Citation Nr: 18154591 Decision Date: 12/04/18 Archive Date: 11/30/18 DOCKET NO. 17-44 405 DATE: December 4, 2018 ORDER 1. Service connection for depressive disorder, as secondary to service-connected skin and knee disabilities, is granted. 2. Service connection for sleep apnea, as secondary to service-connected skin, knee, and psychiatric disabilities, is granted. 3. Service connection for hypertension, as secondary to service-connected skin, knee, and psychiatric disabilities, is granted. 4. A disability rating greater than 30 percent for the left disability is denied. 5. A separate compensable rating for residuals of dislocated cartilage of the left knee is granted, effective December 11, 2015. 6. An initial compensable rating for the left knee scar is denied. 7. A disability rating greater than 10 percent prior to April 15, 2016 and greater than 30 percent thereafter for hidradenitis suppurativa is denied. 8. An effective date earlier than December 11, 2015 for the assignment of a 30 percent disability rating for the left knee disability is denied. 9. An effective date of October 17, 2011 for the award of service connection for a left knee scar is granted. 10. An effective date earlier than April 15, 2016 for the assignment of a 30 percent disability rating for the hidradenitis suppurativa is denied. REMANDED The issue of entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The Veteran’s depressive disorder was caused by, or aggravated by, his service-connected skin and knee disabilities. 2. The Veteran’s sleep apnea was caused by, or aggravated by, his service-connected skin, knee, and psychiatric disabilities. 3. The Veteran’s hypertension was caused by, or aggravated by, his service-connected skin, knee, and psychiatric disabilities. 4. Throughout the appeal period, the Veteran’s left knee had limitation of motion on extension to 20 degrees. 5. Throughout the appeal period, the Veteran’s residuals of dislocated cartilage of the left knee have been manifested by frequent episodes of pain and effusion into the joint. 6. The left knee scar is stable, superficial, does not cause limited motion, and is less than 144 square inches 7. Prior to April 15, 2016, the Veteran’s hidradenitis did not affect more than 20 percent of the entire body or exposed areas and did not required systemic therapy such as corticosteroids or other immunosuppressive drugs. 8. Since April 15, 2016, the Veteran’s hidradenitis suppurativa has not affected more than 20 percent of the entire body or exposed areas and has not required systemic therapy or intensive light therapy on a constant or near-constant basis 9. It is not factually ascertainable that the Veteran satisfied any of the schedular criteria for a 30 percent rating for the left knee disability prior to December 11, 2015. 10. The Veteran’s left knee surgery scar was present at the time he filed a formal claim for service connection for a left knee injury on October 17, 2011. 11. It is not factually ascertainable that the Veteran satisfied any of the schedular criteria for a 30 percent rating for the hidradenitis suppurativa prior to April 15, 2016. CONCLUSIONS OF LAW 1. The criteria for service connection for depressive disorder, as secondary to the service-connected skin and knee disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for sleep apnea, as secondary to the service-connected skin, knee, and psychiatric disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for obstructive sleep apnea, as secondary to the service-connected skin, knee, and psychiatric disabilities, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 4. Throughout the period on appeal, the criteria for a disability rating greater than 30 percent for the left knee disability have not met. 38 U.S.C. §1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5261. 5. The criteria for a separate 20 percent disability rating for residuals of meniscectomy of the left knee under DC 5258 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5258. 6. The criteria for a compensable disability rating for a left knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, DC 7805. 7. The criteria for a disability rating greater than 10 percent prior to April 15, 2016, and greater than 30 percent thereafter, for hidradenitis suppurativa have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.118, DC 7822. 8. The criteria for an effective date earlier than December 11, 2015, for the assignment of a 30 percent disability rating for the service-connected left knee disability have not been met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.96, 4.97, DC 5261. 9. The criteria for an effective date of October 17, 2011, but not earlier, for the grant of service connection for a residual scar due to a left knee surgery have been met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.1, 3.151, 3.155, 3.400. 10. The criteria for an effective date earlier than April 15, 2016, for the assignment of a 30 percent disability rating for the service-connected hidradenitis suppurativa have not been met. 38 U.S.C. §§ 5110, 5107; 38 C.F.R. §§ 3.102, 3.400, 4.96, 4.97, DC 7822. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1979 to March 1982 and from December 1982 to June 1989. These matters come before the Board of Veterans’ Appeals (BVA or Board) on appeal from November 2015 and November 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine and Winston-Salem, North Carolina, respectively. Jurisdiction currently remains with the RO in Winston-Salem, North Carolina. A December 2016 rating decision increased the disability rating assigned to the hidradenitis suppurativa to 30 percent effective April 15, 2016. As this does not constitute a full grant of the benefits sought, the claim remains on appeal and will be addressed below. Service Connection Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition to the regulations cited above, service connection is warranted for a disability which 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 condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric, respiratory, or orthopedic disorders. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Service connection for depressive disorder, as secondary to the service-connected skin and knee disabilities, is granted. The Veteran has been diagnosed with unspecified depressive disorder. See April 2018 Private Opinion Letter. In April 2018, the Veteran submitted a medical opinion letter from Dr. H. H., who opined that the Veteran’s depressive disorder more likely than not began during military service and was aggravated by his service-connected left knee and skin disabilities. She specifically attributed the psychiatric symptoms to the pain resulting from these disabilities. Dr. H. H. explained that her opinion was based on medical literature, as well as the Veteran’s reported symptoms and lay statements. The Board is persuaded by the April 2018 medical opinion letter, which indicates that the current depressive disorder is aggravated by his service-connected disabilities and finds it to be the only probative medical opinion of record. Thus, the evidence demonstrates that the Veteran’s depressive disorder was at least as likely as not caused or aggravated by his service-connected knee and skin disabilities. The benefit sought on appeal is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert, supra. 2. Service connection for sleep apnea, as secondary to his service-connected skin, knee, and psychiatric disabilities, is granted. There is no dispute that the Veteran has been diagnosed with sleep apnea. See April 2018 Private Opinion Letter. In April 2018, the Veteran submitted a medical opinion letter from Dr. H. S., who opined that the sleep apnea was more likely than not caused and permanently aggravated by pain and medication related to his skin and knee disabilities, as well as due to his depressive disorder (which has been granted herein). Dr. H. S. explained that medical research demonstrated a causal relationship between chronic pain and disrupted sleep. He also cited to medical findings that pain medications and depression could lead to sleep apnea. The Board is persuaded by the April 2018 medical opinion letter, which indicates that the Veteran’s sleep apnea is related to his service-connected disabilities and finds it to be the only probative medical opinion of record. Thus, the evidence demonstrates that the Veteran’s sleep apnea was at least as likely as not caused or aggravated by his service-connected knee, skin, and psychiatric disabilities. The benefit sought on appeal is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert, supra. 3. Service connection for hypertension, as secondary to the service-connected skin, knee, and psychiatric disabilities, is granted. The Veteran has been diagnosed with hypertension. See April 2018 Private Opinion Letter. In April 2018, the Veteran submitted a medical opinion letter from Dr. H. S., who opined that the hypertension was more likely than not caused and permanently aggravated by the pain resulting from his knee and skin disabilities, as well as his depressive disorder. He cited to medical literature that supported a relationship between chronic pain and hypertension. Dr. H. S. further explained that depression was found to influence blood pressure reactivity. The Board is persuaded by the April 2018 medical opinion letter, which indicates that the current hypertension is related to the Veteran’s service-connected disabilities and finds it to be the only probative medical opinion of record. Thus, the evidence demonstrates that the Veteran’s hypertension was at least as likely as not related to his knee, skin, and psychiatric disabilities. The benefit sought on appeal is granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert, supra. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where a claimant appeals the denial of a claim of an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA’s adjudication of the claim for increase is lengthy, and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different, or “staged,” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 1. A disability rating greater than 30 percent for the left knee disability is denied. Historically, a June 2012 rating decision granted service connection for the Veteran’s left knee disability, assigning a noncompensable rating, effective October 17, 2011. A November 2016 rating decision awarded a 30 percent disability rating, effective December 11, 2015 pursuant to 38 C.F.R. §4.71a, DC 5261. The Veteran has appealed the rating assigned. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and lateral instability and recurrent subluxation of the knee. The Board will explore all possibilities in this case. DC 5260 rates based on limitation of flexion. When flexion of the leg is limited to 60 degrees, a noncompensable rating is warranted. When flexion is limited to 45 degrees, a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. However, where the Veteran shows noncompensable limitation of motion, but painful motion and functional impairment are evident, the Veteran is entitled to a 10 percent rating. DC 5261 rates based on limitation of extension. That code provides that when extension is limited to 5 degrees, a noncompensable rating is assigned. Extension limited to 10 degrees warrants a 10 percent rating. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. The diagnostic criteria applicable to recurrent subluxation or lateral instability is found at 38 C.F.R. § 4.71a, DC 5257. Under that code, slight impairment is assigned a 10 percent rating, moderate impairment a 20 percent rating, and severe impairment a 30 percent rating. The terms “mild,” “moderate,” and “severe” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “mild” or “moderate” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding a higher rating. 38 C.F.R. §§ 4.2, 4.6. Other DCs pertaining to the knee include DC 5258, under which a maximum 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. DC 5259 holds that symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating, which is the maximum rating under the diagnostic code. The diagnostic criteria applicable to impairment of the tibia and fibula are found at 38 C.F.R. § 4.71a, DC 5262. Under that code, a 10 percent evaluation is warranted when malunion of the tibia and fibula is productive of slight knee or ankle disability. A 20 percent evaluation is warranted when malunion of the tibia and fibula is productive of moderate knee or ankle disability, and a 30 percent evaluation is warranted when such disability is marked. A 40 percent evaluation is warranted for nonunion of the tibia and fibula, with loose motion, requiring a brace. Finally, the diagnostic criteria applicable to knee replacement (prosthesis) are found at 38 C.F.R. § 4.71a, DC 5055. As the Veteran has not had a knee replacement, or impairment of the tibia and fibula, these codes are inapplicable. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” 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). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Painful motion without functional limitation, however, cannot serve as the basis for a rating higher than the minimum. Mitchell, supra. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. Evidence relevant to the current level of severity of the Veteran’s left knee disability includes a May 2016 VA knee examination report. At that time, the Veteran reported experiencing pain, swelling, popping, and giving out. He described flare-ups as activity-dependent, as they occurred due to bearing increased weight on his left knee. They occurred less than once per month and typically lasted a week. The Veteran further reported that he put weight on his right leg to avoid falls, and did not walk quickly or for long distances. Flexion was to 90 degrees, with extension to 20 degrees. The limited range of motion resulted in impaired gait and ability to stand. There was evidence of pain with weight bearing, crepitus, and tenderness around the patella. The Veteran was able to perform repetitive use testing with at least three repetitions, as well as repetitive use over time, which resulted in flexion to 90 degrees and extension to 20 degrees. The examiner noted that pain and lack of endurance resulted in limited functional ability with repetitive use over time. Although the Veteran was not observed during a flare-up, the examiner concluded that such would not result in additional limitation of motion and that pain would limit functional ability. The report further noted that swelling, disturbance of locomotion, and interference with standing were additional contributing factors of the left knee disability. Muscle strength testing resulted in active movement against some resistance, but there was no evidence of muscle atrophy or ankylosis. Although the Veteran reported recurrent effusion that worsened during flare-ups, joint stability testing was normal. Additionally, he denied recurrent patellar dislocation, medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The examiner noted a left meniscal tear with frequent episodes of joint pain and effusion. The Veteran occasionally used a cane and regularly used a brace to assist with ambulation. Also of record are VA treatment records dated through December 2016. Significantly, these records show complaints of left knee pain but are negative for range of motion findings of the knee. Based on the evidence of record, the Board finds that the preponderance of the evidence is against a disability rating greater than 30 percent for the Veteran’s left knee extension for the entire period on appeal. Initially, the Board finds that the 30 percent rating assigned for the Veteran’s left knee disability under DC 5261 is appropriate. Significantly, the Veteran has demonstrated extension to 20 degrees throughout the appeal period. As the next higher rating requires limitation of extension to 30 degrees, the Board finds that the preponderance of the evidence is against a rating higher than 30 percent for the Veteran’s left knee extension for the entire period on appeal. Furthermore, a separate rating for limitation of flexion under DC 5260 is not warranted. Significantly, the Veteran has demonstrated flexion to 90 degrees throughout the appeal period. As DC 5260 provides for a 10 percent rating when flexion is limited to 45 degrees, the Board finds that the requirements for a separate compensable disability rating for loss of flexion under DC 5260 have not been met. However, the Board finds that a separate 20 percent rating is appropriate for the Veteran’s left knee pain and effusion. The Veteran underwent a meniscectomy during service and has since reported knee effusion and giving way. Moreover, the May 2016 VA examiner determined that the Veteran had a meniscus (semi lunar) condition with frequent episodes of pain and effusion. 