normal radial deviation of the wrist is 20 degrees of motion.  38 C.F.R. § 4.71, Plate I.
Diagnostic Code 5214 provides ratings for ankylosis of the wrist.  Favorable ankylosis of the wrist in 20 degrees to 30 degrees dorsiflexion is rated 30 percent disabling for the major wrist and 20 percent for the minor wrist; ankylosis of the wrist in any other position except favorable is rated 40 percent disabling for the major wrist and 30 percent for the minor wrist; and unfavorable ankylosis of the wrist in any degree of palmar flexion, or with ulnar or radial deviation, is rated 50 percent disabling for the major wrist and 40 percent for the minor wrist.  A Note provides that extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a.  As will be discussed below, this Diagnostic Code is not applicable to the Veteran’s present wrist disability.
In August 2014, the Veteran underwent a VA examination to reassess the severity of his left wrist disability.  The examiner noted a diagnosis of status post left wrist reconstruction with ulnar resection.  The Veteran reported stiffness and loss of mobility during flare ups.  The Veteran retained full range of motion in his wrist with no objective evidence of painful motion on examination.  Repetitive use did not additionally limit his range of motion.  The examiner noted functional loss attributable to loss movement than normal and excess fatigability.  There was no pain on palpation.  Muscle strength was normal.  No ankylosis was found on examination.  Additional range of motion limitations could not be estimated as the Veteran was not experiencing a flare up. 
In August 2015, the Veteran underwent a second VA examination to assess the severity of his left wrist disability.  The Veteran reported weakness with grip, pain and giving way during flare ups.  He reportedly would not elaborate further when the examiner asked for additional details.  Palmar flexion was to 80 degrees and dorsiflexion to 75 degrees.  Ulnar deviation was to 30 degrees and radial deviation to 10 degrees.  Pain was noted on the examination that did not cause functional loss.  There was no pain with weight bearing, and no objective evidence of crepitus.  The examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare up.  The examiner reported that he would need to be examined during flare ups to avoid resorting to speculation.  Muscle strength was normal and there was no atrophy present.  No ankylosis was noted on examination.  The examiner reported that the Veteran’s left wrist disability presented no functional impact.
The Veteran’s VA treatment records reflect complains of chronic pain associated with his left wrist, and are consistent with the reports provided in the VA examinations of record.
As it relates to limitation of motion, applying the range of motion measurements to the diagnostic criteria outlined above, the evidence demonstrates the Veteran is not entitled to an evaluation in excess of 10 percent for his left wrist disability.  38 C.F.R. § 4.71a, Diagnostic Code 5215.  As noted above, the Veteran is already receiving the maximum rating available under Diagnostic Code 5215.  The Veteran could receive an increased evaluation if favorable or unfavorable ankylosis of the wrist was found.  However, as noted, there is no objective evidence of ankylosis of the wrist.  Therefore, Diagnostic Code 5214 is not relevant to the claim.
The Board has considered whether separate ratings are warranted for any neurological disorder associated with the Veteran’s left wrist injury.  In this regard, the Court has held that evaluations for distinct disabilities resulting from the same injury can be combined so long as the symptomatology for one condition is not “duplicative or overlapping with the symptomatology” of the other condition.  See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).  In this case, the Veteran has not reported neurological symptoms, including tingling or burning, associated with his left wrist disability.
The Board has considered whether a higher disability rating for the left wrist is warranted on the basis of functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59.  See also DeLuca, 8 Vet. App. At 204-7.  Here, there is no question that the service-connected left wrist disability has caused pain and stiffness, which have restricted overall motion.  While the examiner in the most recent VA examination concluded that an estimation of additional limitation in range of motion could not be provided without mere speculation, the Veteran did not wish to elaborate on his description of symptoms and limitations, as noted in the examination report.  In this situation, the Board finds that the examiner’s reasoning is sufficient and does not warrant a supplemental opinion for further clarification.  The Veteran has consistently reported chronic pain and difficulty with motion; however, as noted above, even taking into account additional functional limitation due to pain, the general lay statements, the VA examination reports, and VA treatment records, range of motion for this period does not more nearly approximate compensable limitation of motion or ankylosis of the wrist, to include unfavorable ankylosis limited to 20 to 30 degrees of dorsiflexion. 
For these reasons, the degree of functional impairment does not warrant a higher rating based on limitation of motion for the left wrist disability.  As such, the Board finds that a disability rating in excess of 10 percent is not warranted under Diagnostic Code 5214 for the left wrist disability.  For these reasons, the preponderance of the evidence weighs against a finding that the left wrist disability more closely approximated a higher disability rating than 10 percent at any point on appeal.  See 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07.
7. The claim of entitlement to an initial evaluation in excess of 10 percent for a back disability
The Veteran contends that he is entitled to an evaluation in excess of 10 percent for a back disability.
The Veteran’s back disability is rated under Diagnostic Code 5242 for degenerative arthritis of the spine.  Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes).  Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without 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.
The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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 rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  38 C.F.R. § 4.71a.
A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine.  Id.
A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine.  Id.
A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine.  Id.
Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code.  38 C.F.R. § 4.71a. 
Note (2) (See also Plate V) provides that, 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.  The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation.  The normal combined range of motion of the thoracolumbar spine is 240 degrees.  The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.  Id. 
Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2).  Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.  Id. 
Note (4) instructs to round each range of motion measurement to the nearest five degrees.  Id. 
Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.  Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.  Id. 
Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, a rating of 40 percent is warranted for incapacitating episodes with a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.  A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least 6 weeks during the past 12 months.  38 C.F.R. § 4.71a, IVDS Formula.  For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  Id. at Note (1).
In September 2012, the Veteran’s wife, a registered nurse, submitted a statement endorsing ongoing pain related to the Veteran’s back disability.  The Veteran’s VA treatment records reflect complaints of back pain and subsequent treatment, including physical therapy.
