Citation Nr: 18158867 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 14-09 114 DATE: December 19, 2018 ORDER 1. Entitlement to an initial compensable rating for right shoulder bursitis for the period of appeal prior to June 3, 2015, is denied. 2. Entitlement to a 20 percent rating for right shoulder bursitis for the period of appeal from June 3, 2015, to May 23, 2016, is granted. 3. Entitlement to a rating in excess of 20 percent for right shoulder bursitis for the period of appeal from May 23, 2016, is denied. 4. Entitlement to an initial compensable rating for right knee nontraumatic rupture of the patellar tendon and osteoarthritis (right knee disability) for the period of appeal prior to June 13, 2013, is denied. 5. Entitlement to a 10 percent rating for the right knee disability for the period of appeal from June 13, 2013, to June 3, 2015, is granted. 6. Entitlement to a rating in excess of 10 percent for the right knee disability for the period of appeal from June 3, 2015, is denied. 7. Entitlement to an initial compensable rating for left knee nontraumatic rupture of the patellar tendon and osteoarthritis (left knee disability) for the period of appeal prior to June 12, 2013, is denied. 8. Entitlement to a 10 percent rating for the left knee disability for the period of appeal from June 13, 2013, to October 28, 2015, is granted. 9. Entitlement to a rating in excess of 10 percent for the left knee disability for the period of appeal from October 28, 2015, is denied. 10. Entitlement to an initial compensable rating for right fourth finger disfigurement is denied. 11. Entitlement to an initial compensable rating for gastroesophageal reflux disease (GERD) for the period of appeal prior to June 3, 2015, is denied. 12. Entitlement to a rating in excess of 10 percent for GERD for the period of appeal from June 3, 2015, is denied. 13. Entitlement to an initial compensable rating for residual scars of bilateral knee arthroscopies is denied. 14. Entitlement to an initial compensable rating for eczema, claimed as a skin condition, is denied. REMANDED 15. Entitlement to an initial compensable rating for keratoconus is remanded. FINDINGS OF FACT 1. For the period of appeal prior to June 3, 2015, the right shoulder bursitis did not show evidence of limitation of motion or painful motion. 2. For the period of appeal from June 3, 2015, the right shoulder bursitis manifests by painful motion, without evidence of limitation of motion. 3. For the period of appeal prior to June 13, 2013, the right knee disability did not show evidence of limited motion or painful motion. 4. For the period of appeal from June 13, 2013, the right knee disability manifests by pain and painful motion, without evidence of ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, flexion limited to at least 60 degrees, extension limited to at least 5 degrees, impairment of the tibia and fibula, or genu recurvatum. 5. For the period of appeal prior to June 13, 2013, the left knee disability did not show evidence of limited motion or painful motion. 6. For the period of appeal from June 13, 2013, the evidence is in equipoise on whether the left knee disability manifests by pain and painful motion. There is no evidence of ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, flexion limited to at least 60 degrees, extension limited to at least 5 degrees, impairment of the tibia and fibula, or genu recurvatum. 7. For the entire period of appeal, the right fourth finger disfigurement manifests in a one-inch or more gap between the right ring finger and the proximal transverse crease of the palm when attempting to touch the palm with the fingertips, without evidence of ankylosis or total loss of use of the finger such that the Veteran would be equally served by amputation. 8. For the period of appeal prior to June 3, 2015, GERD was manifested by reflux, without evidence of dysphagia, pyrosis, or substernal, arm, or shoulder pain. 9. For the period of appeal from June 2, 2015, GERD manifests by epigastric distress, pyrosis, reflux, sleep disturbance, recurrent nausea, and regurgitation, which were not productive of a “considerable impairment of health.” There is no evidence of dysphagia or substernal, arm, or shoulder pain related to GERD. 10. For the entire period of appeal, the residual scars of bilateral knee arthroscopies are superficial, linear, and stable, and do not result in pain, limited motion, or other functional impairment. 11. For the entire period of appeal, the eczema is has not involved at least five percent of the Veteran’s entire body or least five percent of the exposed areas of the Veteran’s body, nor has it required any topical or systemic therapy. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for right shoulder bursitis for the period of appeal prior to June 3, 2015, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5019-5201. 2. The criteria for a 20 percent rating for right shoulder bursitis for the period of appeal from June 3, 2015, to May 23, 2016, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5019-5201. 