Citation Nr: 18161043 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 11-24 018 DATE: December 28, 2018 ORDER A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. Prior to November 8, 2016, a rating of 30 percent, but no higher, for service-connected residuals of right knee osteoarthritis and tibia/fibula fracture is granted, subject to the laws and regulations governing the award of monetary benefits. From September 16, 2014 to November 8, 2016, a rating of 30 percent, but no higher, for instability associated with service-connected residuals of right knee osteoarthritis and tibia/fibula fracture is granted, subject to the laws and regulations governing the award of monetary benefits. Since January 1, 2018, a rating in excess of 30 percent for service-connected residuals of right knee osteoarthritis and tibia/fibula fracture, status post total knee replacement, is denied. An initial rating in excess of 10 percent for service-connected chronic left knee strain is denied. Prior to March 13, 2014, a rating in excess of 10 percent for service-connected right leg sensory cutaneous neuropathy and paresthesias is denied. Since March 13, 2014, a rating in excess of 20 percent for service-connected right leg sensory cutaneous neuropathy and paresthesias is denied. FINDINGS OF FACT 1. The Veteran’s service-connected PTSD is rated 100 percent disabling and he is currently in receipt of Special Monthly Compensation (SMC) under 38 U.S.C. §1114, subsection(s) and 38 C.F.R. § 3.350(i) on account of having a service-connected disability rated 100 percent disabling and additional service-connected disabilities independently ratable at 60 percent or more from November 10, 2014 to December 31, 2014, from July 7, 2015 to August 31, 2015, from March 8, 2016 to April 30, 2016, and from November 8, 2016 to December 31, 2017. 2. Prior to November 8, 2016, the Veteran’s service-connected residuals of right knee osteoarthritis and tibia/fibula fracture were manifested, at their worst, by malunion of the tibia/fibula with marked knee or ankle disability. 3. From September 16, 2014 to November 8, 2016, the Veteran had “severe” instability associated with his service-connected residuals of right knee osteoarthritis and tibia/fibula fracture. 4. Since January 1, 2018, the Veteran’s service-connected residuals of right knee osteoarthritis and tibia/fibula fracture, status post total knee replacement, were manifested, at their worst, by flexion from 0 to 140 degrees and extension from 130 to 0 degrees, as well as evidence of pain with weight bearing; these residuals did not result in any additional functional loss or range of motion after repetitive use or immediately after repetitive use over time. 5. Throughout the appeal period, the Veteran’s service-connected chronic left knee strain has been manifested, at its worst, by x-ray evidence of degenerative arthritis and painful motion of the knee resulting in functional loss sufficient to allow for the assignment of the minimum compensable evaluation of 10 percent under 38 C.F.R. § 4.59. 6. Prior to March 13, 2014, the Veteran’s service-connected right leg sensory cutaneous neuropathy resulted in “mild” incomplete paralysis of the anterior crural (femoral nerve). 7. Since March 13, 2014, the Veteran’s service-connected right leg sensory cutaneous neuropathy has been productive of “moderate” incomplete paralysis of the anterior crural (femoral nerve). CONCLUSIONS OF LAW 1. The criteria for entitlement to a TDIU is dismissed as moot. 38 U.S.C. § 7105; Bradley v. Peake, 22 Vet. App. 280 (2008). 2. Prior to November 8, 2016, the criteria for a rating of 30 percent, but no higher, for service-connected residuals of right knee osteoarthritis and tibia/fibula fracture have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5262. 3. From September 16, 2014 to November 8, 2016, the criteria for a rating of 30 percent, but no higher, for instability associated with service-connected residuals of right knee osteoarthritis and tibia/fibula fracture have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 4. Since January 1, 2018, the criteria for a rating in excess of 30 percent for service-connected residuals of right knee osteoarthritis and tibia/fibula fracture, status post total knee replacement, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5055. 5. Throughout the appeal period, the criteria for a rating in excess of 10 percent for service-connected chronic left knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Hyphenated Diagnostic Code 5003-5260. 6. Prior to March 13, 2014, the criteria for a rating in excess of 10 percent for service-connected right leg sensory cutaneous neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8526. 