Citation Nr: 18147914 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 09-06 076 DATE: November 6, 2018 ORDER Entitlement to service connection for headaches is granted. Entitlement to service connection for a right knee disorder is granted. Entitlement to service connection for a right hip disorder is denied. Entitlement to service connection for a skin disorder, diagnosed as pseudofolliculitis barbae and acne keloid, is granted. Entitlement to a rating in excess of 10 percent for bursitis and chronic sprain of the left knee is denied. Entitlement to a rating in excess of 10 percent for gout of the bilateral feet with calcaneal spurs and bone spurs is denied. REMANDED Entitlement to a rating in excess of 30 percent for anxiety, not otherwise specified is remanded. FINDINGS OF FACT 1. The Veteran’s active duty service spanned from February 1979 to February 1982 and from November 2004 to January 2008. 2. Resolving reasonable doubt in the Veteran’s favor, his headache disability was caused by or incurred during his active service. 3. Resolving reasonable doubt in the Veteran’s favor, his right knee disability was caused by or incurred during his active service. 4. The preponderance of the evidence is against finding that the Veteran has a right hip disorder due to a disease or injury in service. 5. Resolving reasonable doubt in the Veteran’s favor, his skin disorder was caused by or incurred during his active service. 6. The Veteran’s left knee disability manifested as limitation of flexion to 95 degrees with pain, limitation of extension to 5 degrees without pain, and no evidence of subluxation or instability. 7. The Veteran’s gout of the bilateral feet with calcaneal spurs and bone spurs is manifested by objective evidence of painful motion but not by foot disability that is at least moderate, moderately severe, or severe; the Veteran has not demonstrated actual loss of use of the foot. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§3.159, 3.303, 3.304 (2017). 2. The criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§3.159, 3.303, 3.304 (2017). 3. The criteria for service connection for a right hip disorder, to include on a secondary basis have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§3.159, 3.303, 3.304, 3.310 (2017). 4. The criteria to establish service connection for a skin disorder have been met. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 5. The criteria for a rating in excess of 10 percent for the Veteran’s service-connected left knee disability have not been met. 38 U.S.C. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a (2017). 6. The criteria for a rating in excess of 10 percent for gout of the bilateral feet have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1979 to February 1982 and from November 2004 to January 2008. This appeal to the Board of Veterans’ Appeals (Board) arose from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Specifically, the issues of entitlement to service connection for pseudofolliculitis barbae, entitlement to service connection for headaches, entitlement to an initial rating in excess of 10 percent for bursitis and chronic sprain of the left knee, and entitlement to an initial compensable rating for gout of the bilateral feet with calcaneal spurs come to the Board from an October 2008 rating decision. The Veteran filed a timely Notice of Disagreement (NOD) in October 2008. The RO issued a Statement of the Case (SOC) in February 2009 and the Veteran filed a VA Form 9 in February 2009. The Board notes that the Veteran was afforded a Travel Board hearing in December 2010. The transcript is associated with the claims file. The Board issued a remand in March 2011. The issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability, whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right hip disability, and entitlement to an initial rating in excess of 30 percent for an anxiety disorder, not otherwise specified come to the Board from a February 2015 rating decision. The rating decision continued the 30 percent evaluation of anxiety disorder, not otherwise specified, continued the denial of entitlement to service connection for a right hip condition, and continued the denial of entitlement to service connection for a right knee condition. The Veteran filed a NOD in February 2016 and the RO issued a SOC in October 2016. The Veteran filed a VA Form 9 in December 2016. In April 2017, the Board determined that new and material evidence had been received to reopen the claims of entitlement to service connection for a right knee disability and a right hip disability; as such, these claims were reopened. The Board denied the claims of entitlement to service connection for a skin disorder and headaches, as well as a rating in excess of 30 percent for anxiety NOS. Further, the Board remanded the issues of entitlement to service connection for a right knee disorder, entitlement to service connection for a right hip disorder, entitlement to a rating in excess of 10 percent for bursitis and chronic sprain of the left knee and entitlement to a compensable rating for gout of the bilateral feet with calcaneal spurs and bone spurs for further development. In a June 2018 rating decision, the RO increased the Veteran’s compensable rating for gout of the bilateral feet to 10 percent. Following the Board’s decision, the Veteran timely appealed the Board’s denial