3. The criteria for a rating in excess of 20 percent for right shoulder bursitis for the period of appeal from May 23, 2016, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5019-5201. 4. The criteria for an initial compensable rating for the right knee disability for the period of appeal prior to June 13, 2013, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 5. The criteria for a 10 percent rating for the right knee disability for the period of appeal from June 13, 2013, to June 3, 2015, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 6. The criteria for a rating in excess of 10 percent for the right knee disability for the period of appeal from June 3, 2015, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 7. The criteria for an initial compensable rating for the left knee disability for the period of appeal prior to June 13, 2013, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. 8. Resolving all reasonable doubt in favor of the Veteran, the criteria for a 10 percent rating for the left knee disability for the period of appeal from June 13, 2013, to October 28, 2015, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. 9. The criteria for a rating in excess of 10 percent for the left knee disability for the period of appeal from October 28, 2015, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. 10. The criteria for an initial compensable rating for right fourth finger disfigurement are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5230. 11. The criteria for an initial compensable rating for GERD for the period of appeal prior to June 3, 2015, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7399-7346. 12. The criteria for a rating in excess of 10 percent for GERD for the period of appeal from June 3, 2015, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7399-7346. 13. The criteria for an initial compensable rating for residual scars of bilateral knee arthroscopies are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7805. 14. The criteria for an initial compensable rating for eczema are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7806. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force for over 21 years, from May 1990 to March 2012. Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Musculoskeletal disabilities 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. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all these elements. Id. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitively related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the U.S. Court of Appeals for Veterans Claims (Court) held that for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. The Court 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, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). As stated in Correia v. McDonald, 28 Vet. App. 158 (2016), the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Indeed, Correia stated “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.” Id. at 9. The Board finds the June 2015 VA examinations adequate under Correia. First, retroactive range of motion testing cannot be performed; as such, the June 2015 VA examinations are still adequate as Correia stated “its decision today will be taken as requiring the range of motion testing listed in the final sentence of § 4.59 in every case in which those tests can be conducted.” Id. at *8 n.7. Furthermore, the Veteran was scheduled for a series of VA examinations in January 2017, which were to include Correia considerations. However, the Veteran failed to report for the examinations. He indicated that he did not attend the examinations because they were scheduled too far from his home. In an October 2017 letter, VA advised the Veteran that he could not be scheduled at the VA Medical Center (VAMC) in Jackson, Mississippi, because he was an employee at that facility. The Veteran was further advised that if he wished to report for VA examinations at a facility other than the Jackson VAMC, he had 30 days to respond to the letter. To date, no response has been received, and the Veteran indicated in the March 2018 Board hearing that his concern was regarding initial compensable ratings more than worsening of his disabilities. As such, the Board will adjudicate the issues, except for the eye issue, on the current record. Finally, arthritis shown by x-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Diagnostic Code 5010 (traumatic arthritis) directs that arthritis be rated under Diagnostic Code 5003 (degenerative arthritis), which states that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The 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, x-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. 