7. Since March 13, 2014, the criteria for a rating in excess of 20 percent for service-connected right leg sensory cutaneous neuropathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from December 1986 to May 1990. These matters come before the Board of Veterans’ Appeals (Board) on appeal from Department of Veterans Affairs (VA) Regional Office (RO) rating decisions dated in March 2010, September 2014, February 2017, and May 2018. On his September 2011 VA Form 9, the Veteran raised new claim that included a request to reopen the previously denied claim of entitlement to service connection for a right hip disability. In a September 2014 rating decision, the RO denied the Veteran’s request to reopen his right hip disability claim. In a February 2016 VA Form 9, the Veteran appealed that decision and challenged the determination that new and material evidence had not been received to reopen the right hip disability claim. When the Veteran submitted his September 2011 and February 2016 substantive appeals to the Board, he requested the opportunity to testify at hearings before a Veterans Law Judge (VLJ). In February 2015 and August 2016 statements, the Veteran withdrew those hearing requests. The Board therefore deems both hearing requests withdrawn pursuant to 38 C.F.R. § 20.702(e). In a February 2017 rating decision, the RO reopened the Veteran’s right hip disability claim and granted service connection, with noncompensable ratings assigned for limited flexion and extension and a 10 percent rating assigned for limited adduction. The Board notes that this award of service connection represented a full grant of benefits regarding the Veteran’s right hip disability claim. Therefore, the Veteran’s right hip disability claim is no longer on appeal before the Board. Neither the Veteran nor his representative has raised any issues with VA’s duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Beyond the above, it is important for the Veteran to understand that he is already at 100 percent disability rating and that further increased ratings, based on a review of this record, will not result in increased compensation beyond the 100 percent rating. SMC, as noted above, has already been granted. The Board wishes to fully address all remaining claims to give the Veteran closure. Claim 1: Entitlement to a TDIU due to service-connected disabilities. In November 2009, the Veteran indicated that his right knee disability impacted his ability to work (although the Veteran did not qualify for schedular TDIU until March 13, 2014). In its February 2017 rating decision, the RO deferred the issue of entitlement to TDIU benefits and requested that the Veteran apply for Increased Compensation Based on Unemployability. In January 2018, the Veteran filed a formal claim seeking a TDIU. Subsequently, the RO issued a May 2018 rating decision that, in pertinent part, determined that the Veteran’s claim for TDIU was moot by being assigned a 100 percent disability rating for his service-connected PTSD and SMC. See March 2017 and May 2018 rating decisions. TDIU remains on appeal as part of the Veteran’s increased rating claims. A TDIU may be assigned “where the schedular rating is less than total” and a veteran is unable to secure or follow substantially gainful employment as a result of his service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In some cases, but not all, the assignment of a total schedular rating renders a TDIU claim moot. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008). The Veteran may receive a total (100 percent) rating based on a combination of his service-connected disabilities, or for a single service-connected disability. Special monthly compensation (SMC) may be warranted in addition to his regular compensation if the Veteran has a total disability rating for a single disability, and additional service-connected disability or disabilities rated at 60 percent or more. The total rating for the single disability for SMC purposes may be schedular, or may be based on TDIU, so long as TDIU was granted solely because of that single disability. Thus, if the Veteran’s total rating is based on a combination of his service-connected disabilities, (which would mean that his individual service-connected disabilities are each rated at less than 100 percent), then TDIU is not moot if it could be granted on a single disability, in turn making the Veteran eligible for SMC. If, however, he has a single disability already rated at 100 percent, entitlement to TDIU becomes moot, because he has already met that portion of the requirement for SMC. Here, the Veteran is in receipt of a 100 percent disability rating for his service-connected PTSD since January 10, 2018. Therefore, the issue of entitlement to a TDIU is moot. In addition to PTSD which is now rated 100 percent, the Veteran is in receipt of SMC from November 10, 2014 to December 31, 2014, from July 7, 2015 to August 31, 2015, from March 8, 2016 to April 30, 2016, and from November 8, 2016 to December 31, 2017. Given that the Veteran is receiving the maximum benefits allowed under the applicable statutes and regulations, the issue of entitlement to a TDIU is moot and will be denied as a matter of law. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of a 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. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Each disability is viewed in relation to its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Id. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability demonstrates symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), reversed in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When adjudicating an increased rating claim, the relevant period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. A claim is denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Furthermore, any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. Claims 2 & 3: Entitlement to a rating in excess of 20 percent for service-connected residuals of right knee arthritis, prior to November 8, 2016, and to a rating in excess of 30 percent since January 1, 2018 (excluding the period from November 8, 2016 to January 1, 2018 when the Veteran was in receipt of a temporary 100 percent rating). AND Claim 4: Entitlement to a separate rating in excess of 20 percent for instability associated with service-connected residuals of right knee arthritis, from September 16, 2014 to November 8, 2016. AND Claim 5: Entitlement to an initial rating in excess of 10 percent for chronic left knee strain. By way of background, the Veteran was involved in an accident in 1989 and sustained a right knee tibial plateau fracture. The Veteran underwent an open reduction internal fixation with bone grafting. The Veteran had medial meniscus surgery in 1994 but he eventually developed tricompartmental osteoarthritis of the right knee. In approximately 2000, the Veteran began experiencing pain in his left knee. It was determined that this left knee pain was secondary to his right knee disability. The Veteran underwent total right knee replacement surgery in 2016. He now seeks increased disability ratings for his service-connected right and left knee disabilities. Procedural Background In January 2010, the Veteran filed a claim seeking an increased disability rating for his service-connected “right knee condition.” In a March 2010 rating decision, the RO increased the rating assigned to the Veteran’s impairment of the right lower leg tibia and fibula with arthritic changes (hereafter “right knee osteoarthritis and tibia/fibula fracture” or “right knee disability”) from 10 percent to 20 percent, effective January 11, 2010. The Veteran appealed that rating by filing a VA Form 9 in September 2011. On his September 2011 VA Form 9, the Veteran also raised a new claim of entitlement to service connection for a left knee disability. In a September 2014 rating decision, the RO granted entitlement to service connection for chronic left knee strain (hereafter “left knee disability”) and assigned a 10 percent disability rating, effective March 13, 2014. The Veteran appealed that initial 10 percent rating by filing a VA Form 9 in February 2016. In a February 2017 rating decision, the RO continued the previously assigned 20 percent rating for the Veteran’s right knee disability, prior to November 8, 2016, assigned a 100 percent rating for 13 months following prosthetic replacement of the knee joint (effective November 8, 2016, which was the date of the total knee replacement), and assigned a minimum 30 percent rating beginning January 1, 2018, the first date of the month following the mandatory 100 percent rating for 13 months. The RO also assigned a separate 20 percent rating for the Veteran’s right knee disability based on instability, effective from September 16, 2014 to November 8, 2016. Lastly, the RO granted an earlier effective date of August 25, 2011 for the grant of service connection for the Veteran’s left knee disability. In May 2018, the RO issued a rating decision that continued both the 30 percent rating for the Veteran’s right knee disability and the 10 percent rating assigned for the Veteran’s left knee disability. As the Veteran has not received a total grant of benefits sought on appeal for his service-connected right and left knee disabilities prior to November 8, 2016, and since January 1, 2018, these issues remain on appeal before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Rating Criteria The Veteran’s right knee disability was rated 20 percent disabling under Diagnostic Code (DC) 5262 from January 11, 2010 to September 16, 2014, and then under Hyphenated DC 5003-5261 from September 16, 2014 to November 8, 2016. Additionally, a separate 20 percent rating was in effect for lateral instability associated with the right knee disability under Hyphenated DC 5003-5257 from September 16, 2014 to November 8, 2016. Since January 1, 2018, the Veteran’s right knee disability has been evaluated 30 percent disabling under 38 C.F.R. § 4.71a, DC 5055 (knee replacement with prosthesis). Throughout the appeal period, the Veteran’s service-connected left knee disability was rated 10 percent disabling under Hyphenated DC 5003-5260. Although the RO previously assigned ratings under the aforementioned DCs, the Board will consider whether the Veteran can receive higher ratings for his service-connected right and left knee disabilities under all applicable diagnostic codes pertaining to degenerative arthritis, total knee replacement, and disabilities of the knees. Degenerative arthritis established by x-ray findings is rated under DC 5003, which is rated based on the limitation of motion under the appropriate diagnostic code for the specific joint involved, or in this case, DC 5260 for limitation of leg flexion or DC 5261 for limitation of leg extension. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree, a 10 percent rating is assigned for each major joint affected. 38 C.F.R. § 4.71, DC 5003. The knee is considered a major joint. 38 C.F.R. § 4.45. Ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. DC 5055 applies to cases of total knee replacement. A 30 percent evaluation is the minimum evaluation that may be assigned following a total knee replacement. 