In August 2014, the Veteran underwent a VA examination to assess the nature and severity of his back disability.  He was diagnosed with a thoracolumbar strain, status post lumbar spine surgery, and degenerative joint disease of the thoracic spine.  The Veteran reported pain and back spasms associated with flare ups.  The Veteran’s exhibited full range of motion on examination with pain at the end ranges of motion.  Repetitive use testing did not additionally limit his range of motion.  Functional loss was noted with excess fatigability.  There was no tenderness or pain to palpation.  The Veteran did not exhibit guarding or muscle spasm of the spine.  His muscle strength, reflexes and sensory examinations were normal with no atrophy noted.  The straight leg raising test was negative.  No indications of radiculopathy and IVDS were found on examination.
In August 2015, the Veteran underwent a second VA examination to assess the nature and severity of his back disability.  The examiner again noted degenerative joint disease.  The Veteran reported flare ups of the back that involved difficulty bending and lifting due to pain and stiffness.  He exhibited full range of motion with pain on extension that did not result in or cause functional loss.  Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time.  The examiner noted that the examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare up or after repetitive use.  To estimate additional loss would require speculation on the part of the examiner.  The Veteran did not exhibit guarding or muscle spasm.  His muscle strength was normal with no atrophy.  His deep tendon reflexes were normal, as was his sensory examination.  Radiculopathy was noted as bilateral lower extremity numbness.  There was no indication of ankylosis on examination, nor did the Veteran have IVDS.  The examiner found no functional impact.
In March 2018, the Veteran underwent a third VA examination to assess the nature and severity of his back disability.  He described his flare ups as “throbbing pain” that could be “sharp” as well.  He reported needing to be cautious with twisting and turning.  Flare ups occurred every 1-2 weeks and lasted 1-2 days.  The Veteran reported that this caused him to be unable to do yardwork, nor could he twist, turn or lift heavy things.  Forward flexion was limited to 80 degrees.  Extension was limited to 10 degrees.  Right lateral flexion was limited to 15 degrees with left lateral flexion limited to 20 degrees.  Right and left lateral rotation were limited to 15 degrees.  Repetitive use testing did not additionally limit range of motion.  There was objective evidence of pain on range of motion testing and evidence of localized tenderness or pain on palpation of the pain.  Pain on flexion and extension were noted to cause functional loss.  Examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare ups.   The examiner could not estimate additional limitation in range of motion without speculation as “there is no conceptual or empirical basis of making such a determination without directly observing function under these conditions.”  The Veteran exhibited guarding that did not result in abnormal gait or abnormal spinal contour.  Normal muscle strength was noted without atrophy.  The Veteran’s reflex and sensory examinations were normal.  The straight leg raising test was negative as well.  The Veteran’s radiculopathy caused mild intermittent pain, paresthesias and/or dysesthesias and numbness of bilat lower extremities. There was no indication of ankylosis or IVDS.  The examiner reported that the Veteran’s back disability caused difficulty standing for long periods of time, bending and heavy lifting.
In April 2018, the Veteran underwent a fourth VA examination to assess the nature and severity of his back disability.  The Veteran described flare ups in his back as spasms that caused him to be unable to move.  He stated that it was hard to pick up, twist or bend down.  Flexion was limited to 70 degrees, extension to 25 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, and right and left lateral rotation to 30 degrees.  The examination was consistent with the Veteran’s reported functional loss with repetitive use and during flare ups.  The examiner estimated range of motion in those situations as follows: flexion to 75 degrees, extension to 25 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, right and left lateral rotation to 30 degrees.  There was no guarding or muscle spasm found on examination.  Pain during walking, sitting or standing for prolonged periods contributed to his overall disability.  There was no muscle atrophy.  His reflexes and senses were normal.  There were no signs of radiculopathy on examination.  There was no indication of ankylosis or IVDS.
After a thorough review of the medical and lay evidence of record, the Board finds that a 10 percent evaluation, and no higher, is appropriate throughout the period on appeal.  At worst, the Veteran’s forward flexion was limited to 70 degrees in April 2018, and his combined range of motion of the thoracolumbar spine was limited to 145 degrees in March 2018.  These measurements fall squarely within the 10 percent evaluation.  At no time in the evidence of record did the Veteran’s forward flexion fall to between 30 and 60 degrees.  Similarly, his combined range of motion was not less than 120 degrees.  Additionally, while, at one point, the Veteran had guarding of the spine, it did not result in an abnormal gait or abnormal spinal contour.  While the Veteran’s wife reported an abnormal gait in her September 2012 statement, she indicated that the pain in the Veteran’s left ankle was the primary cause. 
The Board has also considered application of 38 C.F.R. §§ 4.40, 4.45, and 4.59, and DeLuca for the entire appeal period, specifically the additional limitations of motion due to pain, fatigability, and weakness, in reaching the finding that a disability rating in excess of 10 percent is not warranted.  Although the record contains reports that the Veteran experienced pain during range of motion testing, such findings do not provide for higher ratings in this case.  The pain experienced by the Veteran during range of motion testing is already accounted for in the ratings awarded by the Board.  The DeLuca factors go to additional loss of function caused by limitation of motion due to pain, fatigability, and weakness.  Even with consideration of the additional limitation of motion due to pain as estimated in the April 2018 VA examination, ranges of motion did not rise to the level of a 20 percent evaluation.  Therefore, a 10 percent rating under the General Rating Formula for Disease and Injuries of the Spine and 38 C.F.R. § 4.59 is appropriate, and a higher rating is not warranted. 
Neither the VA examination reports of record nor the VA treatment records indicated that the Veteran had IVDS.  While Veteran reported having exacerbations of his low back pain that may be alleviated by rest, there is nothing in the evidence to suggest that these exacerbations required both bed rest prescribed by a physician and treatment by a physician.  For this reason, the Board finds that a disability rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted.  See 38 C.F.R. § 4.71a.