1. – 3. Increased ratings for the right shoulder. The Veteran’s right shoulder bursitis is rated under Diagnostic Code 5019-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the hyphenated diagnostic code indicates that bursitis (Diagnostic Code 5019) is rated under the criteria for limitation of motion of the arm (Diagnostic Code 5201). Under Diagnostic Code 5019, bursitis is rated based on limitation of motion of the affected parts. Under Diagnostic Code 5201, a 20 percent rating is assigned for limitation of motion of the major arm or minor arm to the shoulder level, or for limitation of motion of the minor arm to midway between the side and shoulder level. A 30 percent rating is warranted for limitation of motion of the major arm to midway between the side and shoulder level, or for limitation of motion of the minor arm to 25 degrees from the side. A schedular maximum 40 percent rating is warranted for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Standard range of motion of the shoulder is forward elevation (flexion) to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. The terms “major” and “minor” are used in the rating criteria to refer to the dominant or nondominant upper extremity. 38 C.F.R. § 4.69. Here, the Veteran is right-handed. Therefore, his right shoulder is evaluated as major. The Veteran was assigned an initial noncompensable (zero percent) rating, a 10 percent rating from June 3, 2015, and a 20 percent rating from May 23, 2016. In the March 2018 Board hearing, the Veteran asserted that his shoulder symptoms had been present since 2012 and that the 20 percent rating should be retroactive to the grant of service connection date. Period of appeal prior to June 3, 2015 The sole evidence for this period of appeal is a March 2012 VA examination. In the examination, the Veteran reported dislocating his shoulder in service in 1995. He now had achy pain in the shoulder once every other week, which lasted for 8-12 hours. He did not do anything to relieve the symptoms. On examination, flexion was to 165 degrees and abduction was to 160 degrees, without objective evidence of painful motion. After repetitive-use testing with three repetitions of movement, ranges of motion were unchanged. There was no tenderness or pain to palpation of the shoulder and results of muscle strength tests were normal. The Veteran did not have ankylosis, a rotator cuff condition, mechanical conditions, an AC joint condition, or any shoulder surgery. X-rays showed osteoarthritis. The examiner indicated there were mild functional limitations caused by the shoulder. The Board finds that a compensable rating for the shoulder for this period of appeal is not warranted. A 20 percent rating requires limitation of motion of the major arm to the shoulder level, which the Veteran’s shoulder did not show in the examination. Moreover, there was no finding of painful motion to warrant a compensable percent rating pursuant to 38 C.F.R. § 4.59. Period of Appeal from June 3, 2015 In a June 3, 2015, VA examination, the Veteran reported having pain in the deltoid area, which rated as 7 out of 10. He denied having flare-ups. Range of motion measurements were normal, including flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. There was pain on external and internal rotation, which did not cause any functional loss. There was soreness/tenderness at the right upper arm deltoid area, due to a recent tendon surgery (after a bicep injury that occurred while weightlifting in March 2015), and evidence of pain with weight-bearing. After repetitive-use testing with three repetitions of movement, ranges of motion were unchanged. There was no evidence of pain, fatigue, weakness, lack of endurance, or incoordination. Results of muscle strength testing, rotator cuff conditions, and instability testing were normal. The RO subsequently granted a 10 percent rating for painful motion under 38 C.F.R. § 4.59, effective June 3, 2015. In a February 2018 rating decision, the RO increased the rating to 20 percent for the right shoulder effective May 23, 2016, pursuant to a Court decision, Sowers v. McDonald, 27 Vet. App. 472, 478-79, 482 (2016) (stating that application of 38 C.F.R. § 4.59 warrants at least the minimum compensable rating for painful motion of a joint); see also Downey v. McDonald, 2016 U.S. App. Vet. Claims LEXIS 1997, *9 (Dec. 28, 2016) (nonprecedential Memorandum Decision). The Board finds that the Veteran first exhibited painful motion in the June 3, 2015, VA examination. As such, he is entitled to the minimum compensable disability rating under Diagnostic Code 5201 from this date, which is 20 percent. The Veteran is not entitled to a rating in excess of 20 percent at any point during the period of appeal. A higher 30 percent rating requires limitation of motion of the major arm to midway between the side and shoulder level. Here, the Veteran has never been found to have any limitation of motion. As such, a rating in excess of 20 percent is denied. Other considerations The Board has considered whether higher disability ratings are warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board notes, however, that the rating criteria are intended to take into account functional limitations, and