38 C.F.R. § 4.71a. A higher evaluation of 60 percent is warranted when there is evidence of chronic residuals consisting of severe painful motion or weakness in the extremity. A 100 percent evaluation is warranted for 1 year following the implantation of the prosthesis. Otherwise, when there are intermediate degrees of residual weakness, pain or limitation of motion, it is to be rated by analogy to diagnostic codes 5256, 5261 or 5262. Id. Knee disabilities are generally rated under 38 C.F.R. § 4.71a, DCs 5256-5263. Those DCs evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). In this case, the Veteran has not shown signs of having genu recurvatum at any time during the relevant appeal periods. Therefore, DC 5263 will not be discussed below. Under Diagnostic Code 5256, ankylosis of the knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating. Ankylosis of the knee in flexion between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more warrants a 60 rating. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 28th edition, p.86. Under Diagnostic Code 5257, a knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and a maximum 30 percent when severe. 38 C.F.R. § 4.71a. Descriptive words, such as “slight,” “moderate” and “severe,” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent rating is warranted when extension is limited to 10 degrees. A 20 percent rating is warranted when extension is limited to 15 degrees. A 30 percent rating is warranted when extension is limited to 20 degrees. 38 C.F.R. § 4.71a. Separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same knee. However, any separate rating must be based on additional disabling symptomatology that meets the criteria for a compensable rating. VAOGCPREC 9-2004 (2004); 69 Fed. Reg. 59990 (2004). A claimant who has arthritis or limitation of motion and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VA’s General Counsel has held that separate ratings are only warranted in these types of cases when a veteran has limitation of motion in his knees to at least meet the criteria for a zero-percent rating under Diagnostic Codes 5260 or 5261, or (consistent with DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995) and 38 C.F.R. §§ 4.45 and 4.59) where there is probative evidence showing the veteran experiences painful motion attributable to his arthritis. See VAOPGCPREC 9-98 (1998). Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. 38 C.F.R. § 4.71a. The Board also must consider pain, weakness, excess motion, incoordination, excess fatigability, and other functional limitation factors when determining the appropriate rating for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In addition, VA examiners should test involved joints for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). Right Knee Disability Evaluation As an initial matter, the Board notes that the Veteran underwent total right knee replacement surgery on November 8, 2016. After that surgery, the Veteran’s right knee disability, characterized as residuals of right knee osteoarthritis and tibia/fibula fracture, status post total knee replacement, was rated 100 percent disabling for 13 months following implantation of the prothesis, from November 8, 2016 to January 1, 2018. See 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board further notes that the Veteran underwent a VA examination of his right knee in February 2017. During that examination, the Veteran’s right knee forward flexion was limited to 110 degrees and his right knee extension limited to 10 degrees. Pain was noted on examination and the VA examiner found that the pain caused functional loss and resulted in the Veteran’s inability to squat. While the examiner found that the Veteran did not have any additional functional loss or loss in range of motion after immediate repetitive use, the examiner indicated that pain, weakness, fatigability, or incoordination significantly limited right knee functional ability with repeated use over a period of time and resulted in flexion of the right knee limited to 90 degrees and extension of the right knee limited to 10 degrees. Flare-ups of pain were note reported but the Veteran indicated that he had swelling after use and that pain/incoordination caused him to sometimes fall. The examiner noted that the Veteran had right knee ankylosis resulting in a favorable angle in full extension or in slight flexion between 0 and 10 degrees. Joint stability testing revealed no recurrent subluxation or instability and no recurrent effusion. Regardless of the February 2017 VA examination findings, the Board observes that the Veteran was in receipt of the maximum available schedular rating during this period of the appeal. Likewise, he has not expressed disagreement with the effective date or duration of this total rating; as such, evaluation of the Veteran’s service-connected right knee disability during the period, from November 8, 2016 to January 1, 2018, is not at issue and will be excluded from the discussion below. Accordingly, the two appeal periods that will be addressed below involve the period “prior to November 8, 2016” and the period “since January 1, 2018.” Prior to November 8, 2016 Prior to November 8, 2016, the Veteran’s service-connected right knee disability was rated 20 percent disabling based on limitation of extension of 15 to 19 degrees and malunion of the tibia and fibula with moderate knee or ankle disability. The question for the Board is whether the Veteran is entitled to an increased rating