of the claims of entitlement to service connection for a skin disorder and headaches, as well as the increased rating claim for anxiety NOS to the U.S. Court of Appeals for Veterans Claims (Court). A January 2018 Joint Motion for Partial Remand (JMPR) moved to vacate the parts of the April 2017 Board decision that denied the Veteran’s claims of entitlement to service connection for a skin disorder, diagnosed as pseudofolliculitis barbae and acne keloid (skin disorder), service connection for headaches, and a rating in excess of 30 percent for an anxiety disorder NOS and to remand the matters for further development. Specifically, the JMPR noted that the Board erred by not providing an adequate statement of reasons or bases regarding the Veteran’s dates of active service, which the Board found to end in September 2006. In making this finding, the parties asserted that Board did not address a DD Form 214 and Address Code 11 of record indicating that the Veteran had a period of active service ending January 5, 2008. Based on the records indicated above, the Board concludes that the Veteran’s periods of active service span through January 5, 2008. Further, the Board did not comply with the Veteran’s request for a copy of the October 2016 examination report before deciding that he was not entitled to a disability rating in excess of 30 percent for a service-connected anxiety disorder. Lastly, the JMPR also noted that the Court should dismiss the denial of service connection for a left shoulder disability. In January 2018, the Court granted an Order for a partial remand consistent with the terms set forth in the JMPR. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247 (1999). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Alternatively, service connection for certain chronic diseases may be established under 38 C.F.R. § 3.303 (b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307, (ii) present manifestations of the same chronic disease, and (iii) evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. § § 1101, 1112; 38 C.F.R. § § 3.307. 1. Entitlement to service connection for headaches. The Veteran contends that service connection is warranted for headaches. As the Veteran’s second period of duty spanned from November 2004 to January 2008, the Board concludes that the Veteran had in-service complaints of head-related pain, as well as a diagnosis of headaches within one year of service. Specifically, the Veteran’s VA outpatient treatment reports, dated from July 2004 to September 2010, reflect that the Veteran complained of left hemi body pain including the face and head in May 2007 and June 2007. Additionally, a June 2007 MRI of the brain reflected findings of right and left maxillary retention cysts; however, the Veteran was informed that there was no structural abnormality or obvious reason for his left hemi body numbness and pain. An August 2008 VA examination revealed a diagnosis of headaches, more likely than not due to a cyst in each sinus, noted on an MRI of the brain. The examiner found no evidence of any brain injury causing memory loss. In a December 2010 video conference hearing, the Veteran reported that while on active duty, he had constant headaches on a daily basis and that he has continued to have them since that time. His representative also testified that, while the Veteran’s headaches were related to a cyst in the brain by a VA examiner, no one had addressed whether the cyst originated during the Veteran’s active service. The Veteran was afforded a VA examination in November 2011. The examiner noted that the Veteran did not have a current or historical diagnosis of a headache condition, but instead noted a diagnosis of a maxillary cyst. The Veteran reported that he began experiencing daily headaches while serving in Iraq in 2004. He denied trauma. The examiner noted that the Veteran was followed by neuropsychology clinic at VA without a history of diagnosis of or treatment for headaches. The Veteran denied that his headaches interfered with his activities of daily living. The examiner noted that it was less likely than not that the Veteran’s headaches were related to service. The examiner stated that the opinion was based on a review of the claims file, the service treatment records, VA treatment records, history, and physical examination. Here, the Veteran’s MRI completed in June 2007 which documented cysts in his maxillary sinuses occurred while he was on active duty. Further, the August 2008 VA examination, conducted seven months following separation, indicates that the Veteran was diagnosed with headaches and the examiner considered such to be related to his cysts. The Veteran has consistently reported that his headaches began in service and continued thereafter. The Board, thus, finds the Veteran’s testimony that he started having headaches almost immediately after leaving service credible. Furthermore, the Veteran was diagnosed with headaches within one year following his separation from service. Although the November 2011 VA opinion is negative as to direct service connection, the Board affords the opinion little probative weight because it was based on the inaccurate factual premise that the Veteran’s service ended in 2006, rather than in 2008, and did not give thorough consideration to the Veteran’s competent, credible, assertions of manifestation within one year and continuous symptomatology