therefore the provisions of 38 C.F.R. §§ 4.40 and 4.45 could not provide a basis for a higher evaluation. See 68 Fed. Reg. 51454 -5 (Aug. 27, 2003). In any event, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination, as the probative evidence of record demonstrates that the Veteran had essentially fully range of motion even with the shoulder pain. Finally, consideration has been given to other potentially applicable diagnostic codes. However, the Veteran has not been found to have ankylosis of the scapulohumeral articulation, impairment of the humerus, or impairment of the clavicle or scapula to warrant consideration of Diagnostic Codes 5200 (scapulohumeral articulation, ankylosis of), 5202 (other impairment of humerus), or 5203 (impairment of clavicle or scapula). 4. – 9. Increased ratings for the bilateral knee disabilities. The Veteran’s right knee is rated under Diagnostic Code 5260 and the left knee is rated under Diagnostic Code 5003-5260. Diagnostic Code 5260, which governs limitation of leg flexion, provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. 38 U.S.C. § 4.71a, Diagnostic Code 5260. The Veteran was assigned initial noncompensable ratings for the right and left knees. The rating for the right knee was increased to 10 percent effective June 3, 2015, based on evidence of painful motion. The rating for the left knee was increased to 10 percent effective October 28, 2015, based on evidence of painful motion. The Veteran asserted in the March 2018 Board hearing that his bilateral knee symptoms had been present since 2012 and that the 10 percent ratings should be retroactive to the grant of service connection date. Period of appeal prior to June 13, 2013 The sole evidence for this period of appeal is a March 2012 VA examination. In the examination, the Veteran was noted to have had bilateral patellar tendon repair surgeries in service. He reported continuing left knee pain “every blue moon” after prolonged standing or after running. He had injections every 6-8 months. The right knee had throbbing pain every other day after prolonged standing, running more than 15 minutes, or jumping. The Veteran reported having flare-ups that made him walk with a limp. Ranges of motion included bilateral flexion to 140 degrees and zero degrees of extension, without objective evidence of painful motion. After repetitive-use testing with three repetitions of movement, ranges of motion were unchanged. There was no tenderness or pain to palpation of either knee, and results of muscle strength and stability tests were normal. The Veteran did not have recurrent patellar subluxation or dislocation, a meniscal condition, or total knee replacement. X-rays showed bilateral osteoarthritis. The examiner indicated there were no functional limitations caused by the knees. The Board finds that a compensable rating is not warranted for either knee for this period of appeal. A 10 percent rating requires flexion limited to 45 degrees, which neither knee showed in the examination. Moreover, there was no finding of painful motion of either knee to warrant a 10 percent rating pursuant to 38 C.F.R. § 4.59. The Board acknowledges that the Veteran reported having left knee pain “every blue moon” and right knee pain every other day after certain activities; however, there was no evidence of painful motion in either knee, nor was there tenderness or pain to palpation of either knee. As such, a 10 percent rating for painful motion under 38 C.F.R. § 4.59 is not warranted for this period of appeal Period of appeal from June 13, 2013 VA treatment records indicate that on June 13, 2013, the Veteran reported having bilateral knee pain. He was found to have pain in the bilateral lower extremities with McMurray’s test with medial and lateral joint compression. He had an orthopedic consultation in July 2013, in which he reported having no problems with the left knee since surgery but persistent problems with the right knee, which was slowly getting worse. The treating doctor indicated that the Veteran had bilateral full extension. The left knee had normal strength, no tenderness, and a solid-feeling tendon. The right knee had tenderness and weakness of extension. The doctor noted that the Veteran may have had a partial rupture of the right patellar tendon, and as such, was not a candidate for corticosteroid injections. He had an MRI of the right knee, which did not show a rupture. In another orthopedic consultation in September 2013, he was found to have symptoms consistent with deep infrapatellar tendon bursitis. He had a corticosteroid injection in the right knee. In November 2014, the Veteran reported having right knee pain. He was found to have crepitus on flexion and extension bilaterally, especially in the right knee. The degenerative joint disease of the knees was noted to be severe. In a June 2015 VA examination, the Veteran reported having pain in his knees when he stood for more than 15 minutes. It was hard to bend his right knee, run, and go up and down steps. He used