in excess of 20 percent for his service-connected right knee disability prior to November 8, 2016. Additionally, the Board must determine whether the Veteran is entitled to an increased separate rating in excess of 20 percent for instability associated with his service-connected right knee disability from September 16, 2014 to November 8, 2016. Prior to November 8, 2016, VA treatment records show that the Veteran received ongoing treatment for chronic right knee pain and osteoarthritis. These records reflect that the Veteran was receiving medication for his right knee pain and that the pain would often fluctuate in severity. It was noted that the Veteran was trying to do physical therapy to improve his condition. The Veteran underwent a VA examination in January 2010. During that examination, it was noted that the Veteran experienced deformity, giving way, instability, pain, stiffness, weakness, incoordination, and a decreased speed of joint motion. There was no subluxation, dislocation, or effusion. The Veteran reported having tenderness. He reported having daily flare-ups that occur for hours. The examiner noted that these flare-ups were “severe,” occurred daily, and lasted for hours. The Veteran reported that he used a cane and brace occasionally to help ambulate. The examiner noted that the Veteran’s gait was antalgic. The examiner noted that the Veteran had a bony joint enlargement, crepitus, and deformity. There was a note of genu varus deformity of 5 degrees. Crepitus and clicking were noted. The Veteran had a positive McMurray’s test. Range of motion revealed right knee forward flexion to 110 degrees and normal extension. An x-ray of the right knee showed arthritis change that was marked in the medial joint compartment associated with a genu varus deformity, an intra-articular loose body anteriorly, and small joint effusion. The examiner diagnosed the Veteran as having right knee degenerative joint disease. The Veteran was afforded another VA examination in September 2014. During that examination, the Veteran exhibited right knee forward flexion limited to 80 degrees and right knee extension limited to 15 degrees. There was objective evidence of painful motion. Repetitive use testing revealed forward flexion limited to 90 degrees and extension limited to 15 degrees. While the examiner found that the Veteran had functional loss and/or functional impairment of the knee, the examiner noted that the Veteran did not have additional limitation in range of motion of the knee after repetitive use. The examiner characterized the functional loss as less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, deformity, instability of station, and disturbance of locomotion. The examiner noted that the Veteran had previously had a meniscectomy and that residuals of that procedure included severe pain, severe traumatic arthritis, and a 15-degree genu varus defect. The examiner opined that functioning of the right knee was so diminished that amputation with prothesis (i.e., a total knee replacement) would equally serve the Veteran. Based on the foregoing, the Board finds that the Veteran’s service-connected right knee disability warrants a 30 percent rating prior to November 8, 2016. During this period of the appeal, there was evidence of malunion of the tibia/fibula with both moderate and marked disability caused by right knee disability, and this evidence is approximately evenly balanced between the two degrees of severity. See DC 5262, criteria for a 30 percent rating. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, a schedular rating of 30 percent is warranted for the Veteran’s service-connected right knee disability prior to November 8, 2016. 38 C.F.R. §§ 4.3, 4.7. However, a higher rating of 40 percent is not warranted during this period of the appeal. Although both VA examiners indicated that assistive devices were required to help ambulate, neither the January 2010 VA examiner nor the September 2014 VA examiner found that the Veteran had nonunion of his right tibia/fibula. Furthermore, there were no findings of or approximating loose motion or other symptoms that indicated that the level of severity more nearly approximated that required for a 40 percent rating. Lastly, there was no evidence of ankylosis in flexion between 10 and 20 degrees or extension limited to 30 to 44 degrees. Similarly, the Board finds that the Veteran’s instability associated with his service-connected right knee disability – which was assigned a separate 20 percent rating – also warrants an increased 30 percent rating. See DC 5257, criteria for a 30 percent rating. Specifically, the January 2010 VA examiner noted that the Veteran experienced the following myriad of joint symptoms: deformity, giving way, instability, pain, stiffness, weakness, incoordination, and a decreased speed of joint motion. The examiner noted that the Veteran was experiencing daily flare-ups of these symptoms that lasted for hours. The examiner noted that these flare-ups were “severe.” Given the severity of the Veteran’s joint symptoms, which included daily “severe” joint instability, the Board finds that the Veteran’s disability picture prior to his total right knee replacement surgery, more closely approximates “severe” level of knee impairment required for the 30 percent rating under DC 5257. The 30 percent rating is the highest schedular rating allowed under