The preponderance of the evidence weighs against a finding that the Veteran’s back disability more closely approximated an evaluation in excess of 10 percent at any point on appeal.  See 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07.  As such, the Board finds that a disability rating in excess of 10 percent is not warranted under Diagnostic Code 5214 for a back disability.  
8. The claim of entitlement to a compensable evaluation for a left ankle disability
The Veteran contends that he is entitled to a compensable evaluation for his left ankle disability. 
The Veteran’s left ankle disability is presently evaluated under Diagnostic Code 5271 for limitation of motion of the ankle.  Moderate limitation of motion of the ankle warrants a 10 percent rating.  Marked limitation of motion of the ankle warrants a 20 percent rating, which is the maximum schedular rating under Diagnostic Code 5271.  The Board notes that “normal” ranges of motion of the ankle joint for dorsiflexion is 0 to 45 degrees, and for plantar flexion, 0 to 20 degrees.  See 38 C.F.R. § 4.71a, Plate II. 
In June 2012, the Veteran underwent a VA examination to assess the nature and severity of his left ankle disability.  The Veteran reported that his left ankle was “giving out” more, which caused him to put stress on his right ankle.  Flare ups were reported as swelling and difficulty walking.  The Veteran’s left ankle exhibited full range of motion with no objective evidence of pain on examination.  Repetitive use testing did not change the range of motion.  There was no pain on palpation and normal muscle strength.  No instability was found on examination.  Similarly, no ankylosis was noted.  The examiner sound no functional loss or functional impairment of the ankle.  The Veteran reported that his ankle impaired his ability to stand or walk for long periods of time. 
In September 2012, the Veteran’s wife reported that the Veteran would return home from work and experience pain in his left ankle.
In August 2014, the Veteran underwent a second VA examination to assess the nature and severity of his left ankle disability.  The Veteran reported being unable to walk due to swelling and pain.  Range of motion of the left ankle was normal with no objective evidence of pain on examination.  Repetitive use testing did not further limit range of motion.  There was no pain on palpation, and muscle strength was normal.  The examination found no instability or ankylosis.  The examiner noted no functional loss or impairment of the ankle.
An August 2015 VA examination report did not deviate substantially from the August 2014 examination report.  The Veteran reported flare ups of the left ankle consisting of pain, weakness and swelling with walking or standing.  Left ankle range of motion was normal with no objective pain on examination.  There was no localized tenderness of pain on palpation.  Repetitive use did not further limit range of motion.  Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over time.  The examiner noted that the examination with neither medically consistent or inconsistent with his statements describing functional loss during flare ups.  The examiner reported that he would need to be examined in a flare up to avoid resorting to mere speculation.  Muscle strength was normal and no atrophy was found on examination.  There was no ankylosis on examination.  The examiner found no functional impact.
The Veteran’s VA treatment records reflect ongoing complaints of chronic pain associated with his left ankle, but the Veteran retained full range of motion throughout his treatment records.  
Upon review of all the evidence, the Board finds the Veteran’s disability has manifested primarily as pain and swelling with prolonged standing or walking; however, these symptoms have not resulted in moderate limited motion of the ankle.  While the Board has considered the Veteran’s symptoms as reported in VA treatment records, lay statements and VA examinations, the range of motion testing conducted during the June 2012, August 2014 and August 2015 VA examinations show full range of motion with no objective evidence of pain on examination.  These symptoms warrant a noncompensable disability rating under Diagnostic Code 5271.  See 38 C.F.R. § 4.71a, Diagnostic Code 5271.  While the Veteran reports swelling of the ankle, he did not, through three VA examinations and his VA treatment records, provide subjective reports of limitation of motion that might be considered by VA examiners or the Board.  Overall, the claims file does not include any medical or lay evidence showing moderate or marked motion limitation of the left ankle.
The Board has also considered whether the Veteran’s disability warrants a separate or higher disability rating under a different Diagnostic Code.  However, the clinical evidence does not reflect the presence of ankylosis, malunion of the os calcis or astragalus, or astragalectomy in any of the medical treatment records during the appellate period.  38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272-5274.  Therefore, a separate disability rating and/or a compensable disability rating is not warranted under any other Diagnostic Code.  38 C.F.R. § 4.71a.
Finally, treatment records and lay statements throughout this appeal show continued complaints of left ankle pain.  Painful motion is entitled to at least the minimum compensable rating for the joint under 38 C.F.R. § 4.59.  As there are examination findings reflecting previous surgical reconstruction of the left ankle, and credible subjective evidence of painful motion, the criteria of 38 C.F.R. § 4.59 are met.  Based upon credible evidence of pain and the provisions of 38 C.F.R. § 4.59, a 10 percent evaluation, but no higher, is granted for left ankle disability.
9. The claim of entitlement to an initial evaluation in excess of 50 percent for major depressive disorder prior to January 12, 2017
The Veteran contends that he is entitled to an initial evaluation in excess of 50 percent for major depressive disorder.
The Veteran’s service-connected major depressive disorder is evaluated under Diagnostic Code 9434.  Mental disorders are rated under the General Rating Formula for Mental Disorders pursuant to 38 C.F.R. § 4.130.  A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.
A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).
A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.
A 70 rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships.
A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.
The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating.  Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002).  However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that those symptoms have resulted in the type of occupational and social impairment associated with that percentage.  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013).
In September 2012, the Veteran’s wife reported that his physical pain caused sexual dysfunction, depression and anxiety.