a right knee brace occasionally and denied having flare-ups of the knees. The examiner indicated that she was unable to test the right knee’s range of motion because the Veteran was guarding the knee in flexion and extension “to decrease the pain.” The left knee showed flexion to 140 degrees and zero degrees of extension, without evidence of pain. There was also no objective evidence of left knee localized tenderness or pain on palpation, or pain with weight-bearing. There was evidence of left knee crepitus. After repetitive-use testing with at least three repetitions of movement, the left knee range of motion was unchanged. The left knee showed normal muscle strength (5/5) and the right knee showed active movement against some resistance (4/5). There was no history of recurrent subluxation or lateral instability. The knees swelled with use. The examiner was unable to evaluate the right knee stability because of the pain the Veteran was experiencing. The left knee did not show any instability. The examiner indicated that the Veteran had severe pain when bending the right knee and could not bend the left knee while sitting. Any activities that required those functions would be grossly impaired. The Board finds that 10 percent ratings for the bilateral knees are warranted from June 13, 2013, the earliest finding of tenderness or pain to palpation. The right knee was subsequently found to have tenderness of extension the next month and subsequent VA treatment records and an examination indicate continued complaints of pain, painful motion, and crepitus. With regard to the left knee, the Board acknowledges that the Veteran was not found to have painful motion in the June 2015 VA examination; however, he was noted to have left knee pain in June 2013, he was found to have crepitus in flexion and extension in November 2014, and was noted in the June 2015 VA examination to be unable to bend the left knee while sitting. Thus, resolving all reasonable doubt in favor of the Veteran, a 10 percent rating for the left knee is warranted from June 13, 2013. See 38 C.F.R. § 4.59. Ratings in excess of 10 percent are not warranted for either knee under Diagnostic Code 5260, as there is no evidence of flexion limited to 30 degrees in either knee at any point during the period of appeal. Other considerations The Board has considered whether higher disability ratings are warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board notes, however, that the rating criteria are intended to take into account functional limitations, and therefore the provisions of 38 C.F.R. §§ 4.40 and 4.45 could not provide a basis for a higher evaluation. See 68 Fed. Reg. 51454 -5 (Aug. 27, 2003). Consideration has also been given to other potentially applicable diagnostic codes; however, the Board finds no basis upon which to assign evaluations in excess of the two 10 percent ratings already assigned for each knee. The Veteran clearly does not have ankylosis to warrant a separate rating under Diagnostic Code 5256 (ankylosis), and there is no evidence of recurrent subluxation or lateral instability, dislocated cartilage with frequent episodes of locking and effusion, removal of semilunar cartilage, limitation of extension, malunion of the tibia and fibula, or genu recurvatum to warrant separate ratings under Diagnostic Codes 5257 (recurrent subluxation or lateral instability), 5258 (dislocated cartilage), 5259 (removal of semilunar cartilage), 5261 (limitation of extension), 5262 (malunion of the tibia and fibula), or 5263 (genu recurvatum).   10. Increased rating for the right fourth finger. The Veteran’s right fourth finger is rated under Diagnostic Code 5230, for limitation of motion of the ring or little finger. This code provides a noncompensable rating for any limitation of motion of the ring or little finger of the major or minor hand. This noncompensable rating is the maximum schedular rating available under this code, and there is no schedular compensable evaluation. Other diagnostic codes for consideration include Diagnostic Code 5227, which also only provides a 0 percent (maximum) rating for unfavorable or favorable ankylosis of the ring or little finger, and Diagnostic Code 5223, which provides for a maximum 10 percent rating when there is favorable ankylosis of long and little fingers, or the ring and little fingers. A Note to Diagnostic Code 5227, in pertinent part, states that VA is to consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall functioning of the hand. In this case, the Board finds that the preponderance of the evidence is against an award of a compensable initial rating under any applicable criteria for the service-connected right fourth finger disability. In a March 2012 VA examination, the Veteran reported dislocating his right fourth finger in 2010. He indicated that the finger did not bend normally anymore and he could not make a complete fist. He had pain daily, which he rated as 2 out of 10. If he hit his finger against something, the pain increased