DC 5257. While the Board is granting higher disability ratings for the Veteran’s underlying right knee disability and the associated right knee instability prior to November 8, 2016, the Board finds that the preponderance of the evidence is against the assignment of ratings in excess of 30 percent during that period of the appeal. Even when considering the applicability of other DCs used to rate knee disabilities, the Board finds that higher ratings for the Veteran’s right knee disability and associated instability are not warranted prior to November 8, 2016. In other words, the Veteran’s symptomatology and disability picture are adequately compensated by the newly assigned ratings under DCs 5262 and 5257, respectively. The benefit of the doubt doctrine is therefore not for application as to whether higher ratings are warranted, and that doctrine has been applied in granting the 30 percent ratings as indicated above. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Since January 1, 2018 The next question for the Board is whether the Veteran is entitled to an increased rating in excess of 30 percent for his service-connected right knee disability since January 1, 2018. The Veteran was afforded a new VA examination in April 2018. The Veteran indicated that, since his total right knee replacement, his knee is “painful from time to time, and it’s somewhat less flexible.” The Veteran indicated that he uses a brace with his right knee to help with ambulation. He indicated that he cannot flex the right knee well so he finds it difficult to put on his pants. Range of motion testing revealed flexion from 0 to 140 degrees and extension from 130 to 0 degrees, as well as evidence of pain with weight bearing. The examiner found no additional functional loss or range of motion after repetitive use or immediately after repetitive use over time. The Veteran did not report having any flare-ups. The examiner found no evidence of ankylosis, recurrent subluxation, lateral instability, or recurrent effusion. The examiner found no evidence of a residual meniscus (semilunar cartilage) condition. The Veteran had normal muscle strength in his right knee. The examiner noted that the Veteran continued to regularly use a brace to help with ambulation. Based on the findings of the April 2018 VA examination, the Board finds that Veteran is adequately compensated by the assigned 30 percent rating since January 1, 2018. As noted above, the 30 percent rating, status post total right knee replacement surgery, was assigned as the minimum evaluation following prosthetic replacement. A higher evaluation of 40 percent is not warranted unless there is ankylosis in flexion between 10 and 20 degrees; extension is limited to 30 to 44 degrees; or there is nonunion of the tibia and fibula with loose motion, requiring a brace. Additionally, a higher evaluation of 60 percent is not warranted unless there is post-prothesis placement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. The evidence of record since January 1, 2018 does not show that the Veteran’s right knee symptomatology or disability picture meets any of the criteria necessary for a higher rating. While the Veteran continued to use a brace to assist with ambulation, it does not appear that he had any nonunion of his tibia and fibula or any chronic residuals consisting of painful motion or weakness. Any pain experienced by the Veteran during flexion or extension was already contemplated by the previously assigned 30 percent schedular rating and the Board concludes that a rating in excess of that percentage is not warranted at any time since January 1, 2018. Accordingly, the Veteran’s claim seeking a rating in excess of 30 percent for service-connected right knee disability, since January 1, 2018, is denied. Left Knee Disability Evaluation The Veteran’s service-connected left knee disability has been rated 10 percent disabling based on painful motion of the knee (under 38 C.F.R. § 4.59) and x-ray evidence of degenerative arthritis. The question for the Board is whether the Veteran is entitled to a rating in excess of 10 percent for his service-connected left knee disability. VA treatment records show that the Veteran received ongoing treatment for chronic left knee pain. The Veteran was afforded VA examinations in September 2014, August 2016, February 2017, and April 2018. During the September 2014 VA examination, the Veteran exhibited normal flexion (with objective evidence of painful motion at 130 degrees) and no limitation of extension. There was functional loss and impairment in the form of pain on movement and disturbance of locomotion of the left knee. However, the examiner found that the Veteran did not have any additional limitation of motion after repetitive use. The examiner found no evidence of ankylosis, joint instability, recurrent subluxation, or meniscal conditions affecting the left knee. During the August 2016 VA examination, the Veteran exhibited flexion from 0 to 85 degrees and extension from 85 to 0 degrees. Pain was noted on evaluation and was found to cause functional loss in terms of disturbance of locomotion, sitting, and standing. The examiner found localized tenderness and pain to palpation of the joint or associated soft tissue. There was no evidence of crepitus. After repetitive use, the Veteran had an additional loss of 10 degrees of range of motion (flexion