In September 2014, the Veteran underwent a VA examination to assess the nature and severity of his major depressive disorder.  The Veteran was diagnosed with both major depressive disorder and alcohol use disorder in remission.  The Veteran’s symptoms were entirely attributable to his depressive disorder.  Overall, the examiner assessed occupational and social impairment due to mild of transient symptoms.  The Veteran had been married three times, and was in a good relationship at the time of examination.  The Veteran reported good relationships with his mother, son and grandson.  He also endorsed a history of domestic violence in previous relationships, as also reflected in his service treatment and personnel records.  He reported working a variety of jobs primarily as the general manager of multiple restaurants.  The Veteran changed jobs frequently, either move to a better position, or his wife’s career required them to move, or the restaurants themselves closed.  He exhibited low appetite and energy at the time of examination.  He expressed a loss of interest in projects around the house, including yard work.  The Veteran endorsed suicidal ideation in the past, but denied it at the time of examination.  He denied panic attacks.  The Veteran’s symptoms were: depressed mood, and disturbances of motivation and mood.  The Veteran was appropriately dressed and groomed for the examination.  He was alert and oriented throughout.  His thoughts were logical and organized with no evidence of psychosis.  The Veteran denied both suicidal and homicidal ideation. 
In August 2015, the Veteran underwent a second VA examination to assess the nature and severity of his major depressive disorder.  His September 2014 diagnoses were confirmed and continued.  Overall, the examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  The Veteran denied both in-patient and out-patient treatment.  He was prescribed medication by his general practitioner.  The Veteran reported periods of low moods, trouble concentrating, low energy, poor motivation, daytime tiredness, isolative behaviors, feelings of withdrawal, detachment reactions and poor sleep patterns.  He denied suicidal and homicidal ideation.  The Veteran’s symptoms were noted as: depressed mood, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.  On examination, his affect was flat with poor range.  There was no evidence of psychotic thinking.  The Veteran’s judgment, thought content, insight and thought processes were intact. 
After a thorough review of the medical and lay evidence of record, the Board finds that an initial evaluation in excess of 50 percent is not warranted for the Veteran’s service-connected major depressive disorder. 
The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his major depressive disorder.  The Board’s determination of the appropriate degree of disability is a finding of fact.  In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation.  See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017); citing Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013).  While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency and duration.  Mauerhan v. Principi, 16 Vet. App. 436, 442 (U.S. 2002).  As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal, and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130.
With relative consistency, the Veteran has reported symptoms of depression throughout this period.  While he endorsed more severe symptoms, VA examination reports noted that his depression in this period was mild overall.  The Veteran continued a positive relationship with his significant other throughout the period on appeal, and shared positive familial relationships with his mother, son and grandson.  While he and his wife reported a limited social circle, he still engaged with others during this time.  He also reported poor motivation and appetite, as well as daytime tiredness and low energy.  
Throughout this initial period on appeal, the Veteran consistently denied more severe symptoms, including: suicidal ideation, homicidal ideation, and hallucinations.  The Veteran remained alert and oriented in all spheres throughout this initial period.  The record does not reflect obsessional rituals, intermittently illogical speech, near-continuous panic or depression that affected the ability to function independently, unprovoked irritability with periods of violence, spatial disorientation, and neglect of personal appearance and hygiene.  The Veteran presented to the VA examinations as alert and oriented with his judgment, thought process, thought content and insight intact.  Further, the Veteran reported to examination adequately groomed with good hygiene.  The Veteran’s contemporaneous VA treatment records do not undermine these findings, and he did not seek additional mental health treatment throughout this initial period on appeal.
For this initial period, the Veteran’s symptomatology most closely approximates the 50 percent evaluation.  This evaluation still represents significant impairment in occupational and social life due to a service-connected mental disorder.  The category includes symptoms such as changes in speech patterns, panic attacks, difficulty understanding complex commands, memory impairments, impaired judgment and abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.  The Veteran’s affect was noted to be flat with poor range in his August 2015 VA examination.  No impairment of complex commands was noted.  His thinking remained clear and logical throughout the period on appeal.  The Veteran expressed some difficulty with his relationship with his father, but maintained productive relationships with the rest of his close family.  
In sum, the Veteran’s major depressive disorder manifested primarily with some impairments to social interactions and occupational functioning.  While evidence of record indicates some difficulty with social relationships and poor motivation, these symptoms, as demonstrated in years of treatment records, do not rise to the level of severity, frequency, and duration contemplated by a 70 percent, or higher, evaluation under the rating schedule.  Similarly, the Veteran experienced some difficulty with employment in this period, but he reported that his job changes were unrelated to his major depressive disorder.  Instead, the frequency with which he changed job was related to external factors, such as moving locations for his wife’s employment, and changing positions to find a better employment opportunity.   Overall, it is not the symptoms themselves that determine the evaluation, but their effects.  When taken as a whole, the effects of the Veteran’s symptomatology in this period of time do not present occupational and social impairments in most areas of daily life. 
Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable.  The Veteran’s claim of entitlement to an initial evaluation in excess of 50 percent for major depressive disorder prior to January 12, 2017, must be denied.
10. The claim of entitlement to an evaluation in excess of 50 percent for major depressive disorder since January 12, 2017
In January 2017, the Veteran’s neighbor submitted a statement reporting that the Veteran struggled with depression, and that his short-term memory was worsening.  The Veteran seldom had company, and while the neighbor interacted with the Veteran, he reportedly did not divulge many details about his life.  The neighbor felt he lacked motivation, and had a temper.  The neighbor believed the Veteran did not cope well with stress.  He reportedly became angry and either “throws a fit like a child” or shuts down.  The Veteran’s wife submitted a concurrent statement reporting that the Veteran experienced panic attacks at least once a week and short-term memory loss.  She reported that he had difficulty understanding complex commands and lacked motivation.  The Veteran’s wife stated that he had a limited social circle and lost interest in sexual activity.  Additionally, his appearance and hygiene declined, and she needed to remind him to shower.  
In April 2017, the Veteran underwent a private evaluation to assess his major depressive disorder.  In the Disability Benefits Questionnaire (DBQ), the private examiner reported that the Veteran exhibited occupational and social impairment with deficiencies in most areas.  His symptoms included: depressed mood, anxiety, panic attacks weekly or less often, near continuous panic or depression affecting the ability to function independently, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and neglect of personal appearance and hygiene.  The Veteran’s attention was normal but his concentration was variable.  He exhibited trouble with his short-term memory.  The Veteran’s speech flow was normal, and his thought content was appropriate.  He reported feeling anxious and depressed, and acted suspiciously during the examination.  The examiner believed him to be paranoid when speaking with her.  The examiner opined that the severity of his condition related back to his original claim date of March 2012.  