to an 8. He had not had any injections or surgeries on the finger. The examiner noted that he the Veteran’s dominant hand was his right hand. The Veteran had a one-inch (2.5 cm) or more gap between the right ring finger and the proximal transverse crease of the palm when attempting to touch the palm with the fingertips. There was no evidence of painful motion. After repetitive-use testing with three repetitions of movement, there was no additional limitation of motion. There was no tenderness or pain to palpation of the joints or soft tissue, and muscle strength testing was normal. X-rays showed an old avulsion fracture of the ulnar aspect of the PIP joint of the right fourth digit. There was no arthritis. In a June 2015 VA examination, the Veteran reported low grade pain at times, for which he took Motrin, but largely no progressive symptoms and he denied having flare-ups. Range of motion measurements did not reveal any limitation of motion or evidence of painful motion for any fingers or the thumb. After repetitive-use testing with three repetitions of movement, there was no additional limitation of motion. There was also no tenderness or pain to palpation of the joints or soft tissue, and muscle strength testing was normal. The examiner indicated that the Veteran did not have any functional loss or functional impairment of the any of the fingers or thumb. In light of the VA examination results above, a compensable initial rating is not warranted under Diagnostic Code 5230 or any other applicable rating criteria. Diagnostic Code 5156 is not applicable, as there is no indication of total loss of use of the finger such that the Veteran would be equally served by amputation. 38 C.F.R. § 4.71a, DC 5156. Additionally, the service-connected right fourth finger does not constitute a major joint; hence, Diagnostic Codes 5003 and 5010 for arthritis are not appropriate and cannot support a compensable initial rating. 38 C.F.R. § 4.71a, DC 5003, 5010. Finally, the Board has considered a rating decision based on painful motion under 38 C.F.R. § 4.59. Generally, when painful motion is present, the minimum compensable rating for the joint should be assigned. In this case, however, there is no level of disability that warrants a compensable rating under Diagnostic Code 5230. Sowers v. McDonald, 27 Vet. App. 472, 479-81 (2016). Therefore, a compensable rating for painful motion cannot be assigned. See id.; 38 C.F.R. § 4.59. In sum, the Board finds that a compensable initial rating is not warranted for the service-connected right fourth finger disability. The preponderance of the evidence is against the claim, there is no doubt to be resolved, and an increased rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 11. – 12. Increased rating for GERD. The Veteran’s GERD is rated under Diagnostic Code 7399-7346, indicating that a condition of the digestive system (Diagnostic Code 7399) is rated under the criteria for hiatal hernia (Diagnostic Code 7346). Under Diagnostic Code 7346, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. (Material weight loss is not defined in Diagnostic Code 7346, but “substantial weight loss” is defined under 38 C.F.R. § 4.112 as a loss of greater than 20 percent of the individual’s baseline weight, sustained for three months or longer, and “minor weight loss” is defined as a weight loss of 10 to 20 percent of the individual’s baseline weight, sustained for three months or longer under.) 38 C.F.R. § 4.114, Diagnostic Code 7346. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. The Veteran asserted in the March 2018 Board hearing that the 10 percent rating assigned from June 3, 2015, should date back to the initial date of service connection. Period of appeal prior to June 3, 2015 In a March 2012 VA examination, the Veteran reported that he took Nexium daily to control his symptoms, which worked, but not as well as Prevacid used to (before the Prevacid formula was changed). His only reported symptom was reflux. The examiner noted that results of an upper GI radiographic study done in April 2012 were normal. VA treatment records indicate that in April 2013, the Veteran reported having reflux. He had an esophagogastroduodenoscopy (EGD) in May, which showed fundic gland polyps. A November 2014 treatment record indicates that the polyps were benign and did not need follow-up. The Board finds that the preponderance of the evidence is against an award of a compensable rating for this period of appeal. As discussed above, a 10 percent rating requires at least two symptoms of persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. Here, for this period of appeal, the sole symptom the Veteran had due to GERD was reflux. As such, a compensable rating is not warranted prior to June 3, 2015. Period of appeal from June 3, 2015 In a June 2015 VA examination, the Veteran reported that he had stopped taking Nexium due to cost and was taking omeprazole instead, which he took twice per day. He stated that his symptoms occurred about every