20 percent is the highest scheduler rating under this DC. The Board notes that a recent United States Court of Appeals for Veterans Claims (Court) decision clarified that compensation under DC 5257 or 5258 as well as limitation of movement, such as expressed in DC 5260 or 5261, is not pyramiding. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Therefore, the Board may assign a separate compensable rating under DC 5258 when the Veteran is also rated under DC 5261 for limitation of extension. The Board finds, given the specific facts of this matter, that the Veteran’s current rating under DC 5258 which encompasses episodes of locking and giving way, and a separate rating under DC 5261 would not constitute impermissible pyramiding. Therefore, a separate 20 percent rating is warranted under DC 5258 effective December 11, 2015, the date of the increased rating claim on appeal. The Board also finds that there is no basis for the assignment of any higher rating beyond 30 percent 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. Competent medical evidence reflects that the currently assigned 30 percent rating properly compensates him for the extent of functional loss resulting from any such symptoms for the applicable periods on appeal. Although it was noted on the VA examination reports that the Veteran exhibited pain on motion and had additional loss of motion due to pain, the functional loss is not equivalent to limitation of extension to 30 degrees or more to meet the criteria for a 30 percent evaluation. See 38 C.F.R. § 4.71a, DC 5261. Additionally, the Board has considered the Court’s recent holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017), addressing 38 C.F.R. § 4.40, which states that a VA examiner must “express an opinion on whether pain could significantly limit functional ability” and the examiner’s determination in such regard “should, if feasible, be portrayed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups.” In this regard, the Court concluded that, when a VA examiner is asked to provide an opinion as to additional functional loss during flare-ups of a musculoskeletal disability, the examiner must obtain information from the Veteran regarding the severity, frequency, duration, characteristics, and/or functional loss related to such flare-ups. The Court further concluded that, if the examination was not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of range of motion that may be present during a flare-up. Additionally, if the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that he/she has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran). In this case, the Board finds the musculoskeletal examination of record is adequate for rating purposes and that a higher disability rating is not warranted based on limitation of motion, even when considering the functional effects of pain, to include during flare-ups and after repetitive use. At the examination, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed. Here, the Veteran reported flare-ups at his VA examination, primarily resulting from physical activities. He generally described them as moderate in severity and lasting for up to a week. Furthermore, the Veteran did not report that he had loss of motion to the degree required for a higher rating higher than 30 percent due to flare-ups during the appeal period. In the Mitchell case, the Court found that a veteran’s contention that pain, even if experienced throughout the range of motion on examination, does not warrant a higher rating under the diagnostic codes providing ratings for limitation of motion. Rather, it is the functional limitation, i.e., the additional limitation of motion, caused by pain or the other orthopedic factors under DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59, that must be considered in determining whether a higher rating is warranted. Thus, flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. Notably, regulation provides that rating agencies will handle cases affected by change of medical findings or diagnosis to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. 38 C.F.R. § 3.344. It stands to reason that the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. Here, the medical evidence regarding flare-ups would not warrant an evaluation higher than 30 percent, since such flare-ups do not additionally limit range of motion, as determined by the May 2016 VA examiner, and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. Therefore, the Board finds that such factors do not result in functional loss more nearly approximating extension limited to 30 degrees or more. The Board has also considered the Court’s recent holding in in Correia v. McDonald, 28 Vet. App. 158 (2016), wherein the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. While the May 2016 VA examination discussed above failed to test passive range of motion and range of motion in non-weight-bearing conditions, the Board finds that the examination is nevertheless adequate for VA rating purposes. Passive range of motion is the amount of motion possible when an examiner moves a body part with no assistance from the individual being evaluated. It is usually greater than active range of motion because the integrity of the soft tissue structures does not dictate the limits of movement. Comparisons between passive range of motion and active range of motion provide information about the amount of motion permitted by the associated joint structures (passive range of motion) relative to the individual’s ability to produce motion at a joint (active range of motion). CYNTHIA NORKIN & D. JOYCE WHITE, MEASUREMENT OF JOINT MOTION: A GUIDE TO GONIOMETRY 8-9 (2016). Testing the joint under weight-bearing conditions involves movement of the body against gravity. J. Randy Jinkins, et. al., Upright, Weight-bearing, Dynamic-kinetic Magnetic Resonance Imaging of the Spine: Initial Results, 15 J. Eur. Radiol. 