This period on appeal also reflects ongoing mental health treatment, primarily focused around the Veteran’s stepdaughter living at home.  By way of example, in June 2017, he reported that his stepdaughter was living with him, and her issues had become overwhelming for him and his wife.  The couple was also engaging in couple’s counseling concurrently.  The Veteran continued to deny suicidal and homicidal ideation, as well as nightmares and flashbacks.  He reported to the appointment well-groomed and appropriately dressed.  The Veteran’s speech was clear and within normal limits. 
In April 2018, the Veteran underwent another VA examination to assess the nature and severity of his major depressive disorder.  The examiner determined that the condition caused occupational and social impairment with deficiencies in most areas.  His symptoms included: depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and impaired impulse control.  Upon examination, the Veteran’s affect was flat with delayed speech.  
After a thorough review of the medical and lay evidence of record, the Board finds that a 70 percent evaluation, but no higher, is warranted for the period since January 12, 2017. 
The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his major depressive disorder.  The Board’s determination of the appropriate degree of disability is a finding of fact.  In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation.  See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017); citing Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013).  While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency and duration.  Mauerhan v. Principi, 16 Vet. App. 436, 442 (U.S. 2002).  As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal, and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130.
When considering the severity, frequency and duration of the impairments as delineated in the 70 percent evaluation, the Board notes that the symptoms listed present a significant impediment to daily life.  Symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression, and the inability to establish and maintain effective relationships, present obstacles to routine functioning on a daily basis.  Personal hygiene and grooming are not limited to one particular sphere, but affect work, school, and family relations.  Spatial disorientation and intermittently illogical speech are markedly severe symptoms associated with basic cognitive function and the ability to interact with the world.  Suicidal ideation, in of itself, represents the impulse or desire to remove oneself from the world entirely.  As exemplified by the symptoms listed in this category, the 70 percent evaluation is appropriate for deficiencies that harm most areas of life.  Either symptoms are continuous, or near-continuous, or represent such a severity that routine daily functions are chronically impeded.  
In contrast, the evaluation for a 100 percent impairment includes symptomatology that presents a total impairment to daily functioning.  Not only are the representative symptoms of the most severe possible from a psychiatric disorder, but they interfere with the ability to independently engage in activities of daily life.  Persistent delusions or hallucinations, disorientation to time or place, and significant memory loss all prevent the person from routine engagement with the world.  The ability to even maintain the most basic hygiene standards has been harmed by the severity or frequency of the associated symptomatology.  When symptoms of a psychiatric disorder are so severe as to present a total impairment to occupational and social activity, then a 100 percent evaluation should be afforded.
Throughout the period on appeal, the Veteran endorses symptoms of depressed mood, panic attacks weekly or less often, mild memory loss, disturbances of motivation and mood, difficulty adapting to stressful circumstances, and neglect of personal appearance and hygiene.  The Veteran’s wife and neighbor both reported a significant worsening of symptoms from the August 2015 VA examination that are in line with those reported in the April 2017 DBQ.
However, the manifestations of the Veteran’s service-connected depressive disorder in this timeframe do not rise to the level of a total occupational and social impairment for the purposes of 38 C.F.R. § 4.130.  His impairments, while touching on many areas of his life, are not of such severity to interfere with routine functions necessary for daily life.  The Veteran maintained positive relationships with his family, and entered counseling to help cope with the additional stressors of his stepdaughter’s own psychiatric disorder as she lived with him.  The Veteran continued to deny both suicidal and homicidal ideations.  His thought processes and content, as well as judgment and insight, remained intact throughout this period.  The Veteran continued to competently handle his household finances.  In sum, the Veteran’s symptoms do not mirror the severity, frequency and duration of ones such as persistent delusions or hallucinations, or inability to attend to basic hygiene, though his wife may remind him to shower.  
The Board has reviewed carefully the medical opinions in this matter.  The credibility and weight to be attached to a medical opinion are within the Board’s province as finder of fact.  Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).  Greater weight may be placed on one opinion over another depending on factors such as reasoning employed and whether or not, and the extent to which, the prior clinical records and other evidence were reviewed.  Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994).  Also, the probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the analytical findings, and the probative weight of a medical opinion may be reduced if the physician fails to explain the basis for an opinion.  Sklar v. Brown, 5 Vet. App. 140 (1993).  Factors considered when assessing the probative value of a medical opinion include the physician’s access to the claims file along with the thoroughness and detail of the opinion.  Prejean v. West, 13 Vet. App. 444, 448-9 (2000).
The Veteran’s private examiner opined that the severity of the symptoms associated with his major depressive disorder related back to his original claim in March 2012.  While the Board agrees that the Veteran exhibited occupational and social impairment with deficiencies in most areas as early as January 12, 2017, the date of his neighbor’s lay statement, the Board cannot substantiate the private examiner’s claim based upon the evidence of record.  The Veteran underwent two VA examinations in the initial period on appeal, both of which determined that, based on extensive examination, his symptoms did not exceed an impairment with occasional decrease in work efficiency.  The private examiner, additionally, did not substantiate the claim that the severity of the symptoms dated back to March 2012.  This conclusion is reported in isolation and does not address any purported oversights in the two previous VA examinations.  Accordingly, this conclusion by the private examiner is afforded significantly diminished probative weight.
While the Veteran certainly continues to cope with manifestations of his depression, they do not rise to the level of a total occupational and social impairment as contemplated by the rating schedule.  Accordingly, resolving reasonable doubt in favor of the Veteran, the manifestations of his major depressive disorder most closely approximate the criteria for a 70 percent evaluation since January 12, 2017, the date of his neighbor’s lay statement as this was the earliest ascertainable increase in his disability.  As the preponderance of the evidence weighs against the claim for an evaluation in excess of 70 percent, and the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable.  The Veteran’s claim of entitlement to an evaluation of 50 percent, but no higher, since January 12, 2017, is granted.