from 0 to 70 degrees and extension from 70 to 0 degrees). After repeated use over time, the Veteran had an additional loss of 20 degrees of range of motion (flexion from 0 to 50 degrees and extension from 50 to 0 degrees). The Veteran did not report experiencing any flare-ups regarding his left knee. The examiner found no evidence of ankylosis, recurrent subluxation, lateral instability, or meniscal conditions affecting the left knee. During the February 2017 VA examination, the Veteran’s left knee flexion was limited to 114 degrees and his right knee extension limited to 0 degrees. Pain was noted on examination and the VA examiner found that the pain caused functional loss and resulted in the Veteran’s inability to squat. While the examiner found that the Veteran did not have any additional functional loss or loss in range of motion after immediate repetitive use, the examiner indicated that pain, weakness, fatigability, or incoordination significantly limited right knee functional ability with repeated use and repeated use over time and resulted in flexion of the left knee limited to 90 degrees and normal extension of the left knee. Flare-ups of pain were note reported but the Veteran indicated that he had swelling after use and that pain interfered with activities such as walking and standing for greater than five minutes. The examiner noted that the Veteran had no ankylosis, recurrent subluxation, lateral instability, or meniscal conditions affecting the left knee. During the April 2018 VA examination, the Veteran demonstrated normal left knee flexion and extension. There was no pain, crepitus, or localized tenderness noted on evaluation. Range of motion measurements remained the same after repetitive use testing and the examiner did not test for functional impairment with repetitive use over time. The examiner found no evidence of ankylosis, recurrent subluxation, lateral instability, or meniscal conditions affecting the left knee. As with the right knee, the Board has carefully reviewed and evaluated the medical and lay evidence of record as it pertains to the Veteran’s chronic left knee strain disabilities. After considering the applicable diagnostic criteria, the Board finds that the Veteran does not warrant a higher disability for his service-connected left knee disability. A higher evaluation of 20 percent is not warranted for degenerative arthritis of the left knee as there is no indication that the x-ray evidence of record shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Likewise, a higher evaluation of 20 percent is not warranted because the pertinent left knee evaluations do not show that the Veteran ever had limitation of flexion to 16 to 30 degrees; limitation of extension to 15 to 19 degrees; moderate recurrent subluxation or lateral instability; any ankylosis, or any meniscal condition associated with his left knee. The previously assigned 10 percent rating for the Veteran’s left knee disability contemplates the chronic pain and functional loss experienced by the Veteran and the evidence of record simply does not support a higher initial rating at this time. The preponderance of the evidence is against the assignment of a higher disability rating for the Veteran’s service-connected left knee disability at any time during the appeal period. Other Considerations The Board notes that the Veteran has four scars associated with his right and left knee disabilities. These scars were previously assigned separate compensable and noncompensable ratings. The Veteran has not indicated dissatisfaction with any of the assigned ratings for his scars. Therefore, the ratings assigned to these scars will not be addressed herein. Neither the Veteran nor his representative has raised any other issues regarding the Veteran’s service-connected right and left knee disabilities, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the veteran or reasonably raised by the evidence of record). Claims 6 & 7: Entitlement to a rating in excess of 10 percent for service-connected right leg sensory cutaneous neuropathy and paresthesias, prior to March 13, 2014, and to a rating in excess of 20 percent thereafter. In January 2010, the Veteran filed a claim seeking an increased disability rating for his service-connected “right knee conditions.” In a March 2010 rating decision, the RO increased the rating assigned to the Veteran’s sensory cutaneous neuropathy and paresthesia of the lateral aspect of the right leg (hereafter “right leg neuropathy”) from 0 percent to 10 percent, effective January 11, 2010. The Veteran appealed that rating by filing a VA Form 9 in September 2011. In a September 2014 rating decision, the RO increased the rating of the Veteran’s right leg neuropathy from 10 percent to 20 percent, effective March 13, 2014. In his February 2016 VA Form 9, the Veteran appealed the newly assigned 20 percent rating for right leg neuropathy. Subsequently, the RO issued a May 2018 rating decision that, in pertinent part, continued the 20 percent rating for his right leg neuropathy. In a February 2017 rating decision, the RO continued the previously assigned 20 percent rating for the Veteran’s right leg neuropathy. As the Veteran has not received a total grant of benefits sought on appeal for his service-connected right leg neuropathy, this issue remains on appeal to the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran’s