1815-25 (2005). When evaluating range of motion, it is preferable to test in weight-bearing conditions because testing in non-weight-bearing conditions underestimates the degree of pathology present. Id. at 1823. Because there is no indication that the structural integrity of the Veteran’s left knee is compromised, such that passive range of motion in this case would be more limited than active, and because testing in weight-bearing conditions is more demonstrative of the degree of pathology, the Board finds that the failure to test for limitation of motion on passive range of motion and in non-weight-bearing is not prejudicial. The Board will therefore evaluate the Veteran’s range of motion using the available findings of active range of motion. The Board has also considered the possibility of separate ratings for limitation of flexion under DC 5260. Such ratings are not warranted during the appeal period. VA examination reports have consistently reported degrees of flexion that are within normal limits, and in this regard, there was no degree of flexion that was limited to a compensable degree, as the Veteran was capable of flexion to at least 80 degrees throughout this period. Thus, the Board finds that the preponderance of the evidence is against a finding that a separate rating for left knee limitation of flexion is warranted at any time during the period on appeal. Although there have been lay reports of giving way of the left knee, stability testing was documented as normal in the VA examination report. The Board finds the VA examination more probative as to whether the Veteran experiences the type of giving way or instability required for a separate rating under DC 5257. Therefore, the Board finds that a separate rating is not warranted under DC 5257 for recurrent subluxation or lateral instability at any point during the appeal. The medical evidence is also negative for a diagnosis of ankylosis or genu recurvatum, precluding a rating under DCs 5256 and 5263 for the left knee. As indicated above, the record is silent for any complaints, treatments or diagnoses of an impairment of the tibia or fibula. Thus, a rating under DC 5262 is not warranted. The Board finds that the preponderance of the evidence does not support a rating in excess of 30 percent for the left knee disability throughout the period on appeal. See 38 C.F.R. § 4.71a, DC 5261. 2. An initial compensable rating for the left knee scar is denied. The Veteran’s left knee scar is evaluated as noncompensable under DC 7805. Scars are covered under DC’s 7801-7805. The Board notes DC 7800 concerns scars, but only to scars of the head, face, or neck. DC 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to DC 7801 provides that a deep scar is one associated with underlying soft tissue damage 38 C.F.R. § 4.118. The Board observes Note (2) does not apply to the Veteran’s disability as it applies to multiple qualifying scars, or a single qualifying scar affecting more than one extremity or area. DC 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to DC 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. The Board observes Note (2) does not apply to the Veteran’s disability as it applies to multiple qualifying scars, or a single qualifying scar affecting more than one extremity or area. DC 7804 provides a 10 percent rating for superficial unstable scars. DC 7804 provides that one or two scars that are unstable or painful are rated 10 percent disabling. Three or more scars that are unstable or painful are rated 20 percent disabling. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to DC 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (3) provides that scars evaluated under diagnostic codes 7800, 7891, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. The Board observes Note (2) does not apply to the Veteran’s disability as it applies to multiple qualifying scars, or a single qualifying scar affecting more than one extremity or area. 38 C.F.R. § 4.118. DC 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under DC’s 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118. Evidence relevant to the current level of severity of the Veteran’s left knee scar includes the May 2016 VA knee examination report which noted a left knee scar that measured 7 cm. by 1 cm., and was not painful or unstable. Also of record are VA treatment records dated through December 2016. Significantly, these records show complaints of left knee pain but are negative for complaints regarding the left knee scar. Based upon the above evidence, the Board finds that a compensable disability rating for the Veteran’s left knee scar is not warranted. Significantly, there is no medical evidence establishing the Veteran has superficial unstable scars, deep scars, or scars that cause limited motion other than the limitation of motion already considered for his service-connected left knee disability. Instead, the most probative evidence of record shows that the left knee scar is stable, superficial, and does not cause limited motion. The minimum for a compensable scar, 10 percent, is 144 square inches (929 sq. cm.), one that is painful or unstable, or one that is deep or that causes limited motion in an area or areas exceeding 6 square inches (39 sq. cm.). Here, the Veteran’s scar measures 7 cm. by 1 cm. and does not meet the schedular criteria for a compensable rating for a scar disability. Finally, the medical evidence or lay evidence does not establish any other disabling effects of his left knee scar. As the preponderance of the evidence is against a finding that the Veteran’s disability more nearly approximates the criteria for a compensable rating, a compensable rating is not warranted. 