Effective Date
The statutory guidelines for the determination of an effective date of an award of disability compensation are set forth in 38 U.S.C. § 5110.  Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later.  38 C.F.R. § 3.400.  
A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid to any individual under the laws administered by the VA.  38 U.S.C. § 5101(a).  A “claim” is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit.  38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-5 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992).  Any communication indicating intent to apply for a benefit under the laws administered by the VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought.  See 38 C.F.R. § 3.155(a); Servello, 3 Vet. App. at 199 (holding that 38 C.F.R. § 3.155(a) does not contain the word “specifically,” and that making such precision a prerequisite to acceptance of a communication as an informal claim would contravene the Court’s precedents and public policies underlying the statutory scheme).  To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim.  See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992).
Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution.  If received within one year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim.  An application is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit.  38 C.F.R. § 3.1(p); see also Rodriguez v. West, 189 F.3d. 1351 (Fed. Cir. 1999), (an expressed intent to claim benefits must be in writing in order to constitute an informal claim; an oral inquiry does not suffice).
38 C.F.R. § 3.155(c) provides that when a claim has been filed which meets the requirements of 38 C.F.R. § 3.151 or 38 C.F.R. § 3.152, an informal request for increase or reopening will be accepted as a claim.
Like an increased rating, the effective date for a staged rating is the earliest date it is factually ascertainable there has been an increase in disability.  38 C.F.R. § 3.400 (o)(2), Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).  Determining the effective date for rating claims, in sum, requires analyzing when the claim was received and when the increase in disability actually occurred.  A claim is a written communication requesting a determination of, or evidencing a belief in, entitlement to benefits.  38 C.F.R. § 3.1 (p).  For claims dated prior to March 24, 2015, claims were either formal or informal.
11. The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of service connection for a back disability
The Veteran contends that he is entitled to an effective date earlier than January 24, 2014, for the grant of service connection for a back disability.
On January 24, 2014, the Veteran submitted a claim of entitlement to service connection for a back disability.  In accordance with the applicable regulations concerning the assignment of effective dates, January 24, 2014, is the earliest date for the award of service connection for a back disability as it is the date on which the Veteran’s claim of entitlement to service connection was received.  See 38 C.F.R. § 3.400.  Prior to this claim, the Veteran did not submit any other formal or informal claim of entitlement to benefits for the disability.  While the Veteran believes he is entitled to an earlier effective date, without a corresponding claim, such an effective date cannot be established.  Accordingly, an effective date earlier than January 24, 2014, cannot be established for the grant of service connection for a back disability. 
12. The claim of entitlement to an effective date earlier than April 2, 2012, for the grant of an increased evaluation for a left ankle disability
The Veteran filed an informal claim for an increased evaluation for his left ankle that was received on March 29, 2012.  The Veteran next filed a formal claim of entitlement to a compensable evaluation for his left ankle disability, which was received on April 2, 2012.  In an August 2013 rating decision, the RO continued the Veteran’s previously noncompensable evaluation for his left ankle disability.  The Veteran filed a notice of disagreement on this issue with respect to the evaluation and its effective date.  The Veteran has been service connected for his left ankle since the date of his discharge from active duty.  Herein, the Board granted a 10 percent evaluation for his left ankle disability. 
The Veteran submitted an informal claim immediately prior to his formal claim of entitlement to an increased evaluation for a left ankle disability.  The date of the informal claim controls the effective date for the grant of the 10 percent evaluation.  Additionally, it is not factually ascertainable based upon the evidence of record that the Veteran’s left ankle disability worsened within the year prior to his March 29, 2012, informal claim.  The Veteran’s VA treatment records do not reflect complaints of pain in that one-year period.  The lay statements of record report pain overall, but only provide retrospective statements with respect to the Veteran’s left ankle disability.  In order to afford an effective date prior to the date of the informal claim, the evidence of record would need to reflect worsening before the date of that claim.  
In accordance with the applicable regulations concerning the assignment of effective dates, March 29, 2012, is the earliest date for the award of 10 percent for a left ankle disability as it is the date on which the Veteran’s claim of entitlement was received.  Prior to this informal claim, the Veteran did not submit any other formal or informal claim of entitlement to benefits for the disability.  While the Veteran believes he is entitled to an earlier effective date, without a corresponding claim, such an effective date cannot be established.  Accordingly, an effective date of March 29, 2012, is appropriate for the grant of a 10 percent evaluation for the Veteran’s left ankle disability.  An effective date earlier than March 29, 2012, cannot be established.
13. The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of a 10 percent evaluation for a left wrist disability
The Veteran filed his claim of entitlement to an evaluation in excess of 10 percent for his left wrist disability, which was received on January 24, 2014.  In a November 2014 rating decision, the RO granted a 10 percent evaluation for the Veteran’s previously noncompensable left wrist disability.  The Veteran filed a notice of disagreement on this issue with respect to the evaluation and its effective date.  The Veteran has been service connected for his left wrist since the date of his discharge from active duty.  
It is not factually ascertainable based upon the evidence of record that the Veteran’s left wrist disability worsened within the year prior to his January 24, 2014, claim.  The Veteran’s VA treatment records do not reflect an ascertainable worsening within that one-year period.  In order to afford an effective date prior to the date of claim, the evidence of record would need to reflect worsening before the date of the claim.  In accordance with the applicable regulations concerning the assignment of effective dates, December 2, 2010, is the earliest date for the award of service connection for IVDS as it is the date on which the Veteran’s claim of entitlement to service connection was received.  See 38 C.F.R. § 3.400.  Prior to this claim, the Veteran did not submit any other formal or informal claim of entitlement to benefits for the disability.  While the Veteran believes he is entitled to an earlier effective date, without a corresponding claim, such an effective date cannot be established.  Accordingly, an effective date earlier than January 24, 2014, cannot be established for the grant of a 10 percent evaluation for a left wrist disability.  