service-connected right leg neuropathy is evaluated under the criteria of 38 C.F.R. § 4.124a, DC 8626. The diagnosed sensory cutaneous neuropathy and paresthesias is not specifically listed in the Rating Schedule. Therefore, it is rated by analogy to a disability in which the functions affected and the anatomical localization and symptoms are closely related. The question for the Board is whether the Veteran is entitled to rating in excess of 10 percent prior to March 13, 2014, and to a rating in excess of 20 percent thereafter under DC 8626 or any other potentially applicable DC used to evaluate lower extremity nerve disabilities. DC 8626 provides a rating for neuritis of the femoral nerve. Specifically, neuritis that results in “mild” incomplete paralysis of the femoral nerve warrants a 10 percent rating. Neuritis that results in “moderate” incomplete paralysis of the femoral nerve warrants a 20 percent rating. Neuritis that results in “severe” incomplete paralysis of the femoral nerve warrants a 30 percent rating. Neuritis resulting in complete paralysis of the quadriceps extensor muscles is rated 40 percent disabling. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. Turning to the evidence of record, the Board notes that the Veteran has received ongoing treatment for numbness in his right lower extremity. He also was afforded VA examinations of the nerves in his right lower extremity in January 2010, September 2014, and April 2018. On VA examination in January 2010, it was noted that the Veteran experienced increased paresthesias that occurred when was asleep. He reported that this paresthesias would often awaken him. The Veteran reported that he felt weakness in his right lower leg that had increased gradually and that he had not been able to perform normal daily activities. The examiner noted that the femoral nerve was primarily affected. The examiner further noted that in the region of the lateral femoral cutaneous, lateral sural and superficial peroneal nerves, the cutaneous nerves of the lower leg were less affected than the lateral thigh cutaneous nerve. The examiner noted that the Veteran’s vibration and position sense were normal but that his light touch was decreased. The examiner noted that deep tendon reflexes were normal. The examiner noted that there was muscle atrophy present and there was abnormal muscle tone or bulk. The examiner found evidence of neuritis and paralysis but no neuralgia. The examiner noted that the Veteran’s paresthesias and dysesthesias did not affect your activities of daily living but affected his ability to sleep. The examiner diagnosed the Veteran with sensory cutaneous neuropathy of the right lower extremity. On VA examination in September 2014, the Veteran reported experiencing moderate numbness in his right lower extremity. The examiner noted that there was cutaneous anaesthesia on the lateral aspect of the right lower extremity from the hip to the ankle. Muscle strength, reflex, and sensory testing revealed normal findings in all categories tested. The examiner found that the Veteran had normal nerves (including the femoral nerve) in his right lower extremity. It is unclear why the September 2014 VA examiner reported that the Veteran had normal nerves in the right lower extremity as the examiner did not provide any explanation regarding this finding. On VA examination in April 2018, the Veteran reported experiencing mild paresthesias/dysesthesias and moderate numbness in his right lower extremity. Muscle strength and reflex testing revealed normal findings in all categories tested. Sensory testing revealed decreased sensation for light tough in the upper anterior thigh and thigh/knee areas. The examiner reported that the Veteran had moderate incomplete paralysis of the anterior crural (femoral) nerve. Based on the foregoing, the Board finds that the Veteran’s right leg sensory cutaneous neuropathy and paresthesias does not warrant a rating in excess of 10 percent prior to March 13, 2014. During this period of the appeal, the Veteran’s nerve symptomatology and disability picture most closely approximated “mild” incomplete paralysis of the anterior crural (femoral) nerve of the right leg. He did not exhibit symptoms that were “moderate” in terms of severity. Similarly, the Board finds that the Veteran’s right leg sensory cutaneous neuropathy and paresthesias does not warrant a rating in excess of 20 percent since March 13, 2014. The September 2014 and April 2018 VA examiners specifically found that the Veteran had “moderate” symptoms affecting his right leg anterior crural (femoral nerve). Lastly, the Board finds that the Veteran is not entitled to a rating in excess of 20 percent at any time since March 13, 2014. Specifically, the Veteran’s nerve symptomatology and disability picture was never found to be productive of “severe” incomplete paralysis of the anterior crural (femoral nerve). The Board thus concludes that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent prior to March 13, 2014, and the assignment of a disability rating in excess of 20 percent from that date. Neither the Veteran nor his representative has raised any other issues regarding the Veteran’s service-connected right leg neuropathy and paresthesias, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 366. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. L. Marcum, Counsel