38 C.F.R. §§ 4.3, 4.7. 3. A disability rating greater than 10 percent prior to April 15, 2016, and higher than 30 percent thereafter for hidradenitis suppurativa is denied. The Veteran is in receipt of a 10 percent disability rating for hidradenitis suppurativa prior to April 15, 2016, and has been assigned a 30 percent rating thereafter under 38 C.F.R. § 4.118, DC 7822 (papulosquamous disorders not listed elsewhere). Under DC 7822, a 10 percent rating is warranted when at least 5 percent, but less than 20 percent, of the entire body or of exposed areas are affected; or when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted when 20 to 40 percent of the entire body or of exposed areas are affected or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted where more than 40 percent of the entire body or of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118. Throughout the course of the appeal, the Veteran has contended generally that his skin condition has been manifested by more severe symptoms than those contemplated by the assigned ratings. Evidence relevant to the current level of severity of the Veteran’s skin condition includes November 2015 and December 2016 VA dermatological examinations. During the November 2015 VA examination, the Veteran did not have any benign or malignant skin neoplasms, nor any systemic manifestations associated with the skin condition. He had not been treated with oral or topical medications in the past 12 months, and had not undergone any treatments or procedures for exfoliative dermatitis or papulosquamous disorder. He had not experienced any debilitating episodes in the previous 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examiner noted that between 5 percent and 20 percent of the Veteran’s total body area was affected by this condition. During the December 2016 VA examination, the Veteran reported that his condition had worsened in the past 12 months, primarily in size and the degree of pain. He did not have any benign or malignant skin neoplasms, nor any systemic manifestations associated with the skin condition. The Veteran had been treated with Minocycline, an oral medication, for less than six weeks in the past 12 months. He had also been prescribed Humira for six weeks or more, but not on a constant basis. He had not experienced any debilitating or non-debilitating episodes in the previous 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examiner noted that the hidradenitis suppurativa covered less than 5 percent of the total body area, and less than 20 percent of the exposed body area. Also pertinent is a December 2016 VA scar examination which noted five scars on the head, face, and neck. Specifically, these scars were located on the Veteran’s right cheek (5 cm. by 2.2 cm.), right side of the face below the jaw (3 cm. by 1.6 cm.), right side of the neck (2.5 cm. by 1.8 cm.), lower chin (6 cm. by .5 cm.), and left cheek (1.5 cm. by .6 cm.). The scars were not painful, unstable, or due to burns. The examiner noted that the jaw and neck scars demonstrated surface contour elevated on palpation. There was no abnormal pigmentation, or gross distortion or assymetry of facial features. The total area of the head, face, and neck with abnormal texture was 9.3 sq. cm. After a review of all the evidence, both lay and medical, the Board finds that the criteria for a disability rating higher than 10 percent for hidradenitis suppurativa have not been met or more nearly approximated for any part of the period prior to April 15, 2016. 38 C.F.R. §§ 4.3, 4.7, 4.118. As discussed above, the next higher (30 percent) rating is warranted when 20 to 40 percent of the entire body or exposed areas are affected or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 38 C.F.R. § 4.118. The weight of the evidence shows that, throughout this period, the Veteran’s skin condition affected less than 20 percent of the entire body area that is required for the next higher rating (30 percent) rating under DC 7822. The Veteran is competent to testify as to his skin symptomatology. See McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (a veteran is competent observe skin conditions such as boils, blotches, and rashes). However, the Veteran has not alleged that the condition affected more than 20 percent of the entire body or exposed areas, and the evidence of record does not otherwise support such a finding. See November 2015 VA examination report. The evidence also reflects that the Veteran was not treated with systemic therapy such as corticosteroids or other immunosuppressive drugs during any part of the rating period prior to April 15, 2016. 