since service. As such, service connection for headaches must be granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a right knee disorder. The Veteran contends that service connection is warranted for a right knee disorder. As the Veteran’s second period of duty spanned from November 2004 to January 2008, the Board concludes that the Veteran had a diagnosis of a right knee disorder within one year of service. A November 2004 service treatment record reveals that the Veteran was treated for cellulitis of the right knee. Specifically, a VA treatment record reveals that the Veteran was diagnosed with right knee bursitis in May 2008, following an orthopedic evaluation. A September 2008 VA mental health examination reveals that the Veteran’s medical problem list included that of bursitis. The Veteran was also afforded a VA examination in June 2012. The examiner opined that it was less likely than not that the Veteran’s right knee condition was caused by or aggravated by an in-service injury or event, to include parachute jumps that occurred during military service. The rationale provided was that the Veteran’s service training records did not support a right knee condition. Further, the examiner noted that there was no clear evidence that an injury to one leg could cause major problems with the opposite leg except for certain conditions and that there was no hard data to support the belief that one leg adversely affects the other. The Veteran was afforded a VA examination in October 2012. The Veteran reported that he was jogging and stepped in a pot hole, for which he reported that he went to sick call immediately. The Veteran was diagnosed with “right knee swelling” with an onset date of 2005. The examiner noted that the Veteran’s knee condition did not impact his ability to work. The examiner then opined that it was less likely than not that the Veteran’s right knee disorder was related to service, to include parachuting. The rationale provided was that the claims file did not reveal a post-military discharge for a right knee condition associated with parachuting within one year following separation. The examiner noted that the Veteran stopped parachuting in 1982 and that he was able to complete an army reserve career without limitations or profiles related to a right knee condition. The examiner also stated that the record is void of in-service care for a right knee injury and that his current examination of the right knee was normal, indicating no residuals associated with parachuting or military service. In a January 2015 VA examination, the examiner noted a diagnosis of right knee bursitis with an onset date of 2006. The Veteran reported that he jumped from the back of his truck and heard a pop. The Veteran also stated that he went to sick call and believed that he had an injection. The Veteran reported flare-ups of the knee, knee weakness, and difficulty walking down steps. The examiner opined that it was less likely than not that the Veteran’s right knee condition was related to service. The rationale provided was that no medical records revealed a condition of the right knee likely to lead to chronic bursitis that the Veteran stated that he had. The examiner also noted that the Veteran had no functional impairment or duty hindering condition of the right knee while in service. The Veteran’s post-service period was silent for a condition of the right knee etiologically related to any event in military service, and that the current examination was normal with reported pain on measured range of motion and no radiographic evidence of a condition attributed to service. Additionally, the examiner noted that the Veteran’s right knee condition did not incur in service and was not caused by treatment for cellulitis of the right knee that occurred in service. The Veteran was afforded a VA examination in October 2016. The examiner noted a diagnosis of right knee bursitis with an onset date of 2006. The Veteran reported that since the last VA examination in 2015, his symptoms were unchanged and that he continued to have prepatellar numbness and pain with flexion. He denied any falls, locking, or swelling of the knee. The examiner opined that the Veteran’s right knee condition was less likely than not due to service. The rationale provided was that the evidence did not support any condition that was diagnosed or treated during his military service that would lead to his post-discharge avascular necrosis. The examiner also stated that the events that occurred during his military service would not have caused his chronic right hip condition. The Veteran was afforded another VA examination in May 2018. The examiner noted a history of right knee bursitis, with an onset date of May 2008, which had resolved. The examiner also opined that it was less likely than not that the Veteran’s right knee disorder permanently progressed at an abnormally high rate due to or as the result of his service-connected condition of chronic sprain of the lumbosacral spine and degenerative joint disease sacroiliac joints. Here, despite the negative VA opinions of record, there is sufficient evidence that the Veteran’s right knee disorder had onset during or within one year after service. At the outset, the Board notes that the Veteran’s service treatment records are silent as to complaints of or treatment for a right knee disorder. However, in May 2008, nearly four months after the Veteran’s separation from service, a private record indicated a diagnosis of right knee bursitis. One month later, the Veteran presented for a VA examination with complaints of right knee swelling. Here, the Board balances the probative weight of the Veteran’s complaints and subsequent diagnosis rendered months following separation, with the negative VA nexus opinions. The VA examiners did not thoroughly address the Veteran’s statements of suffering right knee pain since service. These statements are further supported by the medical evidence which shows a diagnosis of a right knee disorder less than one year following separation, indicating that the Veteran’s bursitis was present within one year of separation from service. Lastly, the VA examination reports were based on the inaccurate factual premise that the Veteran’s active duty service concluded in 2006, rather than in 2008. When the totality of the evidence supports the Veteran’s claim or is in relative equipoise, the Veteran prevails on his claim. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In light of the evidence as so stated, the Board concludes that the evidence is at the very least in relative equipoise as to whether the Veteran’s right knee bursitis had onset during or within one year after his active service. Having resolved any doubt in favor of the Veteran, the Board concludes that service connection for a right knee disorder is warranted and the claim is granted. 3. Entitlement to service connection for a right hip disorder to include as secondary to a low back disability. The Veteran contends that service connection is warranted for a right hip disorder. In an April 2006 service treatment record, the Veteran reported that stretching exercises make him sore and aggravated his hip flexor. The Veteran also reported straining his hip flexor while stationed in Iraq. Upon physical examination, the Veteran’s hips showed a moderate decrease in external rotation with a positive hamstring contracture test. The earliest evidence of a right hip disorder was in February 2011, at which time the Veteran was diagnosed with bilateral early stage avascular necrosis in February 2011. The Veteran was afforded a VA examination in June 2012. The examiner opined that it was less likely than not that the Veteran’s right hip disorder was due to service. The rationale provided included that the Veteran’s service training records did not support a right hip condition and that the hip complaints noted in service were for the left hip. The examiner also noted that the Veteran’s left hip complaint was not associated with the current claimed right hip condition. Instead, the examiner noted that there is no clear evidence to suggest that an injury to one leg could cause major problems to the other leg and that there was no hard data to support the belief that ‘favoring’ one adversely affects the other. The Veteran was afforded a VA examination in October 2012. The examiner opined that the Veteran’s military medical records did not reveal significant care for a right hip condition related to parachuting and that it was consistent with the Veteran’s testimony. The examiner cited that the Veteran was able to complete physical fitness testing without a permanent profile related to the right hip and that there was no post-discharge treatment for a right hip condition associated with parachuting or an event in military service one-year post-discharge. The examiner further stated that the Veteran had findings of avascular necrosis of the bilateral hips on an MRI and that it was not caused by his in-service parachuting that ended in 1982 nor his military service as a whole. The Veteran was afforded a VA examination in January 2015. The examiner noted the previous diagnosis of avascular necrosis of the bilateral hips, with an onset date of 2011. The examiner opined that it was not at least as likely as not due to military service. The rationale provided was that the Veteran’s medical records did not reveal a condition diagnosed or treated during service likely to lead to the post-service condition of avascular necrosis and that the Veteran’s in-service events would not cause a chronic right hip condition. The examiner noted that the current examination revealed normal, painful range of motion of the right hip with radiographic evidence of avascular necrosis, but that it was not related to any event in or related to military service. The examiner also stated that the Veteran’s right hip condition did not incur in or was caused by complaints of right hip pain and soreness that occurred during military service. The Veteran was afforded a VA examination in October 2016. The Veteran reported that since the last VA examination in 2015, his right hip pain was unchanged and continuous, to include a bad flare-up. The examiner noted the previous diagnosis of avascular necrosis of the bilateral hips, with an onset date of 2011. The examiner opined that it was less likely than not that the Veteran’s right hip condition was due to service. The rationale provided was that the evidence did not support any condition that was diagnosed or treated during his military service that would lead to his post-discharge avascular necrosis. The examiner also noted that the events that occurred during his military service would not have caused his chronic right hip condition. A September 