14. The claim of entitlement to an effective date earlier than January 24, 2014, for the grant of service connection for major depressive disorder
The Veteran contends that he is entitled to an effective date earlier than January 24, 2014, for the grant of service connection for major depressive disorder.
On January 24, 2014, the Veteran submitted a claim of entitlement to service connection for major depressive disorder.  In accordance with the applicable regulations concerning the assignment of effective dates, January 24, 2014, is the earliest date for the award of service connection for major depressive disorder as it is the date on which the Veteran’s claim of entitlement to service connection was received.  See 38 C.F.R. § 3.400.  Prior to this claim, the Veteran did not submit any other formal or informal claim of entitlement to benefits for the disability.  While the Veteran believes he is entitled to an earlier effective date, without a corresponding claim, such an effective date cannot be established.  Accordingly, an effective date earlier than January 24, 2014, cannot be established for the grant of service connection for major depressive disorder.
15. The claim of entitlement to an effective date earlier than May 30, 2012, for the grant of service connection for a right knee disability
The Veteran contends that he is entitled to an effective date earlier than May 30, 2012, for the grant of service connection for a right knee disability.
On May 30, 2012, the Veteran submitted a claim of entitlement to service connection for a right knee disability.  In accordance with the applicable regulations concerning the assignment of effective dates, May 30, 2012, is the earliest date for the award of service connection for a right knee disability as it is the date on which the Veteran’s claim of entitlement to service connection was received.  See 38 C.F.R. § 3.400.  Prior to this claim, the Veteran did not submit any other formal or informal claim of entitlement to benefits for the disability.  While the Veteran believes he is entitled to an earlier effective date, without a corresponding claim, such an effective date cannot be established.  Accordingly, an effective date earlier than May 30, 2012, cannot be established for the grant of service connection for a right knee disability.
REASONS FOR REMAND
1. The claim of entitlement to service connection for a neck disability is remanded.
The Board cannot make an informed decision regarding the claim of entitlement to service connection for a neck disability as the medical examinations of record are inadequate for adjudicative purposes. 
The August 2014 VA examination failed to provide an opinion with respect to the etiology of the Veteran’s claimed neck disability.  In that examination, however, the Veteran was diagnosed with a cervical strain, degenerative disc disease of the cervical spine and degenerative joint disease of the cervical spine.  In the August 2015 VA examination, the examiner could not render a diagnosis pertaining to the Veteran’s neck, and accordingly denied a nexus for lack of a present disability.  This appeared to contradict the same examiner’s reference to August 2014 x-rays that showed degenerative disc disease of the cervical spine.  
The Veteran’s VA treatment records reflect ongoing treatment, including physical therapy, for chronic neck pain.  Pain may be considered a disability for VA purposes if it results in functional impairment.  See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018).  It is unclear from the record the degree to which the Veteran’s cervical pain causes functional impairment.  The August 2015 examiner noted the Veteran’s reports of pain, including a previous x-ray evincing degenerative changes, but could not render a diagnosis.  This is insufficient given the parameters set in Saunders.  Accordingly, a new VA examination is necessary on remand in order to obtain an opinion regarding functional impairment that considers the Veteran’s competent lay reports of pain that may cause functional limitation.
2. The claim of entitlement to service connection for a left knee disability is remanded.
The Board cannot make an informed decision regarding the claim of entitlement to service connection for a left knee disability as the medical examinations of record are inadequate for adjudicative purposes.
The Veteran’s VA treatment records reflect ongoing complaints of chronic left knee pain that worsens with walking.  The Veteran subjectively reported that he placed additional stress on his left knee due to his right knee disability.  
An August 2015 VA examination noted a diagnosis of a left knee strain with corresponding flare ups that result in pain and stiffness.  The examiner denied direct service connection as there was no left knee pathology in service and there were no medical records over the years indicating a continuity of care.  Secondary service connection was denied as there were no objective findings of “pain to ankle to show correlation to left knee condition.  Also no medical records indicating problems/physical limitations of ankle to show possible impact to left knee.”  The examiner did not consider the Veteran’s right knee disability and surgeries in this conclusion, nor was it supported by an adequate rationale.  Accordingly, a thorough opinion regarding secondary service connection is warranted on remand. 
3. The claim of entitlement to service connection for a penile condition is remanded.
The Board cannot make an informed decision regarding the claim of entitlement to service connection for a penile condition, to include erectile dysfunction, as the medical examinations of record are incomplete.
While an opinion regarding direct service connection was obtained in August 2015, an adequate opinion regarding secondary service connection is not of record.  The resulting opinion noted that a nerve conduction study was necessary to corroborate the claims of erectile dysfunction secondary to neurological impairment, but it is unclear if the study was ever performed.  The Veteran’s wife, a registered nurse, reported that treatment for his physical disabilities caused his sexual dysfunction.  The Board has an obligation to consider all reasonably raised theories of entitlement to service connection, even if not specifically raised by the claimant.  See Douglas v. Derwinski, 2 Vet. App. 435 (1992) (evidence reasonably raising a service-connection theory not specifically raised by the claimant must be considered in adjudicating a claim); Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008).  In the context of a service connection claim, theories of entitlement such as direct service connection, secondary service connection and presumptive service connection are deemed as part of the appeal regardless of when the issue has been raised in the record.  Bingham v. Nicholson, 421 F.3d 1346, 1349 (2005).  Accordingly, an opinion must be obtained on remand that properly addresses secondary service connection as due to all of the Veteran’s service-connected disabilities, and the appropriate testing must be conducted.
4. The claim of entitlement to service connection for headaches is remanded.
The Board cannot make an informed decision regarding the claim of entitlement to service connection for a left knee disability as the medical examinations of record are inadequate for adjudicative purposes.