38 C.F.R. § 4.118, DC 7822; see November 2015 VA Examination Report. Additionally, the Board finds that the criteria for a disability rating higher than 30 percent for hidradenitis suppurativa have not been met or more nearly approximated for any part of the rating period from April 15, 2016. 38 C.F.R. §§ 4.3, 4.7, 4.118. As discussed above, the next higher (60 percent) rating is warranted when more than 40 percent of the entire body or exposed areas are affected or where constant or near-constant systemic medications or intensive light therapy was required during the past 12-month period. 38 C.F.R. § 4.118. The weight of the evidence shows that, for this rating period, the Veteran’s skin condition has affected less than 20 percent of the entire body or exposed areas. The evidence also reflects that the Veteran was not treated with systemic therapy or intensive light therapy on a constant or near-constant basis. 38 C.F.R. § 4.118, DC 7822; see December 2016 VA Examination Report. The Board has considered whether an alternative rating under DC’s 7800 through 7805 would result in a more favorable outcome for the Veteran. 38 C.F.R. § 4.118, DC 7822. The Veteran was previously in receipt of a noncompensable rating under DC 7805 for scars related to his skin condition. The RO has since awarded him a separate rating under 7899-7822 for his hidradenitis suppurativa with residual scars. Although the December 2016 VA examination identified several facial scars with two characteristics of disfigurement, such would only allow for a 30 percent rating under DC 7800. Thus, such an alternative rating would not provide for a greater benefit for the Veteran than the current rating. Based on the above, the Board finds that, for the period prior to April 15, 2016, the Veteran’s disability picture more nearly approximates the criteria for a 10 percent disability rating for hidradenitis suppurativa; therefore, a disability rating higher than 10 percent must be denied. 38 C.F.R. §§ 4.3, 4.7. Additionally, the Board finds that, for the period since April 15, 2016, the Veteran’s disability picture more nearly approximates the criteria for a 30 percent disability rating for hidradenitis suppurativa; therefore, a disability rating higher than 30 percent must be denied. 38 C.F.R. §§ 4.3, 4.7. Earlier Effective Date Generally, the effective date of a rating and award of compensation is the later of the date of receipt of the claim or the date entitlement arose. See 38 U.S.C. § 5110(a); see also 38 C.F.R. § 3.400(o)(1). An exception to the general rule applies where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of the claim for increased compensation. See 38 U.S.C. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); see also Harper v. Brown, 10 Vet. App. 125 (1997). The question of when an increase in disability is factually ascertainable is based on the evidence in the Veteran’s claims file. See Quarles v. Derwinski, 3 Vet. App. 129 (1992). 1. An effective date earlier than December 11, 2015 for the assignment of a 30 percent disability rating for the left knee disability is denied. Here, the RO awarded a 30 percent disability rating for the Veteran’s service-connected left knee disability effective December 11, 2015, the date of the claim from which this action stemmed. As such, the earliest effective date possible for the 30 percent rating for a left knee disability would be December 11, 2014. For the reasons explained below, the Board finds that an effective date earlier than December 11, 2015, for the grant of a 30 percent rating for a left knee disability is not warranted. As discussed above, the Veteran’s service-connected left knee disability is rated under DC 5261, for limitation of extension. 38 C.F.R. § 4.71a, DC 5261. DC 5261 provides that when extension is limited to 5 degrees, a noncompensable rating is assigned. Extension limited to 10 degrees warrants a 10 percent rating. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. Prior to December 11, 2015, the Veteran’s left knee condition was rated noncompensable under DC 5261. A 30 percent rating under that diagnostic code requires limitation of extension to 15 degrees. 38 C.F.R. § 4.71a, DC 5261. The Board notes that the evidence of record does not indicate that the Veteran experienced such limitation prior to the filing of his increased rating claim. The remainder of the record for this period is silent regarding any complaints, symptomatology, or treatment showing that the Veteran’s left knee disability worsened to the degree approximated by the 30 percent rating prior to December 11, 2015. The latest of the potential effective dates is therefore the date of the increased rating claim. An effective date prior to December 11, 2015 for the award of a 30 percent disability rating for the left knee disability is not warranted. 2. An effective date of October 17, 2011, but no earlier, for the award of service connection for a left knee scar is granted. The Veteran contends that the effective date assigned for the award of service connection for the left knee scar should be earlier than December 11, 2015. The law regarding effective dates states that, unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). This statutory provision is implemented by a VA regulation, which provides that the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 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 or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101(a)(1); 38 C.F.R. § 3.151 (a). For claims received on or after March 24, 2015, VA amended its regulations governing how to file a claim. The effect of the amendment was to standardize the process of filing claims, as well as the forms accepted, in order to increase the efficiency, accuracy, and timeliness of claims processing, and to eliminate the concept of informal claims. See 38 C.F.R. § 3.155; 79 Fed. Reg. 57660-01. However, prior to the effective date of the amendment, an informal claim was any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA. The benefit sought must be identified, see Stewart v. Brown, 10 Vet. App. 15, 18 (1997), but need not be specific, see Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). See 38 C.F.R. § 3.155(a) (2013). In general, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of the receipt of the application. 38 U.S.C. 5110 (a); 38 C.F.R. 3.400. Effective March 24, 2015, a specific claim in the form prescribed by VA must be filed in order for benefits to be paid or furnished to any individual under laws administered by VA. 38 U.S.C. 5101(a); 38 C.F.R. 3.151 (a). The Veteran contends that the effective date for the grant of service connection for his multiple residual scars should be earlier than December 11, 2015, because he had a meniscectomy during service and has had a left knee scar earlier than December 11, 2015. The Board has thoroughly and sympathetically reviewed the evidence of record and finds that an effective date of October 17, 2011, but not earlier, for the grant of service connection for a left knee scar is warranted because the Veteran’s left knee surgery scar was present at the time he filed a formal claim for service connection for a left knee injury. The record shows that the Veteran filed a formal claim (VA Form 21-526) for service connection for a left knee injury, which was received by VA on October 17, 2011. The Veteran’s left knee status post meniscectomy with scar was granted service connection by a June 2012 rating decision, effective October 17, 2011. VA’s Schedule for Rating Disabilities (Schedule) indicates that separate evaluations should be assigned for scars associated with service-connected disabilities. See generally 38 U.S.C. § 1155; 38 C.F.R., Part IV. The May 2012 VA examination for the left knee indicated that the Veteran had a scar related to his left knee disability. Additionally, the May 2016 examination shows that the Veteran underwent a meniscectomy during service, which resulted in a scar. Because the Veteran’s left knee surgery scar was present at the time he filed formal claims for service connection for a left knee injury, an effective date earlier than December 11, 2015, for the grant of service connection for a left knee scar is warranted. Accordingly, an effective date of October 17, 2011, and no earlier, is granted. The law is dispositive of the issue. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 3. An effective date earlier than April 15, 2015 for the assignment of a 30 percent disability rating for the hidradenitis suppurativa is denied. The RO assigned a rating of 30 percent, effective April 15, 2016, for the hidradenitis suppurativa based on a VA treatment record which noted that he was prescribed Humira on that date. The Veteran asserts that he is entitled to an effective date earlier than April 15, 2016, for the award of a 30 percent rating for the skin disability. The Veteran’s skin disability is currently rated as 30 percent disabling under 38 C.F.R. § 4.71a, DC 7822, which provides that a 30 percent rating is warranted when 20 to 40 percent of the entire body or of exposed areas are affected or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Based upon the evidence of record, there is no indication that the hidradenitis suppurativa was of the severity warranting a 30 percent disability rating prior to April 15, 2016. The VA examination reports and post-service treatment records prior to that time do not indicate that he required systemic therapy for six weeks or more, or that 20 to 40 percent of his body was affected. Thus, the evidence reflects that the first time such symptoms were shown was the date of the April 2016 VA Treatment Record. The latest of the potential effective dates is therefore the date of the treatment record showing actual worsening. An effective date prior to April 15, 2016, for the award of a 30 percent disability rating for the hidradenitis suppurativa is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND The issue of entitlement to service connection for GERD is remanded. The Veteran has not been provided with an examination for his GERD. The current evidence of record indicates that the Veteran was previously diagnosed with GERD. See VA Treatment Record dated January 4, 2011. Furthermore, service treatment records documented several complaints of stomach problems. See Service Treatment Record dated February 22, 1985. Thus, a remand is necessary to provide the Veteran with an examination to obtain an opinion concerning the etiology of his GERD. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file all non-duplicative VA treatment records relating to the Veteran and his claim. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed GERD. The claims file should be made available to and be reviewed by the examiner. The examiner should identify all current gastrointestinal diagnoses, to include GERD. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed gastrointestinal disorder, to include GERD, is due to service. A rationale is requested for any opinion given. 3. Readjudicate the claim. APRIL MADDOX Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Erin J. Trojanowski, Associate Counsel