2017 private treatment record indicates that the Veteran reported that his hips felt fairly good, but that he tended to have pain in his right hip than in his left hip. The Veteran was afforded a VA examination in April 2018. The examiner noted a diagnosis of aseptic bony necrosis. The examiner also opined that it was less likely than not that the Veteran’s right hip disorder permanently progressed to an abnormally high rate due to or as the result of his service-connected condition of chronic sprain of the lumbosacral spine and degenerative joint disease sacroiliac joints. The rationale provided was that there was no pathophysiologic mechanism or process that supports causation of avascular necrosis due to chronic lumbosacral strain and degenerative sacroiliac joints. The examiner also noted that the current known causes of avascular necrosis are categorized as traumatic causes, to include femoral neck fracture and dislocation or fracture dislocation of the femoral head or nontraumatic causes, to include alcohol use, sickle cell, lupus, hyperlipidemia, hyperuricemia, cigarette smoking, and idiopathic causes. As to traumatic causes, the examiner noted that the Veteran did not have and history did not support a femoral neck fracture or dislocation. As to nontraumatic causes, the examiner noted that the Veteran had a significant smoking history of 30 pack years. The examiner also noted that there was no medically sound basis to attribute the Veteran’s right knee disorder to his service-connected lumbosacral spine and degenerative joint disease. Initially, the claim must be denied on a direct basis. First, the service treatment records, including the separation examination, revealed no pertinent complaint, diagnosis or treatment of avascular necrosis of the right hip during service or within one year thereafter. Additionally, the Board finds that service connection for a right hip disorder, to include as secondary to the Veteran’s service-connected back disorder is not warranted. In this regard, the April 2018 VA examiner noted that there was no relationship between the Veteran’s right hip disorder and his service-connected low back. The examiner also cited to the more likely etiology. As the April 2018 addendum opinion, offered clear conclusions with supporting data well as a reasoned medical explanation connecting the two, the Board accords great probative weight to the opinion. See Nieves-Rodriguez, supra. Lastly, the Board addresses the Veteran’s representative’s assertion that the Veteran’s right hip disorder is related to an undiagnosed illness. Yet, the Board finds that service connection is not warranted on this theory, as the Veteran’s right hip disorder resulted from a clear and specific etiology. Furthermore, in a January 2015 VA Gulf War general medical examination for an unrelated condition, the examiner noted that the Veteran did not have any diagnosed illnesses for which no etiology was established. The Board has also considered the Veteran’s lay statements, in which the Veteran relates his right hip disorder to incidents in service, to include a history of paratrooping. The Veteran has also submitted an article which relates avascular necrosis to joint or bone trauma, fatty deposits in blood vessels, and certain diseases. The article also speaks to risk factors to include traumatic injuries, steroid use, excessive alcohol use, bisphosphonate use, and certain medical treatments as well as medical conditions associated with avascular necrosis. In this regard, to the extent that the Veteran may believe that his right hip disorder is related to active service, as a layperson, he is not competent to provide an opinion concerning this matter requiring medical expertise. Additionally, as to the provided article, the Board finds that the April 2018 VA examiner’s opinion is more probative as to the causes of the Veteran’s specific right hip disorder as opposed ot the article which is generic in nature and does not establish a favorable etiological relationship between the Veteran’s injuries or events in service to his right hip condition. As such, the Board affords more probative weight to that of the medical professional’s opinion. Therefore, based on the foregoing, the Board determines that service connection for a right hip disorder is not warranted on any basis. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a right hip disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 4. Entitlement to service connection for a skin disorder, diagnosed as pseudofolliculitis barbae and acne keloid. The Veteran asserts that service connection for a skin disorder is warranted. In April 2017, the Board broadened the Veteran’s claims to include any type of skin disorder. The Veteran asserts that service connection for a skin disorder is warranted based on continuity of symptomatology since service. The Veteran’s VA outpatient treatment records, dated form July 2004 to September 2010, reflect that the Veteran was treated for and diagnosed with folliculitis and pseudofolliculitis in May 2010. In an August 2008 VA examination, the examiner noted that the Veteran reported that in 2006, he noticed bumps on the left and right side of his face while at Fort Benning, Georgia and that he did not seek treatment on active duty. He was diagnosed with a skin condition with obvious pseudofolliculitis barbae, involving less than five percent of his total exposed face. During a December 2010 video conference hearing, the Veteran testified that he currently had pseudofolliculitis barbae which began during his active service when he noticed his skin began to be irritated after he was required to shave every day in service. He reported that he probably noticed his skin changing during his active service while in Kuwait, just prior to going to Iraq. The Veteran testified that skin changes included ingrown hairs which turned out to be something besides ingrown hairs, with itching, pustules, lesions and a rash. The Veteran was afforded a VA examination in November 2011. The examiner reviewed the claims file and noted a diagnosis of acne keloid dating back to 2008. The examiner noted the Veteran’s history. The Veteran stated that he started getting “bumps” on his face that look like pimples while he was serving in Iraq “in the field.” He told the examiner that he was told he was photosensitive and told to take vitamin D. The Veteran stated that he was never told he had a skin condition induced from shaving with a razor or any other form of hair remove. He stated that the bumps on his face popped up and he started picking and pulling on it out of habit and it never went away. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner included three relevant VA treatment records that indicated the Veteran was diagnosed with some variation of acne keloid. The examiner indicated that there was no supporting documentation available to show a history of a skin condition while the Veteran was serving on active duty. The Board initially notes that none of the documented skin disorder diagnoses are enumerated “chronic diseases” under 38 C.F.R. § 3.309. Accordingly, presumptive service connection for a skin disorder is not warranted. Here, no skin disease was noted on the Veteran's entrance examination. He was discharged from service in January 2008. Here, the Veteran reported that he had bumps on his face in 2006. Further, the November 2011 examiner noted that the Veteran’s acne keloid dated back to 2008. The Veteran, throughout the pendency of the appeal, has stated that he had skin problems since service. In this regard, the Board notes that the Veteran is competent to describe that his skin conditions began in service and continued following discharge. Upon review of the lay and medical evidence, the Board finds that the evidence is in relative equipoise on the question of whether the current skin diseases began in service, that is, whether the above listed conditions were directly incurred in service. Evidence weighing in favor of this finding includes the Veteran’s competent statements that he has had recurrent skin issues since service. Indeed, the Veteran is competent to witness a bump, rash, or keloid on his body, as such are generally observable to the naked eye. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a Veteran is competent observe skin conditions such as boils, blotches, and rashes). The Board also finds the above-referenced reports of skin symptoms in service and after service separation to be credible. The evidence weighing against a finding of his current skin disorders having onset during service includes negative VA nexus opinion. Despite the negative nexus opinion of record, the Board is granting service connection due to continuity of symptomatology. See McCartt, 12 Vet. App. at 167-68 (Veteran alleged skin disorder of boils, blotches, rash, soreness, and itching since service; Court implied that this may be the type of condition lending itself to lay observation and satisfy the nexus requirement); see also Jandreau, at 1377 (lay evidence may establish symptoms that later support a diagnosis by a medical professional). Accordingly, for the reasons discussed above and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for a skin disorder is warranted. Increased Rating The Veteran’s entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will also consider entitlement to staged ratings to compensate for times since the claim was filed when the disability may have been more severe than at other times during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7(1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40). 5. Entitlement to a rating in excess of 10 percent for a left knee disorder. The Veteran contends that his left knee disability is more disabling than the 10 percent rating currently assigned under Diagnostic Codes 5099-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2017). Diagnostic Code 5024 addresses tenosynovitis, which is to be rated as limitation of motion of affected parts as arthritis, degenerative. See 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2017). Disabilities of the knee are rated under Diagnostic Codes 5256 to 5263. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides that flexion of the leg limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a 0 percent (noncompensable) rating. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides that extension of the leg limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 5 degrees warrants a 0 percent (noncompensable) rating. 38 C.F.R. § 4.71a. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. When the knee disability affects the meniscus, a 10 percent rating is warranted when there is dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. A 20 percent rating is warranted when there has been removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Having reviewed the record, the Board determines that a rating higher than 10 percent is not warranted for the Veteran’s left knee disability. In a November 2011 VA examination, range of motion testing reveals active range of motion of the left knee of 0 to 115 degrees. In an October 2016 VA knee examination, the examiner did not note a left knee disability. The examiner noted that the Veteran did not have a history of left knee recurrent subluxation, lateral instability, or recurrent effusion. Range of motion testing and functional limitation testing was not provided as it was not requested. During the Veteran’s hearing and in correspondence dated in January 2017, the Veteran expressed disagreement with the examination of record. Specifically, as to the November 2011 VA examination, the Veteran asserted that the examination was not performed by a specialist, inaccurately noted that the Veteran did not have pain upon examination, and was too remote in time. Further, because the VA examination did not address joint testing pursuant to Correia, a new examination was provided. The Veteran was afforded a VA examination for his increased rating claim in April 2018, at which time the examiner noted a diagnosis of left knee bursitis and chronic sprain. At the time of the examination, he reported that his left knee condition worsened since the October 2016 VA examination. Specifically, the Veteran reported that his current treatment includes the use of pain medications. He denied physical therapy, injections, and surgeries. He rated his daily pain level as a 7/10. Range of motion (ROM) testing revealed a normal range of motion of the left knee with no objective evidence of pain. Specifically, the Veteran’s flexion of the left knee was 0 to 140 degrees and extension was from 140 to 0 degrees. There was also no evidence of pain with weight bearing or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of crepitus. There was no additional loss of function after three repetitions. The examiner also noted that there was no objective evidence of pain, weakness, fatigability, or incoordination which significantly limited functional ability with flare-ups since he reported no flare-ups at the time of the examination. fatigue, lack of endurance, incoordination, weakness, or guarding of movement. There was no evidence of ankylosis, joint instability, or recurrent subluxation. In this case, the Veteran’s right knee disability is assigned a 10 percent rating for functional loss due to painful motion pursuant to 38 C.F.R. § 4.59, as well as objective evidence of bursitis. Under the provisions of 38 C.F.R. § 4.59, the lowest compensable rating available for limitation of motion for a joint is allowed if there is acknowledged painful motion even if the range of motion is not limited to the lowest compensable level under the applicable diagnostic code. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The Veteran has previously demonstrated painful motion and, as such, is in receipt of the 10 percent rating. See 38 C.F.R. § 4.71a; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board also notes that the 10 percent rating assigned is the highest evaluation allowed under the law for bursitis. However, a higher rating is not warranted. Under Diagnostic Code 5260, a 20 percent rating requires flexion limited to 30 degrees. Here, the record reflects that the Veteran has not shown limitation to 30 degrees. Instead, the Veteran has shown normal flexion to 140 degrees. The Board has also considered whether additional compensation is warranted for functional loss under 38 C.F.R. §§ 4.40, 4.45, and 4.59 (2017). However, the record shows that his functional loss is limited to painful motion, and this is compensated for with the 10 percent rating assigned. There is no evidence of weakness, fatigue, incoordination, pain on weight-bearing, or greater functional loss on repetitive motion or during flare-ups. Thus, additional compensation for functional loss is not appropriate. The Board has also considered the Veteran’s lay statements, but concludes that he is not competent to identify a specific level of disability according to the appropriate diagnostic code. Thus, the Board affords more probative weight to the objective medical evidence of record discussed above which does not support an increased rating. Given the probative evidence of record, the Board finds the criteria for an increased rating greater than 10 percent for his left knee disability have not been met. The objective evidence of record indicates that the limitation of extension of the knee has not been limited to 15 to19 degrees and flexion was not limited to 16 to 30 degrees. Also, in reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against these claims, the doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. 6. Entitlement to a rating in excess of 10 percent for gout of the bilateral feet with calcaneal spurs and bone spurs Again, in a June 2018 rating decision, the RO increased the Veteran’s compensable rating for gout of the bilateral feet to 10 percent. The Veteran contends that a rating in excess of 10 percent is warranted for gout of the bilateral feet. Specifically, the Veteran contends that his bilateral foot disability is more disabling than the rating currently assigned under Diagnostic Codes 5017-5284. Under Diagnostic Code 5284, other foot injuries are rated 10 percent when moderate, 20 percent when moderately severe, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2017). With actual loss of use of the foot, a 40 percent rating is assigned under Diagnostic Code 5167. 38 C.F.R. § 4.71a, Diagnostic Code 5167 (2017). Diagnostic Code 5284 refers to other foot injuries and applies to foot disabilities for which there is not already a specific diagnostic code, such as in this case. When a condition is specifically listed in the Schedule, it may not be rated by analogy under Diagnostic Code 5284. Copeland v. McDonald, 27 Vet. App. 333 (2015). The Veteran was afforded a VA examination in April 2018 to assess the severity of his condition. At the time of the examination, the Veteran reported no improvement in his condition and stated that your condition had worsened. The Veteran reported that he used over-the-counter anti-inflammatory medications to treat his gout. He also reported three flare-ups of gout per year, which lasted form a couple of days to a couple of weeks. During the time of flare-ups, the Veteran reported that he was unable to put his weight on his affected foot. Otherwise, the Veteran was able to participate in activities of daily life without any impediment. Review of your record revealed the last time medication was prescribed for gout was in October 2011. Further review reveals that the Veteran had been prescribed other gout-specified medications, but neither had been prescribed since 2008. Additionally, the Veteran had not been diagnosed with a flare-up of gout since March 2012, at which time he was prescribed a prednisone taper. The Veteran reported pain of the foot that affected the heels and the top of the feet, as well as the arches and left foot, little toe side. Further, the Veteran’s physical examination revealed no objective evidence of pain; however, he reported subjective complaints of pain in both feet. The examiner indicated there was pain on weight-bearing of both feet. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability during flare-ups or when the foot was used repeatedly over a period of time. The examiner concluded that the Veteran’s gout of the bilateral feet with calcaneal spurs and bone spurs was mild. The findings from the April 2018 VA examination do not reflect evidence of a moderate foot disability. While the Veteran is noted to have had periods where he sought medical treatment for a gout flare-up in March 2012, this flare-up is not shown to reflect moderate foot disabilities. Further, in the April 2018 VA examination, there were no findings of a moderate, moderately severe or a severe foot disability; or, on the other hand, one involving an actual loss of use of the foot. VA policy, however, is to provide at least the minimum compensable rating for joints affected by actual painful motion. 38 C.F.R. § 4.59. Diagnostic Code 5284 may encompass limitation of motion. Here, the Veteran is in receipt of a 10 percent evaluation for such painful motion. The Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent as the evidence does not a reveal a right or left foot injury which is moderately severe or severe or one which results in actual loss of use of the foot. 38 U.S.C. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 7. Entitlement to a rating in excess of 30 percent for an anxiety disorder, not otherwise specified, is remanded. Pursuant to the JMPR, the Court vacated the Board’s denial on the basis of fair process concerns. Specifically, the Board did not comply with the Veteran’s request for a copy of the October 2016 examination report before deciding that he was not entitled to a rating in excess of 30 percent for anxiety NOS. As the Veteran has received a copy of the examination report and has been provided an opportunity to provide evidence and argument in response to the received October 2016 examination, the issue is properly before the Board. Again, the Veteran contends that a rating in excess of 30 percent is warranted for anxiety NOS. Specifically, the Veteran contends that his anxiety disorder is more disabling than the rating currently assigned under Diagnostic Code 9413. The Veteran was last afforded a VA examination in October 2016, at which time the examiner opined that the Veteran’s occupational and social impairment was best summarized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. In correspondence, dated in June 2018, the Veteran reported that he is still experiencing more than one panic attack on a weekly basis, which lasts 10 to 20 minutes in duration, depending on the severity. The Veteran also reported that he has ongoing problems with short-term memory, and also experiences avoidance, isolation, and difficulty establishing social relationships. Given the evidence reflecting possible worsening of the Veteran’s anxiety NOS, a remand is also necessary to afford the Veteran a new VA mental disorders examination to assess current severity of the disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). This matter is hereby REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected anxiety NOS. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In doing so, the Veteran must consider the Veteran’s reported symptoms provided in the correspondence dated in June 2018. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel