Citation Nr: 18157412 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 12-20 981A DATE: December 12, 2018 ORDER Entitlement to an initial evaluation in excess of 20 percent for degenerative arthritis of the lumbar spine is denied. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the left knee is denied. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right knee is denied. Entitlement to an initial compensable evaluation for atopic dermatitis prior to February 13, 2015, is denied. Entitlement to an initial evaluation in excess of 30 percent for atopic dermatitis on or after February 13, 2015, is denied. FINDINGS OF FACT 1. The Veteran does not have forward flexion of the thoracolumbar spine to 45 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. He also does not have incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the previous 12 months. 2. The Veteran’s degenerative arthritis of the left knee is not productive of actual or functional flexion limited to 30 degrees or extension to 10 degrees; recurrent subluxation or lateral instability; dislocated semilunar cartilage; removal of semilunar cartilage; ankylosis; impairment of the tibia and fibula; or genu recurvatum. 3. The Veteran’s degenerative arthritis of the right knee is not productive of actual or functional flexion limited to 45 degrees or extension to 10 degrees; recurrent subluxation or lateral instability; dislocated semilunar cartilage; removal of semilunar cartilage; ankylosis; impairment of the tibia and fibula; or genu recurvatum. 4. Prior to February 13, 2015, the Veteran’s atopic dermatitis did not affect at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas; or, require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. 5. Since February 13, 2015, the Veteran’s atopic dermatitis has not affected more than 40 percent of the entire body or more than 40 percent of exposed areas; or, require constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. The criteria for an initial evaluation in excess of 10 percent for degenerative arthritis of the left knee have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Codes 5003, 5257-5263. 3. The criteria for an initial evaluation in excess of 10 percent for degenerative arthritis of the right knee have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Codes 5003, 5257-5263. 4. The criteria for an initial compensable evaluation for atopic dermatitis prior to February 13, 2015, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.118, Diagnostic Code 7806. 5. The criteria for an evaluation in excess of 30 percent for atopic dermatitis on or after to February 13, 2015, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1980 to February 2008. This case comes before the Board of Veterans’ Appeals (Board) on appeal from May 2008 and March 2010 rating decisions. In July 2013, a hearing was held before the undersigned Veterans Law Judge at the Agency of Original Jurisdiction (AOJ). A transcript of that hearing is associated with the record. In a March 2015 rating decision, the AOJ increased the evaluation for the Veteran’s service-connected atopic dermatitis to 30 percent, effective from February 13, 2015. Nevertheless, a claimant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and a claim remains in controversy where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, the issue remains on appeal. In November 2014 and August 2017, the case was remanded for further development. That development was completed, and the case has been returned to the Board for appellate review. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where a veteran appeals the denial of a claim for 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 the veteran’s 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). However, where the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. §4.71a, Diagnostic Code 5003. Lumbar Spine The Veteran’s degenerative arthritis of the lumbar spine is currently assigned a 20 percent evaluation, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 indicates that degenerative arthritis should be evaluated under the General Rating Formula for Diseases and Injuries to the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diagnostic Codes 5235-5243. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the thoracolumbar spine is 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. See 38 C.F.R. § 4.71a, General Rating Formula, Note (2) and Plate V. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Id., Note (2). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a rating in excess of 20 percent for degenerative arthritis of the lumbar spine. The evidence does not show that the Veteran has forward flexion of the thoracolumbar spine limited to 30 degrees. In fact, during an April 2008 VA examination, the Veteran demonstrated forward flexion to 55 degrees, and during a February 2015 VA examination, he had forward flexion to 80 degrees. The February 2015 VA examiner also noted that the Veteran had no loss of function or range of motion after repetitive use. In addition, during an October 2017 VA examination, the Veteran demonstrated forward flexion to 65 degrees. The VA examiner noted that there was pain on active and passive range of motion testing; however, there was no additional limitation of motion due to repetitive testing. Moreover, based on the aforementioned range of motion findings, the record shows that the Veteran’s thoracolumbar spine is not fixated or immobile. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, surgical procedure.” Lewis v. Derwinski, 3 Vet. App. 259 (1992) (internal medical dictionary citation omitted). In addition, the February 2015 and October 2017 VA examiners specifically noted that there was no ankylosis of the spine. Therefore, the Veteran has not been shown to have met the criteria for an increased rating under the General Rating Formula for Diseases and Injuries of the Spine. The Board has also considered whether a rating in excess of 20 percent could be assigned, pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59. The current 20 percent rating is based on evidence showing that the Veteran’s spine disability is manifested by symptoms that include significant pain, flare-ups, and functional loss. The record shows no additional factors, such as atrophy of disuse, which would restrict motion to such an extent that the criteria for a rating in excess of 40 percent would be approximated or met. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45 (2017). The Board has also considered whether the appellant is entitled to a rating in excess of 20 percent under the rating criteria for evaluating intervertebral disc syndrome. However, in this case, the Board finds that these criteria have not been met. There is no indication that the Veteran has had incapacitating episodes having a total duration of at least 4 weeks during the past 12 months. In fact, the February 2015 and October 2017 VA examiners both noted that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. Thus, the Board finds that a rating in excess of 20 percent is not warranted under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Board further finds that a separate disability rating is not warranted at any time during the appeal period because the evidence does not demonstrate that the Veteran suffers from a separate neurological disability distinct from his already service-connected lumbar spine disability. See Bierman v. Brown, 6 Vet. App. 125, at 129-32 (1994). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board notes that the Veteran is already in receipt of a separate disability rating for radiculopathy of the right lower extremity associated with degenerative arthritis of the lumbar spine, and there is no other separate neurological disability shown by the evidence of record. For these reasons, the Board finds that the Veteran’s degenerative arthritis of the lumbar spine does not warrant a rating in excess of 20 percent during the appeal period. Knees In this case, the Veteran’s service-connected left and right knee disabilities are currently assigned separate 10 percent evaluations, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant’s painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Under Diagnostic Code 5260, a noncompensable evaluation is contemplated for flexion limited to 60 degrees. A 10 percent disability evaluation is assigned when flexion is limited to 45 degrees, and a 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is assigned when flexion is limited to 15 degrees, which is the maximum evaluation available under Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees, and a 10 percent disability evaluation is contemplated for extension limited to 10 degrees. When there is limitation of extension to 15 degrees, a 20 percent disability evaluation is warranted. A 30 percent rating will be assigned for extension limited to 20 degrees, and a 40 percent rating is contemplated for limitation of extension to 30 degrees. A 50 percent disability evaluation is warranted for extension limited to 45 degrees. The regulations provide that the normal range of motion of the knee is zero degrees on extension to 140 degrees on flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. §4.71a, Diagnostic Code 5003. Under Diagnostic Code 5258, dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint, warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Semilunar cartilage is the meniscus lateralis articulationis genus (lateral meniscus) and the meniscus medialis articulationis genus (medial meniscus). See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 273, 1013 (28th ed. 1994). A 20 percent rating is the maximum schedular evaluation available under Diagnostic Code 5258. Under Diagnostic Code 5257, a 10 percent disability rating is assigned for slight recurrent subluxation or lateral instability. A 20 percent disability rating is warranted when there is moderate recurrent subluxation or lateral instability, and a 30 percent disability rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words “slight,” “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Rating 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. Under Diagnostic Code 5259, a 10 percent disability evaluation is assigned for the symptomatic removal of semilunar cartilage. Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent disability rating is assigned for acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5263. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to increased ratings for his service-connected right and left knee disabilities. As previously noted, the Veteran has been assigned separate 10 percent evaluations for arthritis of both knees under Diagnostic Code 5003. Those evaluations were based upon the finding of painful or limited motion that would be noncompensable under the Diagnostic Codes for limitation of motion. See May 2008 rating decision. As such, an increased evaluation is not warranted under Diagnostic Codes 5003 or 5010. Moreover, the Board finds that the Veteran is not entitled to a higher or separate evaluation under Diagnostic Code 5260 for limitation of flexion for either knee during the period on appeal. Specifically, the record does not show that flexion was limited to 45 degrees or less to warrant a higher or separate evaluation at any point during the appeal period. In fact, during April 2008 and February 2010 VA examinations, the Veteran had left and right knee flexion to 140 degrees. During a February 2015 VA examination, the Veteran demonstrated left and right knee flexion to 130 degrees with pain on flexion. The VA examiner noted that the pain did not result in or cause functional loss. In addition, during an October 2017 VA examination, the Veteran had left knee flexion to 120 degrees and right knee flexion to 125 degrees. The VA examiner indicated that the Veteran had pain on flexion of both knees. As such, an increased or separate evaluation under Diagnostic Code 5260 is not warranted for either knee. The Board also finds that the Veteran is not entitled to a higher or separate rating under Diagnostic Code 5261 for limitation of extension. For the entire period on appeal, the record does not show that extension was limited to 10 degrees to warrant a separate compensable disability rating for either knee. In fact, during April 2008, February 2010, February 2015, and October 2017 VA examinations, the Veteran demonstrated left and right knee extension to 0 degrees. As such, an increased or separate evaluation under Diagnostic Code 5261 is not warranted for either knee. In an effort to afford the Veteran the highest possible rating, the Board has also considered whether any other rating criteria are applicable. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Nevertheless, the Board finds that the Veteran is not entitled to a separate evaluation for lateral instability or recurrent subluxation under Diagnostic Code 5257 for either knee. The Board notes that the Veteran reported that he had very infrequent transient giving way of his knees during the October 2017 VA examination. During the July 2013 hearing, he also testified that he had sensations of instability that caused him to stumble; however, he also related that he had never fallen due to his knees giving way. Throughout the appeal period, VA examinations have not shown any objective evidence of instability or recurrent subluxation. The April 2008 VA examiner noted that instability testing for medial and lateral collateral ligaments, anterior and posterior cruciate ligaments, and menisci were normal in the left and right knees. During the February 2010 VA examination, the Veteran denied having any instability in his left and right knees, and the VA examiner reported that there was no evidence or history of instability or patellar abnormality. The February 2015 and October 2017 VA examiners also reported that there was no instability with joint stability testing of the medial and lateral collateral ligaments and anterior and posterior cruciate ligaments. Moreover, the February 2015 and October 2017 VA examiners reported that there was no evidence or history of lateral instability or recurrent patellar subluxation in either knee. Thus, the preponderance of the evidence shows that higher or separate evaluations are not warranted under Diagnostic Code 5257. In addition, the Board finds that higher or separate evaluations are not warranted for the left or right knees under Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, or under Diagnostic Code 5259 for the symptomatic removal of semilunar cartilage. The Board notes that semilunar cartilage is the meniscus lateralis articulationis genus (lateral meniscus) and the meniscus medialis articulationis genus (medial meniscus). See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 273, 1013 (28th ed. 1994). The April 2008 VA examiner noted that medial and lateral meniscus tests of the left and right knees were within normal limits. The February 2010, February 2015, and October 2017 VA examiners also reported that there was no evidence of history of meniscus abnormalities. Thus, the evidence does not show that he has semilunar cartilage impairment in either knee. The Board has also considered whether a higher or separate evaluation is warranted under any other diagnostic code. However, as the evidence of record does not demonstrate that the Veteran has ankylosis, impairment of the tibia and fibula, or genu recurvatum, he is not entitled to higher evaluations under Diagnostic Codes 5256 (ankylosis), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum). There is simply no evidence of such manifestations. Indeed, based on the aforementioned range of motion findings, the record shows that the Veteran’s left knee is not fixated or immobile. Moreover, the February 2010 VA examiner specifically reported that the Veteran had no ankylosis of the right or left knee. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, surgical procedure.” Lewis v. Derwinski, 3 Vet. App. 259 (1992) (internal medical dictionary citation omitted). Therefore, separate or higher ratings are not warranted under Diagnostic Codes 5256, 5262, and 5263. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran’s knee disabilities is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran’s symptoms are supported by pathology consistent with the assigned evaluations, and no higher. In this regard, the Board observes that the Veteran complained of pain throughout the appeal period. However, the effect of the pain in the Veteran’s left and right knees is already contemplated in the assigned evaluations. The Veteran’s complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation beyond those already assigned. Indeed, the April 2008 and February 2015 VA examiners indicated that the Veteran’s left and right knees did not have any diminution with repetitive testing. The February 2015 and October 2017 VA examiners also noted normal muscle strength and reported that there was no weakened movement, excess fatigability, incoordination, swelling, deformity, or atrophy of disuse. Accordingly, the Board concludes that an increased or separate evaluation is not warranted for the Veteran’s service-connected knee disabilities under DeLuca. Accordingly, the Board concludes that increased or separate evaluations are not warranted for the Veteran’s service-connected left and right knee disabilities for the appeal period. Skin The Veteran is currently assigned a noncompensable evaluation for atopic dermatitis prior to February 13, 2015, and a 30 percent evaluation thereafter, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806 for a disability that is analogous to dermatitis or eczema. Under Diagnostic Code 7806, a 10 percent evaluation is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or, systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs is required during the past 12-month period. The types of systemic treatment that are compensable under Diagnostic Code 7806 are not limited to “corticosteroids or other immunosuppressive drugs,” but are instead available for “all systemic therapies that are like or similar to corticosteroids or other immunosuppressive drugs.” Warren v. McDonald, 28 Vet. App. 194, 197 (2016). More recently, in July 2017, the Federal Circuit, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), reversed the judgment of the Court of Appeals of Veterans Claims (Court) in Johnson v. McDonald, 27 Vet. App. 497 (2016). At issue in Johnson v. Shulkin, was the question of whether criteria for a 60 percent rating under Diagnostic Code 7806, which requires “constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs,” is inclusive of topical corticosteroids. In reversing the Court’s decision, the Federal Circuit noted that Diagnostic Code 7806 “draws a clear distinction between ‘systemic therapy’ and ‘topical therapy’ as the operative terms of the diagnostic code,” and explained that “systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.’” Id. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that a compensable evaluation is not warranted for dermatitis prior to February 13, 2015, and an evaluation in excess of 30 percent is not warranted thereafter. Prior to February 13, 2015, the Veteran’s dermatitis has not been shown to affect at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas. In this regard, during an April 2008 VA examination, the VA examiner noted that the Veteran’s skin rash involved areas exposed to the sun, including his forearms. The VA examiner reported that the rash did not include the face, hands, neck and head. The VA examiner also noted that the Veteran had no rash or skin lesions. The VA examiner specifically indicated that the Veteran’s skin condition affected 0 percent of his exposed areas and 2 percent of his whole body. A February 2010 VA examiner further reported that the Veteran’s dermatitis affected 0 percent of his exposed areas and less than 5 percent of his total body area. These findings are consistent with the noncompensable evaluation currently assigned for the period prior to February 13, 2015. Since February 13, 2015, the Veteran’s dermatitis has not been shown to affect more than 40 percent of the entire body or more than 40 percent of exposed areas. During a February 2015 VA examination, the VA examiner noted that the Veteran had very mild regions of atopic dermatitis on his arms and legs and a small region on his chest. The VA examiner reported that his dermatitis affected 5 to less than 20 percent of the exposed area and 20 to 40 percent of his entire body. These findings are consistent with the 30 percent evaluation currently assigned for the period beginning on February 13, 2015. The chronic skin rash has also not been shown to require the use of systemic therapy such as corticosteroids or other immunosuppressive drugs during either period on appeal, and the Veteran has not contended otherwise. In this case, the record shows that the Veteran used Cetaphil lotion for six weeks of more (see April 2008 VA examination report); required near-constant use of Triamcinolone cream for one week monthly (see February 2010 VA examination); required constant or near-constant use of topical corticosteroids (see February 2015 VA examination); and was prescribed lotion for moisturization (see February 2015 VA treatment note). Although there is evidence that the Veteran used a topical corticosteroid on a constant or near-constant basis, the Federal Circuit has determined that this type of treatment is not systemic therapy that would warrant a higher rating. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). In Johnson, the Federal Circuit noted that Diagnostic Code 7806 “draws a clear distinction between systemic therapy and topical therapy as the operative terms of the diagnostic code.” Johnson, 862 F.3d at 1354. The Federal Circuit explained that systemic therapy means treatment pertaining to or affecting the body as a whole, whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied. Id at 1355. Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. While the Veteran’s dermatitis has required constant or near-constant treatment with topical medications, to include topical corticosteroids, the evidence shows that his skin condition has only involved his forearms, legs, and chest. There is no evidence that large portions of his anatomy are involved, as his skin condition affected, at most, 20 to 40 percent of his entire body and, at most, 5 to less than 20 percent of his exposed areas. Therefore, although his skin disorder does require a topical corticosteroid treatment, this treatment cannot be considered systemic therapy as contemplated by the Federal Circuit in Johnson and does not rise to the level contemplated for increased evaluations for either period on appeal. The Board has also considered other potentially applicable Diagnostic Codes, including those for disfigurement of the head, face, or neck (Diagnostic Code 7800) and scars (Diagnostic Codes 7801 to 7805) as raised by the record. In this case, the February 2015 VA examiner determined that the Veteran’s dermatitis did not cause scarring or disfigurement of the head, face, or neck, or any significant scarring. The record does not reflect, nor has the Veteran contended, that any related scars, if any, were painful or resulted in other compensable manifestations. Therefore, the Board finds that the weight of the evidence is against an initial compensable evaluation for atopic dermatitis prior to February 13, 2015, or in excess of 30 percent thereafter. Conclusion Neither the Veteran nor his representative has raised any other issues during either appeal period, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 368 (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). J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Osegueda, Counsel