The Veteran’s August 2014 VA examination noted that he experienced tension headaches but did not have a formal diagnosis.  The August 2015 examination report, however, could not diagnose headaches.  Accordingly, a nexus opinion could not be rendered.  In that examination, the Veteran reported headaches that occurred once a day and lasted less than a day with resulting sensitivity to light and nausea.  The Veteran reported that he was diagnosed with tension headaches 3 years prior to the examination.  The Veteran is competent to report diagnoses made by a medical professional.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  Further, pain that results in functional impairment, even without a specific diagnosis, may be a disability for VA purposes.  See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018).  Based upon the evidence of record, the Veteran’s undiagnosed headaches may cause functional impairment due to their duration and frequency.  Accordingly, a more thorough VA examination is necessary to determine the functional impairment of the Veteran’s claimed headaches as well as their relationship with active duty service.
5. The claim of entitlement to an evaluation in excess of 30 percent for a right knee disability since March 24, 2017
The Board cannot make an informed decision regarding the severity of the Veteran’s right knee disability following his temporary total evaluation for a knee replacement as the most recent VA examination is inadequate for adjudicative purposes.
In March 2018, the Veteran reported that his right knee replacement felt “off” and he noted “looseness” in the joint, as well as swelling and heat.  While the March 2018 VA examination notes frequent episodes of joint pain, particularly as associated with prolonged standing and walking, symptoms of looseness and swelling are not discussed.  Diagnostic Code 5055 affords a minimum evaluation of 30 percent for residuals of a knee replacement, but a 60 percent for chronic residuals consisting of severe painful motion or weakness of the affected extremity.  As the symptoms reported in the VA treatment records reflect a much more serious residual impairment than the VA examination, clarification is necessary regarding the present severity of the residuals of the Veteran’s right knee replacement.  See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence... is essential for a proper appellate decision”).
6. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.
As the Veteran is asserting entitlement to TDIU, the Board finds that this issue is inextricably intertwined with the resolution of the remanded issue.  The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim.  See Harris v. Derwinski, 1 Vet. App. 180 (1991).  Accordingly, this issue is remanded for readjudication following evidentiary development.
The matters are REMANDED for the following action:
1. Contact the Veteran and his representative in order to identify any outstanding non-VA treatment records regarding the issues on appeal.  If non-VA providers are identified, obtain releases for those records.  Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file.  If such records cannot be obtained, inform the Veteran and his representative, and afford an opportunity for him to provide these outstanding records.
2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file.  If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e).  All attempts to contact the Veteran should be documented in the record.
3. Once the aforementioned development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his claimed neck and left knee disabilities, as well as the present severity of his right knee disability.  A complete copy of the claims file must be made available to the examiner, including a copy of this remand.  The examiner must consider the Veteran’s lay reports of observable symptomatology associated with each disability.  After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following:
Neck Disability
(a.) Identify any and all diagnoses pertaining to the Veteran’s neck.  Note: pain in of itself may constitute a disability for VA purposes if it results in functional impairment.
(b.) For each diagnosis, is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s neck disability had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service?
(c.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s neck disability was caused by or aggravated by his service-connected disabilities?
(d.) If aggravation of the neck disability is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the neck disability prior to aggravation.
Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability.

Left Knee Disability
(e.) Identify any and all diagnoses pertaining to the Veteran’s left knee.  Note: pain in of itself may constitute a disability for VA purposes if it results in functional impairment.
(f.) For each diagnosis, is it at least as likely as not (50 percent or greater probability) that the Veteran’s left knee disability was caused by or aggravated by his service-connected disabilities?
(g.) If aggravation of the left knee disability is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the left knee disability prior to aggravation.
Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability.
Right Knee Disability
(h.) Describe the current nature and severity of the Veteran’s right knee disability, including residual pain as reported by the Veteran and observed on examination, as well as weakness of the affected joint.
(i.) Assess both active and passive range of motion, as well as range of motion on weight-bearing and non-weight bearing.  If possible, estimate range of motion after repetitive use and during flare ups based upon observations in the examination and the Veteran’s lay reports of symptoms in these situations.
(j.) Discuss the functional limitation, if any, of the Veteran’s right knee disability with consideration of the Veteran’s lay statements regarding his experienced limitations due to symptomatology.  
(k.) If possible, provide a retrospective opinion since his knee replacement surgery regarding limitations due to repetitive use and flare ups based on the Veteran’s lay statements of experienced symptomatology.  
The examination report should specifically state that a review of the record was conducted.  The examiner should provide a complete rationale for all opinions provided.  If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion.
4. Once the aforementioned development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his erectile dysfunction.  A complete copy of the claims file must be made available to the examiner.  The examiner must consider the Veteran’s lay reports of observable symptomatology.  All indicated testing should be conducted.  After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following:
(a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s erectile dysfunction was caused by or aggravated by his service-connected disabilities?
(b.) If aggravation of his erectile dysfunction is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for his erectile dysfunction prior to aggravation.
Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability.
The examination report should specifically state that a review of the record was conducted.  The examiner should provide a complete rationale for all opinions provided.  If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion.
5. Once the aforementioned development is complete, schedule the Veteran for a VA examination to assess the nature and etiology of his claimed headaches.  A complete copy of the claims file must be made available to the examiner.  The examiner must consider the Veteran’s lay reports of observable symptomatology associated with his headaches.  After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following:
(a.) Identify any and all diagnoses pertaining to the Veteran’s headaches.  Note: pain in of itself may constitute a disability for VA purposes if it results in functional impairment.
(b.) For each diagnosis, is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s identified disability had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service?
(c.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s identified disability was caused by or aggravated by his service-connected disabilities?
(d.) If aggravation of the headaches is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the headaches prior to aggravation.
Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability.
The examination report should specifically state that a review of the record was conducted.  The examiner should provide a complete rationale for all opinions provided.  If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion.






6. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal.  If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board.

 
B. MULLINS
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	H. Fisher, Associate Counsel