other day. The examiner indicated that the Veteran had persistently recurrent epigastric distress, pyrosis (heartburn), reflux, sleep disturbance, and recurrent nausea, which occurred four or more times per year; and regurgitation that occurred 3 times per year and lasted less than one day. In January 2016, the Veteran reported having pain in the middle of his chest, which he was unsure if it was acid reflux. It was noted to be probably non-cardiac in etiology. The Board finds that the preponderance of the evidence is against an award in excess of 10 percent for this period of appeal. A higher 30 percent rating requires persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Here, the Veteran was noted to have symptoms of epigastric distress, pyrosis (heartburn), reflux, sleep disturbance, recurrent nausea, and regurgitation. However, he has not been found to have dysphagia or substernal, arm, or shoulder pain related to GERD, nor does the evidence show a disability picture productive of “considerable impairment of health” to warrant a 30 percent rating. There is also no other diagnostic code that would be appropriate to evaluate the Veteran’s GERD. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In this regard, the Board notes that the Veteran has not been diagnosed with esophagus stricture or spasm, adhesions of peritoneum, an ulcer, a liver condition, cholecystitis, resection of the small or large intestine, involuntary bowel movements requiring use of pad, stricture of rectum and anus, hemorrhoids, malignant or benign neoplasms of the digestive system, chronic liver disease, pancreatitis, vagotomy, or hepatitis to render those diagnostic codes applicable. Moreover, 38 C.F.R. § 4.114 states that ratings under diagnostic codes 7301 through 7329, inclusive, will not be combined with each other; a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, which, in this case, is best reflected by the diagnostic code for a hiatal hernia. 13. Increased ratings for bilateral knee scars. The Veteran’s knee scars are rated under Diagnostic Code 7805, for other scars including linear scars. Under this diagnostic code, scars are rated based on limitation of function of the part affected. In a March 2012 VA examination, the Veteran was noted to have two scars, one on each knee. The right knee scar was 11.5 centimeters (cm) long and 0.6 cm wide. The left knee scar was 16.5 cm long an d0.8 cm wide. On examination, the scars were superficial, non-tender, and did not cause limitation of motion or function. In a June 2015 VA examination, the Veteran was noted to have a 12.5 cm by 0.2-millimeter (mm) right knee scar and a 15 cm by 0.2 mm left knee scar. The scars were linear and not painful or unstable. In evaluating the Diagnostic Codes potentially applicable to the Veteran’s scars, the Board notes that Diagnostic Code 7800 does not apply because the Veteran’s scars are not on his head, face, or neck. Diagnostic Code 7801 does not apply because the Veteran’s scars are neither deep nor nonlinear. Diagnostic Code 7802 does not apply because the Veteran’s scars are linear. Diagnostic Code 7804 does not apply because the Veteran’s scars are stable and is not painful. Thus, with Diagnostic Codes 7800 to 7804 excluded, Diagnostic Code 7805 applies, which contemplates the ratings of “other” scars, which are to be rated based on limitation of function of the part affected. The Veteran is not entitled to a compensable rating under this diagnostic code because he has suffered no functional impairment (such as limitation of motion) as a result of his scars, nor does the Veteran so contend. Because the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 14. Increased rating for eczema. The Veteran’s eczema is rated under Diagnostic Code 7806, for dermatitis or eczema. This diagnostic code provides that where there is less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period a noncompensable evaluation is warranted. When 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 affected, or; intermittent systemic therapy such corticosteroids or immunosuppressive drugs required for a total duration of less than six-weeks during the past 12-month period, a 10 percent rating is assigned. Where there is 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, a 30 percent rating is assigned. Where there is more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, a 60 percent rating is assigned. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Federal Circuit addressed the meaning of “systemic” and “topical” for rating skin disabilities under the regulatory criteria prior to August 31, 2018. See Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). For these purposes, 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. The Federal Circuit acknowledged that 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, but the Court emphasized that this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Rather, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the facts of each case. Id. at 1356. Effective August 31, 2018, VA regulations explicitly state that for the purposes of the skin disability ratings, “systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin.” 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Code 7806. Under this formula, a maximum 60 percent rating under this formula requires at least one of the following: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. A 30 percent rating requires at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) systemic therapy such as those listed under the 60 percent criteria required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 10 percent rating requires at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) intermittent systemic therapy such as those listed under the 60 percent criteria required for a total duration of less than 6 weeks over the past 12-month period. A noncompensable (0 percent) rating is assigned where there is no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. In this case, the Board finds that a compensable rating is not warranted at any point during the period of appeal, under the old or new rating criteria. In a March 2012 VA examination, the Veteran reported being diagnosed with eczema in 1994, which usually involved his forearms. He indicated that he used over-the-counter cortisone creams, had not had a prescription for the condition within the last three years, and had never had any skin treatments or procedures for the condition. The Veteran’s skin was noted to be warm, dry, good color, and normal turgor. He had no skin changes, rashes, acne, chloracne, or systemic manifestations due to any skin diseases. He also had no scarring or disfigurement of the head, face, or neck. The examiner indicated that the eczema covered none of the exposed or total body area. VA treatment records dated in April and June 2013 indicate that the Veteran was not found to have a skin rash. In a June 2015 VA examination, the Veteran reported that his eczema went away for extended periods of time. The last episode was in 2005. The examiner indicated that the Veteran did not have any scarring or disfigurement of the head, face, or neck; benign or malignant skin neoplasms; or systemic manifestations; and had not been treated with oral or topical medications in the past 12 months for any skin condition. He also had not had any treatments or procedures other than systemic or topical medications in the past 12 months. The examiner indicated that the eczema covered none of the exposed or total body area. In March 2017, the Veteran was again noted in a VA treatment record to have no skin rashes. In the March 2018 Board hearing, the Veteran asserted that his eczema was not active regularly. The Board finds that the preponderance of the evidence is against an award of a compensable rating at any point during the period of appeal. As discussed above, a 10 percent rating requires the eczema to involve at least 5 percent but less than 20 percent of the entire body or exposed areas, or intermittent systemic therapy for a total duration of less than 6 weeks over the past 12-month period. Here, the Veteran consistently denied using any topical or systemic therapies for the eczema, and he was found by two VA examiners to have eczema on zero percent of his total body and zero percent of his exposed body areas. In short, the Veteran has not been found to have any symptoms of eczema during the period of appeal, nor does he so contend. As such, a compensable rating is not warranted at any point during the period of appeal. REASONS FOR REMAND 15. Increased rating for keratoconus is remanded. VA treatment records dated in March 2017 indicate that the Veteran was treated at University of Mississippi Medical Center (UMMC) for his eye condition, including a follow-up that he had scheduled for later that month. Furthermore, in the March 2018 Board hearing, the Veteran testified that he had his eyes examined approximately one year prior at the University. There are currently no records from UMMC associated with the claims file. As such, remand is necessary to obtain these records. On remand, updated VA treatment records should also be obtained. The matter is REMANDED for the following action: 1. Contact the Veteran and request that he provide sufficient information, and if necessary authorization, to enable the RO to obtain any non-VA treatment records showing any relevant treatment related to the keratoconus or any other eye condition, to include from the University of Mississippi Medical Center (UMMC). The RO should try to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. 2. Obtain from the VA healthcare system all outstanding relevant treatment records, including records dated from February 2018 to present. All records/responses received should be associated with the claims file. If any records sought are not obtained, a written statement to that effect should be incorporated into the record.   A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel